Proximal Hamstring Tendinopathy (High Hamstring Pain)

The story usually shows up in the middle of a training block. A runner eight weeks out from a marathon notices a deep ache right at the sit bone in the last miles of a long run. Then it shows up on the subway bench. Then in the desk chair by mid-afternoon. Harlem Hill makes it worse, and so do the Tuesday track repeats. A friend says it’s a tight hamstring, so every evening they fold forward over a straight leg and pull harder. By week three they can’t get through a meeting without shifting onto the other cheek.

That is proximal hamstring tendinopathy, also called high hamstring tendinopathy and, in most of what you’ll find online, hamstring tendonitis. It is an overload problem in the tendon where the hamstrings attach to the ischial tuberosity, the bone you sit on. Distance runners are a core group, with a prevalence around 12% cited in a 2024 review, but it also turns up in people who never run, often perimenopausal women (Grimaldi 2024).

“Tendonitis” is the wrong word for the tissue. When surgeons biopsied 15 of these tendons, every specimen showed the disorganized collagen of tendinosis rather than inflammation (Lempainen 2009). A tendon that has lost its tolerance for load needs load, applied in the right order, to get it back. Rest and anti-inflammatories alone tend to disappoint.

This page is about the hamstring tendon specifically. If you’re not sure which buttock pain this is, start with our guide to buttock pain when sitting and come back.

Where the hamstrings attach, and why the sciatic nerve is part of the story

The semitendinosus and the long head of the biceps femoris share one tendon of origin on the ischial tuberosity, an oval footprint roughly 2.7 by 1.8 cm, and the semimembranosus originates just lateral to it (Miller 2007). The semimembranosus is the one that gets into trouble most. Its deep, lateral origin makes it the most exposed to compression (Grimaldi 2024), and in an MRI series of people without symptoms, among partial tears confined to a single tendon, the semimembranosus was the one torn 74% of the time (Thompson 2017).

Two anatomical facts drive almost everything about this condition.

First, as the hip flexes, the tendon wraps around the curve of the ischium. Sitting, lunging, and folding forward press it against bone (Grimaldi 2024). A healthy tendon tolerates that. An overloaded one does not, which is why a hard chair can hurt as much as a hill repeat.

Second, the sciatic nerve runs an average of 1.2 cm from the most lateral edge of the ischial tuberosity (Miller 2007). That is why some patients feel a tendon problem as a vague ache down the back of the thigh, and why we will not inject this area without watching the nerve on ultrasound the entire time.

The pattern: sit-bone pain that hates hard chairs, hills, and speed

The most useful feature is how well localized the pain is. Most patients can put one finger on it, on or just below the sit bone. Pain referred from the lumbar spine, hip joint, or sacroiliac joint is typically more diffuse (Grimaldi 2024).

The aggravators follow the anatomy. Symptoms usually begin after a rise in hamstring-heavy activity in hip flexion, such as hill running or hill walking, and get worse with faster running. Sitting on hard surfaces is provocative (Grimaldi 2024). Driving is a common complaint because the pelvis rolls back onto the sit bones for an hour at a time. Lower gluteal pain during running and during prolonged sitting is the hallmark symptom in the Finnish orthopedic group’s review of the condition (Lempainen 2015).

What is not part of the pattern matters as much. An ache that spreads toward the knee can happen, but it is not a key feature (Grimaldi 2024), and burning or numbness below the knee points to a nerve root. Morning stiffness in the back or hip is not a feature of isolated hamstring tendinopathy and should send the exam toward the spine, the hip joint, or an inflammatory enthesitis (Grimaldi 2024). And there is no single moment of injury. A pop is a different diagnosis, covered below.

The exam tests, and which ones have published data

The most informative office finding is pain at the ischial tuberosity with resisted knee bending that worsens as the hip is brought into more flexion (Grimaldi 2024). Palpation is done side-lying with the hips bent, because the hamstring origin sits under the gluteus maximus.

Three stretch-provocation tests have been formally studied: the Puranen-Orava test (standing, heel up on a support, leaning forward over a straight knee), the bent-knee stretch test, and the modified bent-knee stretch test (lying on your back, hip and knee fully bent, then the knee straightened by the examiner). In 92 athletes, half with chronic proximal hamstring tendinopathy, agreement between examiners was high (intraclass correlations 0.82 to 0.88), and all three showed moderate-to-high validity, the modified bent-knee test the best (Cacchio 2012). The catch is that the comparison group was healthy athletes rather than people with other buttock pain, so those accuracy figures are probably optimistic in a real clinic (Grimaldi 2024).

The 90-90 hamstring test, which many runners have done in physical therapy, is used by some clinicians as a provocation here. We could not find a published study of its diagnostic accuracy for this condition, so Dr. Movshis treats a positive 90-90 as supporting evidence and nothing more.

What we rule out at the same visit

The sit bone is crowded, and runners can carry two problems at once.

Deep gluteal syndrome and piriformis syndrome. Pain deeper and more central in the buttock, reproduced by flexing, adducting, and internally rotating the hip, often with sciatic-type symptoms. The overlap is real because the hamstring origin is one of the structures that can irritate the sciatic nerve in the deep gluteal space (Bucknor 2014). See our piriformis syndrome page for that workup.

Lumbar radiculopathy. Pain that starts in the low back and runs down the leg past the knee, with dermatomal tingling and sometimes reflex or strength changes. That is sciatica, treated at the spine.

SI joint pain. One-sided pain over the back of the pelvis, worst with sit-to-stand and rolling in bed. Our SI joint pain page covers the confirming injection.

Ischiogluteal bursitis, ischiofemoral impingement, and stress fracture. The bursa sits on the same bone and can coexist with the tendon. Stress fractures of the sacrum and pelvis are rare but belong on the list in runners and triathletes (Grimaldi 2024). Ultrasound shows a fluid-filled bursa in the office. A stress fracture needs MRI.

Gluteal tendinopathy on the outside of the hip can occur alongside this problem (Grimaldi 2024). If you have both, see hip bursitis and gluteal tendinopathy. If the exam cannot separate the tendon from the nerve beside it, an ultrasound-guided injection of local anesthetic at the suspected structure settles it. If the familiar pain goes quiet, that structure is the generator.

Ultrasound or MRI: which one, and when

Ultrasound is in our office suite. It shows a thickened, darker (hypoechoic) tendon at the origin, fluid in the bursa, and the sciatic nerve beside it, and it is the tool we inject with. Its limitation is depth under a thick gluteus maximus. MRI is more sensitive than ultrasound for peritendinous edema and tendinopathy at the hamstring origin (Zissen 2010).

Dr. Movshis orders MRI in four situations:

• A pop, bruising, or sudden weakness, where the question is a tear. A crescent of bright fluid at the tendon-bone junction, the sickle sign, indicates a partial-thickness tear (Sheean 2021).
• No meaningful progress after a fair trial of loading.
• Night pain, morning stiffness, or bone tenderness in a runner, where a stress fracture or an inflammatory process is possible.
• Before any surgical referral.

MRI also needs reading with skepticism in both directions. Abnormal hamstring origins are common in people with no pain at all, with changes on both sides in 52% of 253 adults scanned for other reasons (Thompson 2017). And standard positioning can undercall disease that a hip-flexed scan reveals (Jokela 2024). The report is read against the exam, never instead of it.

Why stretching the hamstring harder made it worse

Almost every patient with this problem has been told to stretch. The back of the thigh feels tight, so lengthen it. The tendon disagrees.

A deep hamstring stretch, whether a standing toe-touch, a seated forward fold, or a long yoga hold, takes the hip into full flexion with the knee straight. That pulls the tendon taut and wraps it around the ischium at the same time. Tensile load plus compression is the combination most damaging to a tendon, and the proximal hamstring tendons are compressed against the ischium in hip flexion (Grimaldi 2024). The evening stretch delivers exactly the load the tendon tolerates least, and next morning’s sitting pain is the bill.

Older rehabilitation protocols did prescribe frequent stretching alongside eccentric strengthening (Fredericson 2005). Current practice avoids significant hip flexion range early and reintroduces deep-flexion work slowly (Grimaldi 2024). For sitting, raise the chair and tilt it so the hips are not deeply flexed, and use a softer surface or a cushion (Grimaldi 2024). A cushion with a cutout under the painful side works on the same principle.

The loading program, stage by stage

No randomized trial has tested a specific rehabilitation protocol for this condition. Goom and colleagues’ 2016 JOSPT review says so plainly and builds its management outline from principles established in Achilles and patellar tendinopathy (Goom 2016). A systematic review of every studied treatment found insufficient evidence to favor any single intervention, and recommended borrowing what works in other tendons (Nasser 2021). The program below follows that logic. It runs through our in-house physical therapy, and each stage advances on response, not on the calendar.

Stage 1, settle the pain. Isometric holds with the hip fairly straight, such as a bridge hold or a prone knee-bend hold against resistance, while the aggravators are cut. These are a tool, not magic. In the only crossover trial in this condition, one session of isometric exercise was no better than isotonic exercise for pain, strength, or next-day sitting pain in 20 patients (Rich 2026). If slow full-range work feels fine on day one, we skip ahead.

Stage 2, build strength with the hip relatively straight. Prone curls, bridges progressing to single-leg bridges, hip thrusts. Resistance can climb quickly in positions with little hip flexion (Grimaldi 2024). Slow, heavy repetitions are the goal.

Stage 3, add hip flexion gradually. Romanian deadlifts through a short range that grows, step-ups, split squats, then lunges. Range into deep hip flexion generally takes months to rebuild (Grimaldi 2024), and rushing it is the commonest cause of a setback.

Stage 4, restore speed and spring. Skipping and bounding drills, strides on the flat, then hills, then intervals.

The gluteus maximus and the rest of the kinetic chain are trained throughout because they share load with the hamstrings (Grimaldi 2024).

Running with it, and your goal race

Runners who see Dr. Movshis with this in the weeks before a goal race mostly want one answer: can I still run it?

Start by removing speed and hills, the two things that load the hamstring origin hardest (Grimaldi 2024). No track, no tempo, no hill repeats, flat routes for the long run. Easy flat running is often tolerated in less irritable cases (Grimaldi 2024).

Then monitor the response, not the run. Mild pain during the run is acceptable if it settles by the next morning and your next-day sitting tolerance is no worse. If the next day is worse, cut volume. That model comes from a randomized trial in Achilles tendinopathy, where patients who kept running with pain monitoring did as well as those who rested from running for six weeks (Silbernagel 2007). There is no equivalent hamstring trial, so it is an extrapolation.

Shorten your stride. Over-striding is associated with this condition (Grimaldi 2024), and in a gait lab study, raising step rate 5 to 10% above preferred shortened the stride and reduced energy absorption at the knee, and at the hip at the 10% increase (Heiderscheit 2011). A metronome app set a few beats above your current cadence is the simplest way to practice on easy runs.

Dr. Movshis’s race-week rule: if you can run easy flat miles with pain that settles overnight and your gait looks normal, finishing at a conservative even pace is often realistic. If the course has hilly sections, especially late in the race, shorten your stride and ease the effort on the climbs. If the pain changes how you run, or you cannot sit through a workday after an easy run, this race is the wrong goal.

After time off, the return follows the same ladder: brisk uphill walking without symptoms, single-leg bridges comparable side to side, skipping drills tolerated, then walk-run intervals on the flat, then continuous easy running, strides, hills, and speed last.

Injections: what the evidence actually shows

Modal Pain Management offers two injections for this condition, both under real-time ultrasound with the sciatic nerve in view. Neither replaces the loading program.

Ultrasound-guided corticosteroid injection around the tendon

The steroid goes into the space around the tendon at the ischial tuberosity, not into the tendon itself. In a Stanford radiology series, 50% of patients improved for more than one month after ultrasound-guided injection and 24% for more than six months (Zissen 2010). In 22 MRI-confirmed cases in athletes treated with fluoroscopically guided peritendinous injection, average pain fell from 7.22 to 3.94 and 38.8% reported complete resolution at a mean follow-up of about two years (Nicholson 2014). Neither study had a control group, and across the available series the short-term gains were not maintained long term (Grimaldi 2024). Corticosteroid also has adverse biological effects on tendon tissue (Grimaldi 2024).

So Dr. Movshis uses it narrowly. If pain is blocking the loading program, one well-placed injection can open a window of a few weeks to train in. It is not repeated as a standalone treatment, and a patient who gets relief and stops the exercises is set up for a relapse.

PRP (platelet-rich plasma)

PRP is your own blood, spun to concentrate platelets and injected into the damaged tendon under ultrasound. The data in this tendon are thin. The only double-blind trial compared PRP with the patient’s own whole blood, not with saline or exercise, and found no meaningful between-group difference through six months, though both groups improved over time (Davenport 2015). A 2026 systematic review of randomized PRP trials around the hip found exactly one trial in chronic proximal hamstring tendinopathy, with 17 patients (Kuhns 2026). In a prospective series of 29 patients, a single PRP injection produced no significant improvement at 8 weeks, and 69% reported no change in their ability to do sport (Levy 2019). Reported adverse event rates run from 0 to 10%, including significant post-injection pain and sciatic nerve irritation (Grimaldi 2024).

Dr. Movshis offers PRP to patients who have done a real loading program, stalled, and want to try it knowing the evidence is weak. Aftercare is on our PRP aftercare page, and the evidence by condition is on our PRP therapy page.

What we refer for

Percutaneous tenotomy, repeated needle fenestration of the tendon under ultrasound, is not something we perform, and we refer when it fits. In a randomized trial of 40 patients with chronic tendinosis across several tendons, including the proximal hamstring, adding PRP to needle tenotomy made no difference at one and two years (Kirschner 2021).

Shockwave therapy is not something we offer either, and its evidence is split. An early trial in 40 professional athletes found 85% of the shockwave group reached at least a 50% reduction in pain at 3 months, against 10% with traditional conservative care (Cacchio 2011). The larger 2025 trial, 100 patients followed for a year, found shockwave no better than individualized physiotherapy at any point (Rich 2025).

Surgery is worth an opinion after a full year of an evidence-based loading program has failed (Grimaldi 2024). In the largest series, 80 of 90 operated athletes returned to their previous level of sport, at a mean of 5 months (Lempainen 2009). That is an uncontrolled series, and we refer for a surgical opinion rather than promise that result.

A pop is not tendinopathy

A partial or complete tear of the hamstring origin usually happens in one moment, with the hip forced into deep flexion while the knee is straight, often with an audible pop (Grimaldi 2024). Bruising tracks down the back of the thigh over the next few days, and walking or sitting becomes hard.

That is an acute surgical problem, and timing matters. Complete ruptures managed without surgery often leave weakness and poor return to sport, and acute repair is preferred over delayed repair (Degen 2019). Acute repairs also have lower re-tear rates than repairs of chronic tears (Sheean 2021). Get a same-week or urgent orthopedic assessment and an MRI. Our sports medicine page explains how we triage acute injuries.

Separately, if buttock or leg pain comes with numbness in the groin or saddle area, new trouble controlling your bladder or bowels, or rapidly worsening leg weakness, call 911 or go to the nearest emergency room. Constant pain at rest and at night with fever, unexplained weight loss, or a history of cancer needs prompt medical evaluation, not a tendon program.

Hamstring tendinopathy care at Modal Pain Management

Modal Pain Management is a physician-owned interventional pain practice at 369 Lexington Avenue in Midtown Manhattan, and every physician visit is with Dr. Alex Movshis. He is dual board-certified in Anesthesiology and Pain Medicine and completed an ACGME-accredited interventional pain medicine fellowship at the Icahn School of Medicine at Mount Sinai. NPI 1942741160. See the physician bio and our evidence and credentials page.

The first visit covers the history and the provocation exam, which is usually enough for a working diagnosis. Ultrasound of the hamstring origin and sciatic nerve is in the office suite when it is needed, and an injection, when it makes sense, is done under that guidance. The loading program starts in our in-house physical therapy rather than on a printed handout.

If your sit-bone pain has lasted more than a few weeks, is getting worse with sitting, or is threatening a race, book a same-week evaluation or call (646) 290-6660.

References

• Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. J Orthop Sports Phys Ther. 2016;46(6):483–93. doi:10.2519/jospt.2016.5986 · PubMed
• Grimaldi A, Mellor R, Nasser A, Vicenzino B, Hunter DJ. Current and future advances in practice: tendinopathies of the hip. Rheumatol Adv Pract. 2024;8(2):rkae022. doi:10.1093/rap/rkae022 · PubMed
• Lempainen L, Johansson K, Banke IJ, et al. Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy. Muscles Ligaments Tendons J. 2015;5(1):23–8. PMC4396672 · PubMed
• Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. Am J Sports Med. 2009;37(4):727–34. doi:10.1177/0363546508330129 · PubMed
• Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. A cadaveric study. J Bone Joint Surg Am. 2007;89(1):44–8. doi:10.2106/JBJS.F.00094 · PubMed
• Thompson SM, Fung S, Wood DG. The prevalence of proximal hamstring pathology on MRI in the asymptomatic population. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):108–111. doi:10.1007/s00167-016-4253-4 · PubMed
• Cacchio A, Borra F, Severini G, et al. Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Br J Sports Med. 2012;46(12):883–7. doi:10.1136/bjsports-2011-090325 · PubMed
• Bucknor MD, Steinbach LS, Saloner D, Chin CT. Magnetic resonance neurography evaluation of chronic extraspinal sciatica after remote proximal hamstring injury: a preliminary retrospective analysis. J Neurosurg. 2014;121(2):408–14. doi:10.3171/2014.4.JNS13940 · PubMed
• Zissen MH, Wallace G, Stevens KJ, Fredericson M, Beaulieu CF. High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR Am J Roentgenol. 2010;195(4):993–8. doi:10.2214/AJR.09.3674 · PubMed
• Sheean AJ, Arner JW, Bradley JP. Proximal Hamstring Tendon Injuries: Diagnosis and Management. Arthroscopy. 2021;37(2):435–437. doi:10.1016/j.arthro.2020.12.201 · PubMed
• Jokela A, Niemi P, Koski I, et al. Magnetic Resonance Imaging With a Novel Hip Flexion Scanning Position for Diagnosing Proximal Hamstring Tendinopathy. Orthop J Sports Med. 2024;12(9):23259671241265130. doi:10.1177/23259671241265130 · PubMed
• Fredericson M, Moore W, Guillet M, Beaulieu C. High hamstring tendinopathy in runners: meeting the challenges of diagnosis, treatment, and rehabilitation. Phys Sportsmed. 2005;33(5):32–43. doi:10.3810/psm.2005.05.89 · PubMed
• Nasser AM, Vicenzino B, Grimaldi A, Anderson J, Semciw AI. Proximal Hamstring Tendinopathy: A Systematic Review of Interventions. Int J Sports Phys Ther. 2021;16(2):288–305. doi:10.26603/001c.21250 · PubMed
• Rich ALF, Ford JJ, Cook JL, Hahne AJ. The Effect of Isotonic Versus Isometric Strength Exercise for Pain and Strength in Proximal Hamstring Tendinopathy: A Randomized Crossover Trial. Clin J Sport Med. 2026. Published online ahead of print. doi:10.1097/JSM.0000000000001478 · PubMed
• Rich A, Ford J, Cook J, Hahne A. Physiotherapy Compared With Shockwave Therapy for the Treatment of Proximal Hamstring Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2025;53(14):3396–3407. doi:10.1177/03635465251391134 · PubMed
• Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906. doi:10.1177/0363546506298279 · PubMed
• Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan MB. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc. 2011;43(2):296–302. doi:10.1249/MSS.0b013e3181ebedf4 · PubMed
• Nicholson LT, DiSegna S, Newman JS, Miller SL. Fluoroscopically Guided Peritendinous Corticosteroid Injection for Proximal Hamstring Tendinopathy: A Retrospective Review. Orthop J Sports Med. 2014;2(3):2325967114526135. doi:10.1177/2325967114526135 · PubMed
• Davenport KL, Campos JS, Nguyen J, Saboeiro G, Adler RS, Moley PJ. Ultrasound-Guided Intratendinous Injections With Platelet-Rich Plasma or Autologous Whole Blood for Treatment of Proximal Hamstring Tendinopathy: A Double-Blind Randomized Controlled Trial. J Ultrasound Med. 2015;34(8):1455–63. doi:10.7863/ultra.34.8.1455 · PubMed
• Kuhns BD, Becker N, Reyes-Cordova A, et al. Improved Outcomes With Platelet-Rich Plasma for Treating Extra-articular Hip Pathology Especially Greater Trochanteric Pain Syndrome and Hamstring Injury: A Systematic Review of Randomized Controlled Trials. Arthroscopy. 2026;42(1):310–325. doi:10.1002/arj.70024 · PubMed
• Levy GM, Lucas P, Hope N. Efficacy of a platelet-rich plasma injection for the treatment of proximal hamstring tendinopathy: A pilot study. J Sci Med Sport. 2019;22(3):247–252. doi:10.1016/j.jsams.2018.08.001 · PubMed
• Kirschner JS, Cheng J, Hurwitz N, et al. Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial. PM R. 2021;13(12):1340–1349. doi:10.1002/pmrj.12583 · PubMed
• Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F. Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes. Am J Sports Med. 2011;39(1):146–53. doi:10.1177/0363546510379324 · PubMed
• Degen RM. Proximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries. Curr Rev Musculoskelet Med. 2019;12(2):138–146. doi:10.1007/s12178-019-09541-x · PubMed