Proximal Hamstring Tendinopathy: Some Guidance to Deal with the True Pain in the Butt – Part #2

In Part #1 of our blog series on proximal hamstring tendinopathy (PHT), we defined what PHT is, potential causes and risk factors that can predispose you to develop it. In PHT part #2, we will introduce an evidence-based framework to help you deal with this pesky pain in the butt.

Researchers Goom et al have conveniently broken down a 4 stage approach to rehabilitating PHT based on the evidence they reviewed. They stress the importance of monitoring pain during the program and state that some pain is expected with the exercises but should resolve after 24 hours. The individual response of each individual patient will govern the progression of the proposed stages. For details please consult the reference, specifically figures 1-5 and work with your physiotherapist for guidance.


Stage 1 Exercises (Isometric Hamstring Load)

The first phase focusses on isometric (tightening the muscle without moving the limb) in positions that do not compress the PHT in order to load the muscle/tendon and reduce pain when it is irritated as it has been shown to have a pain-reducing effect. There should be a notable reduction in pain after these exercises when load testing the hamstring afterward. They also kept the hip in an almost neutral position (possibly 20-30 degrees of flexion) to minimize compression on the PHT.

Some examples of stage 1 exercises are: 

  • isometric leg curl
  • bridge holds with hip neutral
  • isometric straight-leg pull-down and trunk extensions.

Stage 2 Exercises (Isotonic Hamstring Load With Minimal Hip Flexion)

For stage 2, the authors used a heavy slow resistance (HSR) program including both concentric (muscle shortening against resistance) and eccentric (muscle lengthening against resistance) as this was documented to be easier to complete by patients. This type of exercise has been shown to be comparable in results to the widely accepted isolated eccentric exercise used in most tendinopathy rehabilitation programs. It was seen that HSR showed better collagen turnover in injured tendons than submaximal eccentric contractions. The focus with HSR is on slow, fatiguing, resisted movements starting at low resistance high reps and progressing to higher resistance and lower reps done every other day. The contractions are held for 3 seconds each for a total of 6 seconds. Loaded hip flexion is avoided to minimize compression on the PHT. Single-leg movements are also important to address asymmetrical loss.

Some examples include:

  •  single-leg bridge
  • prone hip extension
  • prone leg curl
  • Nordic hamstring exercise
  • bridging progressions
  • supine leg curl. 

Stage 3 Exercises (Isotonic Exercises in Positions of Increased Hip Flexion 70-900)

The goal of this stage is to continue hamstring muscle strength, hypertrophy and functional position training while progressing into more hip flexion. This phase can be started when the patient can tolerate higher loading hip flexion tests like a lunge. These can be done every second day with a slow and controlled technique being paramount. Hip flexion can progress to 70-80 degrees. At the end of stage 3, there should be little or no pain on more sport-specific movements in the affected PHT.


Some examples of the exercises are:

  •  slow hip thrusts 
  • forward step-ups
  • walking lunges
  • deadlifts
  • Romanian deadlifts and the “diver”.

Stage 4 Exercises (Energy Storage Loading)

The final stage is only required for patients returning to sports involving lower-limb energy storage or impact loading. Reintroducing the power and elastic stimulus for the hamstring can begin when the hamstring loading tests produce little to no pain. Because these exercises pose the greatest load on the PHT, they are done every third day.


This is where acceleration and deceleration  are done in athletic movements, for example: 

  • sprinter leg curl
  • A-skips, fast sled push/pull
  • alternate-leg split squats
  • bounding
  • stair or hill bounding
  • kettlebell swings
  • lateral/rotational and cutting movements.

**It is also important that a specific and graded return to the sport be followed.**

The authors also acknowledge that dry needling, soft tissue techniques, massage and manual therapy may also be useful, but the evidence is limited. They also reference a key statement that I feel is incredibly important, “passive interventions are unlikely to improve tissue load capacity”, which basically drives home the emphasis on an ACTIVE approach to resolve PHT.

This is something you and your physiotherapist will work together on.



Goom TSH, Malliaras P, Reiman MP, Purdam CR (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. J Ortho & Sports PT 46(6): 483-493.