(Also known as Hamstring Origin Tendonitis, Hamstring Origin Tendinopathy, Proximal Hamstring Tendinopathy, Hamstring Tendonitis, Hamstring Tendinopathy, Hamstring Tendinitis)
N.B. Although research suggests that ‘hamstring tendinopathy’ is the more appropriate term to describe overuse injuries to the hamstring tendon (due to the absence of an inflammatory response), we will use the term ‘hamstring tendonitis’ in this document as it is more commonly known.
What is hamstring origin tendonitis?
Hamstring origin tendonitis (tendinopathy) is a condition characterised by tissue damage, swelling and degeneration of the hamstring tendon (at its attachment to the pelvis) causing pain in the buttock.
The hamstring muscles originate from the pelvis at the lower aspect of the buttock (ischial tuberosity i.e. sit bones – figure 1) and insert into the top of the lower leg bones (tibia and fibula). The hamstring muscles attach to the ischial tuberosity via the proximal (upper) hamstring tendon (figure 2).
Figure 1 – Relevant Bony Anatomy for Hamstring Origin Tendonitis
Figure 2 – Anatomy of Hamstring Origin Tendonitis
The hamstring muscles are responsible for bending the knee and straightening the hip during activity and are particularly active during running, jumping, squatting, lunging and kicking. During contraction and stretch of the hamstrings, tensile and compression forces are placed upon the proximal hamstring tendon. When these forces are excessive due to too much repetition, prolonged or high force, damage to the hamstring tendon occurs.
Hamstring origin tendonitis (tendinopathy) is a condition typically involving some or all of the following tendon changes:
collagen fibre disorganisation (the protein giving tensile strength to the hamstring tendon)
thickening of the tendon
growth of new blood vessels (neovascularization) and nerves
Collectively, these changes reduce the tendon’s capacity to tolerate tensile and compression forces and increase the pain sensitivity of the tendon.
3 Phases of Hamstring Origin Tendonitis (Tendinopathy)
Following an inability of the hamstring tendon to appropriately adapt to an increase in stress on the tendon, hamstring origin tendonitis (tendinopathy) typically progresses through 3 phases:
Reactive Phase – Comprising a short term adaptation to stress. This thickens the tendon, increasing its stiffness and reduces stress. Tendon changes during the acute reactive phase are typically reversible (with appropriate management). Generally the tendon structure remains intact.
Dysrepair Phase – If the reactive tendon continues to be exposed to excessive load, further changes will take place within the tendon. These changes include a breakdown in the structure of the tendon. New blood vessels and nerves also begin to grow resulting in an increase in pain and sensitivity of the tendon. Appropriate treatment and load management during this phase is essential to prevent further progression to the degenerative phase.
Degenerative Phase – This involves changes in response to long term overload of the tendon. These changes include further breakdown in the tendon structure, disorganisation of collagen fibres and areas of cell death. Additional growth of new blood vessels and nerves occurs. During this phase, the tendon may appear thickened or nodular and be at a higher risk or rupture.
Causes of hamstring origin tendonitis
Hamstring origin tendonitis (tendinopathy) most commonly occurs due to a sudden increase in repetitive or prolonged activities placing strain and in particular, compressive forces on the hamstring tendon. This typically occurs during activities that contract the hamstrings, particularly when they are in a position of stretch.
Hamstring origin tendonitis is common in athletes involved in distance running (particularly up hills), hurdles, football, sprinting, cycling, jumping activities and hockey. Occasionally, hamstring origin tendonitis may occur suddenly due to a high force going through the hamstring tendon beyond what it can withstand. This most commonly occurs during rapid acceleration whilst running or when a footballer performs a long kick. In the non-athletic population, hamstring origin tendonitis may occur in association with excessive sitting periods (particularly with the leg outstretched e.g. driving) or excessive hamstring stretching (e.g. Yoga).
Signs and symptoms of hamstring origin tendonitis
Patients with hamstring origin tendonitis typically experience fairly localised pain or discomfort in the lower buttock. Symptoms are usually located just below the sit bones (ischial tuberosity – figure 1), corresponding with the hamstring tendon location (figure 2). In less severe cases of hamstring origin tendonitis, patients may only experience an ache, stiffness or tightness in the lower buttock that increases with rest following activities requiring strong, repetitive or prolonged contraction or stretch of the hamstring muscle. These activities may include:
prolonged sitting (especially on hard surfaces)
excessive walking (particularly up hills or stairs)
The pain associated with hamstring origin tendonitis often warms up with activity in the initial phase of the condition. As the condition progresses, patients with hamstring origin tendonitis may experience symptoms that increase during activity and affect performance. Patients with hamstring origin tendonitis often experience pain on firmly touching the hamstring tendon (figure 2). Occasionally, a feeling of lower limb weakness may also be present particularly when attempting to accelerate whilst running.
Diagnosis of hamstring origin tendonitis
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose hamstring origin tendonitis. Occasionally, further investigations such as an Ultrasound, X-ray or MRI scan may be required to assist with diagnosis and assess the severity of the hamstring origin tendonitis.
Prognosis of hamstring origin tendonitis
Most patients with hamstring origin tendonitis (tendinopathy) heal well with appropriate physiotherapy and return to normal function in a number of weeks (particularly those in the acute reactive phase). Occasionally, rehabilitation can take significantly longer and may take many months in those who have progressed to the dysrepair and degenerative phases. Early physiotherapy treatment is vital to hasten recovery in all patients with hamstring origin tendonitis.
Treatment for hamstring origin tendonitis
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Contributing factors to the development of hamstring origin tendonitis
There are several factors which can predispose patients to developing hamstring origin tendonitis. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:
joint stiffness (particularly the hip)
muscle tightness (particularly the hamstrings, hip flexors and quadriceps)
inappropriate or excessive training, stretching or activity
inadequate warm up
muscle weakness (especially the hamstrings, gluteals and quadriceps)
poor pelvic or core stability
inadequate rehabilitation following a previous hamstring injury
leg length discrepancies
history of another lower limb injury
sciatic nerve irritation
poor sporting technique
Physiotherapy for hamstring origin tendonitis
Physiotherapy treatment for hamstring origin tendonitis is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:
activity modification advice
exercises to improve strength, core stability and flexibility
soft tissue massage
electrotherapy (primarily for pain relief)
ice or heat treatment
a gradual return to running program
a gradual return to activity program
Other intervention for hamstring origin tendonitis
Despite appropriate physiotherapy management, some patients with hamstring origin tendonitis (tendinopathy) do not improve adequately. When this occurs the treating physiotherapist or doctor will advise on the best course of management. This may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection, platelet rich plasma injections, extracorporeal shockwave therapy or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the hamstring origin tendonitis.
Exercises for hamstring origin tendonitis
The following exercises are commonly prescribed to patients with hamstring origin tendonitis. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed as directed and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place gradually and provided there is no increase in symptoms.
Begin this exercise lying on your back in the position demonstrated (figure 3). Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Hold this position initially for 10 seconds then slowly lower your bottom back down. Gradually build up to 45 second holds over a number of days, allowing an equal rest period between repetitions. Perform 3 – 5 repetitions provided the exercise is pain free. Repeat 2 – 3 times per day.
Figure 3 – Bridge Holds
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PhysioAdvisor relies on credible scientific sources (ideally from high quality randomised controlled trials, when available) to guide our content creation. Read about our sourcing guidelines and how we create trusted content via our editorial policy.
Ebonie Rio; Dawson Kidgell; G Lorimer Moseley; Jamie Gaida; Sean Docking; Craig Purdam; Jill Cook, Changing the Way we Think About Tendon Rehabilitation A Narrative Review Br J Sports Med. 2016;50(4):209-215.