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1 · SNAPSHOT

Proximal Hamstring Tendinopathy body chart — Illustrative, not diagnostic. Canva body chart for Proximal Hamstring Tendinopathy.

Who: Distance runners, field-sport athletes, gym athletes who hinge.
What: Tendinopathy of the proximal hamstring at the ischial tuberosity.
How it behaves: Deep buttock pain at the sit bone. Worse with sitting. Worse with uphill and long-stride running, acceleration, sprinting, and hinging — deadlifts, RDLs. Gradual onset.

The one thing to take from this page:

Hip flexion with knee extension compresses the tendon against the ischium. That's why sitting, long strides and uphill running all hurt — and it's why the hamstring stretch you were about to prescribe is the same position as the aggravator.

The pattern cue

Fits proximal hamstring tendinopathy	Points elsewhere
Pain sitting + tenderness at the ischial tuberosity	Pain down the posterior thigh with neural behaviour → deep gluteal / nerve
Gradual onset, load-related	Sudden, during a sprint, adolescent → apophyseal avulsion
Pain in the muscle-tendon at the bone	Pain in the muscle belly, acute moment → hamstring strain
Neural tests may be uncomfortable	Neural tests worsen it AND there are neuro signs → spine or nerve
Load-related	Weight-bearing or night pain, RED-S risk → bone stress

⚠️ No guideline exists, and the field is actively arguing about whether this condition is even defined and diagnosed consistently. A core outcome set is still being developed. Reason from the pattern.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. Two questions do most of the work: does sitting hurt, and does anything go down the leg?

MAIN PROBLEM

"It's my sit bone. Driving is the worst."
"It hurts running uphill."
"Deadlifts set it off."

BODY CHART

Right on the ischial tuberosity. A finger, not a hand.
Not the gluteal bulk — that is a different structure and a different page.
Mark anything down the posterior thigh. This is the mark that decides whether you're on the right page.
Mark the lateral hip separately — gluteal tendinopathy coexists.

BEHAVIOUR

	Fits tendinopathy	Points elsewhere
Aggs	Sitting, uphill running, long strides, acceleration, hinging	Sitting and referral down the leg → deep gluteal / nerve
Onset	Gradual	Sudden during a sprint, adolescent → avulsion
Eases	Standing, walking on the flat, unloading	Nothing eases it → screen
Severity	VAS 0–10 at best / at worst / right now	—
Course	Slow	Rapid decline → reconsider
Night	Sore after load	Night or rest pain → bone stress, screen

HISTORY

What changed? Volume, hills, speed work, a new lifting programme.
Sitting tolerance in minutes. This is your outcome measure — get the number now.
Running distance and pace, hinge load. Start tracking function at visit one.
Any low energy availability, menstrual disturbance, weight loss? The bone-stress question.
Previous hamstring injury?

SPECIAL / SCREENING QUESTIONS

Does anything travel down the leg? Any numbness, tingling or weakness?
Night pain, rest pain, weight loss, cancer history?
Can they weight-bear and hop?
Adolescent with sudden onset?

Assessing this region? Download the Hip & Groin assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Deep gluteal syndrome (sciatic-related)	Referred pain down the posterior thigh with neural behaviour, and symptoms worsen with neural tension testing.
Lumbar radiculopathy	Dermatomal distribution, neurological deficit, lumbar behaviour.
Hamstring muscle strain	Acute, with a distinct moment. Pain in the muscle belly rather than at the tuberosity.
Gluteal tendinopathy	Lateral, over the greater trochanter, worse lying on that side.
Ischiofemoral or deep hip pathology	Deep, positional, and the hip joint tests reproduce it.

The two that outrank the table

Ischial apophyseal avulsion, in an adolescent. Sudden onset during a sprint, kick or split. Skeletally immature athlete, and it needs imaging — not a loading programme.

Ischial or pelvic insufficiency fracture. Weight-bearing pain, night pain, a RED-S profile in a young athlete, or osteoporosis risk in an older one. The ischium is also a site for metastatic disease.

And the pearl that decides the page

If symptoms worsen with neural tests and neurological signs are present, think spine or nerve. It is the single most useful discriminator on a posterior hip presentation — because the tendon and the nerve share the address.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Adolescent, sudden onset during a sprint or kick	Ischial apophyseal avulsion	Image — and a surgical opinion if the fragment is displaced more than 15 mm (Eberbach et al. 2017) [21]
Weight-bearing pain, unable to hop	Ischial or pelvic stress fracture	Image. Do not load
Adolescent athlete, any sport, buttock or low back pain — even with tight hamstrings or a positive SLR	Sacral fatigue fracture, and not just in runners (Hiranaka et al. 2024) [22]	Image (MRI)
Night pain or rest pain	Bone stress, malignancy	Image
RED-S profile — low energy availability, menstrual disturbance, weight loss	Bone stress injury	Image and refer
Cancer history with new ischial pain	Metastatic disease	Medical review
Progressive neurological deficit — weakness, numbness, reflex change	Nerve or spinal cause	Urgent medical review
Bowel or bladder change, saddle numbness	Cauda equina	EMERGENCY
Fever, unwell, systemic symptoms	Infection	Medical review, same day

The rule: gradual, load-related ischial pain that hurts to sit on, in someone who can hop and has a clean neurological screen, is yours. Sudden onset in an adolescent, weight-bearing or night pain, or any progressive neurology is not.

Cross-links: Deep gluteal syndrome · Lumbar radicular pain · Gluteal tendinopathy · Hip / pelvic stress fracture

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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No guideline of any nationality exists for proximal hamstring tendinopathy.

Anchored to the JOSPT paper on clinical aspects of assessment and management (Goom et al. 2016, PMID 27084841) for the clinical structure, and to the systematic review of interventions (Nasser et al. 2021, PMID 33842025) for what the treatment literature actually contains.

PubMed Source

Neither anchor is a guideline and neither is Australian. More than that: a 2026 exchange in the sports medicine literature argues over mechanistic mismatch and diagnostic ambiguity in this exact condition, and a core outcome set is still under development — so the field does not yet agree on how to define, diagnose or measure it. Reason from the pattern; do not quote this literature as settled.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2012Cacchio et al. (2012). Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. British journal of sports medicine, 46(12), 883-7. https://doi.org/10.1136/bjsports-2011-090325
2024Jokela et al. (2024). Magnetic Resonance Imaging With a Novel Hip Flexion Scanning Position for Diagnosing Proximal Hamstring Tendinopathy. Orthopaedic journal of sports medicine, 12(9), 23259671241265130. https://doi.org/10.1177/23259671241265130
2010Zissen et al. (2010). High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR. American journal of roentgenology, 195(4), 993-8. https://doi.org/10.2214/AJR.09.3674
2023Nasser et al. (2023). Towards development of a core outcome set in proximal hamstring tendinopathy - A systematic review of measurement instruments and their clinimetric properties. Musculoskeletal science & practice, 66, 102774. https://doi.org/10.1016/j.msksp.2023.102774
2016Goom et al. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. The Journal of orthopaedic and sports physical therapy, 46(6), 483-93. https://doi.org/10.2519/jospt.2016.5986
2017Beatty et al. (2017). Rehabilitation and Prevention of Proximal Hamstring Tendinopathy. Current sports medicine reports, 16(3), 162-171. https://doi.org/10.1249/JSR.0000000000000355
2021Nasser et al. (2021). Proximal Hamstring Tendinopathy: A Systematic Review of Interventions. International journal of sports physical therapy, 16(2), 288-305. https://doi.org/10.26603/001c.21250
2023Dizon et al. (2023). Comparison of Conservative Interventions for Proximal Hamstring Tendinopathy: A Systematic Review and Recommendations for Rehabilitation. Sports (Basel, Switzerland), 11(3). https://doi.org/10.3390/sports11030053
2021Nasser et al. (2021). Proximal hamstring tendinopathy; expert physiotherapists' perspectives on diagnosis, management and prevention. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine, 48, 67-75. https://doi.org/10.1016/j.ptsp.2020.12.008
2025Rich et al. (2025). Physiotherapy Compared With Shockwave Therapy for the Treatment of Proximal Hamstring Tendinopathy: A Randomized Controlled Trial. The American journal of sports medicine, 53(14), 3396-3407. https://doi.org/10.1177/03635465251391134
2021Rich et al. (2021). Randomised, cross-over trial on the effect of isotonic and isometric exercise on pain and strength in proximal hamstring tendinopathy: trial protocol. BMJ open sport & exercise medicine, 7(1), e000954. https://doi.org/10.1136/bmjsem-2020-000954
2025Rich et al. (2025). Education, rapport and convenience are key to participants' perceptions of receiving physiotherapy or shockwave for proximal hamstring tendinopathy: a qualitative study. Musculoskeletal science & practice, 80, 103426. https://doi.org/10.1016/j.msksp.2025.103426
2020Auriemma et al. (2020). Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy. Regenerative medicine, 15(4), 1509-1518. https://doi.org/10.2217/rme-2019-0105
2009Lempainen et al. (2009). Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. The American journal of sports medicine, 37(4), 727-34. https://doi.org/10.1177/0363546508330129
2024Campos-Villegas et al. (2024). Clinical Progression and Load Management For Proximal Hamstring Tendinopathy In A Long-Distance Runner: A Case Report. International journal of sports physical therapy, 19(5), 609-617. https://doi.org/10.26603/001c.116578
2015Lempainen et al. (2015). Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy. Muscles, ligaments and tendons journal, 5(1), 23-8. PubMed 25878983
2018Pietrzak et al. (2018). Proximal hamstring tendinopathy: pathophysiology, diagnosis and treatment. British journal of hospital medicine (London, England : 2005), 79(7), 389-394. https://doi.org/10.12968/hmed.2018.79.7.389
2025Rich et al. (2025). Treatment of Proximal Hamstring Tendinopathy with Individualized Physiotherapy: A Clinical Commentary. International journal of sports physical therapy, 20(6), 892-910. https://doi.org/10.26603/001c.138308
2026Veerasatian et al. (2026). Mechanistic Mismatch, Diagnostic Ambiguity, and Feasibility Constraints in Proximal Hamstring Tendinopathy Trials: Letter to the Editor. The American journal of sports medicine, 54(5), NP26. https://doi.org/10.1177/03635465261425600
2026Rich et al. (2026). Mechanistic Mismatch, Diagnostic Ambiguity, and Feasibility Constraints in Proximal Hamstring Tendinopathy Trials: Response. The American journal of sports medicine, 54(5), NP27-NP28. https://doi.org/10.1177/03635465261425597

Mapped to this pattern

VISA-H
Victorian Institute of Sport Assessment - Proximal Hamstring Tendon
proximal hamstring tendinopathy severity · 8 items · 4 min

Generic measures that also apply

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