If you are a runner who has been experiencing an ache in the back of your upper thigh or buttock – close to your ‘sit bones’- then it is possible that you have proximal hamstring tendinopathy. Proximal hamstring tendinopathy usually develops gradually in response to excessive running. Rarely does it come on entirely out of the blue, as with muscle injuries such as an acute hamstring strain. This blog describes hamstring tendinopathy and guides you on managing it as a runner. Learn about proximal hamstring origin tendinopathy exercises and rehab.
What is Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy is pain felt in the tendon that attaches the hamstring to the sit bones. Often, people report upper hamstring pain during and after sitting, walking, and running. Sometimes, pain can move from the back of the thigh to the back of the knee.
It is essential to understand that high hamstring tendinopathy can sometimes require some detective work, as other injuries can cause pain in this area. Examples include pain from the lower back and stress fractures in the sacrum and hip. So, if you have any doubts, you should seek an opinion from an expert in this area.
Some experts suggest that high compression forces on this tendon are essential in the treatment of hamstring tendinopathy. For example, during running, as the knee drives forward and the hip flexes, the hamstring tendon is placed under compression as it is pulled tight against the sit bone.
Why Does High Hamstring Tendinopathy Occur in Runners?
One of the principal risk factors is a sudden increase in load on the proximal hamstring tendon. This can occur with increased running volume and intensity. High proximal hamstring loads occur with faster running, e.g., track intervals, Fartlek, and tempo sessions. Running on hills, which requires the hip to work in greater hip flexion (knee closer to the chest), results in greater compression on the tendon. Introducing hill sprints or reps is risky, so proceed cautiously.
Other risk factors include running techniques such as overstriding – landing with the foot ahead of the body with a relatively straight knee. Also, we think that weakness in the core, gluteal, and hamstring muscles plays a role in the development of high hamstring tendinopathy.
Simple day-to-day activities such as sitting, driving, and hamstring stretching can compress the tendon, increasing its susceptibility to injury.
Proximal Hamstring Origin Tendinopathy Exercises
The first task is to get the upper hamstring pain under control. On a pain scale, this can be anything that is <3/10. This often means you must alter your activities to get your pain under control. It would be best to change day-to-day factors, such as time spent sitting or deciding whether to drop an interval running session.
This approach of targeting low upper hamstring tendon pain allows the load to be managed. It is the cornerstone of tendon treatment.
Second, strengthening exercises for the hamstrings and muscles that support them, such as the glutes, are necessary treatments. Strengthening the hamstring and supporting muscles, such as the glutes and adductors, helps protect the tendon and support its healing.
Many experts follow a ‘step ladder’ approach to proximal hamstring origin exercises, progressing from static (bridging) hamstring-gluteal strength exercises to plyometric (jumping) exercises that place a far higher load on the hamstring.
The point at which you start on the step ladder will depend on the proximal hamstring tendon pain and your strength. However, not all runners will need to progress to high-intensity plyometric (jumping) exercises if they want to run a few times a week slowly.
What about Hamstring Stretching?
Excessive stretching of the proximal hamstring might not be helpful. Prolonged stretching might push the tendon against the sit bone, causing compression and more pain.
Can You Run with High Hamstring Tendinopathy?
It depends on how irritable your upper hamstring tendon is.
Continuing to run (and exercise in general) is safe if your symptoms aren’t severe when you run (e.g., they don’t make you limp or move differently).
Also, we think running is okay if the proximal hamstring tendon pain does not increase immediately afterwards and the following morning.
Mild pain (<3/10) usually means only a slight change in training. For instance, taking out the hill training or switching to a slower but longer run.
If your hamstring insertion pain worsens, you need a more significant change in your training to reduce it. This could mean a complete rest from running (although rarely for more than a week). For example, a runner might have a pain score of 6/10 after running 15km. On reflection, the runner can run without pain for the first 9km, but then experiences severe pain afterwards. Rather than stop running altogether, we suggest shortening runs to less than 9km for a few weeks. At the same time, the runner begins a hamstring-strengthening program. Gradually, the runner increases running volume by 0.5-1km per week, keeping pain levels low.
As a general rule, we suggest increasing running volume before introducing speed work and hills for high hamstring tendinopathy. Being able to run for 50-60 minutes is a good marker. After that, you can slowly add speed, starting with strides in small amounts (4 x 80m strides in a slower run), followed by longer intervals.
Generally, over time (often 3-6 months), you should notice an uptick in the amount of running you can tolerate without a sudden increase in proximal hamstring pain. An excellent example is 2:16 marathoner Paul Martelletti, who regularly completes 100 miles> per week. In addition, he has successfully managed mild hamstring tendinopathy for several years.
Finally, prevention is also crucial. We suggest you maintain hamstring and buttock strength training (at least weekly) even after returning to regular running. It would be best to avoid sudden spikes or surprises in your training. See this blog on how to prevent injury based on my injury.
What Happens if You Don’t Improve with Proximal Hamstring Tendinopathy Exercises?
It is essential to seek advice from an experienced sports doctor with an interest in running and tendon pain. In addition, you may need investigations (e.g., US or MRI) and a discussion of other options, such as medication, GTN patches, shockwave therapy, or tendon injections. However, using these different treatments with good rehab would be best.
Tendon Neuroplastic Training: How Training with a Metronome Can Accelerate Your Rehab
Tendon neuroplastic training is a new rehabilitation principle for proximal hamstring origin tendinopathy in the upper and lower limbs. Using a metronome during strength training can improve control of muscle contractions. Recent evidence suggests that improving strength and muscle control may accelerate tendon rehab.
Final Word about Proximal Hamstring Tendinopathy
High hamstring tendinopathy is a common injury in runners, causing pain in the upper hamstring and buttocks. Treatment consists of controlling upper hamstring pain by reducing load, strengthening the hip and hamstrings, and gradually increasing running by monitoring pain. Other options, such as shockwave or tendon injections, can be used in complex cases of high hamstring tendinopathy.
Scott Newton is a musculoskeletal physiotherapist interested in managing running-related injuries. He has over 15 years of clinical experience and is a keen club runner with a marathon PB of 2:37, which he hopes to improve. If you have any injury niggles or running-related queries, please get in touch with Scott via his website www.londonrunningphysio.co.uk to discuss rehab for proximal hamstring origin tendinopathy.
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