November 17, 2019

Proximal Hamstring Tendinopathy (PHT)

PHT is a painful overuse injury affecting the hamstring tendons where they attach to the ‘sit bone’ of the pelvis. You may have heard it referred to as TENDONITIS in the past but just to be fussy… is classified as Tendinopathy due to it’s degenerative pathology not inflammatory.

This injury may not be as well known as Hamstring muscle strains but is surprisingly common in endurance and mountain runners. Being a chronic condition it is often difficult to rehabilitate, especially if it has been ignored by the runner for a long time (hem hem). We have seen our fair share of these coming through the door of Pure Physio Clinic. With the available literature on Physiotherapy Management lacking we mainly draw from our own pool of experience and deliver to you… how best to identify and treat this pain in the butt.


There are three hamstring muscles at the back of your thighs: semitendinosus, semimembranosus and biceps femoris.
The 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 of the gluteus maximus.



The mechanism of injury is not particularly clear; however, it is likely related to repetitive microtrauma, typically resulting from nonoptimal gait mechanics, muscular imbalances, over training or improper/ inappropriate training.

Runners suffering with PHT 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. Once aggravated, direct pressure on the hamstring tendon is painful, so sitting on solid surfaces can become uncomfortable, as can direct manual palpation and pressing onto the ischial tuberosity.

The sciatic nerve may also be affected, as it lies fairly close to the common hamstring tendon, this can cause referred pain into the posterior thigh.  Certainly in many of the cases we’ve treated we have to address irritation to sciatic nerve as well.


There are a number of different potential causes for the type of deep buttock pain that PHT sufferers experience. Piriformis syndrome, lower back injuries, sciatic pain and pelvic stress fractures, can create similar symptoms. Needless to say finding out what your specific issue is is important to prevent ineffective rehab or an extended (and frustrating) period of rest from running.

MSK Physiotherapists are trained in differential diagnosis and there are a number of specific manual tests we can do to determine the root cause of your pain. This can then be confirmed with an MRI scan if necessary.


It is possible to continue running. However, you will not be able to continue with your current training plan. We strongly suggest that you avoid hill reps and speed work, as these types of running commonly aggravate an irritable hamstring tendon. Fast running causes you to ‘stride-out’ further and it’s this increased hip flexion that creates the loaded compression of the hamstring tendon.

Stick to easy paced running on the flat… We tell our runners not to focus on what they can’t do but rather use the time as an excuse to build up their fitness in other areas.


Soft Tissue Therapy
Hands on treatment providing deep muscle massage and mobilisation can break up scar tissue and adhesions. It also helps to relax the muscle, improve flexibility, facilitate circulation and promote healing, This can be replicated at home by using a foam roller along the hamstring muscle, or a spikey ball closer to the tendon. It’s important however that direct forceful pressure isn’t applied to the ischial tuberosity itself.

Frequent Stretching
Holding for 20-30 secs X 3 reps X 5+ daily

Eccentric training has been well documented as a successful conservative treatment option in the rehabilitation of chronic tendinopathic dysfunction. A published Physician & Sport Medicine article reviewing ‘Treatment and Rehabilitation guidelines for high hamstring Tendinopathy in Runners.’ Identified a progressive targeted eccentric hamstring strengthening programme as best:

  • Isometric hamstring bridge holds- performed at multiple knee flexion angles (eg, 30°, 60°, 90°) to start exerting tension in the injured muscle. 20 sec holds X 3 X 3
  • Eccentric Hamstrings Curls- starting with a light ankle weight. (I encourage patients to start with a 1kg & build from there) Slowly over 10 secs drop ankle to the floor.
    X 20 X 3

  • Building to:
    Single-leg deadlifts,
    Gym Ball Hamstring Curls
    Nordic hamstring exercises


In our experience athletes presenting with PHT display poor weak core stability. Specifically there is a tendency for the pelvis to tilt forward, this places the hamstring in a postion where it is chronically held on tension. Trunk stabilisation exercises, such as PILATES (yes you’ve heard us say it before), are an important aspect in the successful rehabilitation of any hamstring injury. Alternatively, your physio will help re-educate proper pelvic position and correct imbalances that they suspect have predisposed you to your overuse injury.


It is important to take a consistent and gradual approach to returning to running. Just because you are finally pain-free does not mean you can suddenly jump back to exactly where you left off.
One of the biggest errors made by patients we see is giving up on rehab exercises as running is reintroduced. Hamstring tendinopathy has a whooping 30% recurrence rate. We suggest turning rehab exercises into maintenance exercises.

We recommend that any injury or pain that persists past 3 weeks despite appropriate self management warrants a second opinion. Physiotherapists have a whole host of treatment techniques at their finger tips (literally!) beyond what has been mentioned in this article.

By Rebecca McNamara