High Hamstring Tendinopathy in Distance Runners and Field Athletes: Causes, Symptoms, and Recovery Roadmap

High hamstring tendinopathy, also called proximal hamstring tendinopathy, is a chronic overuse injury where the hamstring tendons become painful and sensitive where they anchor onto the sitting bone (ischial tuberosity) deep in the buttock region.^[1]

Instead of a one-time “tear” or classic hamstring strain in the middle of the muscle belly, high hamstring tendinopathy is a gradual tendon overload problem. The tendon experiences repeated tensile and compressive stress, especially when the hip is flexed (bent) and the knee is nearly straight, such as during:

• Distance running, especially at higher speeds
• Uphill running or stadium stair work
• Aggressive sprint drills and bounding
• Deep lunges, Romanian deadlifts, and heavy gym loading with poor progression

Over time, the tendon structure can show increased cellularity, collagen disorganisation, and new blood vessel and nerve growth similar to other long-standing tendon problems such as Achilles and patellar tendinopathy.^[2]

High hamstring tendinopathy is especially common in:

• Middle- and long-distance runners
• Track and field athletes (jumpers, sprinters, hurdlers)
• Field sport athletes (football, rugby, hockey)

These sports demand repetitive eccentric loading of the hamstring tendon while the hip is flexed and the trunk often leans forward, which creates high tensile and compressive forces at the tendon insertion.^[3]

In long-distance runners, high hamstring tendinopathy often shows up as persistent deep buttock pain that worsens with running and acceleration.^[4]

High hamstring tendinopathy has a characteristic symptom pattern:

• Deep buttock pain right under the gluteal fold on one side, often localised over the sitting bone
• Pain at the start of a run that eases after a few minutes, then returns and worsens later, which is very typical tendon behaviour^[2]
• Pain when accelerating, sprinting, or running uphill
• Discomfort when sitting on hard surfaces, in a car, or on a bike saddle, often worse the longer you sit^[2]
• Pain with stretching the hamstrings, especially when the hip is flexed (for example, forward bends in yoga or straight-leg stretch with the hip flexed)
• Soreness during deep squats, lunges, Romanian deadlifts, or heavy hamstring loading exercises

Athletes frequently report that there was no single “snap” or traumatic event. Instead, pain creeps in gradually over weeks or months of training error, such as a big jump in mileage, rushed return to competition after an earlier injury, or an aggressive new strength programme.^[4]

High hamstring tendinopathy is usually not “bad luck.” Several modifiable factors tend to stack up:

1. Training Errors

   Research on proximal hamstring tendinopathy highlights training mistakes as a major driver:^[3]

   • Rapid increase in weekly mileage or hill volume
   • Sudden addition of sprint sessions or speed work
   • Insufficient recovery days between hard track or field sessions
   • Over-reliance on deep static stretching, especially into hip flexion (yoga, Pilates, aggressive hamstring stretches)

2. Biomechanical and Strength Factors

   Intrinsic risk factors include:^[3]

   • Previous hamstring injury
   • Weak gluteal muscles and weak hamstrings
   • Core and lumbopelvic stability deficits
   • Hip joint stiffness or limited hip extension
   • Leg length difference
   • Poor running form with over-striding or excessive trunk flexion

3. Age and Systemic Tendon Health

   Tendons lose some elasticity and load capacity with age. Runners over 35–40 years, especially if they also have metabolic risk factors such as increased body mass index or diabetes, may be more susceptible.^[3]

4. Sitting and Non-Sport Loads

   Long periods of sitting on hard surfaces (for example, driving to and from training, office work, cycling) compress the tendon against the bone and can worsen symptoms or slow healing.^[2]

A sports medicine physician or physiotherapist will usually diagnose high hamstring tendinopathy based on:

• History: deep buttock pain linked to running, acceleration, uphill training, or prolonged sitting; gradual onset rather than one big tear^[2]
• Palpation: local tenderness over the ischial tuberosity
• Provocation tests: pain reproduced by specific tests such as bent-knee stretch tests, straight-leg raise with hip flexion, and isometric contraction of the hamstrings in hip flexion^[2]

Imaging is sometimes used to rule out other conditions:

• Magnetic resonance imaging (MRI): can show tendon thickening, partial tearing, and bone marrow oedema around the ischial tuberosity^[1]
• Ultrasound: useful but less sensitive for subtle bone changes^[3]

Because other problems can mimic high hamstring tendinopathy (lumbar spine referred pain, sacroiliac joint dysfunction, deep gluteal nerve entrapment, ischial bursitis, or ischiofemoral impingement), a thorough assessment is essential.^[1]

Many runners and field athletes keep stretching the painful hamstring and trying to “loosen it up.” Unfortunately, aggressive stretching into hip flexion actually increases tendon compression against the sitting bone and can irritate the area further.^[3]

Similarly, continuing high-intensity or high-volume running when deep buttock pain is flaring can keep the tendon locked in a reactive or degenerative state. Tendons do not like complete rest, but they also do not tolerate relentless overloading without time to adapt.^[2]

A smarter strategy is load management: replacing highly provocative activities with more tendon-friendly ones while gradually building the tendon’s strength capacity.

There is no single best “recipe,” but expert opinion and case reports suggest that education plus a progressive loading programme is the cornerstone of successful treatment.^[2]

Below is a simplified, evidence-informed framework. Always individualise with a physiotherapist, especially if symptoms are severe.

Goals: Reduce pain, minimise provocative loads, and start loading the tendon in a way that it can tolerate.

Key elements:

• Relative rest, not total rest:
  • Reduce or temporarily stop long runs, hill sessions, and sprint work.
  • Continue gentle, pain-tolerable walking and general movement.^[4]
• Modify sitting:
  • Use a softer cushion or cut-out cushion under the thigh to reduce sit-bone compression.
  • Break up long sitting periods with standing or walking breaks.^[2]
• Isometric hamstring loading:
  • Isometric exercises (where the muscle contracts without visible movement) can reduce pain and start strengthening without excessive tendon compression. Examples include:
    • Supine bridge holds (double-leg and then single-leg)
    • Isometric hamstring curl holds with the heels pressing into a Swiss ball or towel on the floor
  • These are usually progressed to higher load and longer holds (for example, 30–45 seconds, several repetitions), provided pain stays in a tolerable range that settles within 24 hours.^[5]

Once basic isometric loading is tolerated, the next step is to build tendon resilience using progressive eccentric and heavy slow resistance training.

Research in tendon rehabilitation supports eccentric and heavy slow resistance loading for improving pain and function in chronic tendinopathy, and similar principles are applied in high hamstring tendinopathy.^[5]

Typical exercise progressions:

• Romanian deadlifts and hip-hinge variations with controlled tempo and gradually increasing load
• Nordic hamstring variations (used carefully and later in progression for some athletes)
• Single-leg bridge progressions with added load (barbell, weight plate, or resistance band)
• Good-morning exercises and cable pull-throughs

The focus is on:

• Slow, controlled movement
• High effort but well-tolerated pain (usually mild discomfort that does not spike and settles within 24 hours)
• Two to three heavy sessions per week with rest days between to allow tendon adaptation

Gluteal and trunk strengthening (for example, hip thrusts, clamshells, side planks, anti-rotation core work) are also important to improve lumbopelvic control and reduce excessive strain at the tendon.^[3]

When daily activities and gym loading are comfortable, you can gradually reintroduce running and field drills.

Key principles from clinical case reports and running-specific guidance:^[2]

• Start with easy, flat runs at conversational pace, shorter duration, and avoid hills at first.
• Use a pain-monitoring model:
  • Pain during running should stay mild and not worsen progressively.
  • There should be no major flare-up in the 24 hours after running.
• Progress one variable at a time:
  • You can gradually increase either total distance, or introduce gentle strides, or include small hills—but not all at once.
  • Delay maximal sprinting, deep lunges, and heavy plyometrics until later phases when the tendon has tolerated months of progressive loading.

Field athletes may also need a staged return to:

• High-speed changes of direction
• Jumping and landing drills
• Sport-specific kicking or lunging patterns

These should be integrated in a structured plan guided by symptoms and strength benchmarks.

While exercise and load management are considered the foundation of treatment, some athletes explore adjunct options.

Extracorporeal shockwave therapy has shown promising results in chronic proximal hamstring tendinopathy, with clinical trials reporting better pain reduction compared with some conservative programmes in professional or highly active patients.^[6]

However:

• It is usually used in addition to a structured strengthening programme, not as a stand-alone cure.
• The quality of exercise programmes used as comparison in some studies has been criticised, so shockwave should not replace high-quality rehabilitation.^[6]

For stubborn, long-standing cases that fail extensive conservative management, physicians might discuss:^[1]

• Image-guided injections such as corticosteroid or platelet-rich plasma (evidence is mixed and still emerging)
• Surgical debridement and partial release of the diseased tendon, sometimes combined with sciatic nerve decompression in selected cases^[1]

Surgery is generally reserved for a small group of athletes with significant functional limitation despite months of well-supervised rehabilitation.

For distance runners and field athletes who have recovered—or want to avoid developing high hamstring tendinopathy in the first place—prevention is all about smart loading.

Evidence-informed prevention strategies include:^[3]

• Respect gradual progression:
  • Increase weekly mileage or training volume by small increments (for example, about ten percent as a rough guide, not a strict rule).
  • Introduce hills, sprints, and plyometrics gradually, not all in the same training block.
• Maintain year-round hamstring and gluteal strength:
  • Continue heavy slow resistance and eccentric hamstring work two times per week, even in-season.
  • Include hip extension and hip hinge-based exercises that mirror the demands of running and field sport.
• Optimise running technique:
  • Avoid habitual over-striding and excessive forward trunk lean, which increase tendon load and compression at the sitting bone.
  • Work with a coach or therapist who can analyse your gait if you frequently have posterior thigh or buttock issues.
• Balance stretching with tendon comfort:
  • Short, gentle mobility work is fine, but avoid long pushes into painful end-range hamstring stretching, especially in hip flexion.
  • Use dynamic warm-ups centred on active leg swings, hip mobility, and short strides rather than static stretching alone.
• Manage non-sport loads:
  • Break up long drives or desk work with standing or short walks.
  • Consider seat cushions that reduce pressure on the ischial tuberosities.
• Pay attention to early warning signs:
  • Do not ignore persistent deep buttock pain that worsens with running or sitting.
  • Early modification of training and rapid consultation with a physiotherapist can prevent a small tendon reaction from turning into a long-term degenerative tendinopathy.

Distance runners and field athletes should seek assessment from a sports medicine professional if:

• Deep buttock or upper hamstring pain has persisted for more than a few weeks
• Pain is clearly aggravated by running, sprinting, or sitting and is not settling with simple load reduction
• You notice weakness, limp, or difficulty accelerating or pushing off
• Pain wakes you at night, you experience unexplained weight loss, or you have neurological symptoms—these require prompt medical evaluation to rule out other serious causes

Early, accurate diagnosis reduces the risk of long-term tendon changes and makes a full return to sport more likely.^[1]

• High hamstring tendinopathy is a chronic tendon overload injury at the sitting bone, not just a tight hamstring.^[1]
• It often arises from training errors, biomechanical factors, and cumulative compression loads, especially in long-distance runners and field athletes.^[3]
• The hallmark symptoms are deep buttock pain with running, acceleration, or sitting, and pain with stretching into hip flexion.^[2]
• Successful treatment depends on smart load management and progressive strengthening, not constant stretching or total rest.^[6]
• Adjunct therapies such as shockwave may help some stubborn cases, but they work best when combined with a strong, evidence-based rehabilitation plan.^[6]

For athletes, the big picture is encouraging: with early recognition, a structured rehabilitation programme, and thoughtful progression back to running and field drills, most people with high hamstring tendinopathy can return to their chosen sport at a high level—often stronger and more resilient than before.