Rehab exercises for proximal hamstring tendinopathy – What, when, how much?
The many proximal (high) hamstring tendinopathy exercises touted online can be confusing. Here are examples and demos of the most useful exercises and advice on how to personalise them for your unique circumstances.
Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call.
The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles. Read more (opens in new window).
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Some surprising benefits of exercises for high hamstring pain
Yes, of course your rehab exercises can help your tendons to grow stronger, but it’s about so much more than just building strength. These are the top four benefits of including exercise-based rehab in your treatment plan:
It’s a great way to calm the pain system down – people often assume that they should be pain-free before starting rehab exercises, but this is not the case. The exercises, if pitched at the correct intensity, can settle your pain quicker and reduce flare-ups.
It restores your hamstring muscle and tendon strength and endurance so that they are eventually able to tolerate the activities you want to be doing.
It ensures that your nervous system (brain, spinal cord, and nerves in your legs), which is in charge of your movements, is optimally primed to use your hamstring muscles in a well-controlled way.
It ensures that the other muscles that are meant to work with and support your hamstring muscles are strong and doing their work properly – this helps to distribute loads more evenly and prevents overloading the hamstrings.
There is no one-size-fits-all rehab exercise programme for proximal hamstring tendinopathy (PHT). So, before we dig into the actual exercises, let’s take a look at the general principles that will help you to figure out the “what, when, how much” that are best suited to your specific situation and needs.
How to personalise a proximal hamstring tendinopathy rehab exercise programme
Use pain to guide your rehab and recovery
When you have high hamstring tendinopathy, it’s normal to have some pain and discomfort throughout your recovery. And your symptoms will likely change depending on what you’re doing.
💡 It’s important to keep in mind that pain does not necessarily indicate how severe your injury is – you can be in extreme pain even when your scan doesn’t show a big injury to the tendons, and vice versa.
Thanks to research, we now understand that it’s quite useful to view pain as an alarm system; one that can sometimes get triggered or stuck on full blast without any good reason from an injury perspective. But we can also dial down that alarm system if we understand what influences it.
It turns out that the intensity of your pain is controlled by a subconscious part of your brain that’s linked to your fight-or-flight system – and therefore any of the regular stressful events that usually trigger your stress levels to go up will also increase the intensity of your pain, e.g. whether you believe you can recover, stress, worry about loss of income, or loss of social life because you can’t join your regular running club sessions.
The problem is that you can’t just tell your subconscious to chill out – it doesn’t trust your conscious mind – you have to prove to it patiently over time that there really is no reason to create so much pain, and exercise is one of the best ways to do this. (Find advice on how to address the other factors here.)
Resting completely for a very long time (short periods can be beneficial) and over-protecting an injury should be avoided because it seems to actually reinforce the subconscious’ assessment that this is a very bad injury, and therefore it should increase your pain.
It’s now a well-established fact in the research that you can get the pain system to calm down by remaining active but adjusting your exercises to not push your pain above a certain level. Here’s how:
1. Choose exercises that don’t scare you
Have you ever experienced pain in an area of your body when you see or perhaps even just hear about how someone else got injured? That’s an example of how your alarm system can create pain without actually having any good reason to do so. (My hamstrings often ache when my partner describes an injury he has.)
If you’re really worried about doing a specific movement or activity because you believe that it will likely make things worse, that is NOT the place to start – just thinking about it might already give you a ping of pain in the injured area.
💡 Your rehab exercises should be things that you feel are safe to do. It´s OK if you’re feeling a bit apprehensive or want to be careful, but it should not make you very worried.
👉 If you find yourself putting off doing your exercises, ask yourself why that is. If the honest answer is that you’re not looking forward to how they’re going to make you feel or how difficult they are, discuss it with your physio so that they can give you other things to do.
2. Monitor your symptoms
1️⃣ – To do this, you must first observe how your symptoms (pain and stiffness) normally change throughout the day if you don’t exercise – this is your baseline.
2️⃣ – From the research it’s clear that the most beneficial rehab plans are ones that cause:
only a slight increase in discomfort above your baseline symptoms while you’re doing the exercise or activity
only a slight increase in discomfort above your baseline in the hours after completing the exercises
and any increased symptoms should settle back down to your normal baseline levels within about 24 hours.
3️⃣ – You should also keep an eye on how you feel this week compared to last week and compared to 4-6 weeks ago. Ideally, you want to observe signs that things are stable or improving, e.g.:
Your symptoms remain about the same or are perhaps slightly better compared to last week – it can take several weeks to notice significant improvements.
Or, if you look back 4-6 weeks, you notice that you can now do a bit more or sit for longer before your symptoms get worse.
There are daily tasks that you can now complete hassle-free, where you previously had to be a bit careful – this is a clear sign that your tendon’s capacity and tolerance are improving.
💡 If you stay within these parameters, you’ll find your baseline symptoms gradually improving and that you can tolerate more and more activity and rehab exercise without triggering your alarm system.
3. What if you do get a flare-up?
The annoying thing with tendons is that they often don’t tell you in the moment that they’re not happy with what you’re doing. It is often only several hours later or even the next day that your symptoms increase significantly.
💡 You can avoid extreme flare-ups by very gradually increasing rehab loads, but most people will experience at least minor ones at some point in their rehab.
When this happens, remember that it doesn’t mean that your injury has worsened. You’ve very likely just triggered the alarm system, and the alarm goes off long before any tissue damage occurs (otherwise it wouldn’t be a very useful alarm).
Taking things easy for a few days usually helps, but you might also find that light exercise (like isometrics - see below) can help it to settle more quickly.
We teach our patients how to deal with flare-ups, but if you’re unsure about what to do about it or whether anything in your rehab needs to be adjusted, it can be really useful to get it checked by your physio. It might for instance not even be down to what you did on that day – it might be the total workload on your tendons over several days that was the problem.
Your plan must match your strength, symptoms, and goals
Even though there might be similarities between you and someone else with PHT, our bodies (and injuries) are all different. Again, this is why a one-size-fits-all approach to tendon rehab rarely works.
Yes, there are some universal concepts that apply to everyone, but they live within a wide range of possibilities, and you must adapt them to suit your situation. Here are some examples:
A woman in any stage of the menopause will likely need to add in more recovery time and build strength a bit more gradually, because her lower oestrogen levels mean that her tendons take longer to repair and strengthen after each bout of exercise.
If you’ve had a long break from exercise, either due to high pain levels or simply losing motivation because the hamstring pain has stopped you doing what you love, your muscles and tendons might be deconditioned, which requires you to start at an easier level.
Similarly, if you’ve never really done much strength training or exercise, your plan should take this into consideration.
On the flipside, if you only experience mild symptoms after very intense training sessions, you likely just have to adjust your regular training volumes and sessions slightly, and can usually start or progress onto more advanced rehab exercises quite quickly.
Some people find that they simply can’t do certain exercises (like the bridge), because it always triggers a flare-up – there are lots of other exercises that work for PHT, and it would not make sense to try and force bridges in this case.
Recovery is just as important as exercising
For your hamstring tendons to fully benefit from a rehab session, you have to allow them enough time to fully complete the natural breakdown-and-repair process your body uses to grow stronger.
When we exercise, all of the tissue types we use (muscles, tendons, bones, etc.) sustain small injuries. These micro-injuries are what signals your body to strengthen those areas.
It’s as if your body decides “Well, I’m not going to let that happen again!” and then it not only repairs the injured areas but actually makes the tissue more robust than before you did the workout.
👍 If you time your workouts well, this continuous breakdown-and-repair cycle gradually increases your body’s capacity and is the reason you can do more or heavier workouts over time.
👎 However, if you don’t allow your body to fully repair, instead of growing stronger these micro-injuries can accumulate and cause overuse injuries (like PHT) or flare-ups.
How much recovery do you need?
I list typical recovery times in the specific exercise sections below, but keep in mind that there might be events in your life – not related to the exercises – that can also increase your recovery demands.
Some of the things that influence how long your body needs to complete its post-exercise strengthening cycle:
How fit or trained you are – if you’ve had a long break from training or are new to strength training, you will need more recovery time.
How hard you exercise – I’ll explain this in more detail below, but lower-load exercises (using bodyweight or light weights) tend to create fewer micro-injuries and therefore require less recovery time.
The type of muscle contraction – Isometric exercises (where you just hold a position) cause nearly no muscle damage, while exercises where you have to lengthen the muscles slowly while contracting it cause quite a lot (but also provide more benefit!)
Your hormones – lower levels of oestrogen due to the menopause mean that your body needs more time to repair and strengthen your tendons. We don't have clear evidence from the research yet how men's changing hormone levels affect this.
Genetics – some people just recover more quickly than others.
If your muscles are still sore from your previous workout or exercises, they are not yet fully recovered.
Other factors like sleep quality and a well-balanced diet are also important for optimal recovery, but we'll focus on exercise for now.
Progress from low to high compression
Our proximal hamstring tendons have to deal with two types of load or force when we use them:
Tensile (pulling) forces, which are created by the hamstring muscles pulling lengthwise on the tendons.
Compression forces, which are created when you contract your hamstring muscles while your hip is flexed forward (moving your knee closer to your stomach); this pulls your hamstring tendons tightly over your sit bone.
The proximal hamstring tendons usually develop tendinopathy quite close to the sit bone, which is also the area that experiences most of the compression force when it’s being pulled against the sit bone. This is why exercises that create a big hip flexion angle often cause flare-ups during the early stages of rehab.
💡 Starting with rehab exercises that don’t cause a lot of compression can help to improve your tendon’s capacity while limiting the risk of flare-ups.
You do eventually want to train the tendon to be happy with compression, but this is best left for later in the rehab process, once your tendons can tolerate a good volume of low-compression exercises. It also tends to be better to use active movements and strength training into those positions rather than doing passive hamstring or hip stretches.
👉 This is why you won’t see any stretch exercises in the examples below. Here is a detailed discussion on what stretches to avoid with PHT and what you can do instead.
Isometric exercises for proximal hamstring tendinopathy
Who needs these?
Most people with proximal hamstring tendinopathy will benefit from including these exercises at some point in their rehab.
When to start
You can usually start these within a day or two of noticing your symptoms. However, they are not a magic fix, and it doesn’t work to just add them in and then continue with life as normal.
👉 For these exercises to be effective, you also have to adjust and adapt the factors in your daily life and training so that they don’t continue to aggravate your tendons.
What are they?
With an isometric exercise, you tense a muscle but without moving your body. They cause very little micro-damage in the tendons and muscles because the muscle and tendon cells stay the same length for the duration of the contraction.
How do they benefit PHT?
Because your muscles and tendons find this type of muscle contraction relatively easy, they are a great way to start building strength and getting your pain system comfortable with the idea of exercise during the early days of recovery, when it is still very easy to trigger and flare up.
Isometrics can also be a useful way to maintain or build strength and reduce pain if you're currently training for an important competition and can't take time out to properly focus on rehab and recovery.
In later rehab, isometrics can also be used as part of your warm-up or on recovery days.
Examples
The most common isometric exercises used for PHT are:
Isometric version of the bridge exercise – simply lift into the position and hold it. You can make the bridge harder by straightening your knees or lifting using only one leg.
Prone leg curl, where you bend your knee about 45 degrees against resistance and then maintain that position – your hamstring tendons experience very little compression when you lie on your stomach compared to when you’re doing a seated curl.
Sets, reps, frequency
Start by holding the contraction for 10 to 20 seconds (rest at least 30 seconds between reps).
If your leg starts to shake or you lose form, that’s your sign to lower down and rest.
Build to holding the contraction for 30 to 45 seconds (rest for 60 to 90 seconds).
Aim to do 5 repetitions in total.
How often you do this will depend on how your muscles and tendons react. Some people might need a recovery day between sessions while others will find them very easy and might benefit from doing them more than once a day.
👉 Your physio might prescribe very different exercises, sets or reps to what's in this article. These are only some examples and there are many different combinations that can work.
Exercises that combine concentric and eccentric contractions
Who needs these?
Everyone with high hamstring tendinopathy will usually have to include some version of this in their rehab.
When to start
You can usually start low-load versions of these within a few days of your symptoms starting.
What are they?
A concentric muscle contraction is when your muscle cells shorten as you use them – for the hamstring, this is when your heel moves towards your bum during the leg curl, or your body comes back upright during a deadlift.
Your hamstrings work eccentrically when they have to contract while at the same time also lengthening – when you move your heel away from your bum to straighten your knee during a leg curl or you hinge your body forwards during the deadlift.
Your muscles and tendons work much harder during eccentric contractions and therefore sustain more micro-injuries during that part of the movement. However, this is also the type of training that works extremely well to stimulate tendons to repair and strengthen.
👉 So don’t be put off by the thought of eccentric movements being harder – as long as their intensity is properly tailored to you, they are a safe and extremely beneficial component of rehab.
How do they benefit PHT?
Exercises that combine concentric and eccentric contractions stimulate your tendons in a way that is more similar to how we use our hamstrings in daily life, providing functional strength.
Slowing the movement down and really focusing on good control have been shown to improve your neural control (how well your brain and nerves control your legs).
They’ve also been shown to be as effective as isometrics at reducing proximal hamstring pain, and low-load versions can be started quite early in the rehab process.
Examples
The prone leg curl is usually the best option during the early days of rehab due to the straighter hip position.
However, it can be useful to gradually ease into Romanian deadlifts or seated leg curls later in the rehab process to restore the tendons’ ability to tolerate and withstand compression.
Sets, reps, frequency
You usually want to ease into these exercises:
using a weight or resistance band that makes you tired within about 12 to 15 repetitions,
resting for at least 1 to 2 minutes between sets,
and doing 3 sets in total.
But once your symptoms are stable and you’ve done a solid 6 to 8 weeks of the lighter training, you usually want to:
progress gradually to heavier weights that make you tired within 8 to 10 repetitions (sometimes even heavier),
resting at least 2 minutes between sets,
and doing 3 to 5 sets depending on your specific situation.
👉 You only want to do these types of exercises 2 to 3 days a week and never on consecutive days – the frequency will also depend on what other exercise and activities you do in a week.
Exercises that target the rest of the body
Who needs these?
These exercises are very important for anyone who wants to do a lot of sport – it might be OK to leave them out if you’re not really interested in being very active.
When to start
You can start or continue doing any exercises or activities that don't cause an increase in your symptoms (as explained earlier).
How do they benefit PHT?
We never use just one muscle to do a movement. When we walk or run, for instance, your front thigh muscles (quads), buttock muscles (glutes), hamstrings, and calf muscles all work together to propel you forward.
Because your hamstring muscles attach onto the pelvis, all the muscles that control your hips and core also influence how hard they have to work.
Ideally, all of these muscles should be nice and strong to spread the load evenly through your body. So, if your calf muscles are not very strong, your hamstrings and glutes might have to pick up the slack, which would increase their risk of getting injured.
This is why it can be really useful to include strength training exercises for all the key muscle groups in your core and lower body. And if you like high-impact activities that involve running or jumping, this becomes even more important.
What exercises should you do?
There are many exercises that can work, but it’s worth just taking a moment and checking the following:
How much do you have to flex your hip forward while doing it? If it’s more than 45 degrees, you might want to leave that exercise for later in rehab, because it might irritate your tendons in the early days due to compression.
How much do your hamstrings have to work? It’s OK if it’s a little bit, but they should not have to do a significant portion of the work, otherwise it might overwork them if you’re also doing your hamstring-specific rehab exercises.
Take deep squats, for instance. They’re an excellent exercise to strengthen your quads and glutes (and hamstrings to a lesser extent), but they can irritate the upper hamstring tendons in the early rehab days due to how much your hips have to bend – starting with high wall sits or very shallow squats can be a great way to ease into them.
Some options for early rehab:
High wall-sits for quad strength.
Side kicks against resistance for hip strength and stability – the bridges you’re doing for your hamstrings will also help to strengthen the glutes.
Heel raises with straight knees.
Plyometric exercises (energy storage and release)
Who needs these?
Athletes who take part in sports that require jumping or explosive movements usually have to do these.
Some runners might benefit from adding them in, but you can also just use a graded return-to-running plan during the final rehab stage to build the running-specific capacity your tendons need.
When to start
It’s very important that your hamstring tendons are happy to tolerate quite heavy loads in positions of strong compression before you transition to this stage of rehab. They require that strong foundation to be effective and not get overloaded.
Building up to this level can take more than 12 weeks if you were significantly deconditioned when you started building strength.
What are they?
These exercises use movement patterns that look similar to regular strength training exercises, but you perform them at high speeds – they require your legs to become good at decelerating movements and creating an explosive or fast acceleration into the opposite direction.
How do they benefit PHT?
These exercises develop your tendons’ ability to store and release energy quickly – you use this when doing explosive movements like jumping and landing during basketball, or side-stepping an opponent on the football field.
Examples
The type of sport you want to get back to will dictate what type of plyometric exercises are most useful for you:
lunging with weights into different directions
squat jumps
box jumps
scissor jumps.
Sets, reps, frequency
How many repetitions you do will depend on your conditioning and the difficulty or load of the specific drill you’re given – it can range from 3 sets of 8 to 20 reps done 2 to 3 days per week.
You usually want at least one recovery day between these, and you must also consider what other exercise or running drills you’re doing on that day so that you don’t overwork your tendons.
Usually, the regular strength training rehab exercises you’ve been doing up until this point will reduce to a maintenance dose only, so you can then add in and transition to this type of exercise and sport-specific training.
Gradually easing back into your goal activity
Who needs these?
This is an extremely important step that applies to everyone with proximal hamstring tendinopathy, whether your goal is to get back to gardening or doing 100-mile endurance races.
How does this benefit PHT?
Your rehab exercises will prepare your tendons for the work they have to do during your chosen activity or sport, but you can only build the final activity-specific tolerance by actually doing that activity.
When to start
The good news is that you don’t always have to wait until you’re fully recovered to start this process. Here’s how we figure out when a patient can start:
We look at your current ability – what you can currently do without flaring your pain up.
Break the goal activity you want to get back to (gardening, running, etc.) down into smaller targets of what range of motion, level of strength, movement patterns, endurance, etc. your tendons (and general body) require to do this pain-free – this is not an exact science, and these might change a bit as we get to know you better over several sessions.
And then we choose your rehab exercises and rehab targets to gradually build up to those requirements.
Once we feel that you’ve reached a point where you can complete a very basic or easy version of your goal activity, we help you understand how to introduce that safely alongside your rehab exercises.
👉 Some patients might be able to continue with an easier or adapted version of their goal activity right from the start while others might have to wait until much later – it depends on the type of activity, how irritated the tendon is, and how deconditioned you are.
Maintenance exercises
Here, an individualised approach becomes even more important. The easiest way to explain this is by providing two examples – one for someone who just wants to feel strong and healthy in daily life, and one for someone who wants to get back to being very active/sporty.
Example 1 – I just want to be healthy and pain-free doing my daily tasks
Doing two general strength training workouts (that strengthen all the areas of your body) per week is usually enough to ensure your muscles, tendons, and bones remain strong and healthy into old age.
If I had to choose just five exercises to keep me strong, these would be:
squats with weights or using the leg-press machine in the gym
deadlifts with weights, or single-leg hamstring bridges, or doing the leg-curl machine in the gym
heel raises with weights or using the calf machine in the gym
seated row using exercise bands or the seated row machine in the gym
any version of the chest press, e.g. lying on the floor with dumbbells or using the machine in the gym.
Example 2 – I like training hard and often take part in races/competitions
Your approach should be more nuanced and should change depending on what other training you’re doing. Your maintenance exercises sit alongside your other training and contribute to the total load and work your hamstrings have to endure.
So, what you do for maintenance should change depending on what your main focus and aim is for that training block. What is useful during one phase of training might be too much or counterproductive in the next.
Take training for a marathon, for instance:
When you’re in the base-building stage, doing two quite intense strength training sessions per week might be appropriate
But when you progress into the final stage of training, where your running volume and intensity are really pushing your boundaries, reducing the total volume of your strength training sessions while keeping the intensity is usually a good idea – you might even reduce it to just one session per week and drop it during your final taper weeks.
Regardless of the intensity of the workout, it can be useful to include at least one or two exercises that work the hamstrings, e.g. deadlifts or split squats. Your coach might also change these up depending on your training phase, e.g. using more explosive exercises in one session and heavy resistance in the other.
How we can help
Need help with an injury? You’re welcome to consult one of the physio 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.
