Proximal Hamstring Tendinopathy: The Sit-Bone Pain That's Hard to Shake

What is proximal hamstring tendinopathy?

The hamstrings originate at the ischial tuberosity - the sit bone. This proximal attachment is a common site of tendinopathy in runners who do a lot of speed work, hill repeats, or high mileage.

The pain is deep and aching at the sit bone, often mistaken for sciatica (the pain can radiate into the back of the thigh), hip bursitis, or a hamstring strain. The key distinguishing feature is that pain is worst when sitting - especially on hard surfaces - and during activities that load the hamstring at length.

Why it's particularly stubborn

The tendon sits directly over the ischial tuberosity. Sitting compresses the tendon against the bone, creating a compressive load that slows healing. This is why this injury can drag on for months without improvement if you don't modify the compressive load.

What aggravates it

• Sitting for long periods (work, driving, cycling)
• Lunges and stretching - hip flexion with the knee extended compresses the tendon
• Downhill running - high hamstring load at end range
• Sprint training and hill repetitions

What to change immediately

• Use a cushion with a cut-out under the sit bone when sitting
• Avoid sitting for more than 30–40 minutes at a time
• Stop aggressive hamstring stretching - it makes things worse
• Avoid lunges and deep squats until pain settles

The exercises

1. Isometric hamstring bridge

Supine, heels on a raised surface, lift the hips. Hold 30–45 seconds, 4 sets. The starting point.

2. Hip thrust

Both feet on the floor, drive the hips up. 4 sets of 8–10. Loads the hamstring at a shorter length, which avoids compression.

3. Romanian deadlift (double leg)

Gradual loading through the hamstring's full range. 3 sets of 8–10. Introduce slowly - stop if it provokes sit-bone pain.

4. Nordic curl (late stage)

Only after 6–8 weeks of other loading. The gold standard for hamstring strength but creates high compressive load early on.

5. Running: flat surfaces, moderate pace

Flat running is usually tolerated better than hills. Avoid downhill running until pain-free.

Timeline

12–16 weeks in most cases. Proximal hamstring tendinopathy is the slowest of the hamstring injuries to resolve - but with consistent loading and compression management, the outcome is good.