Hamstring Tendinopathy: Why That Deep Buttock Pain Won't Go Away (And What Actually Helps)

Javier Diaz
Apr 9
6 min read

What Is Hamstring Tendinopathy?

You’ve been running consistently for months - maybe training for a spring race, maybe just keeping up with your regular routine along the Burlington waterfront. Then one day you notice a nagging ache deep in your buttock, right under the sit bone. It’s worse when you push the pace uphill, and oddly, it bothers you when you’ve been sitting at your desk for too long. You stretch your hamstrings, roll it out, maybe take a week off. It doesn’t budge. That stubborn pain has a name: proximal hamstring tendinopathy, and it’s one of the most misunderstood running injuries we treat at Pursuit Physiotherapy in Burlington.

Proximal hamstring tendinopathy (PHT) is an overuse condition affecting the hamstring tendons where they attach to the ischial tuberosity - the bony prominence you sit on. Unlike a sudden hamstring strain that happens mid-sprint, PHT develops gradually. The tendon becomes irritated and sensitized from repeated loading, particularly in positions where the hamstring is both stretched and compressed against the bone.

It primarily affects active individuals, and runners are especially susceptible. The repetitive loading cycle of running - particularly uphill running, speed work, and high-volume training - places significant demand on the proximal hamstring. When that demand exceeds the tendon’s capacity to recover, things start to break down.

What Causes Hamstring Tendinopathy?

PHT is fundamentally a load management problem. The tendon gets overloaded relative to its capacity. Several factors contribute:

Training errors - Sudden increases in running volume, adding hills or sprints too quickly, or returning to running too aggressively after time off.
Compressive loading - Activities that involve hip flexion under load - deep lunges, deadlifts, uphill running - compress the hamstring tendon against the ischial tuberosity.
Prolonged sitting - Sitting directly compresses the tendon against the bone. If you run in the morning and then sit at a desk all day, you’re layering compressive load on top of training load.
Hamstring stretching - Aggressive hamstring stretching actually compresses the tendon further. Stretching an irritated hamstring tendon is one of the most common mistakes we see.

Many of our patients in Burlington and Oakville are recreational runners between 35 and 55 who’ve ramped up training for a spring race or returned to running after a quieter winter.

Signs and Symptoms: How to Recognize Hamstring Tendinopathy

PHT has a fairly distinct pattern, but because the pain sits deep in the buttock, it often gets mislabeled as sciatica or a hip problem.

Classic PHT Presentation

Deep, localized pain right at the ischial tuberosity (the “sit bone”).
Pain with loading activities - Running (especially uphill), squatting, lunging, and deadlifting.
Pain with prolonged sitting - The longer you sit, the worse it gets.
A gradual onset - It creeps in over weeks.
Morning stiffness that eases once you get moving, then worsens again during or after activity.

What It’s Often Confused With

Sciatic nerve problems, lumbar spine referral, and hip joint pathology can all produce pain in this area. That’s why a thorough differential diagnosis matters.

What the Research Says: Physiotherapy vs. Shockwave Therapy

A 2025 randomized controlled trial published in the American Journal of Sports Medicine compared individualized physiotherapy to shockwave therapy in 100 patients with proximal hamstring tendinopathy. Both groups received education on load management. The key finding: both approaches produced meaningful improvements over 12 months, with pain and function scores increasing from approximately 50 to 74-75 out of 100 - but neither was clearly superior to the other.Importantly, both groups received identical load management advice, including specific guidance on how to modify running based on pain levels. The researchers noted they couldn’t determine how much of the improvement came from the treatments themselves versus the educational component - suggesting that learning how to manage load may be just as important as the treatment modality.Participants were told they could continue running with up to 4/10 pain during activity, provided there was no significant increase in pain in the following 12-24 hours.Rich A, Ford J, Cook J, Hahne A (2025). Am J Sports Med, 53(14), 3396-3407.

Here are some of the key numbers from the study:

VISA-H scores improved from ~50 to 74-75 by 12 months in both groups
Median symptom duration was 54-59 weeks before participants even entered the study
74% of participants were female, mostly recreational runners with a mean age of 45
Both groups were exercising 3+ hours per week at baseline

How Physiotherapy Treats Hamstring Tendinopathy in Burlington

At Pursuit Physiotherapy, we see PHT regularly - especially in the spring when Burlington’s runners are building mileage for races. Our approach is built on the same principles supported by the current evidence: education, load management, and progressive exercise rehabilitation.

Getting the Diagnosis Right

The first session starts with a detailed assessment. We need to rule out sciatic nerve involvement, lumbar referral, and other conditions that mimic PHT. This includes progressive loading tests that stress the hamstring tendon specifically, neural tension testing (SLR, slump), and a screen for any inflammatory conditions. Our 60-minute initial assessments give us the time to be thorough - you’re not getting rushed through a 15-minute slot.

Education and Load Management

This is arguably the most important piece. Research consistently shows that understanding your condition and learning how to manage load is central to recovery. We’ll help you understand why your tendon is irritated, which activities are feeding the problem (yes, that hamstring stretch has to go), and how to modify your running and training without stopping entirely.

Progressive Exercise Rehabilitation

This is where the tendon rebuilds its capacity. Based on expert consensus and the latest trial data, exercise prescription for PHT follows specific principles:

Start with isolated hamstring loading in positions that minimize compression.
Progress gradually into positions that involve more hip flexion and compressive load as the tendon adapts.
Use a pain monitoring model to guide progression.
Include the full kinetic chain - not just hamstring curls.
Add sport-specific elements later in rehab - plyometrics, change of direction, and running drills.

A qualitative study of 13 expert physiotherapists (Nasser et al., 2020, Physical Therapy in Sport) found unanimous agreement on progressive loading using a pain monitoring model. Experts emphasized thorough differential diagnosis, targeted muscle-tendon rehabilitation, and exercises specific to each patient’s goals and deficits. They recommended against aggressive stretching and invasive procedures like steroid injections in most cases.

Expert physiotherapists also use manual therapy to settle symptoms and improve flexibility around the hip and pelvis.

What to Expect at Your First Appointment

When you come in for a hamstring tendinopathy assessment at our Burlington clinic, here’s what happens. You’ll spend a full 60 minutes one-on-one with Javier - no assistants, no rotating between patients. We start with a detailed history: when did it start, what makes it worse, what have you already tried. Then we move through a thorough physical examination including progressive hamstring loading tests, neural tension tests, lumbar and hip screening, and palpation.

By the end of that first session, you’ll have a clear working diagnosis and a plan. That plan includes what to modify immediately (sitting habits, stretching, training load), a starting exercise program, and a timeline for what recovery looks like. PHT is not a quick fix - most people need 12 to 16 weeks of consistent work - but knowing the path forward makes a real difference.

Five Things You Can Do Right Now

Stop stretching your hamstrings. Forward fold stretches compress the tendon against the bone.
Modify your sitting. Use a cushion that offloads the ischial tuberosity, take regular standing breaks, and avoid sitting on hard surfaces.
Don’t stop moving. Complete rest usually makes tendinopathy worse. Keep active, but reduce the activities that provoke your pain.
Run on flat terrain. If running is tolerable, keep it flat and at an easy pace. Avoid hills for now.
Start isometric hamstring exercises. A simple bridge hold or isometric hamstring curl can help begin loading the tendon. Aim for 4-5 holds of 30-45 seconds.

When to See a Physiotherapist for Hamstring Tendinopathy

The median symptom duration in the 2025 study was 54 to 59 weeks before participants sought treatment. That’s over a year of dealing with pain that often responds well to a structured rehab approach. If your deep buttock pain has persisted for more than a few weeks, isn’t responding to rest, or is affecting your ability to run or sit comfortably, it’s time to get it assessed properly.

The earlier you start the right loading program, the shorter the road to recovery. Waiting - or worse, stretching and resting and hoping - tends to let the tendon decondition further, making the eventual rehab longer and harder.

We help patients across Burlington, Waterdown, Millcroft, Hamilton, Oakville, and Milton get back to the activities they care about - whether that’s running a half marathon or sitting through a meeting without pain.