What is Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy (PHT) is a painful condition affecting the hamstring tendons where they attach to the ischium of the pelvis. Many people with this condition often describe lower buttock pain that eases during exercise but usually returns.
It isn’t necessarily what you first think of when somebody mentions hamstring injuries.
When most people think of running-related hamstring injuries, they picture the classic image of a sprinter pulling up sharply mid-race, as if hit by a sniper shot. This kind of acute hamstring tear is indeed the most common type of injury to the hamstring muscle group.
However, a less well-known but surprisingly common injury, especially amongst endurance athletes (rather than sprinters) is proximal hamstring tendinopathy. This chronic injury is often difficult to rehabilitate, frequently resulting in long and frustrating interruptions in run training.
In comparison to acute hamstring muscle tears, there is little research into proximal hamstring tendinopathy (also known as high hamstring tendinopathy) in runners.
In this article, I’ll take a look at what the research tells us, in combination with my own anecdotal observations having worked with many runners suffering from this specific injury over recent years.
HAMSTRING TENDON REHAB EXERCISES >>
Free Download [PDF]
Anatomy of the Hamstring Muscles
There are actually three hamstring muscles at the back of each of your thighs: semitendinosus, semimembranosus and biceps femoris with its long and short heads. At the top of the muscle group, while the short head of biceps femoris attaches to the femur, all the other hamstring muscles share a common point of origin on the ischial tuberosity (sitting bones) of the pelvis. This point of attachment sits deep beneath the bottom part gluteus maximus (the bigger of your butt muscles).
At the bottom of the hamstrings, around the back of the knee, both semitendinosus and semimembranosus attach to the medial tibia, while biceps femoris attaches distally close to the fibular head, towards the outside of the knee.
Like all skeletal muscles, the individual hamstring muscles act to produce motion in all three planes of motion. However, the linear orientation of their fibres and lever arms at the hip and knee make them most effective in the sagittal (back and forth) plane.
When I was taught anatomy at school, the hamstring muscle actions were described at isolated joints, in an open-chain (non-weight bearing) situation. I was taught that the text-book function of the hamstrings is to contract concentrically to produce hip extension and knee flexion.
However, with the hamstrings being a two-joint muscle group (crossing hip and knee), when we run there are other considerations to take into account, especially during stance phase. During this phase, the foot is anchored to the ground by our body weight creating a closed chain environment. As the hamstrings contract with glute max to create hip extension, propelling us forwards they also create an extension moment at the knee… rather than knee flexion as we learnt at school!
More about this counterintuitive muscle function in a future post!
Symptoms of Proximal Hamstring Tendinopathy
The location of pain for runners suffering from proximal hamstring tendinopathy is specifically around the ischial tuberosity of the pelvis (the sit bones). Pain in this region is often described as ‘deep buttock pain‘, or ‘high hamstring pain‘.
As a quick side-note: proximal hamstring tendinopathy is classified as a tendinopathy rather than a tendonitis, due to it’s degenerative nature rather than being an inflammatory pathology.
Runners suffering with high hamstring tendinopathy will complain of buttock pain around the hamstring insertion area, especially when running at faster paces, and running uphill.
The pain of proximal hamstring tendinopathy is usually an intense ache in nature, rather than being sharp or stabbing as a muscular tear would be.
Occasionally, the sciatic nerve can also be affected, as it lies fairly close to the common hamstring tendon. This can cause referred pain into the posterior thigh. Once aggravated, direct pressure on the hamstring tendon can be painful, thus sitting on solid surfaces can also become uncomfortable, as can direct manual palpation and pressing onto the ischial tuberosity.
Can You Run With High Hamstring Tendinopathy?
It is possible to continue running with proximal hamstring tendinopathy. However, you may need to make alterations to your training plan. Avoid hill reps and speed work, as these types of running usually aggravate an irritable hamstring tendon.
The inevitable question when it comes to an annoying niggling injury like proximal hamstring tendinopathy is whether or not you can run through the injury. I’ve seen lots of runners successfully manage run with this injury, and continue training, perhaps for an upcoming marathon, simply by adapting their marathon training plan a little.
Knowing that speed work, and hill running are both usually aggravating factors for high hamstring tendinopathy, sufferers should consider removing these from their running training schedule, to prevent flare-ups. Stick to easy paced running, and working on building your aerobic base.
When it comes to running style, avoid the temptation to stride-out, as it’s this increased hip flexion that creates the loaded compression of the hamstring tendon that may exacerbate your tendinopathy.
Instead, focus on increasing your running cadence and making short-quick strides for the given pace.
Here’s an article full of running technique tips, which will explain how to increase your cadence, and why it’s important to do so: How to Increase Your Running Cadence
I’ve seen conscious simple changes to running technique make a huge difference to the symptoms of runners with proximal hamstring tendinopathy, to the degree that it allows them to continue training, albeit in a modified fashion.
Proximal Hamstring Tendinopathy Diagnosis
As with all running injuries, if you’re concerned that you may be suffering from proximal hamstring tendinopathy, it’s important to seek face-to-face medical advice, rather than simply consulting Dr Google, and coming to your own conclusions (oh, the irony!).
There are a number of different potential causes for the type of deep buttock pain that high hamstring tendinopathy sufferers know all too well. Piriformis syndrome, lower back injuries, and pelvic stress fractures, can all create a similar set of symptoms, and form a non-exhaustive list of differential diagnoses for proximal hamstring tendinopathy.
It’s not unusual for me to meet runners who have has their high hamstring tendinopathy misdiagnosed for piriformis syndrome, and vice versa… which has lead to ineffective rehab, and an extended period of rest from running. So frustrating!
This is why an MRI scan will often be used to support the diagnosis once and for all.
If your physio suspects you might be suffering from high hamstring tendinopathy, there are of course a number of manual tests they may use to confirm their hypothesis.
Testing For Proximal Hamstring Tendinopathy
In January of 2012 Cacchio et al., published a paper looking at the reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Taking into account the need for further assessment of the three tests used in the study (listed and described below), the authors concluded that the chosen tests represent a valid, reliable means of testing for Proximal Hamstring Tendinopathy.
The three tests they used in the study are as follows:
In the Puranen-Orava test for proximal hamstring tendinopathy, the subject actively stretches the hamstring muscles in the standing position with the hip flexed at about 90°. The knee on the testing side is fully extended and the foot is up on a support
Bent Knee Stretch Test
The bent knee stretch test for proximal hamstring tendinopathy is performed with the patient lying supine (on their back). The hip and knee of the symptomatic leg are maximally flexed, and the examiner slowly straightens the knee.
Modified Bent Knee Stretch Test
In this test for proximal hamstring tendinopathy, the patient lies in the supine position with the legs fully extended; the examiner grasps the symptomatic leg behind the heel with one hand and at the knee with the other hand, maximally flexes the hip and knee, and then rapidly straightens the knee.
As mentioned earlier, MRI and ultrasound imaging provides a great diagnostic resource. MRI, in particular, can identify tendon thickening, tearing, inflammation, and swelling in the bone at the ischial tuberosity.
Proximal Hamstring Tendinopathy Treatment
Compared to other more common running injuries, comprehensive literature on proximal hamstring tendinopathy is fairly limited. However, in 2005 Frederickson et al., at Stanford University published an insightful paper reviewing treatment and rehabilitation guidelines for high hamstring tendinopathy in runners.
Following thorough assessment and diagnosis confirmed by MRI, Frederickson’s group evaluated injured runners for core strength, hamstring flexibility and pelvic stability. The following treatment options are recommended in their paper:
Soft Tissue Treatment, Manual Therapy & Stretching
Hands-on treatments providing soft tissue mobilisations to break up scar tissue and adhesions can be useful, as can transverse frictions to the affected tendon. Care should, however, be taken not to apply direct pressure to the ischial tuberosity itself. This sort of soft tissue work is complementary to a gradual introduction to regular hamstring stretching.
If upon assessment, pelvic misalignment (anterior innominate rotation in particular) is identified, manual manipulation to restore the alignment of the pelvic innominate bones is often useful in restoring proper hamstring function. The work of Cibulka et al., is mentioned, as they reported in their 1986 study that after one manual treatment to realign the pelvis, isokinetic hamstring peak torque was seen to increase by 21.5%.
The question, of course, must always be asked – where does the imbalance come from that caused the pelvic misalignment…?
Exercises for High Hamstring Tendinopathy
Yamamoto is cited for his 1993 work identifying hamstring-to-quads strength ratio (amongst other factors) as a variable affecting the risk of hamstring injury in runners. Although it’s not clear whether his findings also apply to proximal hamstring tendinopathy, Frederickson’s group identify hamstring strengthening as an important part of their rehabilitation guidelines.
They suggest that the progression of targeted hamstring exercises should go as follows:
- Isometric hold exercise:
90 Degree Hamstring Bridge Holds
- Single leg exercises:
Glute March Drill
Single Leg Hamstring Catch
- Loading through range:
Swiss Ball Hamstring Curls
Runner’s Arabesque (only when you’re ready to load into hip flexion)
For full details of sets and reps, feel free to download the rehab exercises worksheet linked below:
HAMSTRING TENDON REHAB EXERCISES >>
Free Download [PDF]
Core Strength & Pelvic Posture Correction – The Key Perhaps?
Hands-on treatments, stretching and progressive strengthening are all important components of any good rehabilitation plan for proximal hamstring tendinopathy. However, in my experience, I find the following core strengthening element to be the key to a successful outcome.
The paper by Frederickson et al., identifies the work of Sherry and Best (2004) in emphasising the vital importance of trunk stabilisation exercises in the successful rehabilitation of hamstring injuries. The emphasis is put on core strength exercises which help the athlete maintain a desired neutral pelvic position throughout dynamic movements.
It’s my experience that many of the athletes I’ve worked with who suffer from high hamstring tendinopathy, or recurrent hamstring strains, present displaying poor ability to control their pelvic position throughout the performance of functional movements for their sport.
Particularly, the tendency seems to be for them to fall into an anterior pelvic tilt / innominate rotation. Of course, this will put the hamstring in a position where they are chronically held on tension.
This article on Gluteal Inhibition further explains the contributing soft tissue imbalances that lead to this issue.
Re-educating proper pelvic position throughout movement, and working to correct imbalances which predispose an athlete to poor pelvic posture should, in my opinion, take equal, if not increased precedence over elements of the rehab programme such as eccentric hamstring strengthening protocols.
Below is an example of one of the various exercises I give athletes to help address imbalances which affect their pelvic posture in running gait.
Related >> Three Exercises You Should Avoid
During High Hamstring Tendinopathy Rehab
Each athlete’s injury is, of course, different, but the guidelines above hopefully provide food for thought and some direction in the treatment and rehabilitation of such cases.
There are other treatment options available, in addition to the conservative options mentioned above. It’s not the remit of this article however to discuss options such as corticosteroid injections, shockwave therapy and surgical interventions.
Return to Running After Proximal Hamstring Tendinopathy
As with all running injuries, it is important to take a very gradual approach to your return to running after proximal hamstring tendinopathy. One of the biggest errors made by athletes is giving up on their rehab exercises as running is re-introduced to the programme. Hamstring problems have a nasty habit of becoming recurrent. It’s always my advice that once an athlete has suffered this sort of injury once, and successfully recovered, their rehab exercises become their maintenance exercises.
Here’s a useful programme to use to help ensure a safe re-introduction to running.Last updated on March 2nd, 2021.
Thanks for highliting this problem.
As you say, the evidence for management of this troublesome condition is sparse but below is commentary based on known tendon pathology and contemporary approaches.
Proximal hamstring tendinopathy is considered to be a compression problem of the tendon upon the ischium during flexion activity of the hip. This is further compromised by muscle contraction, such as described above at the point of heel strike. A compression with tension in the tendon is lethal in development of tendinopathy.
As a compression problem, it follows that activity that forces the hip into flexion will potentially be harmful. As such stretching in rehab is not a good idea and also has no biological rationale in promoting repair to the tendon.
The tendon is a spring and needs progressive rehab from strong/heavy isometric to isotonic (both eccentric and concentric), to finally activity involving the stretch-contract cycle of the tendon. This means ultimately loading the tendon by ballistic type activities, and eventually doing these in flexion.
Only this way will the tendon adapt to its functional design and regain its functional integrity (maybe not structural, as demonstrated in studies in the patella tendon).
Whilst proximal stability of the pelvis as described above by james is helpful, it will not recover the tendon.
The paper presented above by fredricsson i think is merely a review/collection of known therapies, (I don’t have access, happy to receive if anyone has it) but it doesn’t seem like a systematic review, which would then be considered as evidenced based, having followed due methodology of inclusion and rigour.
If the afflicted is a runner, then consideration to stride length is key, and if this is not possible due to inherent weaknesses etc, then these can be addressed for completeness.
I hope this contributes and stimulates debate.
Regards to all.
Interesting stuff, thanks for your input. I’ll be pleased to hear professional views and experiences from all those reading this, to try and add to the overall view of how we rehab this condition.
Your comments about compression of the tendon during flexion activity of the hip make lots of sense to me, when considered alongside the pelvic alignment / stability comments I made in the article – If asked to raise the thigh to horizontal, an athlete displaying an anterior tilting pelvis (or same sided anterior innominate rotation) will be in greater hip flexion in relative terms, when compared to if he/she was holding the pelvis in a neutral position (or proper alignment).
So it stands to reason that while correcting pelvic position and improving proximal control won’t directly affect the healing and remodelling process, it would help to reduce unnecessary compressive forces on the tendon, especially when late stage rehab and return to sport is reached.
Ultimately, the tendon has to be loaded, progressively of course, as a mainstay of the rehab – but I still put a big emphasis on making sure proximal control is maintained.
Perhaps the hip flexion component to the mechanism of injury explains why running at increased pace (relative to the athlete’s normal training load) is reported as being a common factor in the onset of this condition – longer stride length requiring greater hip flexion and increased hamstring loads through range?
Fair point re the “evidence based” treatment and rehab guidelines. I’ll go back and re-word accordingly!
Interesting article James. Have you listened to the BJSM Podcast below on classifying hamstring injuries and their subsequent management. It’s and interesting listen if you have a few minutes. I have found that starting with isometric strengthening exercises and not stretching helps initially and agree that assessing the pelvis and hip flexors is also key.
Super article, James. Thanks much. It was very informative and helpful. I’m putting your stretching exercise into practice along with some other stretches and strength-building exercises and, so far, I think it’s helping.
I was curious about the above comment above by Fizziowizzio “a compression problem of the tendon upon the ischium during flexion activity of the hip…” Does that mean it could be caused by slipping while trying to pedal a bike and landing down hard on the saddle?
Yes I would say its possible. Direct impact onto the ischium would load the tendon/insertion point. I would say that this type of trauma is perhaps less likely as padding in that area protects a bit from external forces such as you describe…but it’s possible.
I think this is exactly what I am suffering from. I made a change to my running form in September of 2012 in an attempt to correct arch pain I was experiencing particularly in the middle of my right foot. On the advice of my local running store, I changed to shoes with little cushioning and a nominal drop – Newton Gravitys. The arch pain did not stop completely, but it did seem to subside. However, it took about three months for my calfs to stop hurting! About four months into the change, I developed pain on the lateral side of my right hip that slowly migrated to the posterior, proximal region. For the last few weeks, I have soreness/tighness at the top of the hamstring and pain at the point of insertion. It hurts to sit down. No pain on the left side. I have been using Trigger Point and some Bridge Holds to some effect. I’ve tried stretching my hamstring and that DOESN’T seem to help. Any suggestions?
Two points I would like to raise.
The first relates to your change in running shoes/style. This is a common case of to much change too quickly. I would guess by the info on your burning calves that you likely changed to becoming a forefoot striker following the change in shoes. Although it may have helped the foot, going to low profile shoes and changing point of loading could have ended up in more problems in other areas, such as the achilles or posterior compartments.
Rather than changing the shoe, which may or may not be helpful, striking under the CoM and perhaps a little flatter on the foot could have done the job.
Secondly, with regards his upper thigh pain, it does sound like a prox hams tendon issue. As the author of this site has commented in the past, a short stride length is advisable, so ensure you have that. Countered by higher cadence.
As far as dealing with the tendon, if its settled a bit from nasty pain and its now more grumbly,I would use very heavy load bridges and leg curls in prone. Bith concentric and eccentric. Hip must remain away from flexing. This can be progress to short range straight leg deadlifts ie don’t start lifting from floor, then single leg good mornings and finally ballistic exercises which both flex the hip and add speed to the cycle of movement therefore enhancing the stretch-shortening cycle needed in good tendon function. Start 2 or 3 days per week initially. Low freq, very heavy weight.
Don’t waste time with trigger pointing, rubbing it, etc. controlled loading will be the main help for your problem. Let me know how u get on.
Excellent article! I’m suffering from a reactive proximal hamstring problem myself at present.
A couple of points to add – the work by Frederickson et al. (2005) is a fairly typical of his type of publications. Without meaning to be too critical of him, his pieces are perhaps more opinion based than research based. When you look at the evidence he presents there is little or nothing to show improved outcome with the approach he recommends. This is the case with some of his work into core stability as well. The problem then with this, as pointed out by Fizziowizzio, is that he makes some poor recommendations such as stretching which is likely to aggravate the condition by compressing the hamstring tendon against the ischial tuberosity.
Since his article our understanding of tendinopathy has progressed and, thanks largely to work by Cook and Purdam, we now know that “staging” the tendinopathy is important and that during the early ‘reactive’ stage our emphasis should be on reducing compressive and tensile load, especially activities like running up hill or over striding when running. In this stage isometric exercises done with the hip in neutral can be helpful too.
Alison Grimaldi has a great podcast on this topic in which she discusses isometrics and rehab progression, well worth a listen!
She also suggests trying to keep runners doing some running on the flat rather than complete rest, any thoughts on this? Would you favour rest from this activity in the reactive stage?
Great article James, and thanks to everyone for their comments. Tom, the Grimaldi podcast was great also. I am a frustrated runner who has been dealing with hamstring tendinopathy for years now, although must admit I kept running with it hoping it would go away for probably 2 years before I really took it seriously. After my third marathon of 2012 around Thanksgiving I knew I was in trouble and had to do something. I haven’t run since hobbling through a Turkey Trot last year and don’t know how much longer I can last without running (ok, that’s a little melodramatic but you runners out there know what I mean!). I have been trying everything in earnest since January – physical therapy with the ART, Graston, and eccentric exercises; a couple prolotherapy injections with 5% dextrose, acupuncture, trigger point dry needling, osteopathic manipulation, and massage. I never knew my hamstring could cost me so much money!
My pain is definitely better from it’s worst, down from an 8 to maybe a 3, but it seems stuck there. My doctors and therapists have all insinuated that I shouldn’t run if I can still feel the pain even with walking. Frankly, I always have a low level ache that now I’m so acutely aware of I even feel it while lying in bed. (and while I’m sitting here typing this message!) I had one doctor who told me I was cured after I couldn’t really feel the pain immediately after he dry needled some spots. Of course, I could feel the pain by the time I walked to my car in the parking lot.
It was interesting that Grimaldi seems to be ok with continuing to run if it’s not making the pain worse and she didn’t say wait until “pain-free”. Also, she said not to do dead lifts or “good mornings” which has been part of my PT eccentric exercises for a while now. I was signed up to do Big Sur Marathon this April but obviously had to bag that idea, especially with all those hills. Now I’m signed up for Chicago in October, which is super flat but I’m still nervous about that fact that it’s not 100% better. Maybe it will never be? I can live with a 1-3 pain level with running if I’m not going to make it worse again.
Anyway, thanks for reading and letting me vent. Any and all opinions and personal anecdotes are very much appreciated!
I self diagnosed myself along with the help of another Physical therapist. I started having proximal hamstring pain 9 years ago while training for the Chicago marathon. I continued to run but did not do anymore full marathons, only halfs. I decreased the #of runs a week. Tried all kinds of manual treatment(cross friction massage,tendon release, and a lot of stretching) none of this helped as a matter of fact the more I stretched my pain increased. While training for a half marathon, the pain increased with constant pain, pain up to 8/10 with attempts to run,pain with sitting and radicular pain, even pain that woke me in the night. My whole hip complex became painful. I stopped running for 4 months( a very long 4 months). I used my elliptical for my cardio. No pain with the elliptical at all as the swing phase and heel strike were eliminated. Started running again and gradually increased distance. Did OK but pain still at 2/10 but could live with that. Maintained for about 9 months then increased irritation after running 2 half marathons and going through a period of a lot of travelling in a vehicle over a period of a month which really flared the condition. I am trying to perform eccentric ex but continue to be flared up. I may have to take another break from running.. My question is what kind of permanent damage can occur if I continue to run once the pain has calmed down? Any other advice is appreciated. Thanks for all the information you all have previously posted.
Just listened to the podcast. Great information there. I’m going to try to follow recommendations from the podcast. I may have let this continue for too long. Now I’m just trying to get it under control so I can continue running for fitness and the enjoyment of it. I am in my late 40’s and hope to still be running into my 70’s and beyond. Going to try conservative measures slowly, I think in the past I started too aggressively with eccentrics. Thanks for taking the time to post all of the information on here.
At what first appeared to be a minor hamstring tear or strain was then diagnosed as what might be piriformas syndrome. Ive been seeing a team of professionals for the past 5 months that include a chiropractor, sports physiotherapist,sports masseuse and pilates instructor that specialises in rehab. The initial finding was muscle imbalance that is common in runners, weak glutes and core. After reading your article I can identify that all my symptoms are consistent with proximal hamstring syndrome, pain in the gluteus and mid to upper hamstring when driving and at rest and at times when walking, the only symptom difference is that i have not had any pain whilst training, I’m currently training for a 70.3 triathlon.
Earlier this year I had a 5 week period with no running and have built to present 10k.
I’m about to have an MRI done to confirm any symptoms i may have.
Ive started to do the exersises linked to this article.
My question is that should i stop running until the symptoms improve or can I continue with rehab and training and keep up with my slow building program
I would encourage you to train lightly for circulation and focus on relaxing, exercising, and stretching the Psoas muscle (many good YouTube videos on massage, Yoga, etc.). Follow all protocols at first and find the one that works best for you as you become more knowledgeable. Don’t rely too much on the so-called experts–take responsibility (as you are) and be fully armed with knowledge; we have become so lazy! What a shame with so much being available on the internet! I’m guilty, but pain has been a blessing because it was the catalyst to encourage me to to learn about these wonderfully designed bodies.
I am in Canton, Michigan (near Ann Arbor). Is there a doctor or someone in this area that can diagnose me for this and help me to rehabilitate? I was SO close to being able to run a 50k ultra but I am sidelined. I really need help with this.
Thanks for your time and replies.
This isn’t exactly “in your area” but I have been seeing a great doctor outside of South Bend, Indiana. His name is Dr. Mark Cantieri and the website to his office is http://www.correctivecare.com. I have driven 100 miles from Chicago to see him after hearing about him from another physician. He co-authored the book “Principles of Prolotherapy” and specializes in treating sports injuries. After getting nowhere with other doctors regarding my hamstring tendinopathy, I decided to see him. He was able to localize some of my problem to my obturator internus tendon, which is located on the pubic bone. Honestly, most doctors just didn’t check there since it is definitely in an intimate location. His knowledge of musculoskeletal anatomy is impressive. I have had three prolotherapy injections and am definitely improving. I’ve been out of running now for almost 6 months and am just being able to start up again on a minimal basis. I really feel like, if anyone can treat this frustrating injury, it’s him. It may be worth the drive for you. Good luck!
Thank you Laura. I am SO tired of hurting and traveling to get this fixed would be SO worth it.
I have started Rolfing or Structural Integration with a trained therapist; even after only one session, I noticed alleviation of some pain. After initial evaluation and therapy, it seemed good to do two more sessions and then re-evaluate. If you have not found relief yet, you might research Rolfing and see if you can find a reputable therapist; be careful–not all are as skillful as they claim!
I am currently dealing with a continuous pain in the glute area. I’ve been through several misdiagnoses, including ‘piriformis syndrome’ which is most common with injuries like this. During this frustrating time of misdiagnoses (almost 9 months) several physical therapists had me stretching the piriformis which I always felt was making the pain worse. The constant pain was a localized uncomfortable ache with some throbbing while sitting or when taking off a shoe. Every physical therapist seems to thing stretching is the answer, I don’t and I’m not a doctor. Nothing was making it better, and I’m a 26 year old male and very active/athletic.
I’ve since seen an osteopathy sports doctor who identified a minor strain in the hamstring. She administered a ultrasound guided injection and some dry pricks to stimulate the healing. After a couple weeks, it did not feel better from just the injection. Before the knowledge of a hamstring strain I had not done one exercise where the main muscle was the hamstring. So I decided to try some low-weight leg curls (seated and laying down) and even after one day of these exercises the constant nagging pain subsided. I saw the osteopathy sports doctor one more time and she advised to keep doing them for another couple weeks and then try running 0.5 miles every other day. She also scheduled an MRI for the same week. The MRI results came back completely NORMAL.
Here it’s been another month and while the constant pain is not all there, I believe it’s being re-aggravated and will be triggered further by running a longer distance. I tried stretching and it makes it worse. I feel like I’ve made progress and now it’s back to the way it was. I’ve read some of the comments and I believe long-stride and fast pace has a lot to do with this. I’m stuck and I’m so frustrated I just want the pain to go away so I can run again.
Totally agree with Robert (above), had mine since February 13 and not really improving, great article but don’t really give me a way forward. Being a footballer running down the wing I am now useless to the team, gaining weight and mentally messed up over this injury. MRI says normal, obviously not! Doctors say just rest, until when? They don’t know! stretching seems to worsen. I feel like I want to snap the hamstring. Someone please find a way forward as it sounds like some of you don’t even have the same injury
Krysiek, I know it has been years since your original comment, so im not sure if you will see this, but I am having the same problem and was wondering how you solved this problem if so.
Just to be clear,and hoping I’m on the same page as everyone else and of course, the author. I believe the issue to be a pain located directly mid butt cheek (pick left or right), if you pushed your finger deep into the muscle you would end up abutting one of the two sitting bones. Forward leg thrust of the leg with the effected region (as in a running motion) causes pain, straight bending over (touching your toes without bending at the knees) causes pain so stretches in that area are off limits, the stretching mentioned relates to supporting muscles etc that would relieve some of the work that the overused hamstring tie in to the ischial tuberosity has been providing. Is this the basic tenet towards recovery and eventual banishment of said ailment.
I have been having gluteal (hip) pain on only one side for almost 6-7 yrs. I don’t run but I do fast walking ( 5km/day). I don’t have any pain on walking but it is almost 7/10 when I am sitting & my job requires prolonged sitting. I don’t know what therapy I should use. I have been advised Steroid injection at local site – is it OK to have it. Please give some suggestions.
I’ve had this problem for about a year now, nothing has worked… PT with all modalities, complete rest, a total f*it attitude b/c nothing was helping anyway, nitroglycerine patches, and now a cortisone shot. I was told not to run for at least a year…. it’s already been a year. My cortisone shot was not even a week ago – and it’s not working at all. They’re now telling me my only other option is surgery… any suggestions??!! MRI does say partial tear with absolutely not changes in the past 9 months (which included all of the above treatments…) HELP!!!!
This type of injury knocked me out in ’06 where I could not even get up or sit down in a chair with out pain. Sitting did not help it either especially on softer surfaces. I am a veteran of 24 marathons with plans to run Boston 2014. This injury has flared up again but now I think I can isolate it to the muscles above my sit bone. I always thought the piriformis was the culprit but now I think it is either the obturator internus or gemellus superior. It flares up during runs of 5 miles or more messing up my stride. Could deep tissue massage help me finally get rid of this? I live in southern NJ so please advise if you know of a professional that could help me. Thank you very much.
I have been looking for a solution to the problems that I have been having for several years now and its brought me to this site. I cannot sit for more than 10 minutes before I have a radiating pain that goes from my rear and down my leg. The issue is only in my left leg and I am not able to run without tightness at the moment. I have tried in vain to stretch it out but that really does nothing to relieve the deep aching.
I really do not like the idea that I will not be able to run. I live in Minneapolis and am going to be looking for a doctor here but my concern is that either they will not be aware of this issue because there is so little information, or that I will bring this information to them and think that I am trying to self diagnose.
Does anyone have any connections here that they can send me? I would really appreciate it!
I’m not qualified to say whether our situations are the same even if I had more info, but they sound similar. I’ve tried various therapy modalities in the last year to try and alieviate the pain in my upper hamstring/sit bone area with little success. Recently, a friend shared info with me about trigger points and referred pain… She loaned me a self-help book called the Handbook of Trigger Point Therapy by Davies and Davies (get Third Addition). At the recommendation of my therapist, I took time off running and any other activity that strained my hams. I started following the steps in the handbook multiple times a day as well as seeing a massage therapist once a week. I have benefitted greatly from the technique and I’m almost pain-free and running/cycling again. I would encourage you to check out the first chapter of the book and I think you will readily see that its scientific, legitamit therapy that, unfortunately, is not utilized the the so-called professional medical community enough. If you stick with it and give it time, I believe you will be helped. More info on trigger points and why not to stretch at sock-doc.com
My search on “proximal hamstring strain” has led me to this website which I’ve been trolling for some time now this morning! At first, I felt I had found some vital information that I could use in order to rehabilitate myself, but now I’m feeling overwhelmed with all of the information. I guess this is exactly why physical therapy is so popular. It can be difficult to figure out a plan for yourself, however, I’m going to try due to insurance issues.
I’m a runner! I was first going to say that I am merely a jogger, as my times would not indicate a seasoned runner, but I decided I’m not going to lesson the fact that I’m a runner. (Even if my 5k time is roughly 32 minutes 🙂 ). I first started “running” for exercise, but now I’m a little addicted. I had continued running outside until January 10th of this year when I needed to finally bring it inside to a dreadmill. The weather here in Chicagoland just did not help when it came to running outside!!
My running in, or outside, was not what caused my issues. On February 22nd I was out with friends and um, did the splits (hehe). Not only did I do the splits, but my body wanted to stop about a foot from the floor. I bounced my body in order to lower myself down further. OOOPS!! The moment I got up I could feel it. A burning in the upper part of the back of my leg. (It is important to not that I DID do the splits!!!!) But now I’m suffering those consequences 🙁
I have not run for 3 weeks in an attempt to heal this injury. I did go to the Ortho doc yesterday and it is apparent that I have a Hamstring strain with sciatic involvement likely. He passed up on doing an MRI because he said the result would still be the same. Physical therapy. I asked if I could start running again, and he told me I’m an adult and can make that decision, but by doing so I could end up with a much bigger problem. He explained that the position of this hamstring strain typically takes a lot longer to heal. He also sees that it is recurring and takes a lot longer in runners, because they do not take the advice of not running!
My symptoms are as follows:
Pain in the upper part of the leg. Pain when sitting and placing pressure on right buttock. I often have to position my body so that the weight is put on the opposite side of my body. Squatting hurts. I attempted a burpee, and that is also a no no UGH! I feel as though I could start some running on the treadmill at a slow pace with smaller steps, but I really don’t want to aggravate my symptoms and create long term problems. I’ve thought about popping a pain patch onto the area or lathering myself up with BenGay and going out for a run! But sadly, I know, that this will just temporarily mask the pain while perhaps doing further damage.
If anyone would like to play doctor and offer up a few exercises I could do to try to rehabilitate myself, I would be forever grateful. Please do not tell me that at 42, I shouldn’t be playing cheerleader in the local bar 🙂
Rehab exercises: “The Trigger Point Therapy Handbook” by Davies and Davies (3rd Edition)
I also have been struggling with tendonosis of the high hamstring. Have had seven surgeries since I have been told I had nerve problems, disc problems etc. I wish anyone could find a solution-this is such a horrific condition to have. I can’t sit for more than 10 min. at a time and it takes over all my life. Very depressing-especially since most people who get this wer once very active=(
I do not think I have the same injury as the one in the article above. My injury did´nt began with running i began with sitting.
And I am responding because I have the exact same 10 minutes syntome as Rhianon an Joanna. 10 minutes and then I have trouble continue sitting. And it has been this way for four years. Four years of avoiding to sit. Terrible!
Hope somone will find the answere!
This injury is a sitting issue ,I am not a medical person I have just stumbled on to this and it is working for me, consult your doctor or pysio before you try this I take no responsibility . I am a runner of 23 years and have been struck down by the same affliction as everyone else . This is the most bothersome injury I have ever experienced and boy have I had it all . Try this not to totally fix the issue but to get you back to doing some running again. Lie on your back and pull the afflicted leg’s knee up to your chest or as far as you can go till discomfort only ,not pain ! . Feel around your sit bone area for where the discomfort is originating and then press a tennis ball onto the site and hold it there while you begin to sit up on to it . Do not let the tennis ball move , once you are sitting up on it press down with your body weight on the trigger point and breath into it relax into it and feel that area loosen off . Then roll the tennis ball over the area with a cross ways movement ten to twenty times to friction the area. Now lay back down on your back and again pull your knee to your chest only till discomfort and hold for 30 seconds to a min in a gentle stretch , I bet you could get it up further ,do this once a day and see how you go long term . Also get you pysio to check out your biceps fem muscle it seems to contribute to this condition . Good luck
My advice is to add to the differential diagnoses list – hamstring syndrome and ischiogluteal bursitis. These two can closely mimic PHT and require an in-depth examination. For more information on these two I highly recommend the following case report:
DIFFERENTIAL DIAGNOSIS OF DEEP GLUTEAL PAIN IN A FEMALE RUNNER WITH PELVIC INVOLVEMENT: A CASE REPORT
Jorge N., PT, DPT
These are outstanding exercises for the hamstring! This can be a tough injury. Check out this article; it has a pretty good take on this:
Thanks a zillion for sharing the article Hannah. Spent hours sifting through internet articles- lots of good information. However finding a good PT / physio is probably the best action I can take!
I have had 4 solid days of excruciating pain in my butt literally ~ region of ischial tuberosity extending down my posterior thigh~midway centre point. It hurts to bend on any plane whether flexing knees or just @ hip/waist…any suggestions to get some relief, though it does subside when lying down or feet up, and minimal relief when standing, but even just twisting or rolling side to side causes pain/ affects. Someone please tell me this is a temporary condition … Any tx other than analgesics which hardly affect relief??
You may want to do some research into Trigger Point Therapy, Rolfing, and/or Myofacial Release Therapy…
Not to be a downer to all of you, but I have had this condition for EIGHT years. Multiple different PT’s, lots of down time (with depression), massage, injections, and still no solution. I am no better than I was. If anyone has something that really works to fix this, I’d would love to hear. I just want my life back…..
I have been following this thread for over 2 years now (about how long I have been dealing with this injury). I have had numerous physical therapists, multiple hip MRIs, multiple injections, and years of rest from running. Obviously, none of it helped. I wanted to write because I actually found an exercise regimen that worked in less than 2 weeks. Yes, I took it upon myself to attack this problem under my own hypothesis and it worked. I am now running again which I thought was an impossibility.
First, buy a stability disk and a medium resistance band. I did the following exercises consecutively for three sets daily:
Lateral leg raises (standing) – 10-15 reps
Lateral leg raises (standing with resistance band) – 10-15 reps
Lateral leg raises (standing on stability disc) – 10-15 reps
One-Leg Bridge Lifts (on stability disc) – 10-15 reps
Results after two weeks allowed me to run with virtually no pain. I am taking it slow getting back into running but these exercises have triggered healing almost immediately. I’m kicking myself that I didn’t think to do this earlier or why no physical therapist was giving me the correct exercises.
Your rehab routine is interesting. What it sounds like is you are concentrating on strengthening the gluteal muscles. By strengthening your flute muscles did this heal your tendinopathy?
Thanks for keeping us updated and sharing your experience.
Alex, yes, strengthening the gluteal muscles and hip muscles is what subsided the pain. I can run again (3-4 miles) without discomfort during or after the run. I will admit that sometimes after longer runs – if I really push the limit – it flares up a little. But by continuing those exercises a few times a week, it feels better. I think that because I sit for 8 hours a day at work it isn’t helping my situation. It seems to be the only thing stopping me from getting to 100% with no limits. I’m willing to accept how far I have come though.
Wow that is really interesting! What a lot of people fail to overlook are antagonistic and synergistic muscles of the hamstring when they have tendinopathy. They feel their hamstring is tight/grumbly and stretch and strengthen that but in fact the issue is related to the muscles around it.
In your case it sounds like as you strengthened the glutes and hip flexors it pulled your pelvis into better alignment and/or allowed your body to recruit the right muscles more efficiently.
Maybe if you added some hip mobility drills you would see some more progress? It could seriously reverse the effects of the sitting.
Check out the Paleo chair, it’s supposed to be a very good practice for restoring hip strength and mobility.
Thanks again for your input! I’m 25 and been dealing with this for years. It sucks and I really want to put this behind me.
Alexandre, yes that was my thinking. Exercising the hamstrings directly made things worse.
Do you know of any hip mobility drills I could try?
I’ll look into the Paleo chair
Sorry i didnt see your response.
I found this routine helpful for hip tightness and mobility issues.
I’m going to get a band and a stability ball and try out those exercises. My glute minimus and medius are so weak. I think my body is compensating by recruiting the hamstring and lower back.
I’ll give it a shot thanks are you still back to running?
Yes still running, not over-working it though
Since this thread first began I’ve written a review paper on PHT with recommendations for rehab based on the latest tendon research. Videos of the exercises from the paper and a link to a podcast discussing PHT in detail can be found here http://www.running-physio.com/phtvids/
I hope it’s helpful.
I too have been following this thread for quite a while and have tried everything under the sun and spent a boatload along the way. So very frustrating. Anyway, saw your exercises and thought I’d give them a try…I have a couple of questions though. .Do you do the exercises on both legs or just the affected side? How far are you able to run now and are you able to do any hills? Have you adied anything else to your routine? Many thanks!
I do exercises on both sides but sometimes only to the affected side. I run about 2-3 5k’s per week. Right now, I run indoors on a treadmill because its freezing in upstate NY. I try to stay away from steep hills although i feel as though I’ve built up enough strength to go up hills.
Please see Tom Goom’s exercises above – they work even better than the ones I posted. The bridge hold’s I find to be the most beneficial. Thanks Tom!!!
Thanks so much Rob! Gives me hope. I was an ultra runner before all this happened and all I want to do is get back to the trails. Baby steps I guess… Were you doing any other glute strengthing exercises as well.. like squats or lunges? Did you stay away from any exercises? Will definitely take a look at Tom’s exercises as well! Thanks again and happy running!
I don’t stay away from anything now. I just don’t lift heavy weights – all body weight stuff. I’ve found that my hip/hamstring feels best outside of work. Go figure I sit for 8 hours a day. I still always feel it while sitting, but when I’m doing anything else it goes away.
Rob, this gives me hope. I was an ultra runner before all this happened and all I want to do is get back to the trails. Baby steps I guess… Were you doing any other glute strengthing exercises as well.. like squats or lunges? Did you stay away from any exercises? Will definitely take a look at Tom’s exercises as well! Thanks again and happy running!
I am writing to you to ask for your advice on where to go and how I might recover from a fall on my coccyx 8years ago.
I slipped an fell bang on my coccyx on a slippery floor, raining, and it was a ramp. The pain went on for a few weeks then it went, I thought then I was better but after years of getting worse, without realising it was from that fall. I get into treatments and treatments trying to get my solution and finally this year that pain in my coccyx came back, which led me to figure out that all these years my pains and bad feeling was from that fall! I am going to manual treatments at this Chiropractor and also doing physic sessions but since October… I feel my coccyx has just gone back slightly to place.
What would you suggest with this quick intro, can’t leave out that my whole body was affected, my pelvis is tilted and frozen shoulder terrible cervicle area, and also along my leg and arm… many cramps and tension, knots!
Ive read your article and it seems that I may be suffering from this too. I am a sports teacher who daily works out( 30 mins), i do kickboxing 2-3 times a week all in addition to daily stretches with the children. I walk alot, cycle a bit too. So ive had tight muscles particularly in my left hamstring, which results in mild throbbing sensations when insit for long, and at nights. Its on and off but now restricting me in my performance. Im soon grading for black belt and i want to be able to execute my performance well. Please help. Can deep tissue massage help? I have tried to slow down and give my self rest but it still keeps popping back
After almost 6 years of dealing with this injury (diagnosed by MRI) I’ve lost hope of it ever getting better. I’ve tried ALL of these exercises (still do) as well as had myofascial release massage every other week for years. I’ve also had extensive PT, acupuncture, chiropractic adjustments to my pelvis and PRP injections to no avail. My question is will this get worse and eventually tear, or will it just remain in this phase forever?
last week I was playing basketball, a possession when I jump to get the ball in air and run back toward the other side I immediately felt pain on my (R) butt. I stop to reassess myself and tried running in a slow pace but then I realized it is bad. so I immediately go off the court. as I sit and was resting I was putting pressure on my (R) butt, couple of minutes I felt numbness on my (R) posterior thigh so I assumed I was compressing my sciatic nerve.. I went off to evaluate myself. I tried all ROM to find what specific movement causes pain. to be exact it was SLR on 90 then doing and rotating my body and my (R) leg toward the opposite side. so u could imagine it as stretching the lateral portion of your gluteus then I felt pain on my butt but the lower portion. couple of days I went to have a body massage and what part of it the lady was stretching my hamstring on (R). as she did an SLR going to 90 I felt pain and I realized its near my ischial tuberosity. so what treatment could I do aside from soft tissue mobilization and stretching. I don’t need to be bother right cause this aint a severe injury? I could still walk and do normal ADL’s (activities of daily living) except for running. first couple of days I couldn’t squat but know I am able to do squat after a week. I am reading others experience about it and it doesn’t say a good prognosis about this. I am very bothered about this its my first time I injured my hamstring. I hope after 2 to 4 weeks I am healed. thank you for responding
Can walking (not running ) in barefoot shoes aggravate an upper hamstring injury. I think I am recovering from an upper hamstring injury and was previously walking in barefoot shoes and running Nike Free’s. I changed back to ordinary shoes (sketchers ) and I now that I am running a little again I have changed to NIKE pegasus zoom, but I would be keen to go back to walking in barefoot shoes. Do you think there would be any reason not to?
What if I have the pain when I stretch this area but i don’t have the pain when I run.
Do not stretch the hamstrings directly if doing so provokes pain, as you’ll just make the condition worse. It seems like a good thing — stretching those tight hamstrings — but it’s the exact wrong thing to do. Roll ’em, massage ’em, heat ’em — that’s all good — but don’t stretch those hammies directly if that’s causing pain.
I am not a runner, and am very flexible but included stepping exercises for osteopenia prevention and stretching exercises (among others) that compress the H tendon. I have been struggling with PHT for 5 months with some help (PT and NKY) but with out medical diagnosis. I’ve partially responded to NeuroKinetic Therapy, meaning no pain after sitting or walking up or down steps following an average of half of all daily at-home therapy (unless I’m required to sit for a long time that creates more compression. I am wondering if I should get additional testing such as an MRI to assure this is the tendon and not a hamstring muscle tear. The PT (during the first 3 months was primarily finding the knots up the IT band to the Hamstring tendon. The question is who is accessible in my area (Montgomery Alabama) that has been successful with diagnosis and therapy for PHT?