Proximal hamstring tendinopathy: signs, symptoms and how physiotherapy can help
Pain where the hamstring meets the bottom of the pelvis can be surprisingly persistent. It may initially feel like a minor strain or a tight hamstring, but it often behaves differently. It settles when activity is reduced, returns when running builds again and can become uncomfortable during something as ordinary as sitting at a desk or driving.
This is a common presentation of proximal hamstring tendinopathy (PHT), sometimes called high hamstring tendinopathy.
The problem is not usually that the hamstring simply needs stretching or resting. More often, the tendon has become less able to tolerate the combination of running load, speed and compression. Recovery therefore depends on identifying what is aggravating it and rebuilding strength in a progressive way.
Where is the proximal hamstring tendon?
The hamstring muscles run down the back of the thigh. Their upper tendons attach to the ischial tuberosity—the “sitting bone” at the base of the pelvis.
The tendon is loaded when the hamstrings produce force, particularly during faster running, acceleration, hills and movements such as deadlifts. It is also compressed against the sitting bone when the hip is deeply flexed. This helps explain why prolonged sitting, stretching, deep lunges and repeated bending can aggravate the condition.
What does proximal hamstring tendinopathy feel like?
Typical symptoms include:
A deep, localised ache at or just below the sitting bone
Pain after sitting, particularly on a firm chair or during a long journey
Symptoms when running uphill, accelerating or running faster
Pain during lunges, deadlifts or bending forward
Stiffness or discomfort at the beginning of activity that may temporarily ease as the body warms up
A delayed increase in pain later that day or the following morning
It may affect one side or, less commonly, both sides. The discomfort can sometimes spread a short distance down the back of the thigh, but marked tingling, numbness or pain extending below the knee raises the possibility of irritation involving the sciatic nerve or lumbar spine.
How does it usually start?
Some people notice symptoms after a clear increase in running volume, hills or speed work. Others cannot identify one particular incident. A familiar pattern is:
The upper hamstring starts to feel tight or mildly sore.
Running is continued because the discomfort warms up or remains manageable.
Symptoms become more noticeable after harder sessions or prolonged sitting.
A period of rest helps, but the pain returns when normal training resumes.
This stop-start cycle can continue for months. Rest reduces the immediate irritation, but it does not restore the tendon’s capacity to tolerate the original load.
PHT can also follow an acute hamstring injury. However, sudden pain accompanied by a pop, bruising, marked weakness or difficulty walking needs assessment for a strain or proximal tendon tear rather than being treated automatically as tendinopathy.
Why stretching may make it worse
Because the area feels tight, stretching is an understandable response. Unfortunately, strong hamstring stretching places the hip into flexion and increases compression at the tendon attachment. Repeatedly stretching into pain can therefore maintain the irritation.
That does not mean hip movement must be permanently avoided. The aim is initially to reduce provocative compression and then gradually rebuild tolerance to longer muscle lengths. Stretching is not usually the main treatment.
When should you seek physiotherapy input?
An assessment is worthwhile when:
Symptoms repeatedly return as running or sport increases
Sitting has become uncomfortable
You have reduced training for several weeks without a lasting improvement
Pain is beginning to affect walking, sleep or everyday activity
You are uncertain whether the pain is coming from the hamstring tendon, hip, back or sciatic nerve
There was a sudden injury, loss of power, bruising or a popping sensation
Getting advice early does not necessarily mean stopping all activity. It often allows training to be adjusted before the problem becomes more entrenched.
What will a physiotherapist assess?
PHT is not diagnosed from a scan alone. Assessment usually considers:
The precise location and behaviour of the symptoms
Recent changes in running, speed, hills, gym work and recovery
Pain during tendon-loading and compression tests
Hamstring strength in both knee-flexion and hip-extension positions
Hip and lower-limb strength and movement
The lumbar spine and nervous system when symptoms are less localised
This is important because several conditions can resemble PHT, including an acute hamstring injury, referred lumbar pain, sciatic nerve irritation, ischiofemoral impingement and other causes of deep gluteal pain.
Imaging is not routinely required when the presentation is clear and progress is satisfactory. Ultrasound or MRI may be useful after significant trauma, when substantial weakness is present, when the diagnosis remains uncertain or when appropriately progressed rehabilitation has not produced the expected improvement. Tendon changes can also appear on scans in people without pain, so imaging must be interpreted alongside the clinical picture.
How can physiotherapy help?
The main treatment is a progressive loading programme rather than rest alone. The initial exercise level depends on current irritability and strength.
For a sensitive tendon, treatment may begin with comfortable isometric contractions or bridge variations. Once symptoms are stable, strengthening normally progresses across two main hamstring functions:
Knee flexion: exercises such as seated or prone hamstring curls and slider curls
Hip extension: exercises such as bridges, hip thrusts and Romanian deadlifts
Split squats, step-ups and single-leg exercises may be added to improve the strength of the whole lower limb. Load, repetitions, range and speed are then progressed gradually. Later rehabilitation should restore strength with the hamstring in a longer position and, where required, its ability to produce force quickly.
A typical programme may involve two or three strength sessions per week with recovery between heavier sessions. The exact exercises are less important than selecting an appropriate starting point and progressing them consistently.
Does shockwave therapy help?
Shockwave therapy may be considered when proximal hamstring symptoms have become persistent. It is a non-invasive treatment in which mechanical pressure waves are applied over the painful tendon attachment, usually over several sessions.
Earlier research in professional athletes suggested that shockwave could be helpful for chronic PHT, although it was compared with a relatively limited conservative treatment programme. More recent research compared shockwave with individualised physiotherapy incorporating education, progressive strengthening and a graded return to activity. Both groups improved over 12 months, with no meaningful difference in pain or function between them.
This suggests that shockwave is a reasonable treatment option, but it has not been shown to be better than well-designed rehabilitation. We also do not yet know whether adding shockwave to an appropriate strengthening programme produces better results than rehabilitation alone.
In practice, it may be useful for selected patients whose symptoms remain difficult to settle or who are struggling to progress their loading. It should be viewed as an adjunct rather than a replacement for rebuilding hamstring strength and restoring tolerance to running or sport.
Is pain during exercise acceptable?
Rehabilitation does not always need to be completely pain-free. Mild discomfort—often up to around 3 out of 10—may be acceptable if it settles promptly and symptoms have returned to their usual level by the following day.
The delayed response is particularly useful. If sitting pain or morning pain is clearly worse for more than 24 hours, the session was probably too demanding. The answer is usually to adjust the weight, range, repetitions or overall training load rather than abandon strengthening altogether.
Can you continue running?
Often, yes. Running may be maintained when symptoms remain mild and stable, but the provocative elements may need temporarily reducing. Faster running, hills, acceleration and large increases in volume generally place more demand on the proximal hamstring than easy running on level ground.
A return-to-running progression commonly moves through:
Easy, flat running
Increased duration or weekly volume
Gradual reintroduction of hills
Controlled faster running
Sprinting, acceleration and sport-specific demands
Not every runner needs to start from walking or short run-walk intervals. The starting point should reflect what can already be completed without a significant delayed reaction.
How long does recovery take?
There is no single timescale. A recent, mildly irritable problem may improve relatively quickly, while longstanding symptoms usually require several months of consistent loading. Progress is rarely perfectly linear: a temporary reaction after a new exercise or harder run does not necessarily mean the tendon has been damaged again.
Useful signs of progress include easier sitting, improved strength, less next-day pain and the ability to tolerate progressively harder running—not simply the absence of pain during one particular exercise.
The key message
Proximal hamstring tendinopathy is usually a load-capacity problem, not a hamstring that needs endless stretching. Reducing the most provocative loads can help settle symptoms, but lasting improvement normally requires progressive hamstring and lower-limb strengthening followed by a structured return to faster running or sport.
If pain at the sitting bone keeps returning whenever you increase your running, an individual assessment can confirm the likely source and establish how much activity you can safely continue while rebuilding capacity.
Fit by Physio provides assessment and rehabilitation for running injuries and tendon problems in Tooting Bec, South West London.
Related physiotherapy services
Read more about tendon rehabilitation, running injury assessment and shockwave therapy.
Not sure whether your symptoms fit PHT? Email Fit by Physio for advice or to arrange an assessment in Tooting Bec.
References
Rich A, Cook J, Mosler A, et al. Individualised physiotherapy compared with shockwave therapy for proximal hamstring tendinopathy: a randomised controlled trial. American Journal of Sports Medicine. 2025. View the study.
Rich A, Cook J, Mosler A, et al. Treatment of proximal hamstring tendinopathy with individualised physiotherapy: a clinical commentary. International Journal of Sports Physical Therapy. 2025. Read the clinical commentary.