Proximal hamstring tendinopathy (PHT) is a common cause of deep, localized pain in the lower buttock, near the ischial tuberosity (the sitting bone). This condition is typically an overuse injury causing structural breakdown and disorganization within the tendon tissue, a degenerative process known as tendinosis. PHT primarily affects athletes involved in running, sprinting, or deep hip flexion, but it can also affect those who spend long periods sitting. Successful treatment is overwhelmingly conservative, centered on structured exercise, and requires a methodical approach to tendon healing.
Immediate Load Management and Pain Control
The first step in managing PHT is implementing relative rest, which means modifying activities that aggravate the tendon rather than complete cessation of movement. Activities involving deep hip flexion, such as deep squatting, lunging, or aggressive hamstring stretching, should be temporarily limited or avoided. Running volume, intensity, and frequency often need adjustment, particularly avoiding uphill running and high-speed sprinting, which place high tensile load on the proximal tendon. Finding a tolerable level of activity that does not dramatically increase pain promotes healing without complete deconditioning.
Prolonged sitting is a frequent source of irritation, as it compresses the tendon against the ischial tuberosity. Using a cushioned seat or a wedge cushion that shifts pressure away from the sitting bones can provide immediate relief. Taking frequent standing breaks is also recommended to prevent irritation from sustained compression. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) may be used for short-term pain relief during a flare-up. However, since PHT is primarily a degenerative process, NSAIDs do not alter the long-term tendon pathology and should not be relied upon for sustained management.
The Role of Progressive Loading in Rehabilitation
The core of PHT treatment involves a structured, progressive loading program designed to restore the tendon’s capacity to tolerate mechanical stress. Tendons respond to controlled loading by strengthening their collagen structure, a process that must be introduced gradually to avoid further irritation. The rehabilitation program is typically divided into phases, starting with exercises that minimize tendon compression and progressing toward high-demand activities.
The initial phase focuses on isometric exercises, where the muscle contracts without changing length, which can have an immediate pain-relieving effect. Examples include low-level bridge holds or straight-leg pulldowns performed at a moderate intensity for sustained periods (e.g., five sets of 45-second holds). These exercises help settle the tendon’s irritability and provide a foundation of strength. Movements should be performed without increasing pain significantly, generally keeping discomfort below a two or three out of ten on a pain scale.
As pain settles, the program progresses to isotonic exercises, involving the muscle shortening and lengthening against resistance. This includes heavy slow resistance training, incorporating both concentric and eccentric muscle actions. Movements like single-leg hamstring bridges or seated leg curls are used to build strength through a controlled range of motion. The load should be heavy enough to challenge the muscle but slow enough to maintain control, generally aiming for 3 to 4 sets of 6 to 12 repetitions.
The final phase, typically required for those returning to high-intensity sports, involves energy storage loading, preparing the tendon to act like a spring. This phase introduces speed and high force, including bounding, agility drills, and sport-specific running. Progression requires achieving pain-free execution of the heavy slow resistance exercises and demonstrating sufficient strength symmetry. Working with a physical therapist is highly recommended, as overloading the tendon too quickly is the primary risk of a setback.
When Conservative Treatment Requires Medical Intervention
If pain and function fail to improve despite a diligent rehabilitation program over three to six months, a physician may suggest additional interventions. Targeted injections are sometimes considered, but the type is important due to specific risks. Corticosteroid injections are generally avoided directly into the tendon due to the risk of weakening the tissue and causing rupture. If used, they are limited to the area around the tendon for short-term pain relief, but they do not address the underlying tissue degeneration.
Platelet-rich plasma (PRP) injections use a concentration of the patient’s own growth factors to stimulate tendon healing. While promising, the scientific evidence supporting the long-term effectiveness of PRP for PHT remains mixed. Extracorporeal shockwave therapy (ESWT) is another non-invasive adjunct therapy that directs high-energy sound waves to the tendon insertion. ESWT has demonstrated effectiveness in pain modulation, but it is typically used in conjunction with a loading program, not as a standalone treatment.
Surgery is reserved as a last resort for severe, chronic cases that have failed all forms of conservative management. Procedures typically involve debridement of the damaged tendon tissue and possible reattachment or release from the ischial tuberosity. This option is only considered after a failed trial of conservative care lasting six months or more, usually for cases involving significant tendon tears or persistent, debilitating pain.
Recovery Timeline and Maintenance Strategies
Proximal hamstring tendinopathy is a slow-to-heal condition, requiring patients to manage recovery expectations. While some improvement may be felt within a few months, full recovery and return to high-load activities often require six to twelve months of consistent effort. The criterion for returning to sport is not simply the absence of pain, but the demonstration of pain-free, symmetrical strength and endurance in the affected leg. The tendon must be able to withstand the high forces of dynamic movement without symptom reproduction.
Long-term maintenance strategies are crucial for preventing PHT recurrence. This involves continuing a strength-based training program, often including high-load exercises like single-leg deadlifts, even after symptoms resolve. The tendon’s capacity must be maintained and gradually built upon. Monitoring training volume and avoiding sudden spikes in activity, particularly speed work or hill running, is necessary to keep the tendon healthy and resilient.