Exercises to avoid with proximal hamstring tendinopathy (and what to do instead)

There are three main factors that can irritate your high hamstring tendons when they are injured:

1. Compressing the tendons against the sit bones
2. Stretching the tendons
3. Working the tendons too hard

Every person’s hamstring injury is unique, and these factors may affect your tendons differently depending on how long you’ve had the injury, how irritable your tendons are, and where you are in your recovery process.

The ultimate goal is for your tendons to tolerate all of these factors without restriction, but you usually have to limit them initially and then gradually restore their tolerance.

The Exakt app’s treatment plan introduces these elements progressively until you’re able to tolerate high loads through your functional range.

Evidence-based rehab plans for High Hamstring Tendinopathy

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Exercise positions that stretch and compress the hamstring tendons

It’s not just your typical hamstring stretch exercises that cause the high hamstring tendons to stretch. Any exercise where you move your hip forward and start to straighten your knee will stretch the upper hamstring tendons and compress them against your sit bones.

Examples of positions that stretch the upper hamstring tendons include:

• Lying on your back and straightening your leg up to the ceiling
• Sitting upright with your legs straight out in front of you (e.g., during exercise or while reading in bed) — leaning forward increases the stretch
• Bending forward with your legs straight (e.g., doing deadlifts or picking something up off the floor)
• Doing a squat

Alternatives to hamstring stretches

It's normal for your hamstrings to feel tight and uncomfortable when their tendons are injured. Someone may have even told you that tight hamstrings caused your injury — this is outdated advice.

The stiffness in your tendons and hamstring muscles is caused by the injured tissues, and it will improve as your injury heals. It’s not something you can stretch out, and pulling the tendons forcefully over the sit bones usually just irritates them when they are injured — similar to pressing on a bruise.

Using a massage gun, foam roller, or getting a massage is a good alternative if your muscles feel very tight. Just avoid applying strong pressure over the painful tendons themselves.

Picking the right strength exercises

Strength training exercises that target the hamstring muscles play an essential role in treating high hamstring tendinopathy.

That doesn’t mean all exercises are equally useful — how sensitive your tendons are to stretch and compression will determine what works best for you.

Usually, it’s best to progress the exercises as follows:

• Early rehab: Choose exercises that work the hamstrings with the hips straight (e.g. bridges or prone leg curls against resistance).
• Middle rehab: Introduce gentle compression and stretch by working into positions that require more hip flexion (e.g. high squats).
• Later rehab: Slowly increase the amount of stretch and compression, working toward a full range of motion (e.g. squatting to 90 degrees and introducing deadlifts).

We designed the workouts in the Exakt app to follow these principles: starting with exercises with the hips straight, gradually introducing more stretch and compression, and slowly restoring your tendons’ capacity over several weeks.

Evidence-based rehab plans for High Hamstring Tendinopathy

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Glute exercises to avoid

In our experience, any glute (buttock) exercise that involves rotating your hip, moving it out to the side, or crossing the midline often irritates the high hamstring tendons when they are injured. This is most likely due to the tendons rubbing and pressing against the sit bones, causing irritation.

Examples of exercises that may fall into this category include:

• Any glute or piriformis stretch
• Clamshell exercise
• Side leg lift exercise

Straight-line exercises (such as glute bridges) are usually a better option for strength training. Tight glutes are best addressed with foam rolling or using a massage gun.

Reminder: Pain does not equal damage

Thanks to advanced scanning techniques (like MRI and ultrasound) we’ve come to understand that the intensity of pain is not directly correlated to tissue damage. We now understand that:

• Not all pain you experience is due to the injured tissues.
• Some of it is “extra” pain created by your subconscious brain to try to protect you better.
• Research shows that a mild increase in pain (up to 3 out of 10) that settles within 24 hours is usually just the alarm system being triggered and is acceptable during tendinopathy rehab.
• Staying as active as possible within these low pain levels leads to better recovery than avoiding all activities or simply pushing through pain.

It’s usually unrealistic to expect no pain during the early stages of rehab, but ideally, we aim to reduce it to mild discomfort rather than significant pain.

You can read more about the different factors that may impact your pain and how to calm a hyper-sensitive alarm system in this article.

Start your High Hamstring Tendinopathy plan today!

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