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A pain in the butt - a closer look at hamstring tendinopathy

Updated: Sep 20, 2021

A pain in the butt. This is what some might describe an injury called a proximal hamstring tendinopathy. That’s because it quite literally is. This injury is common in change of direction sports like football, soccer and hockey, but it can also occur in a non- athletic population. It is characterised by a deep, localised pain over the ischial tuberosity (a large, bony bump on your bottom) and is often aggravated by running, lunging, squatting and sitting.

Hamstring injuries are one of the most common injuries in sports. They are especially frustrating due to the high recurrence rate (largely because it isn’t appropriately managed) and lengthy rehabilitation.

Anatomy of the hamstrings

The hamstrings are a complex of three different muscles: the biceps femoris (comprised of a long and short head), semitendinosus and semimembranosus. All three musculatures (with the exception of the short head of biceps femoris), originate from a bony structure called the ischial tuberosity, also known as your “sitting bone”. These muscles cross the hip and knee joints, allowing the movement of hip extension and knee flexion.

What is a tendinopathy?

Tendinopathies are a functional and structural change of the tendon. The changes that occur in the structure result in a tendon that is less capable of withstanding repeated forces which in turn results in reduced exercise tolerance. Tendinopathies becomes less symptomatic after a few minutes of activity (such as a warm up), only for the symptoms to worsen afterwards. They typically develop due to a sudden increase in training volume, or in the non-athletic population, from compressive load at the tendon insertion, which in this instance, is usually from prolonged sitting.

The key to managing all tendinopathies is through load modification and progressive loading performed in a pain-monitoring framework. This is by progressing through multiple stages of rehab.

Stages of rehab

Stage 1: Isometric hamstring load

Isometrics are a form of muscle contraction where tension is built without the muscle changing length. Research shows this to be an effective means to load the muscle-tendon unit and induce a pain inhibitory response.

Stage 2: Isotonic hamstring load with minimal hip flexion

Isotonics occur when the muscle contracts and change length to include both concentric and eccentric contractions. A concentric contraction is when the muscle shortens under load, while an eccentric contraction is when the muscle lengthens under load. Here we start to introduce heavy slow resistance training which has been proven to show favourable outcomes. This stage aims to improve hamstring length and capacity in function ranges of motion.

Stage 3: Isotonic hamstring load with hip flexion

The aim of this stage is the same as stage two, except now into deeper ranges of hip flexion.

Stage 4: Energy storage loading

This is a stage where generally, only athletes need to complete to return to sport as it focusses heavily on lower limb energy storage or impact loading. The amount of hip flexion in the early stages of this phase may be limited to minimise tendon compress as the higher elastic load is added. The exercises chosen should be specific and meaningful to the individual in terms of their functional and sporting demands (eg. sprinting, lifting, jumping).

Once an athlete can tolerate all the loading requirements to their sport, a gradual return to sport can be introduced, eventually progressing to a full return to play.


Arner, J. W. , McClincy, M. P. & Bradley, J. P. (2019). Hamstring Injuries in Athletes. Journal of the American Academy of Orthopaedic Surgeons, 27(23), 868–877. doi: 10.5435/JAAOS-D-18-00741.

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.

Goom, T. S., Malliaras, P., Reiman, M. P., & Purdam, C. R. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy, 46(6), 483-493.

Schmitt, B., Tim, T., & McHugh, M. (2012). Hamstring injury rehabilitation and prevention of reinjury using lengthened state eccentric training: a new concept. International journal of sports physical therapy, 7(3), 333–341.

van der Horst, N., Smits, D. W., Petersen, J., Goedhart, E. A., & Backx, F. J. (2015). The preventive effect of the nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. The American journal of sports medicine, 43(6), 1316-1323.

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