Do you have a deep, localized pain around your sit bone that often gets worse during or after activities like running, squatting, or sitting?
In this blog, I am going to tell you everything you need to know about proximal hamstring tendinopathy, including guidelines for how to best manage this condition.
Looking to improve the strength, range of motion, and control of your hips to enhance your function and performance? Check out our Hip Resilience program!
Hamstring Anatomy & Function
Your hamstring muscles attach to your ischial tuberosity, also known as your sit bone, and consist of 3 muscles: the semimembranosus, semitendinosus, and the long head of the biceps femoris. They insert onto your lower leg and primarily contribute to knee flexion and hip extension.
What is Proximal Hamstring Tendinopathy and Why Do You Get It?
Similar to other tendinopathies, proximal hamstring tendinopathy is characterized by persistent tendon pain and loss of function related to mechanical loading.
This pain is located around the lower gluteal region, which may or may not radiate down the back of the thigh and often occurs during activities and positions that place more stretch, load, and/or compression through the proximal portion of the hamstring tendon. Examples include running uphill, sprinting, movements involving deeper hip flexion (like squatting or lunging), stretching, and sitting for prolonged periods of time.
A sudden increase in some of these activities may be a contributing factor as to why you developed this condition in the first place. A simplified explanation is that the loads you placed on your hamstring tendon through different positions and movements may have exceeded your capacity to recover and adapt appropriately. Or in other words, you might have done too much, too soon.
This load is often associated with external factors, such as the intensity, volume, and frequency of your training. For example:
- Did you recently incorporate uphill running or sprint intervals into your sessions?
- Or have you been practicing yoga and including more stretching at the end range of hip flexion?
While tendon loading is a major component, lifestyle and systemic factors may also play a role, as these can reduce your tendon’s capacity to tolerate certain loads. For instance:
- Are you getting enough sleep?
- How well do you manage your stress?
- Do you engage in regular physical activity?
Addressing these factors during the rehab process is low-hanging fruit that can have a significant impact on your overall health.
Also, it is worth noting that since hamstring tendon pathology is common in people without pain, imaging is usually not necessary for this condition.
Proximal Hamstring Tendinopathy Management
In terms of management, Nasser et al in 2021 found that “…injection therapies and surgery were believed to have limited utility.”
This lines up with other tendinopathy research, as they also have similar recommendations against these treatments.
Therefore, management will focus on 2 main components: (1) load management & activity modifications, and (2) exercises that emphasize progressive loading.
Load Management & Activity Modifications
The first main component of rehab is load management & activity modifications which are about temporarily modifying and minimizing painful activities to aid in long-term recovery. This will help reduce the load side of the equation in order to allow you to continue running, exercising, sitting, etc. with tolerable symptoms.
It is often a trial-and-error process, but here are some suggestions:
If you have pain when sitting on hard surfaces, you can try sitting on a pillow or cushion.
Another option is using a rolled-up towel and placing it under your thighs in order to reduce the weight you place through your sit bone.
If it is the duration of sitting that is problematic, you can take periodic standing breaks or get up and move around more frequently.
If you experience pain while running, you will have to play around with your intensity, volume, and frequency. As an example, sprinting and uphill running will require more hamstring loading, so reducing your speed and/or running on flat surfaces can be simple solutions.
Other considerations include modifications to your technique. Overstriding, where your foot is contacting further out than necessary, and running with a forward trunk lean can increase the load placed on your hamstrings. Therefore to address these, you can try to increase your cadence by 5-10% or adopt a more upright trunk while running, respectively.
If you still can’t find a tolerable entry point after adjusting these variables, you may need to hold off on running temporarily in order to allow symptoms to calm down. In the meantime, you could substitute it for other activities like biking, swimming, or an elliptical to help maintain fitness levels.
If you have pain with squats, lunges, or other similar movements, you can try to reduce the range of motion, decrease the load or weight used, perform them at a slower tempo, or substitute for another exercise that is more comfortable.
Finally, it is not uncommon for stretching to exacerbate symptoms. If they feel good & don’t significantly increase your pain, it is probably okay to continue doing them, but just know they are not necessary for recovery.
Progressive Loading Exercises
The second component of rehab will be performing exercises that emphasize progressive hamstring loading. These will help to further increase your capacity so you can eventually tolerate more load.
To date, there are no clear guidelines for how to implement exercises for this condition. However, using the work from Goom et al in 2016, Nasser et al in 2021, and other tendinopathy research, we can create a general rehab framework.
This revolves around the concept that pain has a dose-dependent relationship with the magnitude and rate of loading. In other words, a greater intensity (magnitude) and a faster speed (rate) of force will tend to increase the load on the hamstring, which can lead to more severe symptoms.
For example, a single-leg RDL, or hip hinge, is probably going to be more painful than a double-leg RDL. And sprinting is probably going to be more painful than jogging.
Using this as a guideline, rehab will follow a 3-stage progression which gradually increases hamstring loading. It will start with isometrics, build up to heavy slow resistance through increasing amounts of hip range of motion, and if necessary for your goals, progress to jumping and plyometric exercises (energy storage and release) that prioritize a faster rate of loading.
Understanding and Monitoring Pain
Before reviewing the exercises, it is first essential that you are able to appropriately monitor and manage your pain.
Similar to other tendinopathies, it is unlikely that your rehab will be pain-free. As a matter of fact, exercising into a tolerable level of pain has been found to be acceptable during this process. This “tolerable level” is unique to each individual. Whether this means minimal or moderate pain is up to you, but in any case, here are 3 strategies to help monitor your symptoms:
- Keep pain tolerable during exercise or activity. The easiest way to do this is to rate your pain on a scale from 0-10. What is the highest number acceptable for you? Whether this is a 3/10 or a 5/10, the decision is up to you.
- Make a note of how you respond immediately after exercise or activity. Is the pain better, worse, or the same? Similar to other tendinopathies, you may actually feel better after exercising due to what is called a warm-up phenomenon.
- Arguably the most important, assess how your symptoms feel the day after exercise. If you feel better, you might be able to make small progressions. However, if your symptoms are significantly worse, this likely means you did too much the previous day and need to scale back.
Let’s look at how you can implement these strategies using a self-assessment test.
First, choose one of the following single-leg exercises, which are listed in order of difficulty based on hamstring loading:
- Bridge, Long Lever Bridge, Foot Elevated Bridge, Long Lever Foot Elevated Bridge, or RDL.
Choose a variation that is within a “tolerable level” of pain. If you can’t find one, you may perform any of these with two legs instead.
In this example, let’s say you choose a single-leg foot-elevated bridge. On day 1, you perform 1 repetition and rate your pain as a 2/10. You then perform your rehab exercises later that day and feel good during and immediately after. The next day, you perform the single leg foot elevated bridge again, but now rate your pain as a 7/10. This means that even though you felt good during and after your rehab routine, you may have done more than you can recover from. This isn’t necessarily bad, but the next time you do your exercises, it would be recommended that you scale back the volume or intensity. This might be the number of repetitions or the weight you use.
At first, it might be helpful to minimize exposure to multiple activities, so you can gauge a more accurate response. For instance, if you perform your rehab exercises, run, and sit for a prolonged duration in one day, and then the next day symptoms are worse, it would be hard to determine what caused an increase in pain. Was it one exercise? Running? Or a combination of these activities?
You also don’t have to use one of these exercises. Alternatively, you can use one of your normal functional activities, such as a daily morning walk, as your self-assessment test.
Stage 1: Isometrics (Optional)
Because these exercises involve little to no movement, they are generally well-tolerated and therefore often used as a starting point in most tendinopathy rehab protocols. If you have more irritable symptoms, these can be particularly helpful, but I listed this stage as optional since not everyone will need to start with or include isometrics.
Here are 7 options in order of relative difficulty based on potential hamstring loading:
- Bridge
- Hamstring Curl, either prone or standing
- Long Lever Bridge
- Foot Elevated Bridge
- Long Lever Foot Elevated Bridge
- Roman Chair Hip Extension
This means that the bridge exercise will theoretically be less demanding on your hamstrings, while the Roman chair hip extension will require your hamstrings to work harder. Therefore, if you have increased symptoms, starting with a bridge or hamstring curl may be more tolerable. If you want a more difficult exercise, you can build up to the long lever foot elevated bridge or Roman chair hip extension.
You can do these exercises either with both legs or on a single leg. The option you choose will be based on factors such as your tolerance, symptoms, function, and access to equipment.
Programming For Stage 1
For programming, pick one option and perform for 3-5 sets of 30-45 second holds at around a 7/10 effort with a 2-minute rest between sets. These exercises can be done independently, up to three times a day, or integrated into your warm-up routine prior to your workouts.
Stage 2: Heavy Slow Resistance (Recommended)
The goal of this stage is to gradually load the hamstrings and surrounding muscles through their full range of motion. I will review 5 exercise categories, including modifications and recommendations as appropriate.
There are no set criteria you must meet before starting this stage, rather you will have to experiment with the exercises and determine if they fall within the pain guidelines mentioned earlier.
For example, can you perform a double leg bridge or prone hamstring curl for repetitions without a significant increase in pain the next day?
You also might not be able to perform all 5 categories right away. Maybe you can tolerate bridges, knee flexion, and hip abduction exercises early on, but the hip hinge and squat movements might be too irritable. These might be exercises you work up to over time.
Category 1: Hip Extension (With Glute Emphasis)
Here is a 4-level bridge progression:
- Level 1 – Double Leg Bridge. Lift your hips up and squeeze your glutes, before lowering back down. Once you can complete 3 sets of 15 repetitions with tolerable symptoms, progress to the next level.
- Level 2 – Single Leg Bridge. Same as the previous but perform on a single leg. Aim for 3 sets of 15 reps on each side.
- Level 3 – Double Leg Hip Thrust. Place your upper back on a bench or elevated surface so you can move through more hip range of motion. Aim for 3 sets of 15 repetitions.
- Level 4 – Single Leg Hip Thrust. Perform for 3-4 sets of 10-15 reps on each leg. Over time you can make this harder by adding weight.
Category 2: Knee Flexion
Option 1 – Prone Hamstring Curl. If you have access to the equipment, this can be a good entry point for loading the hamstrings since it requires minimal hip flexion. Start with a double leg variation and progress to a single leg once tolerated.
Option 2 – Slider Progression.
- Level 1 – Double Leg Eccentric. With your feet on sliders, bridge up, and then slowly straighten your knees. Lower your hips down, bring your feet back, and repeat. Aim for 3 sets of 12 repetitions.
- Level 2 – Double Leg. Slowly slide your feet out, then use your hamstrings to pull them back in, keeping your hips up. Aim for 3 sets of 12 reps.
- Level 3 – Single Leg Eccentric. Similar to level 1 but on a single leg. Aim for 3 sets of 8 reps on each side.
- Level 4 – Single Leg. Perform for 3-4 sets of 4-8 reps each.
Option 3 – Nordic Hamstring Curl (Advanced). Set up in a tall kneeling position with your knees on a pad and your feet secured. With your hips straight, slowly lower to the floor or object in front of you. Catch yourself with your hands, then push yourself back to the start.
Option 4 – Seated Hamstring Curl (Advanced). Since this exercise involves an increased amount of hip flexion and has a sitting component, it is considered a more advanced option. It might be an exercise you work up to, but it is likely you will find one of the previous options more tolerable.
Category 3: Hip Extension (With Hamstring Emphasis)
Building up to a deadlift or Romanian deadlift will likely be the most challenging resistance exercise since it can place the most load through the hamstring tendon.
Early on, a more tolerable exercise might be a foot-elevated long lever bridge. Here is a 3-step progression.
- Level 1 – Double Leg. Place both feet on a bench or elevated surface, with knees bent about 10 to 20°. Bridge up until your hips are straight, and then slowly lower back down. Once you can perform 3 sets of 15 reps with tolerable pain, progress to the next level.
- Level 2 – Eccentric. Bridge up on two legs, and while keeping hips high, remove one leg, then slowly lower down. Repeat for 3 sets of 10 reps one leg before switching sides.
- Level 3 – Single Leg. Keep one knee toward your chest, and bridge up and down through your full range of motion on a single leg. Perform for 3-4 sets of 6-12 reps on each side. You can add weight over time if needed.
As symptoms allow, progressing toward a hip hinge variation, such as a deadlift, can help build your tolerance to hamstring loading in a maximally stretched position. Here are a few options:
Option 1 – Deadlift. Start with a reduced range of motion, such as a kettlebell deadlift off an elevated surface. As your symptoms improve, gradually progress toward deadlifts from the floor. If it fits your goal, you can work through a similar progression using a barbell.
Option 2 – Single Leg Deadlift. Start with body weight and work up toward holding a dumbbell or kettlebell. If you struggle with balance, you can use your hand for assistance.
Option 3 – Roman Chair Progression.
- Level 1 – Double Leg. Place your arms across your chest, hinge forward, then use your hamstring to pull yourself back to the start. Before progressing, your goal is to build up to 3 sets of 15 repetitions through your full range of motion.
- Level 2 – Single Leg. Same technique & execution, but now perform on one leg. Perform for 3-4 sets 6-12 reps on each side. To make this harder, you can progress by holding a weight across your chest.
Category 4: Step-ups and Squats
This category will introduce movements that involve deeper hip flexion ranges of motion. Similar to the hip hinge, you may find these irritable early on, so ease into these exercises as tolerated.
Here are 2 options:
Option 1 – Step-up. Start at a low height. If this is too difficult, you can use your hands for assistance. To make this harder, gradually increase the height of the step, and eventually, you can add weight.
Option 2 – Split Squat Progression
- Level 1 – Heels Elevated Squat. Elevating your heels will allow you to keep a more upright torso and perform the exercise with less hip flexion. Build up to 3 sets of 15 repetitions through your full range of motion. If this is too hard, you can start with partial squats.
- Level 2 – Split Squat. Start in a split stance and slowly lower your back knee toward the ground, keeping your torso upright. If this is too hard, you can shorten the range of motion or use your hands for assistance. Before progressing to level 3, your goal is to perform 3 sets of 12 reps through your full range of motion on each leg.
- Level 3 – Front Foot Elevated Split Squat. Place your front foot on an object 2 to 4 inches high and execute the same movement as in level 2. Perform for 3-4 sets of 6-12 reps on each leg. Over time, you can make this more challenging by adding weight.
Category 5. Additional Resistance Exercises
Targeting the lateral hip and calf muscles can help address other possible deficits and help better prepare you for running and sport.
For muscles on the side of your hip, there are several options. Some include short side planks, regular ride planks, side steps with a band around your knees or ankles, and hip abduction in standing with a cable or side-lying with or without the use of a band or weight.
For the calves, you can work through this standing progression. Start double leg, progress to a single leg, then a single leg deficit, and finally add weight over time.
Programming For Stage 2
Once you can tolerate Stage 2 exercises, you will perform them 2-3 times a week. For example, you can do bridges, prone hamstring curls, and calf raises on Monday, and the foot elevated long lever bridge, hamstring slider, and hip abductions on Thursday. As symptoms allow, you can gradually introduce more advanced exercises, like deadlifts, squats, and step-ups. You can also continue to perform the isometrics as part of your warm-up and/or on the other days of the week if you have the time and can tolerate them.
Stage 3: Energy Storage and Release (Optional)
If returning to running or sports is one of your goals, jumping and plyometric exercises that prioritize a faster rate of loading should be included. Some research suggests that you should have minimal to no pain during advanced movements like a single leg RDL and comparable strength side to side during Stage 2 exercises prior to starting this stage.
There are endless exercises to choose from but here are 2 options:
The first is a vertical jump progression. Start with a sub-maximal vertical jump on two legs, where you build up to about 80% effort, before progressing to a maximal vertical jump on two legs. Then work the same progression but on a single leg. Make an effort to stick the landing on each jump. Perform for 2-3 sets of 6-8 repetitions.
The second option is a horizontal jump progression, which will require slightly more effort from the hip muscles on takeoff. Begin with a double-leg sub-maximal horizontal jump before moving onto a maximal horizontal jump. After that, repeat the same progression but on a single leg. Perform for 2-3 sets of 6-8 repetitions.
Programming For Stage 3
Once you meet the given criteria, and if appropriate for your goals, the easiest option is to program Stage 3 exercises at the start of your workout. For example, you can do the vertical jumps on Monday and the horizontal jumps on Thursday before performing the heavy slow resistance exercises.
When Can You Return Back To Running or Your Sport
According to Goom et al in 2016, “a graded return to sport can be introduced when the athlete can tolerate the loading requirements of the sport with minimal symptom provocation.”
Each case will be unique, but the main takeaway is that this process will be gradual and determined by your tolerance.
For instance, if you are a recreational runner who wants to run hills or sprint, you would slowly build up the volume and intensity of your training over the course of several weeks to months. If your goal is to play a team sport, you would follow a similar process but would include sport-specific drills, before gradually returning back to practice and then eventually full competition.
For those who are less symptomatic, you may actually be able to continue to compete in your sport by simply adjusting your training loads and incorporating the previously mentioned exercises.
During this phase, you should still continue to perform the other exercises, but you can program your runs, practices, or other activities into your weekly calendar based on your schedule, goals, symptoms, etc.
Proximal Hamstring Tendinopathy Case Examples
Given that every situation is unique, here are 3 case examples to help illustrate how the previous information can be applied.
Case Example #1
For the first example, let’s say you are a 30-year-old recreational runner that experiences mild symptoms after recently introducing uphill running into your training.
Tying in the first component of rehab (load management and activity modifications), you may find that you are able to continue running on a weekly basis as long as it is on flat ground and at slower speeds.
You also then introduce the progressive loading exercises twice a week in order to help build up your tolerance to hamstring loading. You start with the heavy slow resistance exercises and then once you meet the given criteria, you begin the jumping and plyometrics.
After performing the exercises for a month or two, you gradually reintroduce uphill running, starting with less volume and/or less intensity. Then, as you continue to monitor your symptoms, you slowly ramp up your effort over time.
Case Example #2
In the next example, let’s say you are also a runner, but you report progressively worse symptoms over the last 6 months, and can no longer tolerate running, even at reduced speeds, volume, and/or frequency.
The best course of action would be to temporarily stop running and substitute it with a more tolerable form of aerobic exercise. You could cycle, use an elliptical, or try a wide range of other activities. There are a lot of possibilities, so experiment with different options to find what works best for you.
You would then simultaneously incorporate the progressive loading exercises, three times a week. Since you have more irritable symptoms, you begin with the isometrics and then progress to the heavy slow resistance and plyometric exercises, once tolerated.
After performing the exercises for several months, you reintegrate running back into your routine, starting at slower speeds and less mileage. As symptoms allow, you gradually increase your intensity, volume, and frequency, until you are back running at your preinjury level or higher.
Case Example #3
Finally, for the last example, let’s say you’re middle-aged and have been experiencing discomfort for the past two years. This pain tends to intensify when you sit for extended periods and has impacted your ability to perform daily functional tasks.
First, you would try to modify aggravating activities. Maybe it’s sitting on a softer surface, using a towel under your thigh, and/or implementing frequent standing breaks.
Then, to help improve your overall function, you may choose to perform the isometrics and heavy slow resistance exercises a couple of times a week. Since you don’t have any goals to run or play sports, you choose not to include the plyometric exercises.
Another consideration would be to gradually increase your general physical activity in order to address your overall health and well-being. For example, you could go on a 5-10 minute walk every day, and then slowly increase this duration over the following weeks to months.
Expectations For Proximal Hamstring Tendinopathy
The last thing I want to say before wrapping up is that this particular rehab will take time, so you need to be patient, follow the guidelines in this blog, and do not rush the process.
If you look at comments from our previous YouTube video on this topic, you will see that people can struggle with symptoms for months to years. You should set realistic expectations that recovery will take anywhere from 3 to 6 months or longer. Unfortunately, there is no quick fix.
Additionally, it is important to note that if you experience pain related to sitting, this discomfort has been known to persist even after you have a full return to function, as it typically takes a longer time to resolve.
Proximal Hamstring Tendinopathy Summary
In summary, proximal hamstring tendinopathy is characterized by persistent tendon pain and loss of function related to mechanical loading.
A simplified explanation for why this might have occurred is that the loads you placed on your hamstring tendon through different positions and movements may have exceeded your capacity to recover and adapt appropriately. Or in other words, you might have done too much, too soon.
Common examples include the sudden introduction of sprinting, lunging, or hill running into your training, or even excessive stretching into positions of deeper hip flexion.
To help facilitate recovery, rehab will revolve around 2 main components. First, you will focus on load management & activity modifications which involve temporarily modifying or minimizing painful activities in order to aid in long-term recovery. Second, you will implement progressive loading exercises 2 to 3 days a week to help further increase your capacity so you can eventually tolerate more load.
Throughout the rehab process, it is vital that you monitor and manage your symptoms.
- Is your pain tolerable during exercise?
- Is your pain better, worse, or the same after exercise?
- And most importantly, is your pain better, worse, or the same the day after exercise?
Using a self-assessment test like a single-leg long lever bridge or your daily walks can be a helpful tool in monitoring and managing your response to activity.
Lastly, you should set realistic expectations that recovery will take 3 months, 6 months, or even longer. I can’t stress enough the importance of being patient, following the recommendations in this blog, and progressing with exercises and activities as tolerated.
Don’t forget to check out our Hip Resilience Program!
Want to learn more? Check out some of our other similar blogs:
Achilles Tendinopathy, Patellar Tendinopathy, Tibialis Posterior Tendinopathy
Thanks for reading. Check out the video and please leave any questions or comments below.
