PHT Assessment & Management: A 2016 Research Paper

Proximal Hamstring Tendinopathy: Understanding, Assessment, and Management

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Proximal hamstring tendinopathy can be a debilitating condition, causing deep localized pain around the ischial tuberosity, commonly known as the sitting bones. Activities such as running, squatting, lunging, and sitting can exacerbate this discomfort. In this podcast episode, we delve into a research paper that sheds light on the assessment and management of proximal hamstring tendinopathy. This article aims to provide you with a structured overview of the key takeaways from the episode, structured under appropriate headings and sub-headings for easy reading.


Welcome to this podcast episode that will help you overcome proximal hamstring tendinopathy. Hosted by Brodie Sharp, an online physiotherapist and recreational athlete, the show is dedicated to educating and empowering individuals suffering from this condition.

Getting Started with Research

The episode begins by introducing a research paper titled “Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management,” originally intended for physiotherapists. The authors of this paper are esteemed professionals in the field, including Tom Goom, Peter Maliaris, Michael Rehman, and Craig Perdom. This research is significant because it helps us understand the clinical aspects of proximal hamstring tendinopathy.

Understanding Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy is characterized by deep localized pain around the sitting bones. This discomfort often worsens after engaging in specific activities such as running, squatting, and sitting for extended periods. In some chronic cases, coexisting pathologies may further complicate the diagnosis and management of this condition.

Factors Contributing to Proximal Hamstring Tendinopathy

Several factors contribute to the development of proximal hamstring tendinopathy. These include both extrinsic and intrinsic factors:

Extrinsic Factors

Extrinsic factors involve the environment or external loads that can lead to the development of this condition. These factors include:

  • Increasing volume or intensity too quickly
  • Sudden introduction to activities like sprinting, lunging, hurdles, or hill running
  • Activities resulting in provocative tensile and compressive loads on the tendon, especially during insertion into the sitting bone
  • Excessive stretching, such as in yoga or Pilates postures

Systemic Factors

Systemic factors are those occurring within the body, making individuals more susceptible to tendinopathy. These factors may include:

  • Genetics
  • Age
  • High BMI (Body Mass Index)
  • Metabolic issues like diabetes, glucose intolerance, lipid level imbalances, and insulin resistance
  • Hormonal changes
  • Certain medications, such as antibiotics

The Diagnostic Process

Assessing proximal hamstring tendinopathy involves a combination of subjective assessments and diagnostic tests. Subjective assessments are based on patient-reported information, and they should confirm the following:

  • Localized pain around the sitting bone
  • Pain that becomes less symptomatic after a few minutes of activity
  • Aggravating factors related to deep hip flexion, such as squatting, lunging, and sitting for prolonged periods

Psychosocial factors can also influence pain and play a role in central sensitization. Negative beliefs about pain, pathology, and physical limitations can lead to heightened anxiety, hypervigilance, and fear avoidance.

Diagnostic Tests

Diagnostic tests involve assessing pain during loading tests to confirm the diagnosis. These tests help determine if the pain is related to proximal hamstring tendinopathy. Examples of loading tests include:

  • Isometric hamstring loading
  • Isotonic hamstring loading with and without compression
  • Energy storage loading

The Four Stages of Rehabilitation

Rehabilitation for proximal hamstring tendinopathy is structured into four stages, each with a specific focus on loading the tendon progressively:

Stage 1: Isometric Hamstring Loading

  • Isometric exercises provide a pain-relieving option.
  • Dosages should be based on symptom severity, irritability, and can include shorter and less intense contractions.
  • Exercises may include isometric leg curls and bridge holds.

Stage 2 and Stage 3: Isotonic Hamstring Loading

  • Focuses on restoring hamstring strength and muscle bulk.
  • Slow and controlled technique is important.
  • Exercises include single-leg bridges, prone leg curls, Romanian deadlifts, and walking lunges.
  • Dosages are based on a 15-repetition maximum (15RM) initially, progressing to an 8RM over 3-4 sets.
  • Exercises should be performed every other day.

Stage 4: Energy Storage Loading

  • Reintroduces power, elastic stimulus, and speed.
  • High demand on the tendon, resembling movements in high-level sports.
  • Exercises include sprinter leg curls, A-skips, sled pushes, and kettlebell swings.
  • Dosages may vary, but exercises are done less often, typically once or twice a week.

Cycling through these stages is a common approach, where you alternate between stages to provide a balance of load and recovery. Stage 4 is recommended primarily for individuals returning to sports or high-intensity activities.


Understanding, assessing, and managing proximal hamstring tendinopathy is crucial for effective treatment. This podcast episode, along with the research paper, provides valuable insights into the condition. Remember that pain can be a part of the rehabilitation process, but it should be low in intensity and should settle within 24 hours. Rehabilitation should be progressive, encompassing various types of loading and addressing psychosocial factors. By following the recommended stages of rehabilitation, individuals can take the right steps to overcome this challenging condition.

Thank you for tuning in to this episode, and stay empowered on your journey to a pain-free future!