What is proximal hamstring tendinopathy?
Proximal hamstring tendinopathy (PHT), sometimes called high hamstring tendinopathy, is a painful condition of the hamstring tendons. Tendons are fibrous structures that join muscles to bones. This connection allows your muscles to move your bones and body. The proximal hamstring tendons are the tendons at the top (proximal means closer to the head) of the hamstring muscles in the back of the thigh. These tendons join the hamstring muscles onto the sitting bones (ischial tuberosities).
What are the usual symptoms?
People with PHT have pain over their hamstring tendon attachment at the sitting bone. The pain may also extend a little way down into the hamstring muscle in the back of the thigh. The pain from the tendon does not usually continue past midthigh level. Any pain extending further down the thigh or past the knee is likely to have a different cause. In these cases, there may be some associated irritation of the sciatic nerve. The sciatic nerve sits right next to the hamstring tendons as it passes through the buttock to the thigh (the yellow line on the figure adjacent to this paragraph indicates the sciatic nerve). If the hamstring tendon is unhealthy, it can irritate the sciatic nerve as it passes by. This may result in symptoms of ‘sciatica’ (painful sciatic nerve). Pain can extend down the thigh, even all the way to the foot. Nerve irritation may result in sharp, stabbing, shooting or burning pain. There may also be feelings of tingling, buzzing, itching or numbness.
Pain from PHT is most commonly felt at the sitting bone, when:
- Sitting, especially on a hard surface
- Walking or running uphill or upstairs
- Leaning forward (for example loading the dishwasher)
- Running uphill or at higher speeds
What causes proximal hamstring tendinopathy?
The pain of PHT may develop over time, without a clear injury.
This can be due to:
- an increase in exercise, e.g. increasing the amount of walking, running or cycling uphill
- a change in exercise, e.g. taking up exercises like split lunges, stair bounding or kettlebell swings
- a prolonged period standing in a bent over position, e.g. weeding the garden
- friction across the sitting bone, e.g. when rowing or paddling while sitting on a hard seat for long periods.
- an injury or restriction at the knee or ankle, resulting in the hamstrings absorbing more load at the hip
However, for some people the pain may come on during or after a sudden hamstring strain or stretch. This might occur during waterskiing, martial arts or a slip into the splits position.
While too much load can lead to tendon conditions, too little load also reduces tendon health. Tendons that are not regularly exposed to physical load will not be as conditioned. There may reach a point where the tendon is unable to tolerate even everyday activities. Physical inactivity due to sedentary lifestyle, illness or injury elsewhere may contribute. Age and hormonal changes in women postmenopause may also reduce tendon health.
PHT is most common in middle to longer distance runners and triathletes. It may also affect cyclists who spend long periods hill climbing and on timetrial bikes. The hamstring muscles and tendons are also placed under high loads in other sports. Some examples include football, rugby, hockey, martial arts, long jump, ballet and yoga.
But you don’t need to be young and athletic to develop this condition. Older and/or sedentary people can have PHT too, due to relative underloading (not doing enough) of the tendon. Less active people will be less conditioned and less able to tolerate physical load
Getting Help. What is the treatment for proximal hamstring tendinopathy?
It’s best to discuss your pain with a Hip Pain Professional for a correct diagnosis as early as possible. Your Hip Pain Professional will look for reasons underlying your tendon condition. They will then develop a personalised recovery plan for you.
Treatment almost always begins with Education and Exercise. Most people will get an excellent outcome with this approach. Early treatment is likely to lead to more rapid and complete recovery. For those that do not recover with education and exercise, there are extra options.
Gaining an understanding of what the problem is and how to stop provoking it, is the first important step. This is often called ‘load management’. Your Hip Pain Professional can identify specific aggravating factors and provide individualised advice. Things you do regularly may be making the situation worse. For example, hamstring stretching for proximal hamstring tendinopathy is usually not recommended. Seating advice may also be very helpful.
A specific and individualised exercise program is the other main aspect of treatment. Improvements can occur quickly, particularly if you have caught the problem early. If you have had the condition for a long time, progress may be slower. In either case, it is a good idea to continue an exercise program for at least 3-6 months. This will allow time to see the full effect of treatment.
An exercise program can have many benefits such as:
- improving health and co-ordination of the hip and thigh muscles
- improving tendon health and tolerance of physical loads
- reducing pain
- improving ability to perform normal daily tasks
- increasing confidence in your tendon and your ability to do things
- returning to activity and sport
- improving quality of life
Cortisone (corticosteroid) injections usually only provide short-term relief. Cortisone may also reduce health of the tendons, particularly with repeated injections. So, it is usually best to commit to an education and exercise approach first. Platelet Rich Plasma (PRP) injections are sometimes suggested. The evidence for these injections remains unclear. They should rarely be a first treatment choice. Injections are rarely useful in isolation. Results are usually best when combined with load management and exercise.
4. Shockwave Therapy
Shockwave therapy is sometimes offered to those who are slow to recover. Further evidence for Shockwave is still required. Shockwave should always be provided with education and high-quality exercise.
Surgery is a last resort and is usually only considered after 12 months of other treatments. Surgeons rarely operate simply due to presence of a tendon tear. Painfree tendon tears are common in endurance athletes and older adults. Most tears do not need repair and recovery of full painfree function is still possible.
Always seek out a health professional with experience and up-to-date knowledge in this area. Visit our directory to find a Hip Pain Professional near you.
2.Goom T, Malliaras P, Reiman M, Purdam C. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. Journal of Orthopaedic Sports & Physical Therapy, 46(6), pp.483- 493.
3.Lempainen L, Sarimo J, Mattila K, Orava S. (2009). Proximal Hamstring Tendinopathy – Overview of the problem with emphasis on the surgical treatment. Operative Techniques in Sports Medicine, 17, pp.225-228.