Treating Hamstring Tendinopathy: A Guide for a Level 4 Soft Tissue/ Sports Massage Therapists
Jun 3
3 min read
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Hamstring tendinopathy is a frustrating and often persistent issue that can limit performance, hinder daily activities, and lead to long-term complications if not managed correctly. As a sports massage therapist, you play a vital role in helping clients manage symptoms, reduce pain, and return to optimal function. This guide explores a contemporary, evidence-informed approach to treating hamstring tendinopathy, including massage techniques, holistic care strategies, and practical treatment considerations.
Understanding Hamstring Tendinopathy
Hamstring tendinopathy typically affects the proximal hamstring tendon, where it attaches to the ischial tuberosity (sitting bone). Unlike acute strains, tendinopathy is a chronic, degenerative condition marked by tendon overload, leading to collagen disorganisation, reduced tendon stiffness, and impaired load tolerance.
It is common among runners, athletes engaging in sprinting or lunging, and individuals who sit for prolonged periods. Tendinopathy exists on a continuum (Cook & Purdam, 2009), ranging from reactive tendinopathy to tendon disrepair and degeneration.
Causes of Hamstring Tendinopathy
Primary Causes
Excessive loading: Sudden increases in training volume or intensity (especially sprinting, hill running).
Poor load management: Inadequate recovery or repetitive strain.
Biomechanical issues: Poor lumbopelvic control, gluteal weakness, or altered gait patterns.
Poor flexibility or mobility: Limited hip mobility increasing strain on the hamstring tendon.
Secondary Causes
Previous injury: Old hamstring strains or lumbar spine issues may predispose clients to tendinopathy.
Sedentary lifestyle: Long periods of sitting can irritate the proximal tendon.
Poor movement patterns: Compensatory strategies due to other musculoskeletal dysfunctions.
Red Flags and Differential Diagnosis
Sports massage therapists should screen for red flags that may warrant referral:
Unexplained weight loss
Night pain or constant pain at rest
Neurological symptoms (e.g. numbness, tingling, bowel/bladder changes)
Differential diagnoses may include:
Ischial bursitis
Referred pain from lumbar spine (e.g. L5/S1 radiculopathy)
Piriformis syndrome
Avulsion fracture (especially in adolescents)
If red flags or differential diagnoses are suspected, referral to a GP or specialist is essential.
Common Symptoms
Clients with hamstring tendinopathy may report:
Deep, localised buttock pain near the sitting bone
Pain when sitting for long periods
Pain during or after running, especially uphill or sprinting
Discomfort during lunges, squats, or bending from the hips
Tenderness on palpation at the ischial tuberosity
Symptoms often develop gradually and worsen with continued activity or poor load management.
Initial Assessment
A thorough subjective and objective assessment is crucial:
Subjective: Including training history, aggravating/relieving factors, previous injuries.
Objective:
Palpation of proximal hamstring tendon
Provocative tests: e.g., single leg hip hinge, resisted hamstring contraction in lengthened position (e.g., bent-knee stretch test)
Functional movement screening
Use assessment findings to inform treatment planning and client education.
Treatment Approach: Holistic and Biopsychosocial
Biopsychosocial Considerations
Tendinopathy is not purely a biomechanical issue — psychosocial factors matter too:
Fear avoidance
Pain beliefs and expectations
Stress and sleep quality
Effective communication, goal-setting, reassurance, and education around graded loading and tendon adaptation are essential. Avoid "pathoanatomical" language that can create fear.
Holistic Approach
Manual therapy for symptom relief
Exercise-based rehab to restore load tolerance
Lifestyle advice: sitting strategies, stress management, sleep hygiene
Nutritional support: as appropriate and within scope of practice
Massage Techniques and Timing
Massage should be integrated thoughtfully and not used in isolation. Techniques that may help:
Myofascial release of surrounding muscles (glutes, lumbar spine, quads)
Effleurage and petrissage for general soft tissue relaxation
Friction or ischemic compression over the tendon area (with caution) and only if tolerated
Trigger point therapy where appropriate
When to Use Massage:
As part of pain management in early stages
Before or after exercise-based rehab to improve tolerance
To support surrounding musculature under increased load
Avoid aggressive massage over the tendon during reactive or highly irritable stages.
Other Therapies and Interventions
Eccentric and isometric loading exercises: cornerstone of treatment
Shockwave therapy: can be useful in stubborn cases (outside massage therapist scope)
Heat therapy: may assist with muscle tension
Education and reassurance: empowers the client to engage with active rehab
Collaborate with physiotherapists or rehab professionals when possible, especially in persistent or complex cases.
Additional Effective Tips
Use graded exposure to build load tolerance gradually
Encourage movement over rest – avoid prolonged inactivity
Modify activities rather than completely stopping them (e.g., alter running volume/intensity)
Educate on tendon healing timeframes – expect improvement over months, not weeks
Emphasise consistency over intensity
References
Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? British Journal of Sports Medicine, 43(6), 409–416.
Goom, T., Malliaras, P., & Reiman, M. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. Journal of Orthopaedic & Sports Physical Therapy, 46(6), 483–493.
Rio, E., Kidgell, D., et al. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283.
Silbernagel, K. G., et al. (2007). Deficits in heel-rise height and Achilles tendon elongation occur in patients recovering from an Achilles tendon rupture. The American Journal of Sports Medicine, 35(8), 1346–1353.
