Proximal hamstring tendinopathy Rehab for Runners: what is it and how do you overcome it

Are you a runner or hyrox athlete struggling with deep buttock or high hamstring pain when you run or sit you could be dealing with proximal hamstring tendinopathy. In this blog we will learn a little more about what it is and how we can overcome this tricky injury with smart load management and progressive rehabilitation. Information is taken from my experience treating this condition as well as latest research and expert consensus.

What is proximal hamstring tendinopathy in runners ?

Proximal hamstring tendinopathy (PHT) is a condition that affects athletic population including runners, footballers, rugby, track and field athletes as well as hyrox athletes and presents clinically as localised pain into the lower buttock region. Pain is often reproduced with prolonged sitting, high speed running, walking and running up hill as well as during deep flexion activities in the gym such as squads and lunges.

It is often a tricky condition to treat due to the time required for the tendon to adapt to the rehabilitation plan, the location of the hamstring tendon and how it is compressed and irritated in many daily tasks such a driving and sitting at a desk. I also find it can be a condition that can take a while for individuals to get an accurate diagnosis.

Why does Proximal Hamstring Tendinopathy in runners happen?

PHT often occurs after a training load error. By this I mean an increase in an individual’s training loads above what its tissues have build capacity to tolerate. Specifically for PHT, I commonly hear of an increase in high speed running, an increase in volume and intensity of hill repeats or an increased volume of deep squats or lunges. These actions load the tendon in two main ways; tensile loading (typical contract/relax or storage and release of energy loading) or compressive loading on the proximal hamstring tendon against the pelvic bone. As you can see from the picture below as the thigh is flexed or pelvis/trunk is tilted forward this increases the compression of the surface of the hamstring tendon on the pelvis bone. If is often the cocktail of an increase in BOTH compression and tensile loads that can trigger the PHT to become symptomatic.

A-schematic-diagram-of-the-left-hamstring-muscle-divided-into-proximal-middle-and-distal. picture from Shamji, R., James, S. L., Botchu, R., Khurniawan, K. A., Bhogal, G., & Rushton, A. (2021). Association of the British Athletic Muscle Injury Classification and anatomic location with return to full training and reinjury following hamstring injury in elite football. BMJ Open Sport & Exercise Medicine, 7(2), e001010.

Typically, within a running population I typically see two types of individuals present with PHT. Firstly, the trail runner who spends lots of time in high compressive loads on the proximal hamstring due to the high amounts of hip and trunk flexion when running up hill. Care must be taken when introducing hill work as this isn’t ‘dangerous’ for the body it’s more a question of how prepared is this individual for these types of loads.

Top Tip – gradually add in hill work and assess response 24hrs later.

Secondly, would be a track or road runner who displayed some running gait characteristics that might place more load on the proximal hamstring. For example an overstride or a more anteriorly tilted pelvis has been shown to load the proximal hamstring more (Mendiguchia et al., 2024). However, what is more critical here is the change or spike in load than the baseline running gait.

What does rehabilitation for proximal hamstring tendinopathy look like / how do I fix this?

First thing is to set expectations, if you are suffering from PHT it is likely this condition will take 3-6+months to fully rehabilitate. PHT is often provoked in positions of compression of which we find ourselves in daily for habitual and occupational tasks such as sitting at a desk, driving a car etc. so it is often hard to avoid these provocative positions. In addition, the treatment of any tendon typically takes a lot longer than other conditions due to the make up of the tendon tissue.

A typical example of the phased of PHT rehabilitation are shown in the table below:

Table describing phases of rehab for proximal hamstring tendinopathy

Examples of early hamstring loading include short level bridges which can be isometric holds or through ranges progressing to longer levers:

The prone hamstring curl is a great way to load the hamstring with increasing intensity from double to single leg without any compression at the hip:

A good marker of progress can be the pain response to this isometric test in 90* of hip flexion. The aim is to push the tested heel hard down into the block and hold and record a 0-10 discomfort level. A useful way to track progress and readiness to load into hip flexion.

We have not covered return to running in this blog and might be something I cover if there is enough interest so let me know!

If you are struggling with proximal hamstring tendinopathy as a runner and would like some support both online or in person then why not reach out. Appointments can be booked via this link www.newtonphysiotherapy.co.uk

Don’t forget this can take a long time and progress is slow, make sure you have a clear progressive plan!

Liam

Please remember this blog is for educational purpose only and not intended to replace medical advice, consult a registered health professional for specific individual advice.

References

Mendiguchia, J., Garrues, M. A., Schilders, E., Myer, G. D., & Dalmau‐Pastor, M. (2024). Anterior pelvic tilt increases hamstring strain and is a key factor to target for injury prevention and rehabilitation. Knee Surgery, Sports Traumatology, Arthroscopy, 32(3), 573-582.

Nasser, A. M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E., & Semciw, A. I. (2021). Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, 67-75.