Hamstring Tendinopathy

  • 1st Revision: Keri Wilkie
  • 2nd Revision: Shikha Javaharlal
  • 3rd Revision: Olivia Sowerby


Hamstring tendinopathy is also called proximal hamstring tendinopathy (PHT), hamstring origin tendinopathy, and high hamstring tendinopathy.1 Track athletes, such as sprinters and hurdlers, are afflicted by hamstring tendinopathy. Athletes participating in football and hockey, which require changing directions, also regularly experience this problem.2 However, it also sometimes afflicts people who do not participate in sports. 

In hamstring tendinopathy, deep, localised pain is felt in the hip region. When running, lunging, squatting or sitting, the pain is usually worse. An inflammatory reaction around the tendon may be associated with tendon degeneration and partial tearing.

Risk Factors

There are a lot of causes for hamstring tendinopathy; extra load-bearing and training errors are among the most common ones. However, there are a lot of internal and external risk factors that come into play.2 

Some of the internal factors include: 

  • Alignment problems
  • Difference in leg length
  • Imbalance
  • Reduced flexibility of joints
  • Loose joints
  • Ageing
  • Reduction in muscle fibre size and number is associated with ageing, which leads to a loss of strength and mass 
  • Obesity 
  • Proprioceptive impairment
  • Tenderness of the ischial tuberosity (the curved bone that makes up the bottom of your pelvis) 
  • Core weakness 
  • Dysfunctional pelvic floor
  • A previous injury - strength is reduced by previous hamstring, knee or groin injuries 
  • Hamstring/quadricep tightness/weakness
  • Poor core stability

While the external factors include:

  • Overtraining and excessive repetitions
  • Poor training
  • Poor equipment
  • Insufficient warm-up - hamstring injuries and lack of stretching prior to sports participation are associated with lack of warm-up.3
  • Poor technique, decreased concentration and coordination, can be caused by fatigue

How does the pain develop?

The hamstring muscle group is an important muscle group for running. The hamstrings are active at various stages in the gait cycle, specifically when flexing the knee and hip.  Large, sudden loads can also cause hamstring tendon injury. 

When the hip is flexed, the hamstring needs to be contracted or lengthened. Consequently, the hamstring tendon can experience a higher compressive and tensile load.

Static stretching, such as that found in yoga or pilates, can also contribute to symptoms as they involve sustained hip flexion at the end of the range.1 Irritation of the sciatic nerve can result in pain down the back of the thigh, which has a close relationship with the ischial tuberosity and is degenerative in nature.4 


  • Characteristic pattern of tendon pain i.e. pain in the ischial tuberosity that decreases after a few minutes of activity, but becomes worse afterwards
  • Pain in the buttocks and in the posterior thigh
  • There is often pain throughout the hamstrings, particularly in the gluteal area
  • Activities like long-distance running, driving and prolonged sitting can increase the pain
  • Stiffness can occur after prolonged rest or in the morning
  • Gradual development - not sudden
  • Exercises and stretching can aggravate the pain
  • Irritation of the sciatic nerve can cause pain down the back of the thigh



  • MRI: To check the severity of the injury and confirm the diagnosis.
  • Ultrasound: Can also be used, but this technique does not allow for precise visualisation.5 

Passive stretch test 

  • Bent-knee stretch test: The patient lies down during the test. The hips and knees are flexed to the maximum. By slowly straightening the knee, the therapist maintains the hip in a 90° flex while straightening the knee. This test can also be done without professional help.
  • Modified bent-knee stretch test: During the test, the patient lies down with their hips and knees extended, holding the knee with one hand while holding the heel with the other. The hip and knee are brought into maximum flexion, then the knee is rapidly straightened. MRIs do not replace these tests for identifying a hamstrings origin of tendinopathy.
  • Puranen Orava test: Puranen-Orava test is a standing test that actively stretches the hamstrings when the hips are flexed to 90°, the knee fully extended, and the foot resting on a platform that is 90° to the standing body. If the test is negative in less symptomatic cases, it is also important to consider other clinical conditions that might be present and causing the symptoms.1 It is recommended to use MRI in diagnosing PHT.
  • Palpation of ischial tuberosity: During this test, the pain response to palpation (feeling with the fingers or hands during physical examination) can vary, making the test non-specific for diagnosing tendinopathies.

Loading test6

The proximal hamstring tendons are loaded to simulate a pain stimulus. The compression and loads are heightened by increasing the range of hip flexion. It is possible to simulate this pain with various loading tests, but their accuracy has not been fully investigated. 

During a load test, patients with PHT are gradually raised from low to moderate, and then to high loads. Initially, movement is slow, and speed is added only if the patient is symptom-free. As the load increases across all these tests, the pain score will also increase.


Non-Invasive (Conservative) Management7

The goal of non-invasive treatment is to promote healing and reduce the risk of further injury. Physical therapists usually supervise the process of treatment.


Rest will ease tension and give the tendon(s) a chance to heal. In these situations, the activity that caused the pain needs to be precisely determined and stopped. In order to allow the injured tendon to heal, patients may have to take time off from training, switch to another activity, or drastically reduce the training.

Ice and heat8

To reduce pain and inflammation, ice therapy (including cold packs, ice baths, and ice massages) may be recommended. Cold treatment is typically applied for 10 or 20 minutes following activity, and then every 2 to 4 hours throughout the day. 

To loosen scarred or fibrotic tissue, patients can use heat and massage, followed by stretching. A combination of heat and ice may be used. For further information, patients should speak with a qualified medical professional.


In view of the fact that lack of flexibility contributes to chronic (long term) high hamstring tendinopathy, it might be wise to develop a program to stretch tight/inflexible hamstring tendons and associated muscles. Stretching exercises can increase a patient's range of motion and flexibility under the guidance of a therapist. It can take some time for the patient to notice improvement, sometimes months.


As a conservative management method, it is advised to strengthen weak muscles under the guidance of a trained medical professional or physical therapist.9 Studies have shown that eccentric hamstring strengthening can prevent new and recurring hamstring injuries in football players.10 

However, this exercise will not be effective in managing tendinopathy. Hamstring eccentric strengthening can be painful, especially in the first few weeks. It can take up to 12 weeks for the exercises to take effect.6-8 

It is important to ​​perform eccentric strengthening correctly; physical therapists can instruct on the appropriate form and recommend how many repetitions are necessary per set, among other things.

Invasive Treatment

Steroid Injections

Physical therapy may not be enough in some severe cases; instead, a corticosteroid injection into the soft tissues of the tendon area may be necessary alongside physical therapy, but it can be dangerous.

Research has shown that patients with extensive swelling around the ischial tuberosity, and less thickening of the tendon, benefit from a cortisone injection.2 However, corticosteroid injections can also negatively impact the tendons by causing them to weaken or rupture, especially in load-bearing tendons. It may bring temporary relief, but symptoms tend to recur.

Ultrasound-Guided Needle Tenotomy 

Ultrasound guidance is a requirement for injecting steroids for proximal hamstring tendinopathy.11 A real-time ultrasound is used to guide this technique. An anaesthetic and a steroid are usually combined to reduce the pain of the procedure. 

Patients will feel relief from pain within minutes of the injection and a reduction in pain 3-4 days following the procedure. Rehabilitation exercises should be started as soon as the pain subsides.

Platelet-Rich Plasma (PRP) Injections 

An innovative treatment involves injecting platelet-rich plasma at the muscle's origin.12 PRP may be a more effective treatment than corticosteroids. The granules in the platelets secrete growth factors and cytokines that assist with wound healing.13 There is currently insufficient evidence to support the use of platelet-rich therapies to treat musculoskeletal soft tissue injuries.

Extracorporeal shockwave therapy (ESWT) 

Researchers have reported a good result with ESWT in the treatment of hamstring tendinopathy.14 During this procedure, a controlled amount of micro-trauma is delivered to the affected tendon, which stimulates the body's natural healing process. The shockwaves reduce pain by desensitising local nerve endings. 

If performed correctly, this has the potential to provide an opportunity for your rehabilitation to progress.


Surgical treatment is suggested when:15

  • There is an inability to participate in sports due to symptoms
  • MRI results suggest hamstring tendinopathy or scarring from previous tearing
  • There is no benefit to conservative treatment

Surgical treatment ranges from a simple debridement to complete resection of the tendon and its reattachment:16

  • Debridement: The process of removing diseased or damaged tissue in order for new, healthier tissue to grow in its place. This procedure may be performed minimally invasively in certain patients using the same technology used in tenotomy.16
  • Complete tenotomy: Involves separating the tendon from the bone, cutting it, and reattaching it. If the sciatic nerve has become painfully trapped in scar tissue due to tendinopathy, the surgeon can free it during this procedure. A complete tenotomy requires a lengthy recovery process and should only be done when other options have been exhausted.16

Should you continue to run with hamstring tendinopathy?

In order to gradually return to sports, athletes need to be able to cope with the loads required by their sport with minimal symptom aggravation. 

It is important that athletes slowly ease themselves into a return to sport; it is vital to not quickly return to regular training volume since this could cause overloading and aggravation of symptoms.

Hill training and speed training can easily exacerbate symptoms, so care has to be taken around these exercises. For this reason, a graded return to sport should usually consist of gradually increasing activity levels before returning to full competition.


Hamstring tendinopathy is a deep pain felt in the hip region.  Athletes regularly suffer from hamstring tendinopathy. Different stretch tests can diagnose hamstring tendinopathy. There are two types of treatment for hamstring tendinopathy: non-invasive and invasive. Non-invasive treatment includes rest, ice and heat, stretching and strengthening; invasive treatment includes steroid injections, PRP injections, shockwave therapy and surgery.


  1. Goom TSH, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: Clinical aspects of assessment and management. J Orthop Sports Phys Ther [Internet]. 2016 [cited 2022 Mar 23];46(6):483–93. Available from: https://www.researchgate.net/publication/301343168_Proximal_Hamstring_Tendinopathy_Clinical_Aspects_of_Assessment_and_Management
  2. Fredericson M, Moore W, Guillet M, Beaulieu C. High hamstring tendinopathy in runners: meeting the challenges of diagnosis, treatment, and rehabilitation. Phys Sportsmed [Internet]. 2005 [cited 2022 Mar 23];33(5):32–43. Available from: https://pubmed.ncbi.nlm.nih.gov/20086362/
  3. Landry M. Brukner & Khan’s Clinical Sports Medicine. Physiother Can [Internet]. 2014 [cited 2022 Mar 23];66(1):109–10. Available from: http://dx.doi.org/10.3138/ptc.66.1.rev2
  4. Davis J. High hamstring tendinopathy injuries - signs, Symptoms and Research-Backed Treatment Solutions for a literal Pain in the butt [Internet]. Runners Connect. 2013 [cited 2022 Mar 23]. Available from: https://runnersconnect.net/high-hamstring-tendinopathy-injuries-a-pain-in-the-butt/
  5. McCormack JR. The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a case report. J Man Manip Ther [Internet]. 2012 [cited 2022 Mar 23];20(3):142–6. Available from: http://dx.doi.org/10.1179/2042618612Y.0000000003
  6. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. [Internet]. Br J Sports Med. [cited 2022 Mar 23]. 2014;48:506–9. https://doi.org/10.1136/bjsports-2012-092078
  7. Pourcho A, DO, ATC. Treatments for chronic high hamstring tendinopathy [Internet]. Sports-health. [cited 2022 Mar 23]. Available from: https://www.sports-health.com/sports-injuries/leg-injuries/treatments-chronic-high-hamstring-tendinopathy
  8. Tripp A, MS. The P.r.i.c.e. protocol principles [Internet]. Sports-health. [cited 2022 Mar 23]. Available from: https://www.sports-health.com/treatment/price-protocol-principles
  9. Askling CM, Tengvar M, Tarassova O, Thorstensson A. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med [Internet]. 2014 [cited 2022 Mar 23];48(7):532–9. Available from: https://pubmed.ncbi.nlm.nih.gov/24620041/
  10. Petersen J, Thorborg K, Nielsen MB, Budtz-Jørgensen E, Hölmich P. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. Am J Sports Med [Internet]. 2011 [cited 2022 Mar 23];39(11):2296–303. Available from: https://pubmed.ncbi.nlm.nih.gov/21825112/
  11. Singh D, Nayak B, Kumar M, Tomar S, Katyan A, Suman S, et al. Ultrasound-guided percutaneous needle tenotomy for tendinosis. Indian Journal of Musculoskeletal Radiology [Internet]. 2020 [cited 2022 Mar 23];2(52):52–7. Available from: https://mss-ijmsr.com/ultrasound-guided-percutaneous-needle-tenotomy-for-tendinosis/
  12. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev [Internet]. 2013;(12):CD010071. Available from: http://dx.doi.org/10.1002/14651858.CD010071.pub2
  13. Alsousou J, Ali A, Willett K, Harrison P. The role of platelet-rich plasma in tissue regeneration. Platelets [Internet]. 2013 [cited 2022 Mar 23];24(3):173–82. Available from: https://pubmed.ncbi.nlm.nih.gov/22647081/
  14. Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F. Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes. Am J Sports Med [Internet]. 2011 [cited 2022 Mar 23];39(1):146–53. Available from: https://pubmed.ncbi.nlm.nih.gov/20855554/
  15. Benazzo F, Marullo M, Zanon G, Indino C, Pelillo F. Surgical management of chronic proximal hamstring tendinopathy in athletes: a 2 to 11 years of follow-up. J Orthop Traumatol [Internet]. 2013;14(2):83–9. Available from: http://dx.doi.org/10.1007/s10195-013-0226-2
  16. Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal hamstring tendinopathy: results of surgical management and histopathologic findings: Results of surgical management and histopathologic findings. Am J Sports Med [Internet]. 2009 [cited 2022 Mar 23];37(4):727–34. Available from: https://pubmed.ncbi.nlm.nih.gov/19218559/
This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

Get our health newsletter

Get daily health and wellness advice from our medical team.
Your privacy is important to us. Any information you provide to this website may be placed by us on our servers. If you do not agree do not provide the information.

Saima Siddiqui

Master's in Health and Hospital Management specialization in Health IT, IIHMR, Delhi
I have been associated with healthcare for the last decade, and most recently I have completed my Master's in Healthcare management. I firmly believe that credible health information should be readily available and accessible, as it enables the patients and their careers to make informed decisions about their health and adopt a healthy lifestyle.

Leave a Reply

Your email address will not be published. Required fields are marked *

my.klarity.health presents all health information in line with our terms and conditions. It is essential to understand that the medical information available on our platform is not intended to substitute the relationship between a patient and their physician or doctor, as well as any medical guidance they offer. Always consult with a healthcare professional before making any decisions based on the information found on our website.
Klarity is a citizen-centric health data management platform that enables citizens to securely access, control and share their own health data. Klarity Health Library aims to provide clear and evidence-based health and wellness related informative articles. 
Klarity / Managed Self Ltd
Alum House
5 Alum Chine Road
Westbourne Bournemouth BH4 8DT
VAT Number: 362 5758 74
Company Number: 10696687

Phone Number:

 +44 20 3239 9818