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Proximal hamstring tendinopathy (PHT) is commonly seen in long distance runners and athletes taking part in sprinting or hurdles. .

It is also common among athletes taking part in sports such as soccer , football and hockey, which involves a change of direction activities.

What is Proximal Hamstring Tendinopathy ?

Proximal hamstring tendinopathy is also referred to as High hamstring tendinopathy.

It is characterized by deep, localized pain in the region of the ischial tuberosity.

Pain is usually worse during or after activities such as running, lunging, squatting .

This condition can include tendon degeneration, partial tearing and peritendinous inflammatory reactions.

The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy.

The tendon’s thickness, fibrousness and poor blood supply are the causes of difficult healing

Symptoms - How does it feel ?

  • Deep buttock pain and pain in the posterior thigh.

  • Pain with squats, lunging,long periods of sitting, running (especially on harder surfaces)

  • The pain increases with repetitive activities such as long-distance running

  • Occasional stiffness in the morning may be present or when starting to move after a period of prolonged rest

  • The onset is mostly gradual, not with acute trauma.

  • Continued exercises and stretching can cause even more pain

Mechanism of injury

For soccer players the mechanism of injury is the same as for regular hamstring strains with the two typical mechanisms of Sprinting ( High Speed Running) or Stretch Situations.

It seems to be that age plays an important role in this condition as older players (+40) tend to develop this problem and very few cases are in the younger athlete.

Also having a previous Hamstring injury increases substantially the chances of this acute condition to become chronic and highly irritable.

Let’s review the common mechanisms of HS injuries:

1. High Speed Running

During High Speed Running the hamstrings are very active, lengthening ( getting longer) and contracting to absorb the energy from decelerating the weight of the limb and getting the limb ready to stride on the ground again.

This dual demand of contracting and lengthening at the same time is what causes the hamstring excessive “stretch” from its attachment causing the dysfunction.

2. Stretch Situations

The other reason for PHT is a repetitive stretch mechanism.

In this case the hamstrings are required to do hip flexion and knee extension simultaneously.

The most common muscle injured in this type of mechanism is the semimembranosus and its proximal attachment.

What is the best treatment for Proximal Hamstring Tendinopathy

Strengthening of the Hamstrings muscles seem to be the best approach to solver this problem

Acute Phase - Isometric Loading

Isometric exercises in positions that avoid tendon compression is proposed as an effective method of loading the muscle-tendon unit as well as reduce pain in proximal hamstring tendinopathy.

It has been reported that isometric exercises have a pain inhibitory response.

It is recommended that isometric exercises should be repeated several times per day. Symptom severity and irritability are used to determine the dosage. The dosage can be adjusted to shorter/less intense contractions or vice versa, based on the symptoms. Bridges: Hamstring Isometrics and Single Leg bridge Isometric. Start with 5-10 second holds and progress to 45 sec holds Then you can try a single leg hold variance of this exercise Other exercises in this phase could be straight-leg pull downs and Trunk extension

Strengthening Phase - Isotonics with minimal hip flexion

Once pain has settled down, the next steps in the treatment of proximal hamstring tendinopathy are:

  • to restore hamstring strength

  • to restore hamstring muscle bulk and capacity

For this condition in particular Heavy Slow Resistance training (HSR) is preferred instead of eccentric exercises. Heavy Slow Resistance training includes eccentric and concentric elements.

With HSR, the aim is to perform a slow fatiguing resisted isotonic exercise. Commence with 15 RM (the maximum load that can be lifted 15 times in a single set) and progress to 8 RM. Perform 3-4 sets every second/other days. Hold contractions for 3 seconds for each phase of the exercise (concentric and eccentric) with a pause of 1-2 seconds in between.

Minimize loaded hip flexion to in the early stages to protect the proximal hamstring insertion against too much compression.

Progress from bilateral workouts to single-leg work to address asymmetrical strength loss. Continue with stage 1 isometric exercises on the "off" days.

This will help with symptom (pain) management, especially if there are still symptoms present.

Other exercises can include Nordic Hamstrings and Prone Leg Curls.

Strengthening Phase - Isotonic exercises in increased hip flexion (70° - 90°)

The aim of rehabilitation in this stage is:

  • to continue with hamstring muscle strengthening in greater hip flexion

  • to continue with muscle hypertrophy in greater hip flexion

  • to continue with functional training in greater hip flexion.

The technique is important and exercises should be performed slow and controlled.

The progression into greater hip flexion often cause pain and irritability and is important to monitor the 24-hour response post exercise with loading tests into hip flexion.

Other exercises can be Single Leg Deadlift , Step-ups and Walking Lunges.

Symptom Modification and Load Management

Training and activity modification are essential in the management of this condition especially with those cases with very irritable symptoms.

Limit pain-producing activities until the pain irritability settles to stable pain. Stable pain is mild (VAS 0 to 3 out of 10) and usually settles within 24 hours of moderate to high tendon load interventions.

One must determine what activities increase the patients' symptoms and for how long?. . Often the player will be able to continue with certain activities such as steady state running within the pain/aggravation guidelines.

Sprinting or quick starts should be avoided initially and only implemented at later stages.

Load modification options:

  • Swimming and water running are good options

  • Posture modification may reduce symptoms (e.g. reduce hamstring origin compression by reducing anterior pelvic tilt and hip flexion in standing)

  • When sitting is symptomatic, shaped cushions are useful to reduce the compression. It allows for more weight bearing on the posterior thigh rather than the ischium

  • Avoid repeated stretching of the hamstrings in the early, reactive phase

  • Avoid hip flexion dominant movements such as trunk flexion and repeated lifting in the early, reactive stages

If you want to know more about hamstring injuries see our previous blog on this topic


  • Proximal Hamstring Tendinopathy is a very debilitation condition that once chronic will affect any type of physical activity causing pain in the buttocks area

  • This complex condition requires a progressive strengthening program of the Hamstrings and Glute Muscles to restore their capacity.

  • Solving this condition requires a comprehensive approach to correct all deficits that can be causing the deep glute area pain .

  • Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to treat PHT

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

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Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

#westonbuttockspain #glutepain #proximalhamstringteninopathy #PulledMuscle #Soccerinjuries #westonsoccer #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston #whitebayphysicaltherapy

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Hamstring Injury Treatment has changed a lot in the last decade. Professional Soccer teams are putting a lot of emphasis on prevention and quicker recovery. There is good consensus now to safely accelerate the recovery process so player can return to play earlier and most important avoiding a re-injury

Rehabilitation Process - Grade II hamstring Injury

We will use a Grade II injury as an example (see picture above ) . As we mention in our previous posts about HSI, many patients with a hamstring start to feel better within a few days of the injury. However, there is an extremely high hamstring re-injury rate due to a poor rehabilitation process.

Hamstring strains are one injury that professional guidance is highly recommended for both an accurate diagnosis but also provide you with the best chance of avoiding re-injuries. Repeat hamstring injuries have sidelined soccer players for months.


In Physical Therapy the treatment we provide will follow these guidelines:

  1. Reduce hamstring pain and inflammation.

  2. Normalize your muscle range of motion and extensibility. Remember one of the causes of HSI is short and tight Hamstrings.

  3. The hamstrings create Hip Extension and Knee flexion simultaneously . Even though that in the beginning we may concentrate in improving each movement in isolation at some point The rehabilitation should address both the knee flexion and hip extension roles of the hamstrings together. High Speed Running is ultimate expression of the hamstrings doing this double action.

  4. Strengthen your knee muscles and hamstrings. A key factor in the recovery process is Eccentric Load of the Hamstrings. Regular exercises will not do it for this condition reason why we have developed a progressive and comprehensive Strengthening program with this in mind

  5. Strengthen your lower limb muscles: calves, hip and pelvis muscles.

  6. Normalize lumbo-pelvic control and stability - a co-factor in many hamstring strains. Another super important factor is your pelvic position. Almost every Hamstring Injury goes with excessive curvature in the lumbar spine called hyperlordosis and anterior pelvic tilt causing your hamstrings to be under tension constantly just from standing and even more tension during High Speed Running

  7. Improve your game speed, proprioception, agility and balance. Remember most of the HSI are the result of High Speed Running so this should be part of your rehabilitation process but most of the time it does not happened. At White Bay Physical Therapy this HSR and running mechanics drills are mandatory before we release players to train and prevent a re-injury.

  8. One note on Hamstring Stretching: Injured Hamstrings respond much better to strengthening exercises and movement than it does to vigorous stretching. Any tight muscle denotes some type of weakness, lack of movement control or postural deficit. In these situations the muscle gets “tight” to compensate for these other problems. So please, Stop stretching your hamstrings vigorously, it won’t get much softer. There is a type of contraction called Eccentric contraction where the muscle lengthens as it moves a weight ( own body weight or external weight). These types of exercises are the ones recommended for most of the muscular injuries because of this double benefit: strength + lengthening. We ,as therapist, know when to introduce these type of exercises in the rehabilitation process.

  9. To summarize, Long and Strong Hamstrings are the goals of the rehabilitation process

Stage I - Acute Injury

In the Acute phase we focus on resolving the pain with Ice , Ultrasound , Electrical Stimulation for Pain and We initiate an early mobility routine to safely put stress in the muscle to promote healing.

Hamstring Extenders - Mobility Workout


  • Begin lying on your back with one leg straight and the other leg bent


  • Bring your knee toward your chest and grab the back of your thigh with both hands. Slowly straighten your knee until you feel a stretch in the back of your thigh and return to original position. Repeat 10 Times.


  • Make sure to keep your back flat on the floor during the stretch and the opposite heel pushing against the ground during the stretch.

Hamstring Isometrics Strengthening

Bridge on Heels - Isometric HS contraction


  • Begin lying on your back with your knees bent and your feet resting flat on the ground.


  • Keeping your heels on the ground, lift your toes up.

  • Engage your abdominals and slowly lift your hips off the floor into a bridge position. You will feel your hamstring muscles contracting.

  • Hold contraction for 5 seconds. Then, Lower back down to the ground and repeat. Be aware this exercise can make your hamstrings to cramp. If that happens.

  • Repeat a few more times exercise 1. Do this exercise in 3 different angles: 90, 45 and 10-15 degrees of Knee Flexion to target the whole muscle group


  • Make sure to keep your abdominals engaged and do not arch your back during the exercise.

Stage II - Strengthening Phase

In the strengthening phase we will load the muscle progressively to assure proper scar mobilization and remodeling of the muscle to sustain higher loads everyday. We progress from simple contractions like Hold and Relax, then typical Hamstring exercises like leg curls and more Function-related exercises like eccentric contractions which not only make the muscle stronger but also increase the length of it. Remember we mentioned before that Short Hamstrings are highly related with HSIs.



  • Begin bending forward with your back straight and feet hip width apart, holding a barbell that is resting on the ground with your hands placed slightly wider than your feet.


  • Keeping your back straight, stand up, engaging your back, buttock, and thigh muscles. Slowly reverse the movement and repeat. Allow body to move till you feel the workout in your hamstrings and Glutes. Mild discomfort at the injury site is ok .


  • Make sure to keep your abdominals tight, back straight, and do not shrug your shoulders during the exercise. Try to keep the barbell close to your body as you stand and bend over.

Single Leg RDLs


  • Begin in a standing upright position holding a landmine or dumbbell in one hand.


  • Lift the uninvolved leg off the ground and bend forward at your hips, lowering the weight toward the ground. Then return to an upright position and repeat.

  • Allow body to move till you feel the workout in your hamstrings and Glutes. Mild discomfort at the injury site is ok .


  • Make sure to keep your back straight during the exercise and try not to let your knee move forward as you lower the weight.

Stage III - Return to Play Phase

Finally in the third phase we simulate soccer activities to reproduce the demands of the game in a closed environment and assure the scar tissue will tolerate the activity. This includes some field drills by the end of the phase and right before allowing you to play.

Key factors in this recovery are restoring Eccentric strength of the Hamstrings, restoring hip and knee range on motion, restoring proper core strength, and finally restoring dynamic balance and control of the Lumbo - Pelvic - Hip area.

Once all these factor were addressed we expose the injured players to Running Mechanics and High Speed Running itself.

You can see that our rehabiliation process is comprehensive and it covers the gap between the Clinic / Gym and the fields to return to play safely with the only goal of preventing another HSI.


  • Hamstring Injuries (HSI) are the second most common muscular injury in soccer players (quadriceps is #1)

  • Grade I injuries recover quick, while Grade II and III will take long time to recover and have an unfortunate high risk of re-injury and becoming chronic ( Proximal Hamstring Tendinopathy)

  • Most of these injuries does not require expensive MRIs or Test. The clinical examination by a professional specialized in HSI is usually enough to make the diagnosis and treatment

Do you want to find out more about what you can do to get better from your Hamstring Strain?

Click the link below to get access to our PDF E-Book

where you'll find valuable information about Muscle Injuries in general

and Hamstring Injuries in Particular

#Hamstringpain #HamstringStrain #PulledMuscle #Soccerinjuries #Soccergroinpain #westonsoccer #westonhippain #hippainsucks #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

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  • Lionel Pannunzio PT / SCS

Updated: Apr 3, 2019


Hamstring injuries are one of the most challenging injuries to treat as a Physical Therapy due to the high rate of re-injury. Over the years, the medical field has tried to accelerate the recovery, and even though good progress has been made we are not quite there yet: hamstring injury number remain high in the soccer population.

Learn about the Types of HSI and the common symptoms of this condition.

The most infamous Hamstring Injury

If you ask me, when people talk about hamstring Injuries my mind always goes to this picture above.

I don't know if any of you can remember the 2014 UEFA Champions' Final in Lisbon where Diego Costa was substituted in the 9th minute of such an important game.

On the weeks previous to the final Diego Costa reinjured a previous Hamstring injury and his participation in the Final was questionable. He only had two weeks or so to recover and he relied on a controversial treatment using Horse Placenta to expedite the healing time. It looks like Costa demonstrated in practice he was ok to play and convinced Simeone ( his coach ) of that but We all now know the result.

It took only Nine minutes for a recurrent Hamstring Injury to sideline this exquisite player and bury Athletico's chances to win the final.

Let me elaborate on this, Simeone had to burn a substitution in only 9 minutes of play. Athletico and Real Madrid went to overtime in that final after a draw 1-1 in regular time. Juanfran got injured in overtime (ankle sprain ) as well but Simeone had exhausted all the subs ( he had to use one to replace Costa very early in the game ) and Juanfran had to continue playing injured in his ankle. The 2-1 for Real Madrid came from a long run from Dimaria against an injured Juanfran who could not stop Dimaria.

I know, I'm being very dramatic here but go get the point: Hamstrings injuries are one of the most difficult injuries to recover from and can be lingering if you don't treat them properly

Types of HSI

We have four hamstring muscles: semimembranosus and semitendinosus (medially) and biceps femoris - short and long heads (laterally).

As most of the Muscle Injuries, Hamstrings Strain Injuries (HSI) are graded 1, 2 or 3 depending on severity.

Ultrasound scan and MRI are able to identify the location and extent of your hamstring tear but usually the physical exam can reveal what time of muscle injury you have and accurately determine the best treatment options.

On examination, we as Physical Therapist will look for signs of pain on hamstring contraction, reduced hamstring flexibility, tenderness or a palpable lump or gap within the hamstring muscle bulk.

Grade 1 Hamstring Strain

With a grade 1 , the mildest of the hamstring strain, you may have tightness in the back of the thigh but will be able to walk normally. You will be aware of some hamstring discomfort and unable to run at full speed. There will be mild swelling and spasm. Bending your knee against resistance is unlikely to reproduce much pain but stretching or eccentric contraction most like will reproduce your pain

Grade 2 Hamstring Strain

With a grade 2 hamstring strain, you will have to stop playing because of the pain, and you will have problems walking and you will most likely be limping. Almost any activity will be painful. You may notice some hamstring muscle swelling and your hamstring will be tender to palpate. It will also be painful for you to bend your knee against resistance. Still with these Grade 2 strains a simple Xray is usually enough to rule out an avulsion. Expensive MRIs are not necessary in my experience for this type of Hamstring Strain

Grade 3 Hamstring Strain

A grade 3 hamstring strain is a severe injury involving a tear to half or all of the hamstring muscle. A grade 3 injury is a serious condition and most likely you will not be able to leave the field on you own. You may need crutches to walk and will feel severe pain and weakness in the muscle. Swelling will be noticed immediately and bruising will usually appear within 24 hours.

Diagnostic MRI may also be used to specifically identify the grade of hamstring tear and its exact location.

What are the Symptoms of a Hamstring Strain?


  • Hamstring Injuries (HSI) are the second most common muscular injury in soccer players (quadriceps is #1)

  • Grade I injuries recover quick, while Grade II and III will take long time to recover and have an unfortunate high risk of re-injury and becoming chronic ( Proximal Hamstring Tendinopathy)

  • Most of these injuries does not require expensive MRIs or Test. The clinical examination by a professional specialized in HSI is usually enough to make the diagnosis and treatment

Do you want to find out more about what you can do to get better from your Hamstring Strain?

Click the link below to get access to our PDF E-Book

where you'll find valuable information about Muscle Injuries in general

and Hamstring Injuries in Particular

#Hamstringpain #HamstringStrain #PulledMuscle #Soccerinjuries #Soccergroinpain #westonsoccer #westonhippain #hippainsucks #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

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