Proximal Hamstring Tendinopathy: Symptoms, Causes, Treatments


You may have recently found yourself experiencing pain in your lower buttock and wondered “Is this my back, my hip or my hamstring?” If you have pain and tenderness over your 'sitting bone' in sitting, chances are, you may have proximal hamstring tendinopathy. There are some other key features that help distinguish proximal hamstring tendinopathy from back or hip pain. This blog will provide you with a better understanding of proximal hamstring tendinopathy symptoms, causes and treatments.

What is Proximal Hamstring Tendinopathy

So your physiotherapist has just told you that you have a proximal hamstring tendinopathy and you’re wondering “what on earth gobbledegook just came out of their mouth?”. It’s a mouthful to say out loud so if we break down it simply means:

  • “Proximal” : situated closer to the centre of the body,
  • “Hamstring” : the muscles at the back of your thigh, and
  • “Tendinopathy” : a painful tendon (tendons are fibrous structures that join muscles to bone).

Put together, it refers to a painful hamstring tendon in your lower buttock, where the hamstring tendons join into your sitting bone (ischial tuberosity). 


The hamstring muscles sit in the back of your thigh, run from just below your knees up to your sitting bones or sit bones (ischial tuberosities). When moving into hip flexion (moving the knee closer to your chest) the top of these tendons wrap around the ischial tuberosity which produces a compressive force.

Tendons typically don’t like to be compressed for too long and therefore repeated and/or sustained hip flexion may cause changes within the hamstring tendons that may become painful in some people.

Proximal hamstring tendinopathies are most common in people who participate in sports that involve working the hamstring muscles hard, often in lengthened positions (stretching out in front with the foot, bending forward or lifting the leg up in front with the knee straight)  - think long course running, long jump, hurdles, sprinting, hockey, football codes and performance sports such as dance and circus. 

However proximal hamstring tendinopathies can also occur in less aggressive exercise such as Pilates or yoga and in the non-sporting population as well (Goom et al., 2016).

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Because of our expertise in hip conditions, dance injuries and performance, and hypermobility, we also have people visiting us from all over Queensland, Australia and even international visitors. We also have a telehealth service for remote patients.

Do you have pain in your buttock when sitting? Not sure if it's your back, your hip or your hamstring? 

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Symptoms of Proximal Hamstring Tendinopathy

There are a number of symptoms related to Proximal Hamstring Tendinopathy, which include:

Lower buttock pain:

  • Pain is felt over the sitting bone (ischial tuberosity), and it can also extend into the upper thigh. 

Pain when sitting:

  • Compression of the tendon around the ischial tuberosity (sitting bone) can be particularly painful when you have proximal hamstring tendinopathy. Therefore, sitting on hard surfaces can be aggravating as your tendon is compressed under your body weight.

Buttock pain in forward bending or hamstring stretching: 

  • Actions such as bending over or stretching hamstrings compress the hamstring tendon over the ischial tuberosity and therefore may elicit a pain response.
  • You might feel this pain leaning over to empty the dishwasher, pull weeds from the garden or picking something off the floor.
  • The pain will usually be worse if your knees are straighter when you lean over. 

Pain when walking or running up an incline:

  • Leaning forward as you walk or run up a hill may cause symptoms as the hamstring muscles are working hard and the tendon is wrapped firmly around the back of the sitting bone. This can therefore be painful for someone with proximal hamstring tendinopathy.  

Hamstring Tightness or Stiffness:

  • Hamstring tightness or stiffness may be felt first thing in the morning or when beginning exercise. Runners may find it difficult to achieve a full stride length due to the tightness or protective muscle stiffening in the back of their thigh. In earlier stages of proximal hamstring tendinopathy it may feel stiff and then warm up/disappear after a few minutes.
  • In the more severe cases, the hamstrings may feel tight and stiff (with/without pain) at the beginning of exercise, following by gradually increasing pain requiring the person to eventually stop the activity.

Causes of Proximal Hamstring Tendinopathy

Too much exercise - too soon:

  • Increasing exercise volume and or intensity too quickly may lead to symptoms of proximal hamstring tendinopathy. Tendons don't like rapid changes in activity levels - it takes them a little longer to adapt. 

Too much of certain types of exercise:

  • In particular, a sudden introduction of hill walking/running/cycling, sprinting, hurdling or lunging can cause onset of hamstring tendon pain. This is because the muscle is on stretch but working hard, with the tendon wrapped firmly around the sitting bone. This causes maximum compression and tension where the tendon wraps around the sitting bone (Goom et al., 2016).

Too much stretching:

  • Similar to the above, a high volume of sustained hamstring stretching can lead to pain, due to the cumulative compression of the hamstring tendon at its insertion. Some postures in yoga and Pilates such as forward folds, downward facing dog and legs in straps with knees straight can contribute to the development of pain in the proximal hamstring tendons (Goom et al., 2016).


  • Tendon health tends to reduce with age in general. However proximal hamstring tendinopathy is common in younger runners, so this is not just an age-related condition.

Hormonal changes:

  • Oestrogen is an important hormone that is involved in maintaining tendon health in females.  Reduced oestrogen levels after childbirth (temporary) and after menopause, may contribute to reduced tendon health in women, and increase the chances of developing tendon conditions, including proximal hamstring tendinopathy.  

Metabolic factors:

  • Diabetes: Increasing levels of glucose within tendon cells can reduce tendon health, increasing risks of developing tendinopathy (Scott et al., 2015).
  • High cholesterol: Increased levels of cholesterol in the blood or (hyperlipidaemia) may result in an accumulation of lipids within the tendons, reducing tendon health (Abate et al., 2013; Miller et al., 2021). As cholesterol levels are influenced by diet, diet may also be a risk factor for developing tendinopathy (Scott et al., 2015).

Pain in your buttock? Hamstrings? Pain when sitting? Walking/Running on an incline?

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Treatments for Proximal Hamstring Tendinopathy

The first port of call for help with your proximal hamstring tendinopathy should be a physiotherapist experienced with this condition, like our team at PhysioTec. A physiotherapy treatment programme involving education and specific advice, and an individualised exercise programme can be successful in managing this condition for most people.

Cortisone injections should NOT be your first choice - although they may provide short-term relief, they don't 'cure the problem' and may further reduce the health of your tendons. Lots of research on different tendinopathies have shown poor results from cortisone injections in the longer term. So, TRY PHYSIO FIRST!

Physiotherapy for Proximal Hamstring Tendinopathy

Education and Advice for Proximal Hamstring Tendinopathy

The first important step in your recovery from proximal hamstring tendinopathy is understanding your condition. If you understand why it's happening, you can pretty quickly start to figure out what things in your own daily and recreational activities might be aggravating your tendons.

Here are some general tips that will get your started on settling your hamstring tendons:

Decompress your Hamstring Tendons

Spend less time compressing your proximal hamstring tendons. Reduce some of these things until your pain settles:

  • Sitting on a hard chair
  • Walking/running up hills or stairs
    • Stick to the flats for a while
  • Bending over from the hips - in the garden, the house or at work 
    • Try to use your knees as well (squat rather than hinge from the hips), or kneel for floor based activities)
  • Hamstring stretching 
    • While it might seem the natural thing to do, these is likely to be more aggravating than helpful. Give stretching a break.
Other load management strategies for proximal hamstring tendinopathy

Manage your overall tendons 'loads' by managing your general activity levels and being mindful of what exercises you choose.

  • Reduce activity levels, then gradually rebuild
    • Allow the tendon to settle and then gradually rebuild activity levels. It is not usually necessary to stop all activity - exercise is important, right! Your physio can help with providing guidance about how much is better for your situation.
  • In the gym, avoid deadlifts, 'hip-hinge' type exercises, deep lunges and high step ups.
    • Don't worry there are plenty of other things you can do - our physio's can build you an alternative programme.
  • Rest from explosive movements such as sprinting, jumping and bounding
    • We can bring these back in once your tendon has settled


Rehabilitative Exercise for Proximal Hamstring Tendinopathy

An exercise programme specifically designed for proximal hamstring tendinopathy is important for reducing your pain, improving and then maintaining tendon health, and getting your safely back to full activity.

Our team at PhysioTec can build you an individualised program that will suit your current levels of pain and function, and help you progress through your programme to get back to the things you need to do and the things you love to do!


Hands-on Treatment

Our physios can also provide you with some hands-on treatment in the early phases of your rehabilitation, to help ease your pain. This will usually involve massage of the hamstring muscle belly (back of the thigh), and sometimes mobilisation of other areas that might be contributing to your pain (e.g., your back or a stiff ankle from a previous injury that might be changing the way you move).

It's important to be aware however, that long-term success in treatment of proximal hamstring tendinopathy relies on good load management and a progressive exercise programme - these are the key components of rehabilitation, so you'll need to take an active role in your rehab for best outcomes.


Getting help for your Proximal Hamstring Tendinopathy

Physiotherapy is a great place to start to reduce your pain and work together on a plan for recovery. A physiotherapist will be able to help determine if there are any particular things that may have contributed to your proximal hamstring tendinopathy, for example training programmes, movement patterns (the way you move), muscle weakness or problems in other areas that are causing overload of the hamstring tendons. 

PhysioTec physiotherapists will formulate an individualised rehabilitation program for you, in order to get your hamstring tendons happy again and allow you to get back to doing what you love. The staff at PhysioTec Physiotherapy have lots of experience in the treatment of proximal hamstring tendinopathies. So, if you are currently experiencing lower buttock pain, book a consultation with one of our friendly physiotherapists who will help you get back on track.


Is pain in your buttock or hamstring making it hard to move normally, or do regular activities, like running, walking, or even sitting comfortably? Visit us at PhysioTec, and let one of our physios provide an assessment and a personalised program to help you get on-top of that pain, and back to those favourite activities!




This blog was written by Molly Connolly, one of our Sports Physiotherapists and Pilates Instructors.  Molly's undergraduate degree was in Exercise and Sports science and she completed a PhD of the title: A multidisciplinary approach to understanding low back pain in elite adolescent tennis athletes. She also has a love of triathlon! Molly completed a post-graduate Masters in Physiotherapy at the University of South Australia.

You can read more about Molly here.

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Hamstring pain can have a large impact on your life, limiting your movement, and keeping you away from doing the things you love. At PhysioTec, our experienced physios can assess you and provide you with a personalised program to help you get on-top of your pain, and back to doing the things you love!

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