Expert opinions on PHT treatment (2021 paper)

Expert Opinions on Proximal Hamstring Tendinopathy (PHT) Treatment


In this episode, we’ll delve into the expert opinions on the diagnosis, management, and prevention of Proximal Hamstring Tendinopathy (PHT). PHT can be a challenging condition, and understanding the insights from experienced physiotherapists can provide valuable guidance. We’ll explore various aspects of this condition, from its onset to diagnostic methods and treatment options.

The Paper: Proximal Handshake Tendonopathy Expert Physiotherapist Perspectives

A study published in the Journal of Physical Therapy in Sport gathered insights from expert physiotherapists regarding PHT. The study aimed to explore and summarize their perceptions on assessment, management, and prevention of PHT. The experts had a wealth of experience in tendinopathy management, making their insights particularly valuable.

Onset of Pain

All experts unanimously agreed that PHT typically has an insidious onset, meaning there’s no specific triggering event. It’s associated with an increase in mechanical load on the proximal hamstring tendon. This increase in load can result from factors such as higher running speeds, increased exercise intensity, or excessive demands on the tendon.

Location of Pain

Experts reported that patients describe pain at the proximal hamstring insertion, near the ischial tuberosity (sitting bone). Most experts concurred that the pain tends to remain localized and doesn’t typically shift or spread. Any widespread pain could indicate a differential diagnosis or a comorbidity alongside PHT.

Provocation Tests

Diagnostic tests to provoke PHT-related symptoms included lunging, running uphill, hamstring stretching, and activities that place compressive loads on the tendon, such as sitting. Positive tests were identified when localized pain at the ischial tuberosity increased with tasks that loaded the hamstring tendon further. This approach helps clinicians gauge the tendon’s response to different levels of demand.

Contributing Factors

Experts examined various factors, including hip extension strength, knee flexion strength, calf complex endurance, and range of motion in the hip, knee, ankle, and big toe joint. Performance analytics were also considered, particularly in runners, to identify characteristics like overstriding, low cadence, excessive anterior pelvic tilt, or other factors affecting gait.

Scans and Imaging

Imaging was rarely used as a diagnostic tool for PHT by the experts. Instead, they relied on patient interviews and physical examinations to make their assessments. Imaging was reserved for cases where a different condition was suspected or when PHT was unresponsive to management.

Differential Diagnosis

A common differential diagnosis discussed by the experts was the involvement of the sciatic nerve or the nerve sheath, either concurrently with PHT or as a separate entity. Widespread distribution of symptoms, extending into the buttock, thigh, or past the knee, could be indicative of this differential diagnosis. Nerve tests like the slump test or straight leg raise were used to explore this possibility.

Management of PHT

The primary management options for PHT emphasized by the experts were education and exercise. Passive interventions, such as manual therapy, were used in the early stages to help alleviate pain and discomfort but were not considered the core of treatment. Tendon-specific pain education was vital in helping patients understand that pain doesn’t always indicate harm. Pain occurring 24 hours after activity was used to assess how well the tendon tolerated an activity.

Progressive Rehabilitation

Experts recommended a progressive rehabilitation program that started with low-load exercises in positions with minimal hip flexion and gradually advanced to higher-load exercises based on the individual’s pain response. Rehabilitation was progressed by increasing load, speed of contraction, range of motion, and complexity, all while monitoring pain responses.

Passive Treatment

Passive treatment options like manual therapy and injections were considered adjuncts to education and exercise. Massage therapy was sometimes used in the early stages to help settle down the tendon when it was highly irritable. Manual therapy was also used to address associated physical impairments like mobility restrictions.

Prevention and Recurrence

Preventing PHT recurrence was emphasized due to its higher potential for coming back. Experts stressed the importance of maintaining hamstring and kinetic chain strength and addressing any associated past injuries. Strength maintenance and addressing any compensatory movements from previous injuries were seen as critical in preventing recurrence.


In conclusion, expert physiotherapists diagnose PHT through a combination of patient interviews and pain provocation tests. No single test alone is sufficient for diagnosis. Progressive loading of the tendon, along with education and exercise, forms the foundation of management and prevention. Passive treatment strategies were considered less integral, and invasive treatments like injections and surgery were not recommended. The study’s findings align with current best practices for managing PHT, offering reassurance for those dealing with this challenging condition.