Running: Proximal Hamstring Tendinopathy

By Dr. Donald A. Ozello DC

Las Vegas Informer

Healthy hamstrings are necessary for athletic success. The powerful hamstring muscles are major movers used in every sport. Hamstring injuries are painful, frustrating and can be season ending. Proximal hamstring tendinopathy, which will be discussed in this article, is different from a hamstring strain.

Proximal hamstring tendinopathy is an injury that is almost exclusive to runners. It is a persistent injury with an extensive recovery time.

Anatomy: The hamstring muscle group is located on the back of the thigh and crosses two joints. The hamstring muscles work as a unit to pull the hip backward into extension and bend the knee backward into flexion.

Three long muscles make up the hamstrings. One of these muscles contains a long head and a short head. From inner thigh going outward the hamstring muscles are the semimembranosus, semitendinosus and the bicep femoris. The bicep femoris contains two heads. All three of the long hamstring muscles originate on the ischial tuberosity, a bone in the gluteal region.

The ischial tuberosity is part of the pelvis. It is the part of the bone we sit on, therefore it is nicknamed the sitz bone or the sitting bones. The site of the hamstring muscles origin on the ischial tuberosity is the location of symptoms of proximal hamstring tendinopathy. Proximal hamstring tendinopathy is also known as high hamstring tendinopathy.

The tendons at the origin of the hamstrings are thick and fibrous with poor blood supply, thus making healing difficult. The hamstring muscles are largely composed of “fast-twitch” Type II muscle fibers. Contraction of fast twitch fibers generates a large degree of tension on the tendons.

Functions: The hamstring muscles perform several functions while running. Slowing the striding leg down as it approaches the ground. Extending the hip to propel the body forward, Assisting the calf muscle to help move the knee.

Definitions: Often times the terms tendinopathy, tendonitis (tendinitis) and tendinosis are used incorrectly or interchanged with one another. In the past I was guilty of this common mistake. From this point forward I will use the terms correctly in all of my new articles, videos and books. 

Tendinopathy: Disease or disorder of a tendon.

Tendonitis (Tendinitis): Inflammation of a tendon result from micro-trauma caused by a demand that is too heavy or too sudden.

Tendinosis: Degeneration of a tendon’s collagen fibers due to chronic overuse. Continual usage combined with inadequate rest results in tendinosis not tendonitis.

Proximal: Closer to the truck of the body. For example, the ischial tuberosity is the origin of the hamstring muscles and is located proximal to the knee joint.

Distal: Further from the truck of the body. For example, the knee is located distal to the hip joint.

Classification: Proximal Hamstring Tendinopathy is classified as a tendinosis because it is an overuse injury causing degeneration not inflammation.

Symptoms: Intense deep ache in the lower gluteal region and proximal aspect of the hamstring muscles. The symptoms have an insidious onset. Pain increases with repetitive activity, sprinting, uphill running, downhill running and during acceleration. Pain may be aggravated by sitting on a hard surface and intense hamstring stretching. Proximal hamstring tendinopathy may be present simultaneously with sciatica from piriformis syndrome.

Mechanism of Injury: Proximal Hamstring Tendinopathy is an overuse injury. Overtraining is the first and foremost extrinsic factor.

When running, the hamstring muscles begin to concentrically contract as the leg is far in front of the body. At this point the hamstrings are in an extremely stretched position thus increasing the amount of tension placed on the tendon at the origin site.

Intrinsic Factors: Several factors predispose an athlete for proximal hamstring tendinopathy. These include weak core muscles, pelvic instability, downward shifting of the anterior aspect of the pelvis, tight hip flexors, tight hamstrings, weak hamstrings and weak gluteal muscles. All of these factors are part of or a precursor to poor posture and poor movement patterns.

The core muscles include the abdominals, lower back, pelvis, hips, gluteal and medial thighs. Weakness in these muscles leads to pelvic instability. An unstable pelvis places an increased workload on the hamstring muscles. Downward shifting of the anterior pelvis places the hamstring muscles in a stretched position. The stretched position increases tension in the hamstring muscles and their tendons.

Treatment: Begin self-treatment and professional care as soon as possible. The sooner proper healing begins the better the possibility of a positive outcome and quicker return to activity.

A professional evaluation, examination and x-rays helps to formulate a correct diagnosis, treatment plan and rehabilitation plan. Chiropractic treatment to the spine, pelvis, hips and lower extremities re-establishes proper skeletal motion, optimizes transmission of nerve signals and maximizes healing.

Beginning phases of self-management include rest and ice. The goals of the beginning stages of care are to start proper healing, reduce localized swelling, reduce pain and limit the aggravation of symptoms while beginning to remove the intrinsic sources. The duration of this phase is usually short.

Intermediate stages of management include core strengthening exercises. Hamstring and hip passive and active range of motion exercises through pain-free ranges of motions. Hamstring and gluteal strengthening exercises through pain-free ranges of motions. Hip flexor stretching exercises and mild hamstring stretching exercises.

Strengthen the entire core, do not focus just on the rectus abdominus while neglecting the lumbar spine, pelvis, hips and thighs. Execute exercises that do not elicit symptoms. If a stretching or strengthening exercise aggravates the hamstrings discontinue that exercise and perform a viable substitute. The goal of this stage of care is the removal of intrinsic factors without aggravating the condition.

Cross training with non-weight bearing and partial weight-bearing exercises helps maintain cardiovascular and musculo-skeletal fitness. Utilize forms of exercise that do not aggravated the hamstring muscles and tendons.

Advanced stages of management stress improving proprioception, balance and strength, while reducing muscle tension. The most important objective in the advanced stages is a gradual return to activity.

Utilize full-body functional movements to improve core, gluteal and hamstring strength. Perform balance and proprioception training on a BOSU ball. Two-legged balancing, single legged balancing, squats, lunges and pistols are advanced exercises which require professional training and supervision.

Gradually return to running by starting with walking and jogging. Slowly progress to running. Advance to sprinting and cutting in gradual increments. Work with a Doctor of Chiropractic and a sports injury rehabilitation specialist throughout your entire recovery process to achieve maximum results.

Conclusion: Prevention is paramount in running injuries. Train intelligently to eliminate predisposing factors of proximal hamstring tendinopathy before symptoms begin. Strengthen all areas of your core and maintain strong and flexible hamstrings.

Utilize professional and self-management strategies to eliminate the sources and symptoms of proximal hamstring tendinopathy. Receive Chiropractic care on a consistent basis to re-establish proper skeletal motion and optimize nervous system communication. Execute proper stretching and strengthening exercises to ensure proper healing. Improve your body’s ability to grow stronger after an injury to increase running results and prevent reoccurrences. Train smart to stay injury free and accomplish your goals.

Dr_Donald_A_Ozello_thumb_medium150_Dr. Donald A. Ozello DC

Dr. Donald A. Ozello DC is the owner and treating doctor at Championship Chiropractic. 8871 W. Flamingo Rd, Suite #202, Las Vegas, NV 89147.  His web address is He can be contacted at (702) 286-9040 and

Dr. Donald A. Ozello’s mission is to educate and inspire others to live healthier, fitter, more functional lives.

Dr. Donald A. Ozello DC is the author of the book “Running: Maximize Performance & Minimize Injuries: A Chiropractor’s Guide to Minimizing the Potential for Running Injuries.” He writes a weekly health, fitness and nutrition column for The Las Vegas Informer. He is published in OnFitness and He has educational health, fitness and nutritional videos on Informer TV, and YouTube.

Dr. Donald A. Ozello DC proudly handles Standard Process Supplements and Foot Levelers Orthotics.

Dr. Donald A. Ozello DC is an award-winning public speaker. He has spoken to numerous groups on the importance of health, fitness, exercise, ergonomics, nutrition and injury prevention.

Dr. Donald A. Ozello DC is a fitness enthusiast. Functional kettlebell training, running and bike riding are his favorite types of exercise.

Before pursuing his career in Chiropractic, Dr. Donald A. Ozello DC served in the United States Navy aboard the USS Bremerton, SSN 698.

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