The hamstring muscles (known as semimembranosus, semitendinosus and biceps femoris) are three muscles that are located at the back of the thigh. These muscles work in conjunction with other powerful muscles to allow you to walk, run and move normally. The proximal (closer to the centre of the body) hamstring tendons connect the three hamstring muscles to the pelvis forming one large tendon, deep in the buttock (6).
When there is pain in this tendon, we call it proximal hamstring tendinopathy. Proximal hamstring tendinopathy can be a cause of buttock pain in those participating in activities such as running, sprinting and hurdling (2). This condition can include tendon degeneration, partial tearing and peritendinous (outside layer) inflammatory reactions. However, it is also seen in those who are not active (7,8).
Proximal hamstring tendinopathy, like any form of tendon pain, is caused by the relationship between the demand placed on the tendon (load) and the rate at which the tendon can adapt or regenerate (repair) (9, 10). Tissue samples taken from people with tendon pain tend to show similar findings, which suggest the tendon has tried and failed to regenerate, unable to cope with the load placed upon it (10). This in turn can lead to pain and weakness with activities that place further demand on the tendon. It is important to note that rarely is there any evidence of tendon “damage” and findings on medical images do not always correlate well with pain or function (11).
This is not an exhaustive list. These factors could increase the likelihood of someone developing proximal hamstring tendinopathy. It does not mean everyone with these factors will develop symptoms. Risk factors can be divided into extrinsic (external) or intrinsic (internal) and include:
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis (12).
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) scans are usually not required to achieve a working diagnosis, but in unusual presentations they may be warranted.
There are several things you can do to address symptoms. Training (or load) modification is the most important first step towards reducing and managing your pain. This may require reducing the number of times you go for a run, reducing the distance or speed that you run or avoiding activities that involve repetitive forward bending. Avoiding long periods of sitting, or using a cushion, can help reduce compression of the tendon and allow pain to settle.
Once pain has settled to a more manageable level, exercise(s) to strengthen your hamstring or buttock muscles can help reduce pain, improve function and enable you to slowly return to activities that you enjoy (2).
Condition specific strengthening exercises have the highest levels of evidence for the treatment of tendon pain (13). Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body and exercise may need to be changed or progressed over time.
Below are three rehabilitation programmes targeted at addressing proximal hamstring tendinopathy. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
This initial programme focuses on early, appropriate loading of the affected tendon and maintenance of lower limb strength and stability. Some of these simple strengthening exercises can be performed little and often during the day to help relieve pain and begin to strengthen your tendon. Isometric exercises (where the muscles contract against a fixed resistance without a change in the position of your leg) are an effective way to load the tendon and reduce pain in the early stages of this condition. This should not exceed any more than 5/10 on your perceived pain scale.
Once your pain has settled to more manageable levels, you can progress to more challenging exercises that strengthen your hamstring muscles in different ranges of movement. The aim of this intermediate stage of the rehabilitation programme is to restore hamstring muscle strength and capacity in a functional range of movement. Pain during these exercises is safe and acceptable If your pain is above 5 during these exercises, you may need to reduce the amount of resistance you are using or decrease the number of repetitions you perform until the pain settles again. This should not exceed any more than 5/10 on your perceived pain scale.
The goal of the advanced rehabilitation plan is to continue to build further hamstring strength but in positions that place greater functional strain on the hamstring. The exercises you complete here are similar to the intermediate programme, but aim to challenge your hamstring muscles through a larger range of movement, with more repetitions or increased amounts of resistance. Single leg exercises are important to address any differences in strength between your painful and non-painful side. Exercises that encourage your muscles to work for faster, shorter spells of exercise (sometimes known as plyometrics) can help prepare you for a return to sport or running. This should not exceed any more than 5/10 on your perceived pain scale.
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting, and sprinting exercises (5,7).
As part of a multi-modal treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
A graded return to sport can be introduced when you can manage the exercises suggested in the advanced rehabilitation programme with minimal pain during, and 24 hours after, you have completed them. For runners, starting with manageable distances that you can accomplish with minimal pain during, or 24 hours later, is suggested. This can be gradually progressed, and symptoms monitored to ensure you do not provoke your symptoms.
Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.
We have Pure Physiotherapy clinics across the country including Norwich, Ipswich, Manchester, Bolton, Wakefield and Sheffield. Please view our clinics to find the closest physiotherapy clinic for you.
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