Proximal Hamstring Tendinopathy (PHT) is a condition involving irritation and structural changes within the tendon where the hamstring muscles attach to the pelvis. This tendon damage typically manifests as a deep ache or sharp pain located high in the buttock, frequently aggravated by activities that compress the tendon, such as prolonged sitting or deep hip flexion movements. Successfully managing PHT requires a phased approach that shifts from initial symptom reduction to structured, progressive load management designed to rebuild the tendon’s capacity.
Immediate Self-Care and Activity Modification
The initial phase of management focuses on reducing tendon irritation by modifying activities that place excessive strain on the attachment point. Complete rest is generally not recommended; instead, relative rest involves temporarily avoiding specific actions that trigger pain. Activities involving significant hip flexion, such as deep squats, lunges, or running uphill, should be minimized because they create high tensile load on the tendon.
Direct compression of the tendon against the sit bone during sitting is a major source of irritation for PHT. Patients should use a soft cushion or a wedge that slightly elevates the thigh to redistribute pressure away from the painful area. Aggressive stretching of the hamstring should be avoided, as this movement pulls on the tendon and can hinder initial healing. Cold therapy can be applied for short durations to help manage discomfort, though non-steroidal anti-inflammatory drugs (NSAIDs) should be used sparingly and under medical guidance.
Progressive Rehabilitation Through Targeted Exercise
The cornerstone of long-term recovery for PHT is a physical therapy program focused on gradually increasing the tendon’s load tolerance. This structured rehabilitation process is divided into distinct stages, starting with very gentle loading and advancing toward functional strength. The goal is to stimulate the tendon to adapt and strengthen without provoking a painful flare-up.
Phase 1: Isometrics for Pain Relief
Rehabilitation begins with isometric exercises, which involve contracting the hamstring muscle without changing the joint angle. This type of loading is highly effective in reducing tendon pain and maintaining muscle activation in the early stages. A common protocol involves performing several sets of moderate-intensity holds, repeated several times a day. These contractions are typically performed in positions that minimize tendon stretch or compression, such as a double-leg bridge.
Phase 2: Heavy Slow Resistance and Eccentric Loading
Once isometric exercises can be performed with minimal pain, the program transitions to isotonic exercises, focusing on heavy, slow resistance (HSR) training. HSR involves performing both the muscle shortening and muscle lengthening phases of an exercise very slowly under a challenging load. This slow, high-tension loading is essential for promoting positive structural changes within the tendon tissue, helping to reorganize the collagen fibers.
Exercises in this phase may include slow hamstring bridges, prone hamstring curls, or Romanian Deadlifts (RDLs) performed with a controlled, slow tempo. The resistance should be progressively increased, aiming for a low repetition range. Introducing exercises gradually allows the tendon to adapt to tensile loads in positions of increasing hip flexion, preparing it for normal daily activities.
Phase 3: Energy Storage
The final stage of rehabilitation, often reserved for individuals returning to high-demand sports, focuses on energy storage and release. This phase introduces movements that require the tendon to rapidly absorb and release energy, mimicking the stretch-shortening cycle of athletic activity. Exercises include low-level plyometrics, hopping, bounding drills, and controlled speed work. This stage is crucial for fully restoring the tendon’s capacity to handle the high speeds and deep hip flexion angles required for sport.
Non-Surgical Medical Interventions
When a comprehensive, structured exercise program fails to provide sufficient relief after several months, a medical professional may consider advanced non-surgical interventions. These treatments are typically used to either interrupt the pain cycle or stimulate further healing. Procedures are often performed under ultrasound guidance to ensure precise delivery to the proximal hamstring tendon insertion.
Injection therapies are one common route. Corticosteroid injections are primarily used for short-term pain relief and can reduce localized inflammation. However, they do not address the underlying tendon structure and carry a risk of negative effects on tendon strength if injected directly into the tissue. Platelet-Rich Plasma (PRP) injection is another option, involving drawing a patient’s blood, concentrating the platelets, and injecting the solution into the injured tendon. The aim of PRP is to deliver growth factors to promote tissue repair, though current evidence on its effectiveness for PHT remains variable.
Other modalities that may be employed include Extracorporeal Shockwave Therapy (ESWT) and dry needling. ESWT delivers high-energy acoustic waves to the affected area, stimulating blood flow and promoting a healing response within the tendon structure. Dry needling involves inserting thin needles into trigger points or tight muscle bands near the tendon to reduce muscle tension and pain sensitivity. These interventions are typically considered only after a patient has demonstrated consistent effort in a physical therapy program without adequate functional improvement.
Long-Term Strategies for Preventing Recurrence
Preventing the recurrence of PHT requires a permanent commitment to smart training practices and ergonomic adjustments. A foundational strength routine should be consistently integrated into the patient’s long-term exercise regimen. This maintenance program should include exercises that continue to load the hamstring and surrounding hip muscles at a challenging, but non-painful, intensity.
Avoiding the “too much, too soon” error is paramount, as sudden, large spikes in activity, like an abrupt increase in hill running or sprinting, can quickly overload the tendon and lead to a relapse. All increases in load, duration, or intensity should be implemented gradually. Finally, ergonomic considerations remain relevant even after pain subsides. Continued use of a seat cushion or adjusting one’s bike fit can prevent unnecessary compression or strain on the proximal hamstring tendon, securing long-term success.