Proximal hamstring tendinopathy – Causes, stages, and diagnosis
- Maryke Louw
- Aug 15
- 14 min read
Updated: Sep 16
Learn what causes proximal hamstring tendinopathy, how to recognise its symptoms and what stage your injury is in, as well as the tests used for diagnosis. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call.
In this article:
We've also made a video about it:
👉 Read more about other aspects of high hamstring tendinopathy here.
What causes proximal hamstring tendinopathy?
Proximal hamstring tendinopathy (aka high hamstring tendinopathy) develops in the tendons that attach the top end of your hamstring muscles to your sit bone (ischial tuberosity). You also have hamstring tendons lower down in your leg that can get injured, but that’s known as distal (or lower) hamstring tendinopathy.
The hamstring muscles work together to pull your leg back (extend your hip) and bend your knee as you walk, run, and jump. They also help to control movements like bending forward (similar to doing a deadlift).
The natural cycle of tissue breakdown and repair
Tendons are made up mostly of collagen fibres, packed tightly in parallel. It is this parallel structure that makes them so strong.
When we exercise or do activities that use our muscles and tendons, they naturally get micro-injuries. These injuries are normal – they signal to the brain that the tissue needs to be made stronger.
👍 If you allow enough recovery time between bouts of work or exercise, your body then repairs these small injuries so that the various affected tissues grow stronger over time. This is why someone who has been doing a physical job or specific exercise for a long time can do so much more than someone who is just starting out.
Where things go wrong
If you repeatedly don’t allow enough recovery time between hard bouts of work or exercise, or you ramp up the intensity or volume too quickly, your body doesn’t have enough time to repair these micro-injuries properly. They then accumulate over time and can cause overuse injuries like proximal hamstring tendinopathy.
Furthermore, specifically for the hamstring tendons:
Any activity or action that overworks the hamstring muscles will also cause excessive force on the tendons and their attachments and can cause a tendinopathy.
With proximal hamstring tendinopathy there is also the possibility of excessive compression of the tendon against the sit bone, which is thought to play a major role in developing this injury. The upper hamstring tendons naturally pull tight and press against the sit bone as you bend your hip forward or up (when you sit, take a step, squat down, or do a hamstring stretch). Normally, this is not a problem, but if it happens more often or more forcefully than the tendon is used to, it can cause trouble.
Common factors leading to high hamstring tendinopathy
1️⃣ Training errors: Increasing your training volume or intensity too quickly, or not allowing enough recovery time after training sessions are some of the most common training errors that lead to tendinopathies.
And if these activities work the hamstrings hard in positions where the tendons compress strongly against the sit bone, they are more likely to overwork the high hamstring tendons. Examples include:
Uphill walking or running
Running in general – the faster or further you run, the more it affects it
Cycling – especially if using low-drop handlebars (so your hips are more flexed) and high resistance
Squats, lunges, and deadlifts – not just in the gym but also as part of daily life, e.g. bending over to do a lot of weeding in the garden when you’re not used to it.
2️⃣ Overstretching: Activities like yoga and Pilates that involve deep, prolonged hip flexion stretches (e.g. forward folds) can put too much strain on the tendon.
3️⃣ Sitting too much: When we sit, we place most of our weight on our sit-bones. Your specific genetics (shape of your skeleton) as well as the shape of the chair (e.g. low vs. high seats) and how hard the surface is will determine how much pressure is placed on the upper hamstring tendons. If you sit for very long periods without taking breaks, it might create enough compression to trigger proximal tendinopathy.
👉 None of these activities has to be a problem – it is only when you do them excessively or you suddenly ramp up how much you do them that the injury might develop.
Other contributing factors
There are other factors that might make you more prone to developing proximal hamstring tendinopathy.
Genetics: There are certain genes (e.g. the ones linked to hypermobility syndromes like Ehlers-Danlos syndrome) that can affect the quality of your collagen (the main building block of tendons) and how easily your body produces it, which might increase your risk of tendon injuries.
General health: High cholesterol, diabetes, and thyroid problems can make tendons more vulnerable to injury.
The menopause: Women in any stage of the menopause might be at higher risk, because declining oestrogen levels can slow down collagen production.
Medication: Some antibiotics, particularly fluoroquinolones, have been linked to tendon problems. Statins, often prescribed for high cholesterol, can also cause tendon pain in some people.
The stages of proximal hamstring tendinopathy (and why this matters)
When our patients come to us for proximal hamstring tendinopathy treatment, their hamstring tendons will be in a specific stage of healing or injury, depending on how long they’ve had it for. This matters, because the best treatments for the various stages differ quite a bit.
👉 It’s worth noting that the stage of your injury is not the only factor influencing the choice of treatment. How sensitive your tendon is and its current level of strength also play a role. You can read more about this in our other article on treatments (coming soon).
The three stages of proximal hamstring tendinopathy (and other overuse tendon injuries) are:
1. Reactive tendinopathy
This is typically the stage in which your tendon is when you first injure it, i.e. your tendon pain and stiffness started a few days or weeks ago.
🔬 What scans show: When you scan the tendon, it typically shows an accumulation of fluid between the collagen fibres, but without major structural changes or injuries to these fibres. There might be a few inflammatory cells, but researchers seem to agree that inflammation is not the main cause of the pain.
🏃♀️➡️ Impact on recovery: The good news is, if you apply the correct treatment during the reactive stage, the tendon can fully recover without suffering permanent structural changes.
👍 The best ways to deal with proximal hamstring tendinopathy during this stage are rest, load management, and treatments that will help it to settled down.
👎 The worst things you can do during this stage are strength training exercises and stretches. (I’ll explain why in the treatment article to be published shortly.)
2. Tendon dysrepair
If the newly injured tendon isn’t allowed to rest and calm down and you continue to irritate it while it’s in the reactive stage (either through too much physical activity or perhaps by applying the wrong treatments), it might enter the dysrepair stage. Instead of healing, the injury gets a bit worse.
🔬 What scans show: During the dysrepair stage, in addition to extra fluid in the tendon, you start seeing the collagen fibres moving away from each other and starting to lose their nice, strong, parallel structure. It’s worth noting that this tends to affect only a small portion of the tendon – the rest of the tendon is still strong and healthy. There are usually also small blood vessels growing into the tendon, which are normally absent, and there are no signs of inflammation.
🏃♀️➡️ Impact on recovery: Recovery tends to take a bit longer than in the reactive stage. There is evidence that the tendon structure can revert to normal with the correct mix of load management and careful loading. (Keep an eye out for our treatment article – I’ll discuss it there.)
3. Degenerative tendinopathy
This stage sounds a lot more serious than what it actually is. In general I try to avoid using the word "degenerative" because it makes people think of permanent damage and something that won't heal, which is NOT THE CASE. You can still get back to full, pain-free activity even if you think you've entered this stage.
The injured part of your tendon might have entered this stage if the injury has been allowed to drag on for several months.
🔬 What scans show: The injured area of the tendon (remember, this is usually only a small part) now shows signs that the collagen fibres have been damaged and have totally lost their parallel structure. You also see many blood vessels growing into the area. There is no inflammation.
🏃♀️➡️ Impact on recovery: It usually takes even longer to get back to your full level of activity (9 to 18 months even) if you're in this stage. The injured area will likely not “look” normal again on scans (similar to how a scar looks on your knee), but this really doesn't matter. Collagen is super strong tissue (research has shown it to be 10 times stronger than steel) and tendons, just like muscles, can get bigger and stronger through exercise.
Recovery in this stage of injury depends on getting the rest of the tendon (the uninjured part) to grow stronger to take over the work of the injured part.
👍 The best treatments for proximal hamstring tendinopathy during this period should focus on reducing pain and increasing the tendon’s strength with a training plan that gradually becomes more challenging. Often, this involves specific strength training exercises, but in some cases activities like walking, climbing, or very gradually easing into running work better – every person is different.
Pain is not an indicator of how bad your injury is
People with proximal hamstring tendinopathy can experience very different levels of pain. For some, it might just be a mild discomfort that only shows up during activities that place a high load on the tendon – like long-distance running. Others might feel quite a bit of pain even when the tendon isn’t being used much.
It’s helpful to know that imaging studies have shown that pain levels don’t necessarily reflect how badly the tendon is injured. Scans might show only a small issue, yet the pain can be quite severe – or the other way around.
Studies have also found that pain can feel worse if:
the injury has been around for more than three months,
if you’re dealing with a lot of stress,
not sleeping well,
or if you feel pessimistic about your chances of recovery.
So, while it’s essential to treat the tendinopathy, it’s also worth tackling these other things if your pain feels particularly intense or just won’t go away.
If you'd like to explore this idea further, I've written a detailed article about all the factors that might be making your pain feel worse than it should.
How to know whether you have proximal hamstring tendinopathy
Your doctor or physiotherapist will usually make the diagnosis by combining information from the in-depth conversation you have about your injury (how it started, what the symptoms feel like, and how they react) with specific movements tests and, in some cases, scans. This is also how we diagnose it via video call.
Let’s break this down in more detail.
Proximal hamstring tendinopathy symptoms
Your physio or doctor will likely ask about the following:
What the symptoms feel like: The main symptoms of proximal hamstring tendinopathy are pain and stiffness.
💡If you’re getting tingling, weird sensations or numbness, it might mean that you’ve injured or irritated a nerve; this can be in addition to or instead of proximal hamstring tendinopathy. Your physio can easily test for this (even via video call) by performing the slump test.
Location of the symptoms: The pain is mainly in the area of the sit-bone or just below it. In ongoing cases, you may get some stiffness and pain going into your lower thigh or buttock.
💡If you’re getting back pain, strong glute pain, or the main pain is actually more to the outer edge of the thigh (more lateral), it might be worth getting it checked, as you may have a different injury.
How the symptoms started: Proximal hamstring tendinopathy symptoms usually start gradually during an activity, several hours after the activity, or you may even wake up with the pain and stiffness the day after an activity.
💡If your symptoms started when you felt a sudden, sharp pain while doing something, it might be a tear rather than a tendinopathy.
How the symptoms react to activities:
The pain tends to get worse during or after movements that load the hamstring while your hip is bent forward – like squats, lunges, deadlifts, or even uphill walking or running.
Sitting is another common trigger and can make the pain flare up.
After long periods of being inactive – like sitting for a while or first thing in the morning after a night’s rest – the tendon often feels stiffer and sorer. Once you start moving, it usually loosens up as it warms up, although sometimes the discomfort can stick around throughout the day.
You might notice symptoms most at the beginning of a run or workout. As you continue, the pain may settle, only to return later – sometimes more strongly – a few hours after you’ve finished.
Stretches that involve deep hip flexion, like hamstring, glute, or piriformis stretches, can also aggravate the tendon.
💡If your pain is also worse when you do low-load activities with the hip in a straighter position, e.g. while sleeping or walking slowly on flat surfaces, it might be coming from a different area, e.g. your lower back.
Tests for proximal hamstring tendinopathy
People often expect physios or doctors to figure out what’s wrong just by pressing on the sore spot. But for high hamstring tendinopathy, that’s not actually a very useful test.
Because of the way the sit bones are shaped and how the tendons attach, you can’t always reach the injured part by pressing on it. So, if pressing doesn’t bring on any pain, it doesn’t mean the tendon isn’t injured.
A better approach is to use movement tests that stretch or contract the hamstrings in different positions – especially if those movements also press the tendon against the sit bone.
Every tendon injury is a bit different, so the exact tests your physio uses will depend on what they’ve learned from talking to you about your symptoms.
Usually, they’ll start with movements that don’t put too much load on the hamstrings and avoid positions that cause a lot of compression. Then they’ll gradually make the movements more challenging until they reach one that causes some discomfort – which would be seen as a positive test (i.e. confirm you likely have proximal hamstring tendinopathy).
👉 Tendons can be a bit tricky – they don’t always let you know right away if they’re unhappy with a movement. That’s why it’s pretty common to have a pain flare-up the day after your assessment. If that happens, let your physio know – it might mean your rehab plan needs tweaking.
Bridge progression testing
The bridge is a really versatile movement and can be adapted for almost anyone with high hamstring tendinopathy.
You can make the hamstring muscles work harder by moving your feet further away from your bum, or by going from using both legs to just one. You can also increase the amount of compression on the tendon by bending the hip more – for example, moving from a bridge with your feet on the floor (hip not very flexed) to a bridge with your heels on a chair (starting at almost 90 degrees hip flexion, which creates much more compression in the early part of the movement).
The fundamental bridge movement pattern (that can be adapted for the other versions) is as follows:
Lie on your back with your knees bent 90 degrees and feet flat on the floor.
Tighten your tummy muscles.
Squeeze with your glutes (not your back muscles) to lift up your hips – just to where they naturally stop.
You can then hold the position there for several seconds or come back down immediately.
A typical bridge progression I might test could look like this:
Double-leg bridge with feet on the floor and heels close to the bum
Double-leg bridge with feet further out so the knees are at about 45 degrees
If that’s fine, move to a single-leg bridge on the floor
If that’s fine, try a double-leg bridge with feet supported on a chair
Single-leg bridge with heel on a chair
Single-leg high bridge with the knee more extended, or even with added weight over the pelvis.
👉 You obviously wouldn’t keep testing if any of these movements cause pain.
And if a patient tells me their tendon flares up easily, I might stick to only the basic movements and stop before we reach the point of pain, so we can check for a delayed pain response. But if a patient says they can do a fair amount of sport with only mild discomfort, I know I can usually push them further in testing without risking a big flare-up.
Romanian deadlift progression testing
The Romanian deadlift (where you keep your knees slightly bent while hinging at the hips) is a really useful test for diagnosing high hamstring tendinopathy.
It makes the hamstring tendons work while the hip is flexed, which increases compression between the tendons and the sit bone – something that’s more likely to irritate them if they’re injured.
I choose which type of deadlift to test based on what my patient has told me about their symptoms. Here’s how to do the simplest version:
Stand with your feet hip-width apart and bend your knees slightly.
Engage your stomach muscles and keep your back straight.
Begin bending forward from the hips, maintaining a straight back – it can help to guide the movement by sliding your hands down the front of your thighs.
Stop when you feel pain, or when you reach the point where the only way to go lower would be to bend your back. This is your natural limit, and how far you can go will depend on how flexible your hamstrings are.
If that doesn’t cause discomfort, you can make it progressively harder by adding weight or doing it on one leg. Here’s how I would rank the variations from lowest to highest compression/force:
Double-leg deadlift, sliding hands down the thighs to the knees
Double-leg deadlift while holding extra weight
Single-leg deadlift
Single-leg deadlift with extra weight.
Bent-knee stretch test
Another test that can help diagnose high hamstring tendinopathy is the bent-knee stretch test.
In this test, you first bend the hip and then straighten the knee – this creates maximum compression between the sit bone and the tendons, and it tends to be better at picking up high hamstring tendon injuries than the version where you simply lift a straight leg.
Here’s how to do it yourself:
Lie on your back with your legs straight.
Bend the leg you want to test so your knee comes as close to your stomach as possible, and hook a belt around your foot. Ideally, your hip should be bent to 90 degrees or more – but don’t force it.
Using the belt for support, straighten your knee as far as it will comfortably go (it will likely not go completely straight) without forcing it. Don’t let your hip straighten – keep it bent to at least 90 degrees.
If this test causes pain around your sit-bone area it might mean that you have high hamstring tendinopathy.
👉 No single movement test is 100% accurate, so your physio will usually have you do several and then combine the results to make a diagnosis. But if your injury is very easy to irritate, they may only perform one or two.
What about scans?
The best scans for diagnosing high hamstring tendinopathy are ultrasound and MRI scans.
That said, you usually don’t need a scan to confirm the diagnosis. They’re generally only needed if your injury isn’t healing as expected, or if your doctor or physio suspects you might have a different type of injury – for example, a tendon tear or a nerve problem.
It’s also important not to assume that your pain is definitely from tendinopathy just because the tendons show some changes on a scan. Studies have shown that many people with no symptoms at all still have “positive” scan results. So your doctor might still consider other possible causes for your pain – like nerve irritation – even if the scan shows changes in the tendon.
How we can help
Need help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.