Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy (PHT) is an overuse tendinopathy of the hamstring origin at the ischial tuberosity that causes deep, well-localised buttock pain, typically worse with sitting and running.

It affects runners and athletes in sports with repeated hip flexion loading, and also less active adults, often perimenopausal women. It is often misdiagnosed as lumbar referred pain, piriformis syndrome or an acute hamstring strain.

The hamstrings arise from the ischial tuberosity. Semitendinosus and the long head of biceps femoris share a conjoint tendon; semimembranosus has a separate, deeper and more lateral origin and is the tendon most often affected.

The sciatic nerve runs about 1.2 cm from the lateral edge of the ischial tuberosity, so local nerve irritation can coexist with PHT. Lumbar radiculopathy must still be actively excluded.

PHT is a compressive-tensile tendinopathy. In hip flexion the tendon is pressed against the ischium, and running and hamstring work add tensile load:

• •Sitting, especially on hard surfaces, compresses the tendon
• •Deep hip flexion (lunges, deadlifts, deep squats, stretching) combines compression with tension
• •Faster running, hills and over-striding raise hamstring load

Associated factors include a rise in speed or hill training, over-striding, poor control of anterior pelvic tilt, increasing age, the menopause, obesity and diabetes.