Hamstring Tendinopathy | How to Manage that “Pain in the Bottom”

Hamstring Tendinopathy: Have you noticed a pain in the bottom that just wont go away? Then you may have what is called a proximal hamstring tendinopathy. This article will describe the ins and outs of a hamstring tendinopathy and how to treat it!

What is Hamstring Tendinopathy?

A proximal hamstring tendinopathy is a pathology of the high hamstring tendon where it attaches to the ischial tuberosity (sit bone of the buttock). Typically, we see this condition in runners who have suddenly increased their training volume/intensity, or started hill running. Those with a developed hamstring tendinopathy will complain of a deep, annoying buttock pain during activities such as hill walking, running and/or prolonged sitting/driving.

hamstring anatomy

What is the role of the tendon in Hamstring Tendinopathy?

A tendon’s role is to attach muscle to bone. Tendons are designed to take compressive and tensile loads. A normal tendon is made up of a fibrous tissue containing highly organised type one collagen. You can imagine the structure of the tendon looking like a rope.

Within the tendon there are specific cells called tenocytes and tenoblasts, which are responsible for looking after the tendon structure. Tendons do receive blood supply, however this supply is less at the point where the tendon attaches onto the bone. Consequently, this is commonly where a tendinopathy will occur.

rope hamstring tendonopathy


What causes the tendon to become pathological and painful?

To keep it simple, tendons do not like sudden changes. A sudden change in load through the tendon causes adverse changes to the tendon.

When there is too much load through the tendon that exceeds its ability to recover,  the structure of the tendon changes and becomes pathological. When the tendon is unhappy the collagen becomes disoraganised and unfavourable changes occur to the cellular and neurovascular components.

Dr Jill Cook and Craig Purdham (2015) published and revised a model to help explain tendon pathology. Under periods of excessive un-adapted loads, the tendon is believed to progress through stages of a continuum. Load management (adding or removing load) is the primary stimulus that has the ability to change the tendon’s status on the continuum.

The stages of tendon pathology on the continuum are described below:

hamstring tendinopathy diagram

Reactive tendon phase

  • due to an acute overload of activity
  • the tendon will temporarily thicken to decrease the stress (no inflammation involved)
  • the tendon can reverse back to a normal if load is reduced or sufficient time for repair is allowed

Tendon disrepair

  • Chronically overloaded tendon and failed attempt at healing
  • more adverse tendon changes
  • reversibility is possible with load management and progressive exercises to stimulate the tendon matrix

Degenerative tendon

  • continual progression of tendon changes with areas of cell death. A good analogy is to imagine a degenerative tendon looking like a donut. The unhealthy part of the tendon is the hole in the donut and the healthy tendon is the donut part. Therefore management focuses on treating the yummy doughnut rather than the hole!
  • more common in the older individual
  • little capacity for reversibility
  • continue load management and strength training to maximise the tendon’s tolerance


How do you get Hamstring Tendinopathy?

There are many factors that can cause a hamstring tendinopathy, some that we have control over (extrinsic) and others that we do not (instrinsic)


  • Increasing age (middle aged + )
  • auto-immune disorder (such as diabetes Type 1 and 2)


  • obesity
  • Training errors and unaccustomed loads: such as a sudden introduction of hill running, deeper lunges at the gym, or a sudden increase in running distance
  • Decreased gluteus maximus strength and bulk. The gluteal muscles act like a cushion under the hamstring tendon to protect it from compressive loads. If your gluteal muscles are small and weak then there is not much protecting the tendon.


Common Symptoms of Hamstring Tendinopathy?

  • deep buttock pain with prolonged sitting, driving, running, that may radiate down the back of the thigh
  • morning stiffness felt deep in the buttock and extending down to the back of the thigh
  • pain and stiffness with initiation of activity, but as the tendon warms up, the pain will settle. After activity there is often more pain which can be delayed for up to 48 hours


What will aggravate an unhappy tendon?

Activities that involve prolonged compression and/or stretch-shorten loading of the tendon that exceeds the healing capacity.

These activities include:

Compressive loads (squashes the tendon under the sit bone)

  • prolonged driving > 30minutes
  • prolonged sitting >30minutes

Compression with activity loads

  • uphill running
  • deep lunges or squats
  • high speed running
  • long distance running


Diagnosis of Hamstring Tendinopathy

  • pain with physiotherapy provocation clinical tests including: the passive bent knee stretch test, straight leg hamstring stretch test and resisted hamstring tests
  • tendinopathy can be confirmed on MRI or US imaging. However changes to tendon structure have been identified in non sympotmatic tendons. Cook and Purdham’s research found that there is no direct relationship between tendon pain, structure and function.


Differential diagnosis – If it’s not a tendinopathy then what else could cause buttock pain?

  • deep gluteal compression syndrome
  • impingement between the thigh bone and the hip bone
  • apophysitis in adolescents
  • pubic ramus or posterior pubic stress #
  • lumbar spine referred pain
  • deep gluteal tear & management


1. Initial Phase

  • Relative rest or small reduction in training volume. Avoid complete rest because tendons do not like rest
  • Manage the sitting pain  : get up and walk around regularly, use a cushion to sit on,  raise the height of your chair,  bring the seat forward in your car, and use cruise control (if safe).
  • Tendon pain relieving exercises: trial these two exercises to help relieve the tendon pain. The first one is a buttock squeeze which will help create a muscular pillow under the hamstring thereby relieving the compression. The second one is digging your heel into the ground while sitting. This creates an isometric contraction of the hamstring (contracting the muscle without a change in length) thereby helping to relieve tendon pain.
  • Avoid stretching the painful tendon because this will increase tendon pain


2. Gradual loading program

  • a gradual tendon loading program developed by your physiotherapist. The loading program will often consist of heavy slow resistance training which has shown to have the best stimulus for improving tendon structure
  • Muscles that will be strengthened may include: the hamstrings, gluteal muscles and side abdominal muscles


Exercises for Hamstring Tendinopathy

  1. Isometric contractions (medicine for tendon pain)  

2. Arabesques

3. Nordic Hamstring Drops


4. Hamstring Curls

5. Side Planks 



Take Home points

  1. Take relative rest from compressive loads such as sitting and make some adjustments to manage your sitting pain
  2. Don’t stretch the hamstring tendon because this can make it more unhappy
  3. Work with a physiotherapist to construct a gradual tendon strengthening program. Click here to look at an example hamstring tendon loading protocol.









About Josie Pepper

Josie graduated with a Bachelor of Physiotherapy at Newcastle University. Josie is new to the city, and is ready to begin her new chapter at Sport and Spinal Physiotherapy. Her interests include sports injury rehabilitation, women’s health and Pilates. Outside of work, she enjoys triathlons, running, horse riding, snow boarding and shopping.