Proximal Hamstring Tendinopathy Diagnosis and Rehabilitation: A Comprehensive Guide

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Written By Diene Oliveira Cruz

MD, PhD. Physical Medicine & Rehabilitation Physician from São Paulo - Brazil. Pain Fellowship in University of São Paulo.

In this blog post, we’ll explore the diagnosis of proximal hamstring tendinopathy, including its epidemiology, localized pain, muscle wasting, and hallmark signs. We’ll also discuss possible differential diagnoses and how to identify the pain onset and proportional load-pain relationship.

By the end of this post, you’ll have a better understanding of how to diagnose proximal hamstring tendinopathy and differentiate it from other conditions.


Proximal hamstring tendinopathy is most prevalent among fast walkers, distance runners, sprinters, and athletes performing change of direction activities such as football, soccer, or hockey.

It’s essential to consider the patient’s activity level and specific sports when diagnosing this condition.

Localized Pain

Palpation should confirm well-localized pain at the ischial tuberosity. However, be aware that proximal hamstring tendinopathy is one of the few tendinopathies that can present with diffuse referred pain to the backside of the hamstrings.

Symptoms usually become less prominent after a short warm-up period. The pain location requires an extensive differential diagnosis, which we’ll discuss in the next section.

Understanding the Hamstring Anatomy

The hamstring muscles are made up of three distinct muscles: the biceps femoris, which is located on the outside portion of the backside of the leg; and the semimembranosus and semitendinosus, which are situated on the inside portion of the backside of the leg. These muscles attach to the pelvis at the ischial tuberosity.

Interestingly, the orientation of these muscles flips when they attach to the pelvis, with the semimembranosus and biceps femoris converging onto the same tendon on the inside portion of the ischial tuberosity, while the semimembranosus attaches to the outside portion.

Causes of Proximal Hamstring Tendinopathy

Tendinopathy often results from overloading the tendon due to excessive intensity, duration, or frequency of physical activity. The unique anatomy of the hamstring muscles’ attachment to the pelvis also plays a role in the development of proximal hamstring tendinopathy, as the tendons do not tolerate compression well.

Movements like deep lunges, deadlifts, hamstring stretches, sprinting, and uphill running can all cause compression on the hamstring tendons against the ischial tuberosity, potentially leading to tendinopathy.

Differential Diagnoses:

The following conditions should be considered when diagnosing proximal hamstring tendinopathy:

a. Sacroiliac joint pain: Can be included or excluded with the cluster of Laslett.
b. Referred pain from lumbar facet joints, commonly L4-L5 and especially L5-S1.
c. Sciatic nerve irritation in the deep gluteal area, formerly known as piriformis syndrome and now called deep gluteal syndrome.
d. Ischial ramus stress fracture in female runners with pain medial to the ischial tuberosity (diagnosed via imaging).
e. Apophysitis in adolescent kicking athletes and unfused growth plates in post-adolescent athletes in their 20s and 30s.
f. Partial and full ruptures of the proximal hamstring tendon in cases of acute onset.
g. Ischiofemoral impingement, which occurs when the lesser trochanter of the femur impinges against the ischial bone during external rotation of the hip.

Muscle Wasting

Atrophic changes in the case of proximal hamstring tendinopathy are not well-documented. However, the general rule for tendinopathy states that the muscle of the affected tendon and the muscle of the kinetic chain distal to that muscle are affected.

To examine muscle wasting, observe the hamstrings and calves for muscle bulk and differences and palpate them for tone, which is often reduced if patients have not been using them much.

Hallmark Sign

The hallmark sign for proximal hamstring tendinopathy is sitting pain on the tendon insertion, as it is getting compressed between the sitting surface and the ischial tuberosity.

Pain Onset or Exacerbation 24 Hours After High and Fast Load Activities:
In the case of the proximal hamstring tendon, you should specifically ask for an increase in volume, intensity, or frequency of sprinting, lunging, hurdles, or hill running, which has led to the onset of symptoms.

This is often the case after a prolonged break. Activities that require static stretching, such as yoga or pilates, and even simply sitting, can induce tendinopathy as well.

Proportional Load-Pain Relationship

As with other tendinopathies, pain increases with an increase in load on the proximal hamstring tendon. To assess this relationship, start with a double leg bridge, progress to a single leg bent knee bridge, and then continue with a long lever bridge.

Further progress to higher load and speed tests like catches, and finally, to more intense tests like double and single leg deadlifts with added load and speed.

Rehabilitation strategies

Rehabilitation for tendinopathies is rarely pain-free, but it’s important to monitor symptoms and adjust exercises accordingly.

Three key criteria to consider during rehabilitation are:

  1. Tolerable pain during exercise (around 3 out of 10 pain)
  2. No worsening of symptoms that affect daily activities, work, study, or sleep
  3. No flare-ups of symptoms 24 hours after exercise

Four Stages of Proximal Hamstring Tendinopathy Rehabilitation

Stage 1: Isometric Hamstring Load (20-30 degrees of hip flexion or less)

In this stage, focus on isometric exercises such as leg curls, bridge holds, trunk extensions, straight leg pull-downs, and long-lever bridging. Progress these exercises by moving from two limbs to one limb, or by adding resistance.

Perform 1-2 exercises, 3-5 sets of 15-45 seconds, 1-3 times per day with a 2-minute rest between sets.

Stage 2: Isotonic Hamstring Load (minimal hip flexion)

This stage involves isotonic exercises with minimal hip flexion, including single-leg bridges, double-limb hamstring sliders, prone leg curls, and Nordic hamstring curls. Perform 1-2 exercises, 3-4 sets of 8-15 repetitions, every other day.

Continue with isometrics on the alternate days.

Stage 3: Isotonic Exercises (increased hip flexion, 70-90 degrees)

In this stage, incorporate exercises with increased hip flexion, such as hip thrusts, single-leg step-ups, walking lunges, deadlifts, and single-leg Romanian deadlifts. Perform 1-2 exercises, 3-4 sets of 6-12 repetitions, every other day.

Gradually increase the speed of movements over time and continue with isometrics on the alternate days.

Stage 4: Energy Storage Loading (for athletes returning to sport)

This stage is for individuals returning to sport, and includes higher-level activities specific to their sport. Options include A-skips, fast sled pushes or pulls, bounding, kettle bell swings, alternate leg split squats, stair or hill bounding, cutting, sprinting, and sport-specific movements.

Perform 2-4 movements, 1-3 sets, every third day while continuing with the previous stages’ exercises on the other days.

For example, on Monday, perform Stage 4 exercises, Tuesday perform isometrics, Wednesday perform Stage 2 or 3 exercises, Thursday rest, and then repeat this cycle.

Managing Loads and Monitoring Symptoms

It is crucial to manage loads and monitor symptoms throughout the rehabilitation process. Identify and modify aggravating factors, such as sitting for long periods, cycling, or specific exercises. Making short-term sacrifices or changes can lead to long-term benefits.

Hamstring stretches are generally discouraged during rehabilitation, as they place a high amount of compressive and tensile load on the tendon. Instead, focus on progressive exercises as outlined in the four stages.

Rehabilitation for proximal hamstring tendinopathy is expected to take 3-6 months. Patience, consistent effort, and trust in the process are essential for a successful outcome.

Biomechanical Considerations

When returning to sports activities after PHT, it is essential to evaluate the individual’s gait cycle, specifically during running. Reduced glute activation is common in PHT patients, which can lead to overloading the hamstring tendons.

Over-striding is another issue to address, as it can result in more compression and overloading of the hamstring tendons.


Proximal hamstring tendinopathy is a complex condition that requires a comprehensive approach to treatment.

By understanding the anatomy of the hamstrings and addressing both the strength and biomechanics of the affected muscles and tendons, individuals can effectively rehabilitate from PHT and return to their sports activities with confidence.

diene oliveira cruz
Diene Oliveira Cruz
Physical Therapist | + posts

Physiotherapist, with specialization in Orthopedics and Traumatology by Santa Casa de São Paulo. Pain and Rehabilitation Specialist.

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