Proximal hamstring tendinopathy: sitting-bone pain, causes and rehabilitation

The hamstrings are the muscles at the back of the thigh, as the NHS describes them. At the top, they attach by a strong tendon to the sitting bone of the pelvis. Proximal hamstring tendinopathy, sometimes called high hamstring tendinopathy, is a persistent problem of that attachment tendon rather than of the muscle belly.

A systematic review of conservative treatments published in 2023 describes the condition as localised pain in the region of the ischial tuberosity that is often worsened during running, sitting and lunging. It notes that the management of the condition is often challenging because it is multifactorial and can be misdiagnosed due to similarities across other diagnoses.

Tendinopathy is a different problem from the sudden muscle tear that most people think of as a pulled hamstring. The NHS defines tendonitis as a tendon that swells (becomes inflamed) after an injury, causing joint pain and stiffness, and the term tendinopathy is generally used for a longer-term problem with the tendon structure itself.

The NHS describes the symptoms of tendon problems generally as pain in a tendon that gets worse when you move, difficulty moving the joint, a grating or crackling sensation, and swelling sometimes with heat or redness. For proximal hamstring tendinopathy in particular, the review describes localised pain at the sitting bone that is made worse by running, sitting and lunging.

Some people notice an ache that builds with sitting on hard surfaces or with fast running, and that eases with rest but returns. Compared with an acute strain there may be no single moment of injury. These patterns are for guidance only, and a clinician needs to examine you to separate this condition from other causes of buttock and back-of-thigh pain.

The review explains that the hamstring complex suffers the most fatigue and susceptibility to injury during rapid changes from an eccentric to a concentric contraction, with an overall injury incidence of 10 to 55% in recreational and high-performance sports. It describes two types of hamstring injury mechanism: sprinting-type injuries, and injuries during active stretching, such as in dancers or high-kicking sports, which more accurately fit proximal hamstring tendinopathy.

The NHS says tendonitis is usually caused by sudden, sharp movements or repetitive exercise, such as running, jumping or throwing, and by repetitive movement or poor posture or technique. Increasing training too quickly, returning to sport after a break, or prolonged sitting on a hard surface are common practical triggers, though the review calls the cause multifactorial.

Diagnosis is mostly clinical. A GP, sports medicine doctor or physiotherapist will ask about the pain pattern, examine the area and test movement and strength. Scans such as ultrasound or MRI are sometimes used to confirm tendon changes or to rule out other problems, such as a partial tear or an avulsion, but the findings are interpreted alongside your symptoms.

The NHS notes that severe hamstring injuries can take weeks or months to heal and may need treatment from a specialist, and that surgery may be needed for the most serious injuries where there has been a complete tear of the muscle. If you have had a sudden pop or snapping sensation, major bruising and difficulty walking, it is a different situation from a gradual tendinopathy and needs prompt assessment.

The 2023 systematic review included 13 studies and concluded that conservative management may best be optimised through a multimodal approach incorporating tendon-specific loading at an increased length, lumbopelvic stabilisation exercises and extracorporeal shockwave therapy. For exercise selection it suggests a progressive loading programme with the hip flexed to 110 degrees and the knee flexed between 45 and 90 degrees. It also notes that eccentric exercise is the most commonly recommended treatment, extrapolated from other tendinopathies, but that high-quality evidence on frequency, load and angles is lacking.

In practice, that means rehabilitation led by a physiotherapist: progressive strengthening that is increased as pain allows, avoidance of the most provocative positions while pain is irritable, and a gradual return to running and sport. The NHS says that physiotherapy can speed up recovery and prevent further hamstring injury, that you can get physiotherapy for free on the NHS, and that there may be a long waiting list.

The NHS tendonitis guidance adds that if pain is severe, lasts a long time or movement is limited you may be offered physiotherapy, that some people may be offered steroid injections, which may provide short-term pain relief, and that if physiotherapy does not help you may be referred to an orthopaedic specialist who may recommend surgery. A pharmacist can recommend a suitable painkiller.

The NHS suggests relative rest for the first few days of a tendon injury, ice wrapped in a tea towel for up to 20 minutes every 2 to 3 hours, and keeping the area moving gently when you can do so without pain stopping you. It advises avoiding heavy lifting, strong gripping or twisting actions that make symptoms worse, and avoiding sport until the tendon has recovered.

For a chronic tendon problem, complete rest is rarely the answer, because tendons usually need graded load to recover. Reduce activities that clearly aggravate the pain, use a cushion when sitting for long periods, and build exercise back gradually. The NHS suggests warming up before exercise, supportive footwear and regular breaks from repetitive activity to reduce the chance of tendon injury.

See a GP if you have injured a joint or tendon and your symptoms do not improve within a few weeks, as the NHS advises, or consider NHS community musculoskeletal services, where you may be able to refer yourself. Get help from NHS 111 if you are in a lot of pain, think you have ruptured a tendon, have large swelling or bruising, or it hurts to walk or stand, or if you have a very high temperature or feel hot and shivery, which can be signs of infection.

Pain at night, unexplained weight loss, numbness or weakness in the leg, or loss of bladder or bowel control are not typical of a tendon problem and need urgent medical assessment.