Hamstring Tendinopathy – A Breakdown of Causes, Treatment & Prevention


Ensure 2018 is an injury free year. Be proactive in protecting your health.

Too often we notice a pain or ache while running and we put this to the back of our minds as just a temporary problem. We put off getting advice from a doctor in the belief that being careful or taking it a bit easy for a while we will see the problem fix itself or go away. For some of us, this approach might even have worked in the past. This type of risk is not worth taking, it is better to be safe than sorry. Minor injuries, aches or pains can very quickly accelerate into a far worse problem and require a lot of medical help combined with a period of serious pain and prolonged discomfort.

Prevention will always be better than cure but if you are heading in the direction of needing a cure, please read on. 

Hamstring tendinopathy is an acute pain in the back of the leg starting at the knee, leading up to the thighs. It’s very common not only in running but in many other sports such as rugby, dancing, and football. There are various degrees of pain and discomfort depending on the injury. It’s very important to have a good understanding of the possible causes of poor treatment and early return to physical activity increases the chance of re-incidence or worsening the symptoms.

That’s why quality information plays an important role in raising awareness about this injury. This guide will give an insight into what causes hamstring Tendinopathy, well-known treatments and how to prevent future strains.


What is Hamstring Tendinopathy?

it’s one of the most common “sports” injuries (not to be mistaken with the most common running-related injury), affecting middle and long-distance runners, and all sports that require usage of the critical areas we will talk about here. Activities that require sudden stops, jumping or kicking are likely to affect the muscles at some point in their life. Although it’s treatable, it can send athletes out of competition for several weeks or even months. Having enough information is critical to maintain healthy muscles and avoid unwanted time off.

Hamstring tendinopathy is a thick pain at the back of the leg and thighs. It affects the knee as the tendons are located in the area between the tibia and fibula. The muscles connecting the knee extend along the leg to the ischial tuberosity which is the sitting bone. This set of muscles helps extend the hip and bend the knee. Therefore, pain can develop in the knee area which is surrounded by tendons or in the actual muscles along the leg up to the bottom area.

Fun Fact: means group of tendons.

What are the Symptoms of Hamstring Tendinopathy?

A wide range of symptoms could indicate the muscle tendinopathy. Symptoms vary depending on the level of injury. It’s also quite common among athletes to experience a sudden pain in the back of the legs and thighs while in the middle of a game, run session, or similar activity.

In mild cases, stiffness, inflammation, and soreness are common symptoms. In severe cases the athlete may experience swelling all along the area, acute pain and difficulties to walk or sit down. Quite often injuries can be mistaken for a lower back injury as the tibial nerves connect with the sciatic nerve which is located on the lower back and runs along the bottom.

Wikimedia Commons | https://en.wikipedia.org/wiki/Piriformis_syndrome

It’s very important to treat the injury as soon as is detected in order to avoid further complications. Most cases are treatable, although recovery times differ from case to case athletes can always go back to their normal routine in no time.

Symptoms of Hamstring Tendinopathy

  • Acute pain in the upper leg
  • some level of discomfort when kneeling or stretching
  • swollen or inflammation at the back of the leg
  • Pain in the tighs, difficulties to sit down
  • Soreness in the knee and thighs

More Severe Symptoms Include

  • Visible hematomas
  • Severe swelling at the back of the legs and thighs
  • Unable to run or walk
  • Persistent pain all along the affected area

What Causes Hamstring Tendinopathy?

Hamstring tendinopathy is triggered by overuse. Sports that require sudden stops, change in speed, repetitive jumping or kicking are more prone to muscle deterioration.

Other causes are the lack of stretching exercises pre and post-training. In some cases stretching exercises are not done correctly.  Efficient stretching is essential to keep an adequate level of flexibility without overstretching the muscles. Poor stretching exercises increase the chances of injury. Gradual muscle conditioning is crucial to avoid later damages.

Causes of Hamstring Tendinopathy

  • Intensive running, jumping or kicking
  • Weak muscle structure
  • Lack of flexibility and strength in the muscles
  • Poor training practices
  • Sudden muscle overload
  • Not enough recovery time between sessions
  • Recurrent injury due to early come back from the previous injury
  • Overweight  or sudden weight gain
  • Poor footwear
  • Natural muscle deterioration
  • Issues in the lower back or pelvis

High intensive training without proper recovery intervals can cause muscles deterioration as well as inflammation of the tendons.

Weak muscle structure or poor recovery from previous tendinopathy injury also add the list of possible triggers.

According to the British Journal of Medicine, the re-injury rate due to poor rehabilitation and early return to sports is 12% to 31%. This means rehabilitation is as important as early detection and prevention. A study from the National Institute of Health informs that injuries involving intramuscular and adjacent muscle fibers require shorter recovery as opposed to those involving proximal tendons. The British Journal of Medicine classifies Tendinopathy in 3 levels according to their severity mild, moderate or severe.


Levels of Hamstring Tendinopathy Severity

The level of severity will determine what further treatment is best in a nutshell,

  • Mild or 1st grade: characterized by a light pain in the muscle which can go away within few days. Grade 1 injury requires, above all, rest as the muscles will recover themselves assuming the right resting time is being given.
  • Moderate 2nd grade: an acute pain makes it hard to move, the muscle tear is quite evident. This level requires several weeks of therapy and progress control.  It’s important to follow medical advice, as early treatment is key to prevent major injuries.
  • Severe 3rd grade: it’s very difficult to walk, persistence pain, hematoma, substantial swelling. Some cases require clinical intervention. The time of recovery goes from few weeks to several months. The muscle or tendons present severe signs of wear and in some cases rupture of ligaments.

Importance of Hamstring Muscles

The structure comprises the biceps femoris, the semimembranosus, and the semitendinosus. They are responsible for body propulsion- walking, running, kicking and jumping. Besides, they assist the thighs in the sitting down movements.


These muscles help to move the leg connecting the hips and thighs with the knee. This essential group of muscles contributes to motor functions, without them we wouldn’t be able to walk.

Risk Factors for Hamstring Tendinopathy

  • Poor stretching exercises
  • Inadequate footwear
  • Weak body structure
  • Not having the correct exercise program or not giving the body enough time to build the right strength.
  • Poor diet, it may deprive the body of essential nutrients that help develop strong muscles.
  • Recurring injury, athletes who have suffered injuries in the past have higher chances of pain recurring.
  • Muscle fatigue

Diagnosing Hamstring Tendinopathy

A visit to the doctor will give a better overview of the condition and the severity of the injury. A doctor will carry an X-ray or MRI scan in order to have a clear picture of the condition. In addition, a scan will guide the doctor to choose the most effective treatment.

What are the most common treatments?

In many cases having few days of rest is enough to heal. Giving the muscles time to restore to their normal condition is essential as they heal by themselves. In most cases, the recovery is quite successful and the athlete can go back to training in a short period of time. However, it’s wise to investigate further what caused the injury in the first place, so the chances of re-injury are out.

Nowadays there’s a wide range of treatments from traditional to fairly new these programs help the patient to get better in no time. Plus modern technology makes it easier to detect ligaments fissures and muscle deterioration.

Though the muscles heal relatively easy, severe injuries may need more than simply rest time. Bear in mind that whatever level of injury you have, there are numerous treatments to treat injuries.

Mild  Tendinopathy may require short recovery time, as the pain is not so acute the person affected with this condition can still perform normal daily activities. In this cases is common to experience pain in the back of the legs, aching or pain around the bottom, soreness, stiffness, and discomfort.

Moderate Tendinopathy may need few sessions with a practitioner or physiotherapist in order to get a proper recovery. In moderate cases is typical experiencing acute pain, difficulties to walk or sit and inflammation.

Severe cases require longer treatments, several sessions with a practitioner and in some cases clinical intervention. In this cases may be very difficult to walk or move the leg due to severe swelling and lack of connective tissue.

Wikimedia Commons | https://en.wikipedia.org/wiki/Stretching

R.I.C.E Treatment

For mild and moderate injuries, the RICE method is the most common.

  1. Rest stands for rest, as the muscles recover by themselves is important to have as much rest as possible. Don’t apply any kind of pressure that may result in worsening the conditions.
  2. Ice: the most effective way of reducing inflammation is applying ice three or four times a day in the area affected. This will help the muscles to reduce tension helping gradual recovery.
  3. Compression: compressing the area with a bandage is another method to ease inflammation and reducing pain. Compression helps the flow of lymph fluids which are the responsible for fighting infection, it carries white blood cells which help fasten the recovery process.
  4. Elevation, keeping the knee elevated helps to reduce the circulation of toxic fluids, the recovery process benefits from this position.

Treatment for Hamstring Tendinopathy

  • Light tissue massage

    touching key points through soft tissue massage can help relieve tension accumulated in the muscles, as well as stimulating blood circulation. Lee J Crosman explains the effects of soft tissue massage: “Massages have been noted to have a number of effects upon human tissues. It involves stimulation of touch, pressure, and proprioceptive receptors of the skin and underlying tissues […] massages serve to increase venous and lymphatic flow which, in turn, promotes dispersal of metabolic waste products and absorption of excess inflammatory exudate” ( The Effects of Massaging the Hamstring Muscle Group on Range of Motion). Massaging is a non-invasive treatment, extremely beneficial to less severe cases of strain. It’s also important to notice that massage can serve as prevention treatment. Massage helps reduce tension accumulated after a long training session and it’s an excellent method to keep the blood flowing. Soft tissue massage main benefits,

  • boost blood circulation
  • helps to eliminate toxic fluids
  • helps relax the muscles
  • Pain and discomfort relief
  • Improve immune system
  • Assist developing muscle flexibility
  • Non-steroidal anti-inflammatory medications (NSAIDS)

    May be taken in mild injuries to reduce pain caused by inflammation. Although a study published by The National Institute of Health confirms the harmful effects these medications have on patients. NSAIDs may alleviate immediate pain, but the chances of experiencing stronger pain may be higher in the long run.

Wikimedia Commons | https://commons.wikimedia.org/wiki/File:200mg_ibuprofen_tablets.jpg


  • Physiotherapy

    once the pain is gone a practitioner can design an exercise plan to follow. Exercises should be carried out once the pain is gone and always under professional guidance. Specific exercises are complementary to other recovery programs such as electrotherapy or cortisone injections. In mild cases after applying RICE treatment is worthy to consult a practitioner to work out an exercise plan to fully restore the muscles.

  • Electrotherapy

    this treatment may work in mild or moderate injuries. It consists of attaching small electric units on the affected area. These units send tiny electrical impulses to the muscles to help dissolve soft tissue, as well as stimulating circulation. Quite a few treatments use the same principles to stimulate scar tissue regeneration.

    These are quite popular,

  • Ultrasound sends mechanical sound waves to the body contributing to freeing and remodeling scar tissue and boosting blood circulation In some cases this treatment speed up the healing process.
  • Interferential therapy is a low-intensity therapy. This treatment stimulates tissues and nerves enhancing blood circulation and reducing swelling.
  • TENS Transcutaneous Electrical Nerve Stimulation is the most painful of the list according to studies. This treatment stimulates the nervous system and can be used in higher or low frequency.
  • Laser, Light treatment although doesn’t go into deeper tissue it can promote healing within other areas such as muscle or nerves.This treatment uses light waves to go into the nerve, variations in the light will contribute to the effects of the treatment.
  •  PSWT Pulsed Shortwave Therapy stimulates cellular activity and goes deeper.
  • Cortisone injections

    for most severe cases, it acts as a powerful anti-inflammatory steroid, reducing pain in a short period of time. Dr. Moran of the University of Maryland says the effects of the injection are almost immediate, speeding recovery time means going back to sports in faster. This treatment uses ultrasound to guide practitioners into the affected area, it may require few sessions. The downside of cortisol is a potential risk of glaucoma, thinning of the skin, infection, alongside other complications. It’s vital to get as much information as possible before the treatment.

Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Syringe2.jpg


  • PRP Platelet Rich Plasma injection

    this is a new treatment which lacks sufficient evidence that supports its beneficial effects. Although patients who’ve been administered PRP showed some kind of improvement. A study by Dr. Badra confirms that PRP injections administered to young athletes “showed no significant difference over routine rehabilitation” (American Association of Orthopaedic Surgeons). This means a lot of research has to be done before we can talk about the efficiency of the treatment.

  • Surgery

    severe cases may require surgical intervention as the muscles may be much damaged or the fissure is so pronounced that only surgical intervention can help to stitch the ligaments together. Sometimes the ligaments pull pieces of bones away and the area has to be fully restored. A surgeon will cut any unwanted tissue and attach the ligaments to the bone. After this procedure, the patient may need to use bandages and crunches in order to speed the recovery process.

    Studies confirm that adequate post-surgery exercises are notable in helping the patient go back to healthy form within 6 months.


Case Study on Hamstring Tendinopathy

This case study by Michael Fredericson reveals how a wrong diagnosis can derive from later complications.

Patient: A female 32 years old middle distance runner presents severe pain in the lower back and buttock area. She was diagnosed with lumbar disk bulge injury and was administered epidural injection alongside physical treatments. The back pain is eliminated but the upper thighs and button remain strong.

She continues training for a period of time until the pain halts any further training. Although, she has plenty of resting time and recovers soon. The pain comes back when she starts training. Previous MRI test on the lumbar area was good. She later has a second test. An MRI magnetic resonance shows accumulation of the water fluids or enema in the ischial tuberosity, alongside soft tissue inflammation.

Diagnosis:  high hamstrings tendinopathy

Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Hamstrings_EMS_recovery.jpeg

Treatment: The patient bottom area was the main cause of concern. She is being given corticosteroid injection in the affected area using ultrasound technique. The injection makes an efficient pain relief. This together with a proper physiotherapy program helped her go back to training within 6 months of initiating treatment.

In this case, the corticosteroid injection was the right treatment to follow. The inflammation that caused the pain was reduced. And there were not visible side effects. The patient was able to go back to her normal life and didn’t need any further treatment other than a proper exercise plan.

 Conclusion: This study demonstrates the efficiency of a combined treatment (injection + physiotherapy). Besides, it shows the risk of re-injury or aggravating injuries if not properly diagnosed. It’s vital then to have a proper diagnosis and treatment to prevent deeper injuries.

Although the first test did not show the problem, in the second test doctors were able to give a proper diagnosis. Having a second opinion or several tests is the best option if the pain persists.

Preventing Hamstring Tendinopathy

Preventing an injury is more effective to avoid time out of sports. Conditioning the muscles to support long training hours should be gradual. It’s vital to know your own limitations and how to work to improve flexibility.

Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Flexibility_training.jpg

Not all the bodies are the same, so knowing your body frail parts or with a known tendency to inflammation helps to identify where you have to work the most. In some cases the knees and legs are strong but the hips are weak and the other way around. This is totally normal as we all have some specific areas that need more attention. What’s more, it is one of the most common muscle injuries of all. One of the best ways to prevent muscle deterioration is exercising.  Stretching and strengthening exercises are the best strategy to prevent injuries.

A study published on the National Institute of Health argues that adding eccentric exercises to a training program could reduce the chances of injuries. The frequency and intensity of the stretching exercises are pivotal.  Consistency then is crucial to grow high levels of flexibility, build resistance and increase strength in the muscles.

  • Method 1: There are many stretches that can help improve flexibility and strength,

Leg Stretch 1

  1.   Lying on the floor face down.
  2. Bend one knee pulling it towards your bottom.
  3. Use an elastic band to help to pull the knee.
  4.  Repeat 5 sets of 20 exercises.

Leg Stretch 2

  1. Lay down on your back.
  2. Lift one leg while the other remains on the floor.
  3. An elastic band may help you to grab the leg and maintain it lifted for about 30 seconds.

Squats are also excellent exercises to stretch the muscles

  1. Slightly separate your legs they should be the same as of your shoulders.
  2.  Stretch and keep your back straight.
  3. Bend your knees.
  4. Do 3 sets of 10 repetitions each.

Bridge posture is really good for the tights,

  1. Down on your back.
  2. Lift your hips and bottom, keeping extended.
  3. Maintain this posture for 20 seconds.
  4. Repeat several times.


A wide range of exercises helps prevent injury while improving strength and flexibility. The examples above are only a few. Keep in mind that the most effective way for developing strong muscles structure is a regular practice.

In order to keep a high level of fitness, you should follow a training program. Other methods that help to prevent possible injuries are listed below.

  • Method 2: Proper warm up before starting training is a universal way of keeping the muscles healthy. Remember the body has to know what you’re about to do, the muscles must pass previous conditioning exercises before the deep training session starts, so you avoid strain and another possible complication.
  • Method 3: Yoga or Pilates are very popular exercises to stretch the body and develop flexibility. These practices are also beneficial to boost concentration, develop good breathing techniques and helping relax the muscles. What’s more,  Yoga helps to improve body balance, correcting any bad posture.
  • Method 4:  A healthy diet is known to benefit every body part. Doctors recommend a diet rich in anti-oxidants, omega 3s, and proteins as they are extremely beneficial to the body. Proteins restore the muscles cells and help to generate new tissue.  In addition, B- complex vitamins contain essentials amino-acids to keep muscles and tendons in good condition. Here some of the best foods: Lentils; Walnuts; Flax-seeds; carrots; spinach; strawberries; blackberries; Fish; chicken; turkey


  • Method 5: Weight control, controlling your weight regularly helps to detect extra pounds that may be adding pressure to the muscles. Controlling the weigh is essential in advance athletes as more body weight means more difficulties to control the body in demanding exercises. Check your weight regularly to keep a good record of unwanted pounds.
  •  Method 6: Stay hydrated, water is one of the body main components, so staying hydrated will benefit the body in its totality.  Besides, while training is recommendable keeping a bottle of water nearby at all times. The body liberates toxins and needs water to compensate. Water also promotes healthy tissue.
  • Method 7: Have a proper rest between sessions. Quality rest time helps relax the muscles and recover after a long training session. Also if you have a history of injury make sure you give the body enough time to recover, as going back to the sport early can increase the chance of recurring injury. The muscles must feel loose in order to perform. If you feel your muscles are not ready for training to take longer rest. It’s preferable to take enough time than damage the muscles later.
  • Method 8: Sudden increase in the level of fitness can also put extra pressure on the muscles without these being properly conditioned. Increase the intensity gradually.Muscles require gradual conditioning before their reach high level of fitness. You must give the body time to gain strength if you don’t want to exhaust the ligaments.
  • Method 9: Doing the exercises properly help to avoid strain in the muscle. Check with your coach or other sports professionals if the exercises are done properly. Or if you don’t have a coach there are many resources that can help to correct your training exercises. Poor practice can end in injury.
  • Method 10: Use the proper footwear. Wrong trainers can cause many problems, among them having to slow down the trail. Trainers must adjust to your feet properly, they must have a proper cushion and aerodynamic system, and they must breathe the feet and feel comfortable.

Remember wrong trainers, wrong movements, and poor balancing.

  •  Method 11: Compression wear is perfect to reduce the chances of a hamstring injury. Compression shorts keep the muscles warm, boost blood circulation and support the area helping reduce muscle stiffness. In addition, it reduces the circulation of external body fluids, while doing intensive training. They come in many different materials such as Lycra, neoprene, and polyester.


To sum it up

The Hamstring the most commonly injured muscle in sports. Every year athletes take massive amounts of time off due to hamstring complications. According to the British Journal of Sports, 10% to 30% of athletes suffer this condition. Although there are many ways to prevent hamstring injuries, muscle deterioration sometimes is unavailable.  Proper rehabilitation is extremely important in order to prevent further injuries.

Don’t forget the muscles recover by themselves. Mild cases should be fine following the RICE method. In addition, having sufficient rest, time is key to achieve full muscle recovery, as explained before hamstrings tendinopathy has a high risk of re-injury, due to insufficient recovery time. Don’t go back to sports if the muscles don’t feel ready.

Always consult your doctor or a physiotherapist to have a clear picture of the state of the muscles. As we have seen in the case study a missing diagnosis can worsen the injury, so early diagnose is essential. Be aware of your body limitations, don’t put unnecessary pressure and work on the best way to build stronger muscles.

If running is a core part of your life, take time to develop your strength. A healthy body is the consequence of extensive training. Don’t try to achieve a lot in short time, go for the opposite instead.

Take conscious but small steps, this is the road to achieving full potential.

Sources used while conducting our research

The objective of this article is to inform.

This research does not substitute for medical advice. Although, the content in this article is backed by scientific research and published articles by professionals you should always consult your doctor in case of pain or discomfort in the hamstrings.



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  2. Bryan C. Heiderscheit, P.T., Ph.D, Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation and Injury Prevention, Public Access Medical Database
  3. Sports Medicine Information, Guide to Sports Medicine: Electrotherapy, Online Medical Journal
  4. Michael Fredericson , MD | William Moore , MD | Marc Guillet , PT, OCS | Christopher Beaulieu , MD, PhD, High Hamstring Tendinopathy in Runners: Meeting the Challenges of Diagnosis, Treatment, and Rehabilitation, Online Medical Journal
  5. UW Health Department, Tips to Prevent Hamstring Injuries, Medical Database
  6. Adam Pourcho, DO, ATC, Minimally Invasive Treatments for Chronic High Hamstring Tendinopathy, Online Medical Resource
  7. UM Medical Center, UMMC Team Reports Innovative Work for Hamstring Injuries, Online Medical Resource
  8. Sports Injury Clinic, Hamstring Strain (Pulled Hamstring), Online Portal for Medical Information
  9. Dr. Bhadra | Arthur C. Rettig, MD | Susan Meyer, MD, Is PRP effective in hamstring injuries?, Online Medical Resource
  10. NHS, Exercises for runners, Online Medical Resource
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