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.
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:
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.