Question 1

What is high hamstring tendinopathy?

Accepted Answer

High (or proximal) hamstring tendinopathy is an overuse injury that affects the tendons attaching the hamstring muscles to the sit bone (ischial tuberosity). It causes deep, localized pain around the sit bone and often flares up with running, lunging, squatting, or sitting.

Question 2

Symptoms of high hamstring tendinopathy

Accepted Answer

The main symptoms of high hamstring tendinopathy are pain and stiffness.

These symptoms are usually felt deep around the sit bone area
If you’ve had your pain for a long time, it may also start to radiate into the buttock or into the back of your thigh due to the pain system being sensitized
The symptoms usually set in gradually during the day or a training session. Sometimes, it is not noticeable at the time but is felt the next morning.
The pain usually worsens during or after activities that use the hamstrings with the hip in forward flexion e.g. squatting, lunging, deadlifts, hill walking or running.
Faster running is usually more aggravating than slow running – besides requiring more forceful contractions from the hamstrings, your strides are also bigger when you sprint vs. jog, which means your hip flexes more, causing your hamstring tendon to compress more strongly against the sit bone
Sitting can trigger or increase the pain – if your tendon is very irritated, even short periods of sitting on soft surfaces may hurt
It usually doesn’t hurt when you do low-load activities with the hip in a more straight position e.g. sleeping or walking slowly on flat surfaces
In most cases, the tendon feels stiffest and most painful in the morning or after sitting still for long periods. However, as you move, it warms up, and the pain eases. In some cases, it may remain sore throughout the day.
Symptoms may be most noticeable at the start of a run or other activity but subside as the tendon warms up, only to return, often more intensely, a few hours later.
If the tendon continues to be irritated, pain may become persistent, preventing running and even making walking painful.
Any stretch where you take the hip into deep forward flexion can irritate the tendon e.g. hamstring, glute, or piriformis stretches.

Not everyone experiences the same symptoms, and the severity can vary. However, if your pain is severe, it doesn’t necessarily mean you have a serious injury — it just means your tendon is really irritated and needs a break.

If you experienced a sudden pain or felt something snap, you may have torn the tendon and should get it checked immediately.

Question 3

When to see a doctor

Accepted Answer

You should consult your doctor or physical therapist before using the app to ensure you have the correct diagnosis and are ready to start rehab exercises.

If you have any concerns about your injury after starting rehab, schedule a review with your doctor, especially if:

You experience sudden, sharp pain, a popping sensation, or feel like someone kicked you in the leg — this could indicate a tendon strain or tear, and the app’s program isn’t designed for tendon tear rehab.
You notice bruising — high hamstring tendinopathy doesn’t cause bruising.
Your leg (thigh, calf, or foot) is swollen, red, hot, or throbbing — these could be signs of a blood clot, which requires urgent medical attention.
You have pain at night that keeps you awake or disrupts your sleep.
You experience pins and needles or tingling in your leg, or your pain radiates to your lower leg (below the knee) — this may indicate a nerve injury, and our rehab plan might not be right for you.
Your pain radiates into your lower back — this may indicate a back injury.
Your symptoms are getting worse.
Your injury isn’t recovering as expected (see expected recovery times below).

If you have a chronic condition, e.g., osteoporosis, heart disease, or an inflammatory condition, the rehab plans in the app are likely not appropriate for you. Please check with your doctor before using the app.

Question 4

What causes high hamstring tendinopathy?

Accepted Answer

Proximal hamstring tendinopathy happens where the hamstring tendon attaches to the sit bone (ischial tuberosity). Excessive compression of the tendon against the sit bone is thought to play a major role in developing this injury, but other factors can contribute.

What causes excessive compression?

When you flex your hip forward, the upper hamstring tendons are pulled tight over the sit bone and compressed against it. This is usually not a problem, but if it happens more often or more forcefully than the tendon is used to, it can cause trouble.This can happen due to:

Training errors – Increasing your running volume or intensity too quickly doesn’t give the tendon enough time to adapt and strengthen, especially if you suddenly add lunges, deadlifts, sprinting, hurdles, or hill workouts without enough recovery time between sessions.
Overstretching – Activities like yoga and Pilates that involve deep, prolonged hip flexion stretches (e.g., forward folds) can put too much strain on the tendon.
Sitting too much – In some cases, just sitting for very long periods — especially on hard surfaces — can create enough compression to trigger symptoms.

Contributing factors

Genetics – Certain genetic traits, like variations in the COL5A1 gene (which affects collagen production and can cause hypermobility syndromes like Ehlers-Danlos syndrome), may increase the risk of tendinopathy.
Metabolic issues – High cholesterol, diabetes, and thyroid problems can make tendons more vulnerable to injury.
Hormonal changes – Women going through menopause may be at higher risk because declining estrogen levels can affect tendon health.
Medications – Some antibiotics, particularly fluoroquinolones, have been linked to tendon problems.

These factors can lower the tendon’s ability to repair itself by hindering the production of new, healthy collagen fibers, making it more sensitive to the stress caused by training or everyday movements.

Question 5

What's the best treatment?

Accepted Answer

A combination of rest and targeted exercise is usually the most effective treatment. Research supports the following approaches:

Relative rest — Avoid or modify aggravating activities and training to allow healing.
Progressive strength training — Gradually rebuild your tendon’s strength and capacity to withstand compression forces.
General strength and control exercises — Strengthen the core and other leg muscles (such as the glutes) to better support the hamstrings and help distribute loads during activity.
Mobility exercises — Gain and maintain good mobility in all your lower-body joints and muscles while avoiding exercises that cause the high hamstring tendons to compress against the sit bones.
Movement retraining — Learn how to use your whole kinetic chain (all the interconnected parts of your body) optimally while running.

The app’s rehab plan incorporates all these elements, starting with low-load exercises that limit high hamstring compression to reduce pain and gradually increasing intensity as healing progresses.

Other treatments include:

Complete rest — Can be useful for reducing pain initially, but prolonged rest can reduce tendon strength.
Massage — May help with pain but does not strengthen the tendon. Vigorous massage over the sit bone area can worsen symptoms.
Electrotherapy (e.g., ultrasound) — Not supported by current research.
Shockwave therapy — Results are mixed; it may be more useful in persistent cases but can increase symptoms if used in the early stages.
Non-steroidal anti-inflammatory drugs (NSAIDs) — May be helpful in early stages but are not recommended for ongoing tendinopathy (>6 weeks).
Corticosteroid injection — May provide short-term pain relief, but symptoms tend to recur, and repeated injections may negatively impact tendon health.
Platelet-rich plasma (PRP) injections — May be useful in persistent cases, but not supported by strong evidence.

Question 6

How long does high hamstring tendinopathy take to recover?

Accepted Answer

Recovery time depends on how long the condition has been present before starting rehab:

Symptoms for less than 3 months: 3 to 6 months
Symptoms for more than 3 months: 9 months or longer

Question 7

How can I stop this injury from coming back?

Accepted Answer

You can reduce your risk of developing high hamstring tendinopathy by keeping your body strong and avoiding common training mistakes.

We recommend that you:

Adopt healthy work and sitting habits, taking regular breaks throughout the day.
Allow enough recovery time between hard training sessions.
Avoid sudden increases in training volume or intensity.
Do regular strength training to ensure all the muscles in your core and legs remain strong and robust.
Avoid excessive passive stretching — having good mobility in all your joints and muscles is important, but you don’t have to be super flexible.
Get plenty of sleep and adjust your training intensity when you're feeling tired — you’re more likely to get injured when you're physically or mentally fatigued.

Once you’ve completed your rehab, switch to one of the running training plans in the app — we’ve designed them with all these elements in mind.

Question 8

Research references

Accepted Answer

Goom, T. S., Malliaras, P., Reiman, M. P., & Purdam, C. R. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy, 46(6), 483-493.
Lempainen, Lasse, Kristian Johansson, Ingo J. Banke, Juha Ranne, Keijo Mäkelä, Janne Sarimo, Pekka Niemi, and Sakari Orava. "Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy." Muscles, ligaments and tendons journal 5, no. 1 (2015): 23.
Mattiussi, Gabriele, and Carlos Moreno. "Treatment of proximal hamstring tendinopathy-related sciatic nerve entrapment: presentation of an ultrasound-guided “Intratissue Percutaneous Electrolysis” application." Muscles, ligaments and tendons journal 6, no. 2 (2016): 248.
Nasser, Anthony Michael, Bill Vicenzino, Alison Grimaldi, Jay Anderson, and Adam Ivan Semciw. "Proximal hamstring tendinopathy: a systematic review of interventions." International journal of sports physical therapy 16, no. 2 (2021): 288.
Nasser, Anthony M., Tania Pizzari, Alison Grimaldi, Bill Vicenzino, Ebonie Rio, and Adam Ivan Semciw. "Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention." Physical Therapy in Sport 48 (2021): 67-75.
Dizon, Pilar, Michael Jeanfavre, Gretchen Leff, and Rachel Norton. "Comparison of conservative interventions for proximal hamstring tendinopathy: A systematic review and recommendations for rehabilitation." Sports 11, no. 3 (2023): 53.

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