One of the more challenging issues I see in the clinic is pain in the upper hamstring region. Proximal hamstring tendinopathy, referred to medically as tendinosis, is common in runners and athletes. With that said, arriving at this diagnosis can also be challenging as proximal hamstring pain can also be caused by sciatica or referred pain from the low back region. A thorough clinical exam and good history will be able to definitively help diagnose the cause.

Chronic hamstring pain can occur as a result of a previous acute tear, or due to ongoing tendinitis that is aggravated by repetitive activity. Running, biking, rowing and even prolonged sitting can aggravate the hamstring tendons where they attach to the ischial tuberosity. There is also an ischial bursa that cushions this region that can become chronically inflamed. It is a common problem for distance runners and athletes involved in sprinting, hurdles, or cutting . Typical signs and symptoms include a deep, local pain in the buttocks/upper hamstring region that worsens with running, squatting, lunging and sitting.

Differential diagnoses include:

  • Sciatic nerve irritation (may be a co-morbidity in some cases)
  • Ischiofemoral impingement
  • Apophysitis or avulsion in adolescents
  • Deep gluteal muscle tear
  • Stress fracture (posterior pubic bone or ischial ramus)
  • Partial or complete rupture

Proximal hamstring tendinopathy is rarely painful during activities that do not involve elastic energy transfer or compression, such as walking on even ground, standing or lying down. Tears are typically accompanied by extreme hip flexion and knee extension during an acute injury (usually hear an audible pop).  In some cases, chronic pain may also be accompanied by an exaggerated pain response, referred to as central sensitization where the central nervous system conveys an amplified neural signal resulting in pain hypersensitivity.

Physical assessments include looking at flexibility and load on the tissue.  I like to assess hamstring flexibility with the hip and knee flexed, hip flexion and knee extension (straight leg raise) and hip/knee flexion with internal and external rotation. Assessing forward trunk flexion reveals a lot about the irritability of the hamstring as well.  Additionally, I like to look at a single leg RDL (comparing mobility and strain to the other side), forward reaching lunges and single leg squats to assess closed chain eccentric loads. Provocative testing to rule in/out low back/SI joint pathology, hip impingement and other soft tissue pathology should be done. According to research, palpation is not a good predictor of hamstring tendinopathy.

Rehab Guidelines

I like to think about rehabbing PHT in 4 different phases: inflammation reduction, mobility and low level strengthening, progressive loading, and functional training. Clients with chronic pain still experience acute episodes of pain. As such, it is important to assess how painful or acute the irritation is. Mobility and force generation capacity will reveal a lot about the level of inflammation that is present.  Below are some sample exercises in each respective phase. The timeline for progression is based upon individual pain responses and the degree of pathology.

Phase 1: relative rest, modalities, gentle ROM/stretching, hamstring setting, and sub maximal isometrics

Phase 2: stretching using body weight/trunk flexion, closed chain isometrics, balance exercises and double leg bridges

Phase 3: single leg bridges, hamstring curls, Nordic hamstrings, RDL, lunge progressions, and cone reaches

Phase 4: single leg sticks, plyometrics, bounding, linear acceleration/deceleration and progression to multi-directional movement patterns

Teaching clients to grade their pain (on 0-10 scale) before, during and after exercise is essential to recovery. I advocate working in no no more than a 3-4/10 range and monitoring soreness afterward. The post-exercise soreness rating should return to baseline in 24 hours or less.  If it does not, then the training or rehab was too intense and needs to be modified.

In addition to progressive loading, other modalities such as ultrasound, IASTM (instrument assisted soft tissue mobilization) and dry needling can also be helpful. Some MDs may advocate PRP, although research has yet to fully substantiate its superiority over other modalities with respect to tendinopathy.  Click here to read on article comparing whole blood and PRP ultrasound guided injections.

In the end, I find a multi-modal approach often works best with my active clients. Age, injury history, activity level and longevity of the problem all impact clinical decision making. Since this is a chronic issue, keep in mind it takes time to resolve, and periods of exacerbation in active individuals is likely long term. Learning how to recognize signs and symptoms along with modifying loads and staying on a maintenance exercise program will go a long way in alleviating pain.