Proximal Hamstring Tendinopathy: Exercises and Running Rehab
If you are a runner with an ache in the back of your upper thigh or buttock — close to your ‘sit bones’ — you may have proximal hamstring tendinopathy. It develops gradually in response to excessive running, unlike an acute hamstring strain, which strikes out of the blue. This guide covers exercises for proximal hamstring tendinopathy, the step-ladder rehab approach, and how to keep running while you recover.
For diagnosis, differential causes, and injection options, read Dr Masci’s complete high hamstring tendinopathy guide — this page focuses on the rehab.
What is proximal hamstring tendinopathy?
Proximal hamstring tendinopathy is pain in the tendon attaching the hamstring to the sit bones. People report upper hamstring pain during and after sitting, walking, and running; sometimes the pain travels down the back of the thigh towards the knee.
Diagnosis can need detective work — lower back problems and stress fractures of the sacrum and hip cause pain in the same area, as do the many causes of deep buttock pain. If in doubt, see an expert.
One concept drives the whole rehab: compression forces on this tendon are central to hamstring tendinopathy. During running, as the knee drives forward and the hip flexes, the tendon pulls tight against the sit bone — compression on top of load.
Why does hamstring tendinopathy occur in runners?
The main risk factor is a sudden increase in load: more volume, more intensity. Faster running — track intervals, Fartlek, tempo sessions — load the proximal hamstring hard. Hills demand greater hip flexion, adding compression; introduce hill work cautiously.
Other risk factors include overstriding (landing with the foot ahead of the body on a straight knee) and weakness in the core, glutes, and hamstrings. Day-to-day compression matters too: prolonged sitting, driving, and hamstring stretching all squeeze the tendon against the bone.
Proximal hamstring tendinopathy exercises
Step one: control the pain. Keep pain below 3/10 by adjusting your day — less sitting time, perhaps dropping an interval session. Managing load through low pain is the cornerstone of all tendon treatment.
Step two: strengthen. Build the hamstrings and the muscles that support them — glutes and adductors — to protect the tendon and promote healing.
Most experts follow a step-ladder approach to proximal hamstring tendinopathy exercises, progressing from static work to high-load plyometrics:
- Start: hamstring bridges, plank rollers, hamstring curls
- Progress: hip thrusters, step-ups, Nordic curls — favouring single-leg work, since double-leg exercises under-load the painful side
- Finish: walking and sideways lunges, sledge pushes, then plyometrics such as jumping split squats and jumping lunges.
Where you start on the ladder depends on your pain and strength — and not every runner needs the top rungs. If your goal is a few easy runs a week, stopping short of plyometrics is fine.
Useful strength goals from the clinic: a single-leg prone curl, single-leg deadlift, or step-up with 15–30 kg added. Train both legs — research shows the pain-free side weakens too — and don’t neglect the calves, quads, and glutes. Tight hip flexors increase running demands, so address those as well.
What about hamstring stretching?
Avoid it. Prolonged stretching pushes the tendon against the sit bone, adding the very compression that drives the problem.
Can you run with hamstring tendinopathy?
Usually, yes — if your symptoms stay manageable. Running is safe when pain doesn’t alter your gait, doesn’t spike immediately afterwards, and doesn’t worsen the next morning.
Mild pain (<3/10) needs only small changes: drop the hills, or swap a fast session for a slower, longer run. Worse pain needs a bigger reset. A practical example: a runner scores 6/10 after 15 km but runs pain-free for the first 9 km. Rather than stopping entirely, cap runs below 9 km, start the strengthening programme, and rebuild volume by 0.5–1 km per week, keeping pain low.
Build volume before speed. Once you can run comfortably for 50–60 minutes, add strides (4 × 80 m at an easy pace), then longer intervals. Expect the process to take 3–6 months. Elite proof it’s manageable: 2:16 marathoner Paul Martelletti regularly runs over 100 miles a week while keeping mild hamstring tendinopathy in check for years.
Prevention matters once you’re back: keep at least weekly hamstring and glute strength work, and avoid sudden spikes in training load.
Tendon neuroplastic training: rehab with a metronome
Tendon neuroplastic training is a newer rehab principle: strength training timed to a metronome improves control of muscle contractions, and early evidence suggests better strength-plus-control accelerates tendon rehab.
What if proximal hamstring tendinopathy exercises don’t work?
See an experienced sports doctor with an interest in running and tendons. You may need imaging (ultrasound or MRI) and a discussion of the next options: medication, GTN patches, shockwave therapy, or a hamstring injection. Whatever you add, keep the rehab going alongside — adjuncts work with exercise, not instead of it.
Dr Masci offers one-stop assessments in London — consultation, diagnostic ultrasound, and treatment planning in a single visit. Contact his team here or call +44 (0) 203 488 0350.
Final word about proximal hamstring tendinopathy
Hamstring tendinopathy is a common running injury causing upper hamstring and buttock pain. The treatment formula: control pain by reducing load, strengthen the hamstrings and hips using the step-ladder, and gradually rebuild running while monitoring pain. Complex cases add shockwave or tendon injections — but the exercises remain the foundation throughout.
Scott Newton is a musculoskeletal physiotherapist specialising in running-related injuries, with over 15 years of clinical experience and a marathon PB of 2:37. For injury niggles or running queries, contact Scott via www.londonrunningphysio.co.uk.
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