Hamstring Tendonitis: Symptoms, Treatment and Exercises

01Anatomy

The hamstring tendons

The hamstrings run from the sitting bone (ischial tuberosity) to just below the knee. At the top, a strong common tendon anchors the muscles to the pelvis; at the bottom, tendons attach to the shin (semimembranosus, semitendinosus and gracilis on the inner side) and to the fibula (biceps femoris on the outer side). Repeated tensile and compressive loads at these attachment sites can lead to tendinopathy.

02Proximal

Proximal hamstring tendinopathy (high hamstring)

• Deep ache or sharp pain in the lower buttock, at the sitting bone.
• Worse with sitting, particularly on hard seats, and with driving.
• Pain on hill running, sprinting, lunging, deadlifts, and stretching.
• Tenderness over the sitting bone; pain may refer to the back of the thigh.
• Common in distance runners, sprinters, hurdlers, cyclists and weightlifters.
• Often slow to settle: weeks to months.

03Distal

Distal hamstring tendinopathy

• Pain behind the knee on the inner or outer side, close to the tendon attachments.
• Worse with running, especially hills, and when bending the knee against resistance.
• Tenderness and sometimes swelling at the tendon.
• Differential diagnosis includes popliteal cyst, meniscal injury, calf strain and nerve irritation.
• See hamstring strain for muscle-belly injuries.

04Causes

Causes and risk factors

• Sudden increases in running volume, speed or hill work.
• Heavy deadlifts, hip hinges and lunges with poor control.
• Prolonged sitting, which compresses the proximal tendon.
• Aggressive hamstring stretching, which can irritate the tendon.
• Previous hamstring strain; weak hamstrings and glutes; tight hip flexors.
• Age, and training errors such as insufficient recovery.
• Lumbar spine and pelvic factors in some people.

05Early

Early management

• Reduce sprinting, hill running and heavy hinging that provoke pain.
• Avoid prolonged sitting on hard surfaces; use a cushion with a cut-out or stand regularly.
• Avoid deep hamstring stretching, which compresses the tendon at the sitting bone.
• Paracetamol or topical anti-inflammatories can ease pain.
• Keep active with pain-free exercise: cycling with a higher saddle, swimming or walking.
• Gentle isometric holds (see below) to calm pain.

06Rehab

Rehabilitation exercises

• Phase 1 – isometrics: lying on your back with the knee bent about 30–45°, press the heel into the floor or a fixed surface; hold 30–45 seconds, 4–5 times.
• Phase 2 – bridges and hip hinges: double-leg glute bridge 3 × 12, progressing to single-leg bridge, Romanian deadlift with light load and hamstring curls.
• Phase 3 – heavy slow loading: single-leg Romanian deadlifts, leg curls with tempo, Nordic exercises with partial range, step-ups.
• Phase 4 – running progression: walk–jog intervals, flat running, strides, then hills and speed.
• Allow pain up to 3–4/10 if it settles within 24 hours; progress every 1–2 weeks.
• Include glutes, calves and trunk strength.

07Time

How long does it take?

Proximal hamstring tendinopathy can take 3–6 months or longer to settle, and distal cases are often quicker. Consistency with the exercise programme and patience with return to running are important. Relapses are common when sprinting or hill work is reintroduced too quickly.

08Other

Other treatments

Shockwave therapy has shown benefit in chronic proximal hamstring tendinopathy in some studies. Platelet-rich plasma and corticosteroid injections are used in selected cases, but evidence is limited and steroid injection risks weakening the tendon. Surgery (debridement or repair) is rarely needed, for persistent pain after about 6–12 months of rehabilitation or for complete avulsions.

10Cases

Three common situations

A runner with buttock pain on hills and when sitting at work: classic proximal tendinopathy; use a cushion, avoid deep stretching and begin isometrics.

A weightlifter with pain at the back of the knee on leg curls: consider distal tendinopathy; adjust load and strengthen progressively.

A sprinter with sudden sharp pain and bruising: likely a tear; seek assessment.

11Sitting

Living with a painful sit-bone: practical tips

Sitting for long periods on a hard chair is a common aggravator. Use a firm cushion with a cut-out or a rolled towel under the thighs to take pressure off the sitting bone, stand or walk every 30 minutes, adjust the car seat and avoid crossing the legs tightly. Cycling can be uncomfortable; a saddle with a cut-out and a slightly higher position may help. Ask your therapist for modifications of gym exercises, such as shortening the range of hip hinges and avoiding deep forward bends early on.

12Summary

Key points to remember

Hamstring tendonitis needs patience. Reduce compression and aggravating loads, start isometrics, progress to strength and return to running gradually. See a doctor for sudden severe pain or neurological symptoms. Our physical therapy team can guide your rehabilitation.

This guide is for general information and does not replace an assessment by your own doctor or physical therapist.