Proximal hamstring tendinopathy (PHT) is a chronic, often debilitating condition that can challenge even the most determined individuals. It’s commonly misunderstood and mismanaged, leading to extended pain, frustration, and limitations in physical function. This blog delves into the science of PHT, examining what it is and is not, its usual patient profile, the hurdles in rehabilitation, and the best clinical exercises for effective management. A comprehensive understanding of tendinopathy, including its classification as a “failed healing response,” is essential for managing PHT effectively.
1. Understanding Tendinopathy: A Failed Healing Response
Tendinopathy refers to pain and dysfunction within a tendon, arising from cumulative overuse without sufficient healing. In a normal injury response, tissues follow a series of healing stages: inflammation, repair, and remodeling (Khan & Scott, 2009). However, tendinopathy represents a “failed healing response,” where the tendon fails to progress beyond the inflammatory and repair stages into full remodeling. This is marked by ongoing cellular changes that disrupt the tendon’s structure, resulting in pain and functional impairment (Rio et al., 2015).
The hallmark feature of tendinopathy is its structural degeneration, or tendinosis, where chronic overload causes microtears that outpace repair, leading to disrupted collagen fibres, hypercellularity, and the formation of disorganised vascular networks (Rees et al., 2014). This process manifests as pain and stiffness, particularly under load or following prolonged rest, impairing the tendon’s capacity to bear weight efficiently. While inflammation does play a role, it is not the primary driver; thus, PHT and similar tendinopathies do not typically benefit from anti-inflammatory treatments alone (Cook & Purdam, 2009).
2. Proximal Hamstring Tendinopathy: Definition and Mechanism
Proximal hamstring tendinopathy specifically affects the common hamstring tendon, located at the ischial tuberosity (the “sit bone”). This area is subjected to compressive forces as it curves around the pelvis and encounters tensile loads from activities like sprinting, jumping, or prolonged sitting (Puranen & Orava, 1988). Repeated loading and compression contribute to microscopic tendon damage, which, without adequate recovery, can progress to tendinopathy. Unlike tendon tears, which involve acute rupture, PHT is a slow, degenerative process that builds gradually, often exacerbated by continued training despite pain or minor discomfort (Goom et al., 2016).
3. What PHT Is Not
Misconceptions about PHT can hinder correct diagnosis and management. PHT is often confused with hamstring strains, lower back pain, or sciatic nerve issues due to its deep gluteal pain and proximity to the sciatic nerve. However, PHT lacks the acute, sharp pain typical of muscle strains and does not directly cause neurological symptoms like numbness or tingling unless secondary nerve irritation is present (Bennell et al., 2021). Imaging can help differentiate PHT from other pathologies, showing characteristic tendon thickening, degeneration, or calcification around the ischial tuberosity.
4. Who Usually Gets Proximal Hamstring Tendinopathy?
PHT predominantly affects two demographic groups: endurance athletes and middle-aged individuals, especially those returning to activity or increasing training volume without sufficient conditioning (Goom et al., 2016). Runners, sprinters, and dancers, who consistently load the hamstring tendons, are particularly susceptible due to the high tensile forces in their sports. Additionally, activities involving hip flexion, such as prolonged sitting or cycling, compress the tendon, increasing the risk for tendinopathy over time.
Several risk factors contribute to PHT development, including:
- Ageing Tendon: Tendons naturally lose elasticity and vascularity with age, reducing their ability to heal (Magnusson et al., 2010).
- Biomechanical Factors: Poor pelvic control, weak gluteal muscles, and tight hip flexors can contribute to excessive strain on the hamstring tendons (Khamwong et al., 2012).
- Training Errors: Rapid increases in activity levels or intensity can overload the tendon before it has adapted (Cook & Purdam, 2009).
5. Challenges in Proximal Hamstring Tendinopathy Rehabilitation
Rehabilitating PHT can be challenging due to several factors:
a. Pain Management and Tolerance to Load
Tendinopathy pain is notorious for being activity-dependent, often easing with warm-up but worsening afterward, which can lead individuals to underestimate the extent of injury. Effective management requires gradual loading while respecting the “acceptable pain threshold” (usually around 3-4 out of 10 on the pain scale) to stimulate tendon adaptation without exacerbating damage (Silbernagel et al., 2007).
b. Tendon’s Slow Adaptive Response
Tendons adapt slowly due to poor blood supply and limited cellular turnover. Rehab protocols, therefore, require patience and consistent, prolonged effort over months rather than weeks (Docking & Cook, 2015). Tendon conditioning should be approached incrementally, as tendons typically take 12-24 weeks to demonstrate significant structural change, unlike muscles that respond in just a few weeks (Rees et al., 2014).
c. Neuromuscular Coordination
Optimal rehabilitation requires not only strengthening the hamstring but also enhancing the coordination of surrounding muscles. Poor pelvic stability or inadequate gluteal strength can perpetuate compensatory patterns, worsening tendon overload (Alentorn-Geli et al., 2009).
d. Load-Specific Rehab Phases
The unique demands of tendons necessitate phase-specific loading that progresses from isometric exercises, which reduce pain, to isotonic and plyometric exercises that restore functional load tolerance (Rio et al., 2015).
6. Medical History and Physical Examination Findings
During clinical assessment of PHT, a thorough medical history and physical examination are crucial for accurate diagnosis. Patients typically report a dull, aching pain located at the lower buttock near the ischial tuberosity (“sit bone”), often worsening with sitting, running, or forward flexion of the hip (Goom et al., 2016). Pain that worsens with sprinting, jumping, or extended sitting often suggests PHT rather than an acute hamstring strain.
Physical examination findings commonly include tenderness at the ischial tuberosity upon palpation, with pain reproducing under resisted hamstring contraction or passive hip flexion with a straight knee (Reiman et al., 2013). The “bent knee stretch test,” where pain is exacerbated when the hip is flexed to 90 degrees with the knee bent, can help identify proximal tendon involvement (Goom et al., 2016). Weakness or discomfort during specific strength tests, such as the single-leg bridge or resisted hip extension, may also indicate PHT. A skilled clinician may further assess for hip or pelvic instability and consider differential diagnoses such as lumbar spine pathology or piriformis syndrome.
Imaging, such as MRI or ultrasound, may reveal characteristic features of PHT, including tendon thickening, degeneration, or calcification at the tendon’s proximal attachment to the ischium. However, imaging is typically reserved for cases where diagnosis is uncertain or conservative management has failed (Khan & Scott, 2009).
7. Best Clinical Exercise Rehabilitation for Proximal Hamstring Tendinopathy
A successful rehabilitation plan for PHT should incorporate progressive loading exercises that promote tendon remodeling and strength. Below are the key exercise phases, each with distinct goals and exercise types.
Phase 1: Isometric Exercises for Pain Reduction
Isometric exercises involve sustained contractions without joint movement, helping to reduce pain and prepare the tendon for more demanding exercises. Studies show that isometric exercises can reduce tendinopathy pain by increasing the tendon’s load tolerance without causing excessive strain (Rio et al., 2015).
- Example Exercise: Single-leg isometric bridge – lying supine with the working leg bent and foot on the ground, the non-working leg extended, holding a raised position for 30–45 seconds per side, 4-5 repetitions.
Phase 2: Isotonic Exercises for Strengthening
Isotonic exercises introduce controlled movement, building tendon strength and resilience. At this stage, exercises should focus on slow, controlled movements through the hamstring’s range of motion.
- Example Exercise: Single-leg Romanian deadlift – balancing on one leg, the athlete hinges at the hips with the spine neutral, lowering and lifting with control to work through hip flexion and extension.
Phase 3: Eccentric Loading for Tendon Adaptation
Eccentric loading exercises strengthen the tendon through lengthening contractions, proven to stimulate collagen synthesis and tendon remodeling (Beyer et al., 2015). These exercises are performed with controlled descent to maximise tendon adaptation.
- Example exercise: Prone Lying Cable Hamstring Curls: Lying face-down on a bench with the ankles connected to a low cable pulley, the athlete curls the heels toward the glutes, using hamstring control to lift the weight. The movement is performed slowly, maintaining tension throughout, and returns to the start position with a controlled descent.
Phase 4: Plyometric and Sport-Specific Training
In this final phase, explosive exercises reintroduce high-velocity, tendon-specific loading to prepare for the rigors of sport or activity. Plyometric drills like bounding, sprinting drills, or quick take-offs and decelerations target the hamstring’s functional role.
- Example Exercise: Bounding – explosive forward leaps alternating legs, focusing on ground contact time and hip control.
Conclusion
Proximal hamstring tendinopathy is a challenging injury that demands a nuanced, science-based approach. Recognising tendinopathy as a failed healing response underlines the importance of controlled loading, gradual progression, and pain monitoring for tendon adaptation. By incorporating phase-specific exercises that progress from isometric pain relief to plyometric and functional training, individuals can rebuild tendon health, ultimately returning to their chosen activities with reduced pain and increased resilience.
References
Alentorn-Geli, E., Alvarez-Diaz, P., Ramon, S., Marin, M., et al. (2009). Assessment of neuromuscular control after an anterior cruciate ligament reconstruction: a comparison between open and closed kinetic chain exercises. Sports Health, 1(3), 256-261.
Beyer, R., Kongsgaard, M., Hougs Kjær, B., et al. (2015). Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. The American Journal of Sports Medicine, 43(7), 1704-1711.
Bennell, K. L., Crofts, G., Weedon, M., et al. (2021). Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. British Journal of Sports Medicine, 55
Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416. https://doi.org/10.1136/bjsm.2008.051193
Docking, S. I., & Cook, J. (2015). Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC). Scandinavian Journal of Medicine & Science in Sports, 25(4), e222-e230. https://doi.org/10.1111/sms.12254
Silbernagel, K. G., Thomeé, R., Eriksson, B. I., & Karlsson, J. (2007). Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy. British Journal of Sports Medicine, 41(4), 276-280. https://doi.org/10.1136/bjsm.2006.033464