Hamstring Tendonitis

Written by Tele Demetrious, Physiotherapist, BPhysio(Hons)
Reviewed by Brett Harrop, APA Sports Physiotherapist, BPhysio(Hons), MPhysio(Sports Physio)

Injuries > KneeHamstring Tendonitis

(Also known as Hamstring Tendinopathy, Hamstring Tendinitis, Biceps Femoris Tendinopathy)

N.B. Although research suggests that ‘hamstring tendinopathy’ is the more appropriate term to describe overuse injuries to the hamstring tendon, we will use the term ‘hamstring tendonitis’ in this document as it is more widely known.

What is hamstring tendonitis?

Hamstring tendonitis is a condition characterized by tissue damage and inflammation to one or more of the hamstring tendons. This occurs at their attachment to the top of the lower leg causing pain in the back of the knee.

The hamstring muscles originate from the pelvis and insert into the top of the lower leg bones (tibia and fibula). The hamstring muscles comprise of 3 muscle bellies: the biceps femoris (outer hamstring) and the semimembranosus and semitendinosus (inner hamstring).The hamstring muscles attach to the outer and inner aspect of the lower leg bones via the hamstring tendons (figure 1).

Hamstring Tendonitis Anatomy

Figure 1 – Anatomy of Hamstring Tendonitis

The hamstring muscles are responsible for bending the knee and straightening the hip during activity and are particularly active during running, jumping and kicking. During contraction of the hamstrings, tension is placed through the hamstring tendons. When this tension is excessive due to too much repetition or high force, damage to the hamstring tendons may occur. Hamstring tendonitis is a condition whereby there is damage to one or more of the hamstring tendons with subsequent degeneration and inflammation.

Causes of hamstring tendonitis

Hamstring tendonitis most commonly occurs due to repetitive or prolonged activities placing strain on one or more hamstring tendons. This typically occurs due to repetitive running, jumping or kicking activities. It is also particularly common in sports requiring frequent acceleration and deceleration such as football and soccer.

Occasionally, patients may develop this condition suddenly due to a high force going through the hamstring tendons beyond what they can withstand. This most commonly occurs during rapid acceleration whilst running or when a footballer performs a long kick, particularly following an inadequate warm-up.

Signs and symptoms of hamstring tendonitis

Patients with hamstring tendonitis typically experience pain that develops gradually in the inner or outer aspect of the back of the knee. Pain may also radiate into the top of the calf or back of the thigh. In less severe cases, patients may only experience an ache or stiffness in the knee that increases with rest following activities requiring strong or repetitive contraction of the hamstring muscle. These activities typically include running, jumping or kicking. The pain associated with this condition may also warm up with activity in the initial stages of the condition.

As the condition progresses, patients may experience symptoms that increase during activity and affect performance. Patients with this condition typically experience pain on firmly touching the hamstring tendons (figure 1). Occasionally, a feeling of lower limb weakness may also be present particularly when attempting to accelerate whilst running.

Diagnosis of hamstring tendonitis

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose hamstring tendonitis. Occasionally, further investigations such as an Ultrasound, X-ray, MRI or CT scan may be required to assist with diagnosis and assess the severity of the condition.

Prognosis of hamstring tendonitis

Most patients with this condition heal well with appropriate physiotherapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time. Early physiotherapy treatment is vital to hasten recovery in all patients with this condition.

Treatment for hamstring tendonitis

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Contributing factors to the development of hamstring tendonitis

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

  • joint stiffness (particularly the hip, knee and lower back)
  • muscle tightness (particularly the hamstrings and quadriceps)
  • inappropriate or excessive training
  • inadequate warm up
  • muscle weakness (especially the hamstrings and gluteals)
  • poor pelvic or core stability
  • inadequate rehabilitation following a previous hamstring injury
  • poor biomechanics
  • decreased fitness
  • neural tightness
  • being overweight

Physiotherapy for hamstring tendonitis

Physiotherapy treatment for patients with hamstring tendonitis is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may comprise:

  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • stretches
  • joint mobilization
  • dry needling
  • ice or heat treatment
  • the use of crutches
  • exercises to improve strength, flexibility and core stability
  • education
  • anti-inflammatory advice
  • biomechanical correction
  • activity modification advice
  • a gradual return to activity program

Other intervention for hamstring tendonitis

Despite appropriate physiotherapy management, some patients with this condition 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, autologous blood injection or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the condition.

Exercises for hamstring tendonitis

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed provided they do not cause or increase symptoms.

Initial Exercises

Static Hamstring Contraction

Begin this exercise in sitting with your knee bent to about 45 degrees (figure 2). Press your heel into the floor tightening the back of your thigh (hamstrings). Hold for 5 seconds and repeat 10 times as hard as possible and comfortable, pain free. Perform 1 – 3 times daily provided there is no increase in symptoms.

Exercises for Hamstring Tendonitis - Static Hamstring Contraction

Figure 2 – Static Hamstring Contraction

Straight Leg Raise

Begin this exercise lying on your back with your injured leg straight and your good leg bent (figure 3). Slowly lift your straight leg until you feel a mild to moderate stretch or as far as possible and comfortable without increasing symptoms. Hold for 2 seconds and then slowly lower. Repeat 10 times 1 – 3 times daily provided there is no increase in symptoms.

Exercises for Hamstring Tendonitis - Straight Leg Raise

Figure 3 – Straight Leg Raise (left leg)

Intermediate Exercises

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Advanced Exercises

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Rehabilitation Protocol

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Physiotherapy Products for Hamstring Tendonitis Physiotherapy products for hamstring tendonitis

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:

  1. Crutches
  2. Ice packs or hot packs
  3. Resistance Band (for strengthening exercises)
  4. Spikey Massage Balls (for self massage)
  5. Foam Rollers (for self massage)

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