Proximal hamstring tendinopathy treatments – What works, what doesn’t, and what makes it worse?
- Maryke Louw
- Sep 10
- 15 min read
Updated: 2 days ago
Discover which treatments work best for proximal hamstring tendinopathy and which to avoid. This guide explains evidence-based strategies to reduce pain, restore tendon strength, and prevent flare-ups, with practical tips for faster, long-term recovery.
Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call.
In this article:
I've also discussed it in this video:
The main elements of effective treatment
You can get really technical about what happens when you have proximal hamstring tendinopathy, but the key approach to understanding the injury and its treatment can be summarised as follows:
Your hamstring tendons get injured when they are overworked in some way (see the most common ways here).
Once injured, your tendons become irritated and their capacity to tolerate load or work reduces.
This means that when you now try to do the things you usually do, it’s too much for the tendons and they become even more irritated.
There is no one-size-fits-all treatment plan that works for proximal hamstring tendinopathy, but the main aims of a successful treatment plan are to:
Get the tendons to calm down and reduce their irritability
Restore their load tolerance and capacity to its previous level
Take steps to prevent it from being overwhelmed and injured in future.
💡 In practice, these three aims can be achieved through many combinations of various treatments, and what works for one person often doesn’t work that well for the next.
So, let’s look at the elements you might include in a treatment plan, starting with the best research-based ones.
What treatment works best for proximal hamstring tendinopathy?
These are our Top 3 treatments – supported by the research and that we find produce the best long-term recovery when used together:
Relative rest: For your injury and pain to settle and start recovering, you must temporarily reduce the loads or forces that go through that area to match its current capacity. But usually you don’t have to rest it completely – more on this below.
Progressive loading: As your pain starts to calm down and settle, you must gradually start increasing activities that load/work the hamstring tendons. This helps to restore the strength and function of the injured tendon and related muscles, and it reduces pain. This includes your daily activities as well as your rehab exercises (see below) and sport.
Addressing other factors that might be dialing up the pain system and causing more pain than it should.
1️⃣ Relative rest vs. complete rest
Resting your hamstring tendons completely (not doing any exercise and avoiding sitting) can be a very effective way to get the pain to settle down in the short term. And this is sometimes needed for a short period (a few days only).
But rest alone doesn’t restore your tendons’ capacity for exercise and work. And if you rest for very long periods, your tendons may decondition further (just like your muscles would without any exercise). Research has also shown that overprotecting an injury can also sensitise the pain system and cause more pain in the long term.
⚖️ So, like with most things in rehab, it’s about getting the balance right.
👉 What you want to do instead is reduce, adapt, or cut out only the activities that significantly aggravate your hamstring pain and continue with all the others that don’t.
Then, once your pain has settled down to an acceptable level (as discussed below), you gradually start easing back into those activities, testing short sessions or durations and observing how it affects your symptoms.
👍 We are big proponents of relative rest and teach all our online patients how to apply this concept to their specific case. Being injured and not able to exercise can make you feel rather low. Relative rest is great, as it not only allows you to maintain your fitness through cross-training but also helps to lift your mood.
How much pain is OK?
We’re often asked “Should I wait until I have no pain before starting physio?” – The answer is no, you are unlikely to get 100% pain-free if you just rest and don’t start rehab.
But with rehab I don’t mean exercises that are hard to do or cause your pain to flare up – an experienced physiotherapist will tailor your rehab plan so that it matches your tendon’s capacity, using a variation of the pain guide below.
✅ When you’re dealing with proximal hamstring tendinopathy, the general rule is that you can keep doing an activity as long as:
the activity only causes a slight increase in discomfort while you’re doing it or within the next 24 hours, and
that extra discomfort settles down fairly quickly.
⬇️ If your symptoms flare up more noticeably – especially the day after – that’s your cue to make the next session easier.
👉 A significant increase in pain doesn’t necessarily mean that you’re making your injury worse, but repetitively pushing into high levels of pain can cause the pain system to become more sensitised, which can cause pain to persist long after the tendon tissue has recovered. Read more about the factors that can contribute to ongoing pain here.
👍 Tailoring your activities (exercise, sitting, rehab, work, etc.) to keep your symptoms within this “niggle” level helps to calm the pain system down.
Activities that often require adapting during the early stages include:
Any activity that presses directly on the tendon, e.g. sitting – See this article for how to adapt your sitting and use it as part of your rehab to restore your tendons’ sitting capacity.
All activities that use or work the hamstring tendons, e.g. running, cycling, jumping, hill or stair climbing, squats, lunges, deadlifts, etc.
Any movement that stretches the hamstring tendons, e.g. bending forward, doing hamstring stretch exercises, sitting with your legs straight out in front of you.
Have a look at our article explaining the causes of proximal hamstring tendinopathy if you want to understand why these activities might irritate your tendons. If you’re looking for advice on how to adjust your running with high hamstring pain, this article is the one.
2️⃣ Progressive loading
Tendons are made up of collagen fibres, which is an extremely tough type of tissue – researchers report it to be 10 times stronger than steel! And you can get the body to produce more and stronger collagen fibres through training your tendons, just like muscle cells strengthen and grow bigger when you train them.
The aim with progressive loading is to restore your tendons’ strength and capacity to tolerate activities (like exercise and sitting) to their pre-injury levels. If you do this correctly, using your symptoms to guide your loading plan, it can also be a great way of desensitizing the pain system and getting it to calm down.
There are three ways of restoring your tendons’ capacity, and most treatment plans use a mix of them:
Specific rehab exercises that strengthen the hamstring muscles and tendons (like hamstring curls and bridges).
Gradually increasing your sitting time.
Gradually increasing other activities and sports that use the hamstrings, e.g. walking, running, and cycling.
👎 Some of the common mistakes (regardless of the activity) we see which can cause painful flare-ups include starting specific activities too early, doing too much too soon, ramping up activities too quickly, or not progressing exercises to the level required for the patient’s sport.
👍 Here are the steps we follow during our video consultations that help us figure it out where to start a rehab plan, how and when to progress it, and what level to build it up to:
First, we have a very detailed discussion with our patients to understand what activities they are currently able to do and how it affects their symptoms – this gives us an idea of what activities they might need to adapt or adjust or do more of.
We also discuss what our patients’ goals are – that tells us what type, volume, and intensity of activity their plan should build up to.
We are also interested in unpacking the details about how the symptoms started – that tells us what we should get our patients to do to avoid getting high hamstring tendinopathy again.
Then we move on to movement tests to understand what exercises might be appropriate. We use the same movements we would use in a physical clinic – we demonstrate the movements in front of the camera, then watch the patient do them, and give feedback.
We then use this information to create a starter plan – but this often has to be adjusted after the patient has had time to test it and observe its effect.
Our patients then provide us with feedback in the subsequent consultations and we use that to decide how to proceed – if they should continue at the same level, can progress, or perhaps should take things a bit easier.
Getting your loading plan right is not an exact science and often takes a bit of experimenting because you have to look at ALL the activities in your day/week that impact the hamstring tendons and match that to what your tendons’ can currently tolerate.
Tendons can also be tricky things and sometimes only tell you hours after an activity or the next day that they didn’t like it. If you find your rehab exercises are irritating your tendons, don’t just give up on it, tell your physio so they can use this new information to further fine tune your plan.
These articles go deeper into the details of how to apply load management for specific activities:
3️⃣ Address other factors affecting pain
Recent research has highlighted how tendon pain can be amplified or reduced by increasing or decreasing our stress and anxiety levels.
We’ve explained it in detail here, but in a nutshell, stress and anxiety cause our bodies to produce more stress hormones (like cortisol) which, if produced over a prolonged period, can cause increased inflammation and tissue hypersensitivity. This may cause our pain system to overreact to movement and activity and cause excessive pain flare-ups even when the activity is not vigorous enough to injure our tendons.
If you’re currently experiencing high levels of stress or anxiety, taking steps to address this may help your recovery.
Other treatments that might promote tendon healing
The treatments in this section are thought to promote tendon healing, and there is some research evidence that they can improve recovery when combined with other treatments.
Red light therapy – evidence is emerging that it likely stimulates healing and reduces pain. For tendinopathies, it’s been found to reduce pain and improve function – researchers report even better improvements in function when combined with rehab exercises. Here’s our comprehensive guide on how to use red light therapy.
Supplements – There is some evidence that a combination of Vitamin C and collagen, when combined with strength training exercises, may enhance your tendon’s ability to restore and strengthen itself. Find a detailed discussion of supplements for tendon injuries here.
Nitroglycerin patches – There’s currently a lack of high quality research for this, and studies show contradictory results, but these patches don’t seem to have any serious side effects. So it might be something worth trying if you find you’re not progressing as expected with your rehab. (Nitroglycerin, trinitroglycerin (TNG), nitro, glyceryl trinitrate (GTN), and 1,2,3-trinitroxypropane are different names for the same thing.)
PRP injections are thought to stimulate tendon healing, but there is no strong evidence to support its use specifically for proximal hamstring tendinopathy. In practice we find that it works for some people and not for others.
PDRN injections (popularly known as "salmon sperm injections") are also thought to stimulate tendon healing and help with pain relief, with initial research showing promising results and no serious side effects. But because the studies into this have been small thus far, it should be seen as experimental, and it might or might not work for you.
Treatments to reduce pain
Getting your high hamstring pain to settle down to a manageable level is important. Pain can wear you down, prevent you from getting on with your life, and discourage you from starting or progressing with your rehab.
The following treatments can help to reduce your proximal hamstring pain temporarily, but they usually don’t have a direct effect on healing and should not be used as a stand-alone solution. For best results, they should be used in combination with a progressive rehab plan that restores your tendon’s exercise tolerance (see above).
Massage or foam rolling, if you avoid strong pressure over the irritated hamstring tendons, can help the hamstring muscles to relax and provide temporary pain relief.
Dry needling - A 2022 review study found that it effectively reduced pain and other symptoms linked to tendinopathy.
Low-level laser therapy has been proved effective without any negative side effects.
Shockwave might help to reduce pain, but it doesn’t work for everyone. In my experience, it often doesn’t produce good results if used too early (a newly flared up injury) but can be useful in chronic cases.
Ice can work well for pain relief, but shouldn’t be overused – find a detailed guide here.
Heat is also an option as long as your injury is more than a week old – it’s generally not advised to use heat when there’s inflammation, which might be the case during the first week of tendon pain.
TENS (transcutaneous electrical nerve stimulation) has been shown to effectively reduce pain while the machine is on you, and the effect might last for a few hours after.
Losing weight – Research shows that carrying extra fat – particularly around the waist – can alter blood chemistry, trigger chronic inflammation, and make tendons less healthy and slower to heal.
Tenex may help to reduce pain and improve function by removing the injured part of the tendon and is less invasive than open surgery, but research specific to high hamstring tendinopathy and long-term effects is still very limited.
Treatments for specific cases of proximal hamstring tendinopathy
These treatments are not generally advised, because they might have unwanted side effects or are only effective under certain circumstances. However, used that at the correct time, they can be beneficial.
High-volume injections consisting of normal saline (clean water) plus anaestetic and a small amount of corticosteroid appear safe and effective for pain relief in tendons.
Hormone replacement therapy (HRT) may improve healing if you’re in the menopause. Oestrogen is one of the main hormones in charge of getting your tendons to produce new and stronger collagen fibres (the main building block of a tendon). The drop in oestrogen levels due to the menopause has been shown to both cause tendonitis and delay healing.
Anti-inflammatory medication might be useful if you have ischial bursitis, inflammatory enthesopathy, or if your tendonitis was caused by antibiotics or an inflammatory condition like gout or arthritis. It is not effective for ongoing hamstring tendinopathy caused by overload and might interfere with your recovery if used for a long time.
Corticosteroid injections are a bit controversial – the research shows that they are very good at reducing pain in the short to medium term but might not be great for long-term recovery. However, some cases of proximal hamstring tendinopathy can be super stubborn and just don’t want to react to any other treatment. If that is the case, corticosteroid injections might be an option to try before considering surgery.
Surgery might be an option in cases of proximal hamstring tendinopathy where no other treatments bring relief. It is currently advised to consider surgery only if you’ve tried a progressive rehab plan (as described above) for at least 12 months.
Useless treatments for proximal hamstring tendinopathy
These treatments are either a waste of time and money and/or might be bad for healing.
Therapeutic ultrasound – this is a very popular treatment used in clinics and is generally safe to use, but its effectiveness is questionable. Animal studies show it has the potential to positively affect tendon healing, but when tested on real patients and compared to other treatments, it usually fails to show any benefit.
Corticosteroid tablets – these should never be prescribed as a treatment for tendon injuries. They are different from injections in that they have a systemic and more long term effect and there is much stronger evidence for the detrimental effects tablets might have on tendon health.
BPC-157 peptides – Although there’s a lack of research into their safety and effectiveness in humans, these peptides are widely promoted online as being helpful for healing. We don’t recommend them, as they are experimental and their long-term safety is unknown.
Treatments that might make your symptoms worse
These treatments irritate or worsen symptoms in most people with proximal hamstring tendinopathy. However, we are all different, and some people will find these treatments don’t affect them or perhaps even beneficial.
Hamstring stretches – Any movement where you bend your trunk forward while keeping your legs straight will stretch your hamstrings. When you do this movement, it pulls the upper hamstring tendons tight over the sit-bones, which can irritate an injured tendon (a bit like prodding a bruise). I discuss hamstring stretching, as well as what to do instead here.
Cross-friction massage – With this type of massage, the therapist really digs into the upper hamstring tendons and strongly rubs over it, sometimes using massage tools. The thinking is that this stimulates healing, but there is no evidence to support this, and if your tendon is very irritated, it often just makes things worse.
Prolonged periods of rest – Resting your tendon for short periods when needed is important. But long periods of rest with very little activity can actually make it feel more uncomfortable (due to reduced circulation) and cause your tendon to lose even more strength. Applying the concept of relative rest is much more effective in the long run.
Recovery times
The recovery time for most cases of proximal hamstring tendinopathy is typically between 3 and 6 months, but it’s not uncommon for it to take more than a year.
Every case is different, and recovery time is influenced by several things, including:
How long you've had your symptoms – the longer you have pain, the more sensitised the pain system becomes and the longer it takes to get it to calm down again.
Your tendon’s stage of injury – tendon injuries in Stage 1 (reactive tendinopathy) recover more quickly than ones in Stage 3.
How effectively you can implement the correct balance between rest and loading – sometimes one's work or daily tasks mean that you have to continue with things that irritate the tendon, which can make recovery take a bit longer.
How well you’re addressing the “extra” factors that can impact pain, e.g. stress and anxiety – these factors can sometimes cause pain to persist long after the tendon has already regained its capacity.
How we can help
Need more 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.