High Hamstring Tendinopathy Injuries – Signs, Symptoms and Research-Backed Treatment Solutions for a Literal Pain in the Butt
The hamstrings are an essential muscle group in running. They flex your knee and assist in hip extension, meaning they are active at multiple points in your gait cycle. While the most common hamstring injuries are acute or chronic muscle strains, they are also vulnerable to tendonitis at their origin, an injury termed high hamstring tendinopathy or proximal hamstring tendonitis.
While rare, this injury is difficult to treat and can become a prolonged and chronic problem. The relatively limited scientific and medical reports extant are fairly recent, and as such, there are no solid numbers on what percentage of runners come down with it.
About the injury
The hamstrings run from the top of your tibia, just behind your knee, up along the back side of your thigh and towards your pelvis. While one branch of the hamstrings attaches to the femur, the rest course up your thigh and underneath your glute muscles, attaching to the pelvis at a bony prominence called the ischial tuberosity. These twin “peaks” of bone are sometimes referred to as your “sitting bones,” as they support much of your weight while sitting, especially on hard surfaces. The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy.
High hamstring tendinopathy feels like a vague, aching soreness high up on your hamstrings and deep in your buttock.
There will be pain when you run, especially when accelerating and when maintaining a fast pace. Sometimes the sciatic nerve, which passes very close to the ischial tuberosity, can become irritated as well, resulting in pain that radiates down the back of your thigh. In addition to pain while running, you may feel irritation at the ischial tuberosity while sitting on hard surfaces. It also may hurt to press directly on the ischial tuberosity.
A host of other injuries can cause deep buttock pain, including piriformis syndrome, muscle strains, a sacral stress fracture, or pain radiating from low back injuries, so it’s important to get an accurate diagnosis.
Tests to diagnose
A review study published in January of 2012 outlined three physical tests for high hamstring tendinopathy.1 The first is a simple standing hamstring stretch, where you rest your foot on a knee- to waist-high support and stretch your hamstrings.
The second is an assisted hamstring stretch, done while you are lying on your back. With your hip and knee flexed, an assistant slowly straightens your knee to stretch the hamstring. It may be possible to replicate this test without an assistant by using a rope or a belt, as pictured below.
The third test is similar to the second, but this time, the knee is rapidly straightened by an assistant. High hamstring or buttock pain with any of these three tests is indicative of high hamstring tendinopathy. While these tests were fairly accurate, correctly identifying between 76 and 89 percent of the injured runners, none were perfect, highlighting the usefulness of high-tech imaging to accurately diagnose or rule out high hamstring tendinopathy.
MRIs can be very fruitful in evaluating hamstring injuries, as described by Marc Sherry of the University of Wisconsin in a recent review article.2 An MRI can spot tendon thickening, tearing, inflammation, and swelling in the bone at the ischial tuberosity. Ultrasound can also used, but unlike an MRI, it can’t visualize bone marrow edema.
Research backed treatment options
In one of the few comprehensive articles on treatment for high hamstring tendinopathy, Michael Frederickson, William Moore, Marc Guillet, and Christopher Beaulieu at Stanford University provide a very insightful outline of treatments their group has found helpful for high hamstring injuries in runners.3
After the diagnosis has been confirmed with a physical examination and MRI scan, the injured patient is evaluated for core strength, hamstring flexibility, and pelvic stability. Frederickson et al. recommend that any pelvic tilt be corrected (presumably by manual or chiropractic manipulation, though the article does not specify how), as it can increase hamstring tension. They also endorse soft-tissue work to break down scar tissue along the proximal hamstring tendon, though the authors caution that direct compression of the ischial tuberosity should be avoided. Other case studies have also supported the usefulness of soft tissue manipulation, including techniques like ART and Graston, for the treatment of high hamstring tendinopathy.3 Gentle stretching of both hamstrings several times a day is also encouraged. But as Frederickson et al. point out, the core of their rehabilitation program is eccentric strengthening of the hamstrings.
Like the patellar and Achilles tendons, the tendon at the origin of the hamstrings is thick, fibrous, and has a poor blood supply, which makes healing difficult. Additionally, much like in these two more common tendon injuries, tendonitis of the high hamstrings appears to be a degenerative process, not an inflammatory one.4 This means that the fibers of the tendon are becoming frayed, damaged, and disordered. However, because we know that both Achilles tendonitis and patellar tendonitis can be effectively treated with eccentric strength exercises, it is quite logical to base a rehab program for high hamstring tendinopathy around eccentric exercise as well.
The strength rehabilitation program begins with simple isometric hamstring and glute exercises like glute bridges. As soon as these are tolerated, Frederickson et al. recommend progressing towards eccentric exercises as soon as the introductory exercises can be done without pain. A standing “hamstring catch” exercise can serve as a good introductory eccentric exercise, and Frederickson et al. endorse Swiss ball curls as ideal for development of both eccentric and concentric strength. These Swiss ball curls can be progressed as tolerated, moving from short range of motion to full range of motion and eventually, single-legged Swiss ball curls.
Frederickson et al. also emphasize the importance of core strength in hamstring injury rehabilitation, citing another study which found that core strengthening reduced the risk of recurrent hamstring strains. It’s possible that a strong abdomen and hip musculature can stabilize the pelvis, taking strain off the hamstring. Frederickson’s paper focuses on the use of plank exercises, particularly with leg lifts incorporated to encourage coactivation of the glute and hamstring muscles, as a key component of recovery.
Other possible treatment options
Other options discussed in the Fredericson et al. paper include corticosteroid injections and extracorporeal shockwave therapy. Both of these treatments have the potential to weaken the tendon, so they are reserved as ancillary treatments, not a sole basis for recovery.
Corticosteroid injections are better understood, and while injections directly into the tendon itself can be quite harmful, Fredericson et al. write that, by using ultrasound imaging to guide the injection needle, the anti-inflammatory drug can be delivered to the irritated tissue surrounding the tendon without penetrating or damaging the tendon itself. They also found that patients whose MRIs exhibited more swelling around the ischial tuberosity and less thickening of the tendon got more relief from a cortisone injection than patients with more pronounced tendon thickening.
Extracorporeal shockwave therapy is mentioned briefly, as it has been found to be effective in other types of chronic tendon injuries in athletes,5 though Fredericson et al. caution that they have little experience using it for high hamstring tendonopathy and that animal studies have shown that it results in a drop in tendon strength (at least in the short term).
Finally, in a small number of cases, surgery is necessary to relieve tension on the sciatic nerve and divide up the fibrous and damaged tendon near the ischial tuberosity. The good news is that, according to a 2009 study by Lasse Lempainen and coworkers in Finland, a high percentage of athletes eventually return to the same level of sport after being referred for high hamstring tendinopathy surgery.6 Eighty of the 90 patients referred in Lempainen’s study made a return to the same level of sport, with 62 of them having “excellent” results. While this is encouraging, the mean recovery time of five months (and ranging from two to twelve) is sobering and serves as a reminder that few surgeries for a running injury are ever really “minor” when it comes to time off from running.
High hamstring tendinopathy is a persistent and difficult running injury to overcome. Additionally, due to its relative rarity (especially outside of running) and the paucity of good review studies on potential treatments, the evidence for solid treatment protocols is still lacking.
On the bright side, however, since it’s known to be a degenerative tendon issue, the same treatment strategies that work with injuries to the Achilles and patellar tendons should also be effective with high hamstring tendinopathy.
As Frederickson’s article outlines, a progressive strength program to strengthen the core, improve glute strength, and promote healing in the proximal hamstring tendon through eccentric exercises should be at the heart of any rehabilitation program. Due to the similarity of some of this injury’s symptoms with other hip injuries, it’s important to get a proper diagnosis; this will likely entail a physical examination and an MRI.
Additionally, because of the individual nature of this injury, it’s recommended that you find a good orthopedist and physical therapist to supervise your rehabilitation and advise you on your return to running.
Outline of Treatment
Because of the recalcitrant nature of high hamstring tendinopathy, exercises for rehabilitation need to be eased into. Unlike the eccentric programs for Achilles or patellar tendonitis, you shouldn’t jump into high-load exercises right off the bat.
According to the protocol outlined in Fredericson et al., the following exercises should be incorporated into your rehab protocol in order, but only after you have been able to do the previous one without pain. Unfortunately, the Fredericson paper does not describe how many sets and repetitions of each exercise to do, but a Runner’s World article on the same injury recommends several similar exercises and advocates progressing to 3-4 sets of 10-15 repetitions of each exercise once per day.7
Double leg glute bridge
Gentle hamstring stretching, 3-4 times a day
Double leg glute bridge with leg lifts
Front plank with leg lifts
Standing hamstring “catch”
Swiss ball curls and Swiss ball curls with one leg
1. See a physical therapist or chiropractor for manual therapy, massage, ART, or Graston Technique to break down scar tissue and adhesions in the high hamstring area. Make sure the practitioner focuses on the muscle and tendon tissue and avoids the ischial tuberosity—you don’t need any additional irritation there. many runners also find sitting on a tennis ball or other hard surface when traveling or sitting for long periods of time to be helpful when first standing up.
2. Talk with an orthopedist about a corticosteroid injection, preferably guided by diagnostic ultrasound imaging. According to Fredericson et al., this can be especially helpful in cases where an MRI shows significant swelling near the ischial tuberosity.
3. Consider talking with your doctor about the risks and benefits of extracorporeal shockwave therapy. While it’s unproven in high hamstring tendinopathy, it has shown some success with chronic tendon issues elsewhere in the body.
4. If repeated attempts at conservative treatments fail, talk with a trusted orthopedist about surgical treatment.
Return to running
High hamstring tendinopathy is reported to take a long time to recover from. Of the few case studies on runners with high hamstring tendinopathy, all report recovery times on the order of 8-12 weeks,8 a timescale echoed by Fredericson et al.
Cross training activities should not stress the lower legs until the bent-knee stretch test can be done without pain; at this point, activities like cycling and pool running can be incorporated into your routine.
Once you can perform a back plank with leg lifts pain-free on both sides (pictured below) and have normal range of motion, you can being the gradual return-to-running program outlined here:
|Week 1||Walk 5min / jog 1min, build to 5 sets on alternating days(ex. 2x5min/1min, off, 3x5min/1min, off, etc.)|
|Week 2||If no pain, walk 5min / jog 5min, build to 5 sets on alternating days|
|Week 3||If no pain, advance to 20min jog, no more than 5 days per week|
|Week 4||If no pain, advance to 20min run at normal training pace, no more than 5 days per week|
|Weeks 5-8||If no pain, gradually increase running speed, volume, and acceleration as tolerated|
One of our gracious readers has shared with us her differential diagnosis after dealing with this injury for over four years. Patricia Burgess wrote this wonderfully in-depth chronicle of her search for pain-free running. You can download it here. Thank you for sharing Patricia!
1. Cacchio, A.; Borra, F.; Severini, G.; Foglia, A.; Musarra, F.; Taddio, N.; De Paulis, F., Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. British Journal of Sports Medicine 2012, 46 (12), 883-887.
2. Sherry, M., Examination and Treatment of Hamstring Related Injuries. Sports Health: A Multidisciplinary Approach 2011, 4 (2), 107-114.
3. Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challanges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.
4. Lempainen, L., Surgical Treatment of Hamstring Injuries and Disorders – the Clinical Spectrum from Chronic Tendinopathy to Complete Rupture. Turun Yliopisto: Turku, 2009; p 66.
5. Wang, C.-J.; Ko, J.-Y.; Chan, Y.-S.; Weng, L.-H.; Hsu, S.-L., Extracorporeal shockwave therapy for chronic patellar tendinopathy. American Journal of Sports Medicine 2007, 35 (6), 972-978.
6. Lempainen, L.; Sarimo, J.; Mattila, K.; Vaittinen, S.; Orava, S., Proximal Hamstring Tendinopathy: Results of Surgical Management and Histopathologic Findings. The American Journal of Sports Medicine 2009, 37 (4), 727-734.
7. McMahan, I. A Pain in the Rear: High Hamstring Tendinitis. http://www.runnersworld.com/injury-treatment/pain-rear-high-hamstring-tendinitis.
8. White, K. E., High hamstring tendinopathy in 3 female long distance runners. Journal of Chiropractic Medicine 2011, 10 (2), 93-99.