// Common injuries: High hamstring tendinopathy

by Paul Wright

Pain in and around the ischial tuberosity (at the origin of the hamstring) is a complaint often seen with gym and running based athletes.

Pain and discomfort in this region of the buttocks and upper hamstring can be due to referred pain from the lumbar spine, sacroiliac joint problems and various bursitis conditions. However, a common cause of buttock pain, and the topic of this article, is hamstring origin tendinopathy.

Signs and symptoms

High hamstring tendinopathy is typiclly an overuse injury seen in middle and long distance runners; however, it can also present itself following an acute hamstring tear that has not been completely rehabilitated. In the fitness industry, this condition is also seen in gym members due to excessive training on the cross trainer, stepper and treadmill – particularly if high inclines are used during treadmill training sessions.

Patients typically report pain deep in the buttock and upper posterior thigh during acceleration and at faster running speeds. In severe cases the pain can make even sitting and driving a car an uncomfortable activity. The pain may initially present as a sudden onset, but it is more likely to come on gradually following a training session.

On examination there is local tenderness and pain with stretching and resisted contraction of the hamstring. On palpation the site of maximal tenderness may be at the attachment site on the ischium, within the tendon or at the musculotendinous junction.

Anatomy and physiology

The hamstring group is made up of the biceps femoris, semitendinosus and semimembranosus – these long muscles extend from a common origin in the ischial tuberosity and eventually insert into the head of the fibula (biceps femoris) and the posteromedial side of the tibia (semimembranosus and semitendinosus). In cases of chronic high hamstring tendinopathy there is often a dense fibrosis at the proximal attachment (origin) of the hamstrings and in some cases degeneration of the hyaline cartilage that covers the ischial tuberosity.

It is also possible for these fibrous adhesions to irritate the sciatic nerve as it descends near to the ischial tuberosity. Should this condition, sometimes referred to as 'hamstring syndrome', fail to respond to manual therapies then surgical exploration and division of these fibrous bands may be required.

In functional terms, the hamstring muscles act with the gluteus maximus to extent the hip and also have a role in knee flexion. They are recruited in all standing activities and are particularly active in exercises such as squats, lunges, romanian deadlifts and leg curls.


As with all episodes of pain it is essential the client is examined by a physiotherapist or sports physician as soon as possible. The medical professional will evaluate the extent of the injury, accurately diagnose and chart the most appropriate management strategy to return the client to full function.

Local physiotherapy treatment for this condition will involve deep transverse friction massage to the hamstring attachment, soft tissue releases to the hamstring group (see photo 1), regular icing, stretching and biomechanical correction. It is common for the patient to have issues with pelvic stability and to have an anterior pelvic tilt – this tilt places the hamstring group on stretch and leads to poor length tension relationships and inflammatory changes.

An important component of the rehabilitation process is the need for an effective strengthening program to restore pre-injury function. The majority of exercises should be performed pain-free with close attention being paid to any post exercise pain and especially increased pain in the morning after a rehabilitation session. The need for appropriate strengthening must not outweigh the risk of possible aggravation of symptoms.

An introductory exercise often used in rehabilitation is the double leg isometric Swiss ball bridge (see photo 2). It is important to note that in most cases of tendinopathy the eccentric phase of any rehabilitation exercise is considered to be the most effective in terms of post injury rehabilitation. Ice is usually applied after each session.

The progression of the strengthening program and a gradual return to full running and cross training activities should always be overseen by the treating physiotherapist or sports physician, as re-injury and poor recovery are often caused by over enthusiastic patients and a premature return to sport or training.

Local physiotherapy treatment for high hamstring tendinopathy

Deep tissue releases to the hamstring group and deep transverse friction are an important component of the physiotherapy management of this condition. Always seek medical advice before commencing any of these therapies with your clients.


Paul Wright, BAppSc (Physio) DipEd (PE)
Paul is the director of Get Active Physiotherapy Health Centres with clinics inside Fitness First clubs at Carlingford, Castle Hill, Dee Why and St Leonards (Sydney, NSW). He is a senior lecturer for the Australian Institute of Fitness (NSW) and a featured presenter at many national and international health and fitness conventions. Paul has also released a series of DVDs specifically for fitness professionals covering knee, shoulder, and lumbar spine injury prevention and rehabilitation, Swiss ball for rehabilitation, and advanced resistance training. For more information visit the Get Active website at www.getactivephysio.com.au or call 1300 8 9 10 11.

NETWORK • SUMMER 2006 • PP67-69