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Injuries are a pain in the bum! PART 2 – Proximal Hamstring Tendinopathy

Part 2 of the “injuries are a pain the bum” saga!

Following on from the previous instalment, the other common complaint we see in clinic is Proximal Hamstring Tendinopathy (PHT). Similar to groin pain, this is one of those injuries that people are almost apologetic in their embarrassment; some people going as far as mouthing the description to avoid saying it out loud. The most common symptom is pain at the hamstring attachment to its origin, the ischium – as seen in the image (the white tendon at the top of the hamstring muscles).


Have you got PHT? People often refer to the pain as in the “sit bones”, or similar, and PHT is mostly characterised by buttock pain in the area just under the glute muscle – as the leg turns into the bum! Area of pain is often consistent with the size of the tendon – generally 2 fingers width. Generally, sufferers have pain upon waking in the morning, with the pain decreasing as they start to move throughout the day. However, it can be aggravated by the simplest of things due to its location; sitting – in a flexed hip position – for prolonged periods compresses the tendon (see; desk workers, driving, cycling [highlighting the importance of a Bike Fit]), as do deep lunges and squats, running fast or uphill, and lastly…..stretching! Yes, you read that correct; hamstring stretching will not help PHT. So if your PT or injury therapist is getting you in the below position, please ask them to stop 🙂


This will not help.

What we can do? As we’ve seen, PHT is aggravated by tension and compressive loads. To reduce pain, we need to decrease these loads to a level that is manageable. This means reducing compression from sitting and activities involving hip or trunk flexion; avoiding stretching the hamstring and reducing running or lifting to a relatively pain free level (I aim for below 3/10 on your pain scale). Tendon research has shown changes in muscle function when pain is present; isometric hamstring exercises, such as the Hamstring Bridge – as seen in the below video – can help reduce pain and maintain muscle strength (Ref 1)

Like the achilles and patella tendons, the tendon at the origin of the hamstrings is thick, fibrous, and has a poor blood supply, which can make healing difficult, and slow. Similar to these two more common tendon injuries, tendinopathy of the high hamstrings appears to be a degenerative process, not an inflammatory one, meaning that the fibers of the tendon are becoming damaged, or are ‘spiltting’. In a 2005 paper, Fredericson et al argue that the key to successful rehablititaion of PHT is eccentric strengthening of the hamstring muscle group, improving the ability of the muscle and tendon to manage the load required. This should be graded, and ideally, in a limited position of hip/trunk flexion.


Ref 1 A meta-analytic review of the hypoalgesic effects of exercise

Ref 2 Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Physician and SportsMedicine, 2005,

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldn’t be seen as such. They are merely guides to a better understanding of how our bodies work.

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