Condition Overview

Hamstring tendinopathy describes a degenerative, overload-related condition affecting the hamstring tendon complex—most frequently the proximal hamstring tendon where it anchors to the ischial tuberosity. Unlike an acute hamstring tear, which produces sudden sharp pain during activity, tendinopathy evolves gradually. Patients often can’t pinpoint a specific moment of injury. Instead, they describe a slow accumulation of tension, discomfort, or stiffness deep in the buttock, eventually giving way to persistent pain during running, lunging, or sitting on firm surfaces.

To understand the condition fully, it’s worth appreciating the mechanical demands placed on the hamstrings. These long, powerful muscles act across two joints, extending the hip and flexing the knee, and they work hard during almost every phase of running and walking. But it is during late swing phase—when the leg is travelling forward while the hamstrings contract eccentrically to decelerate it—that the proximal tendon experiences particularly high loads. Over time, if the tendon’s capacity does not match the volume or intensity of stress placed upon it, microscopic changes begin: collagen fibres become disorganised, local hydration changes, and the tendon becomes less resilient. The clinical picture that follows is recognisable: deep buttock pain that flares with increased speed, hill running, or prolonged sitting, and may linger long after activity ends.

Hamstring tendinopathy is rarely an isolated tendon problem. Many patients present with movement patterns that increase strain on the tendon—insufficient hip extension, a forward-leaning trunk during running, or under-recruitment of the gluteal muscles. Others exhibit reduced lumbopelvic stability, causing excessive motion around the tendon’s anchor point. For these reasons, the most successful rehabilitation programs look beyond the tendon itself and treat the entire functional chain that influences load distribution.

Summary of Current Evidence for Hamstring Tendinopathy

Evidence-Based Management Discussion

Mechanisms of Injury: A Tendon Under Repeated Stress

The proximal hamstring tendon is uniquely vulnerable because of the powerful combination of stretch and load it experiences during normal movement. When a runner’s leg swings forward, the hip flexes while the hamstrings contract eccentrically—an inherently demanding action. Add speed, fatigue, or altered biomechanics, and the tendon may undergo repeated micro-trauma before it has had the chance to adapt.

Sedentary behaviours can aggravate the problem further. Prolonged sitting compresses the tendon against the ischial tuberosity, especially on hard chairs or in cars with bucketed seats. In some patients, this compression is the main driver of morning stiffness or post-activity soreness. Others develop symptoms due to insufficient gluteal function; when the gluteus maximus fails to contribute adequately to hip extension, the hamstrings step in to do the work, continually overloading their proximal tendon.

Understanding these mechanisms helps clinicians design treatment programs that address not only the tendon itself but the broader environment that influences its stress.

Clinical Presentation: Recognising the Pattern

Patients typically complain of a deep, almost toothache-like pain at the sit bone, often describing it as “buried” rather than superficial. Pain is usually worst when accelerating, sprinting, climbing stairs, or bending forward to tie shoes. Many experience discomfort when sitting for long periods—especially on firm surfaces—or report that rising from a chair produces a sharp twinge that eases after a few steps.

During examination, resisted hip extension in positions of hip flexion often reproduces pain because it directly loads the proximal tendon. Stretching the hamstrings with the hip flexed—such as a straight-leg raise—may also provoke symptoms, not because the tendon needs more stretching but because stretching places compressive load on the already irritable tendon.

Differentiation from lumbar radiculopathy is essential, as both conditions can produce posterior thigh pain. Unlike radiculopathy, however, hamstring tendinopathy rarely involves neurological deficits such as changes in reflexes or marked muscle weakness.

Rehabilitation: A Progressive, Narrative Approach 

Early Phase: Reducing Irritation and Establishing a Foundation

The early stage of management focuses on calming the tendon while maintaining meaningful movement. This does not mean rest—complete rest generally worsens tendon health—but it does involve careful modification of aggravating activities such as sprinting, heavy deadlifting, lunging deeply, or running uphill. During this period, patients are guided toward movements that load the tendon gently and predictably without provoking sharp pain.

Isometric contractions—holding the hamstrings under mild to moderate load—are often introduced early. These holds help modulate pain, maintain some tendon load without excessive strain, and provide patients with a sense of control. Sitting tolerance is addressed by recommending softer surfaces, strategic breaks, and awareness of sustained hip flexion, which compresses the tendon and often irritates the area further.

Patients frequently report that simple changes—standing more, alternating between sitting and walking, and avoiding prolonged hip flexion—immediately reduce their baseline discomfort. This phase lays the foundation for the heavier work to come.

Middle Phase: Restoring Strength, Control, and Functional Capacity

As symptoms ease, attention turns to gradually rebuilding the tendon’s load tolerance. Strengthening during this stage is methodical: the goal is to strengthen not only the hamstrings but the entire posterior chain and the lumbopelvic stabilisers that help distribute forces more evenly. Exercises that emphasise hip extension with controlled pelvic alignment become central. Movements such as bridging variations, hip thrusts, and controlled hip-hinge patterns help patients learn how to generate power from the gluteals rather than overloading the hamstrings.

This is also the phase in which patients often discover that their pelvis and trunk have been contributing to their symptoms. Some rely too heavily on lumbar extension, while others lack the ability to maintain pelvic neutrality during dynamic movement. By improving lumbopelvic control, therapists ensure that every stride, lift, or bend places less repetitive strain on the hamstring tendon.

Mobility work is carefully dosed. Instead of aggressive stretching—which places compressive load on the tendon and often worsens symptoms—patients are coached in gentle mobility around the hip flexors, adductors, and thoracolumbar fascia to allow the pelvis to move more freely without compensatory hamstring overload.

Late Phase: Reintroducing Elasticity, Speed, and Sport-Specific Demands

Once foundational strength and control are established, the tendon must regain its capacity for elastic storage and release—its ability to tolerate the rapid loading cycles of running, jumping, and accelerating. At this stage, rehabilitation becomes more dynamic. Patients progress into heavier resistance exercises, then into controlled plyometric or spring-like loading patterns. These movements are carefully monitored to ensure that discomfort stays within acceptable limits and does not spike after sessions.

For runners, gait mechanics are revisited to ensure sufficient hip extension and reduce excessive forward trunk lean. For field sport athletes, cutting, accelerating, and decelerating drills are gradually layered in. The philosophy of this stage is clear: prepare the tendon not just to be pain-free but to meet the real-world demands of the athlete’s or individual’s lifestyle.

Successful completion of this phase gives patients confidence that their hamstring is not fragile but capable — that it can handle speed, stretch, and impact when progressively trained.

Manual Therapy: Supportive but Not Curative

Manual therapy helps improve comfort, mobility, and neuromuscular ease, allowing patients to engage more effectively in rehabilitation. Deep soft-tissue work around the proximal hamstrings, gluteals, and adductors can reduce protective tension. Mobilisation of the lumbar spine and pelvis enhances movement patterns that influence tendon load. Neural mobilisation may help when the nearby sciatic nerve has become sensitive due to proximity irritation.

Manual therapy should be viewed as a facilitator—not the main driver—of recovery. Tendons remodel in response to load, which only structured exercise can provide.

Medical and Surgical Options

Medications such as NSAIDs offer mild symptom relief but do not repair tendon tissue. Corticosteroid injections can temporarily reduce pain in cases with significant compression or bursitis, though they carry risks and should be used sparingly. Emerging treatments such as platelet-rich plasma injections show mixed results and remain controversial.

Surgery is rarely needed. It is generally reserved for chronic, debilitating cases that have not responded to many months of high-quality rehabilitation or for significant structural lesions confirmed by imaging.

Long-Term Outlook and Prevention

Most patients recover fully when rehabilitation is progressive and addresses the underlying contributors to overload. Recurrence tends to occur when individuals return to sprinting, heavy lifting, or sport without completing the endurance and power phases of rehabilitation. Preventive strategies include maintaining posterior chain strength, preserving hip extension mobility, progressing training loads gradually, and avoiding long periods of sitting without movement breaks.

References

Reiman, M., et al. “Proximal Hamstring Tendinopathy: Clinical Management and Biomechanics.” Journal of Orthopaedic & Sports Physical Therapy.

van der Made, A., et al. “Hamstring Tendinopathy: Diagnosis, Rehabilitation, and Return to Sport.” Sports Medicine.

Cacchio, A., et al. “Isometric and Eccentric Exercises for Tendinopathy: Evidence Review.” Clinical Rehabilitation.

Goom, T., et al. “Running Mechanics and Tendon Load in Hamstring Tendinopathy.” British Journal of Sports Medicine.

Woodley, S., et al. “Anatomy and Function of the Hamstring Tendons.” Clinical Anatomy Review.

Disclaimer:
The information in this article is intended for educational purposes within the context of continuing education for massage therapists, continuing education for athletic trainers, continuing education for physical therapists, continuing education for chiropractors, and continuing education for rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Although every effort has been made to ensure accuracy and reflect current understanding at the time of publication, practitioners must always work within the legal scope of their professional practice and follow all regional regulatory guidelines.

Hands-on techniques and clinical applications described in this material should only be performed by appropriately trained and licensed professionals. Individuals experiencing pain or symptoms should be referred to a qualified healthcare provider for assessment. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use or misuse of the information provided in this content.