Is it a hamstring strain or high hamstring tendinopathy?

Both are hamstring problems that hurt at the back of the thigh or low in the buttock, so the two get mixed up, especially when the pain sits high, near the sitting bone. A hamstring strain is an injury to the muscle, or where muscle joins tendon, that happens at one moment, usually sprinting, kicking or a fast stretch, so the pain is sudden, often stops you, and may bruise. High hamstring tendinopathy (proximal hamstring tendinopathy) is a load problem in the tendon where the hamstrings attach to the sitting bone, so it builds over weeks, sits in one spot, and is often worst when sitting. One starts with a moment you can name; the other creeps in with load.

Written by Kareem Hassanein, Registered Physiotherapist. Burlington, Ontario. This is a guide, not a diagnosis. An in-person exam usually narrows it down, though the two can overlap and some cases need imaging or a second look.

Book Assessment Call Clinic

Other Comparisons

Condition A

Hamstring Strains

Hamstring strains from sprinting or kicking, and the rehab back to running and sportRead the full hamstring strain page Condition B

Proximal Hamstring Tendinopathy

Pain at the sitting bone where the hamstring tendons attach, often worse with sitting, hills and runningRead the full hamstring tendinopathy page

Side by side

The patterns that separate hamstring strain from hamstring tendinopathy in clinic. Read across each row and compare.

Aspect	Hamstring strain	Hamstring tendinopathy
How it started	At one moment you can name: a sharp grab or pull at the back of the thigh while sprinting, accelerating, kicking, or in a fast or deep stretch such as a high kick or the splits. It often forces you to stop.	Usually no single moment. It creeps in over weeks, often after adding hills, speed work or lunges, or after a change to a more sitting-heavy routine.
Where it hurts	Along the muscle at the back of the thigh, most often the outer hamstring (biceps femoris), tender over a length of the muscle rather than at one point. Strains from a deep stretch can sit higher, close to the sitting bone.	One spot on the sitting bone (the ischial tuberosity), low in the crease of the buttock. You can usually put one finger on it, and it may ache down into the upper back of the thigh.
Bruising	Can come out over the next day or two at the back of the thigh. A pop right at the sitting bone with large bruising, a gap you can feel or trouble walking is a different injury: see the warning signs below.	Not a feature of tendinopathy. Bruising points to a tear or another injury.
Sitting	Not usually the main complaint. A fresh strain high in the thigh can be sore to sit on, but that tends to ease as it heals.	Often the worst part of the day. Hard seats, long drives and desk work press on the tendon at the sitting bone, and shifting your weight, a cushion or perching on the edge of the seat may ease it.
Walking and running	Often a limp at first, with pain when striding out or bending the knee. Walking normally comes back first, then easy jogging, then speed.	Walking is usually comfortable. Running uphill or fast hurts most, often more later that day or the next morning, while easy, flat running may be manageable.
Stretching	In the early, painful weeks, forceful stretching that brings on the pain is avoided; range comes back with comfortable movement and gradually progressed loading.	Deep toe-touch stretches often aggravate it, because they add pressure at the sitting bone to the stretch. Easing off them while it settles may help.
Over the following weeks	Usually worst in the first days, then improving week by week as walking, jogging and strength come back.	Goes up and down with load. It flares after hills, speed work or a long sit and settles when that load drops, but it can drag on for months if the load does not change.
Typical recovery time	As a guide, 2 to 3 weeks back to sport for a mild (grade 1) strain, 4 to 8 weeks for grade 2, and 3 to 6 months for a complete tear. Strains that reach into the tendon or sit close to the sitting bone tend to take longer.	Usually measured in months. A staged program may run 3 to 6 months or longer, and sitting comfort, strength and faster running can improve at different rates.

How it started: Hamstring strain
At one moment you can name: a sharp grab or pull at the back of the thigh while sprinting, accelerating, kicking, or in a fast or deep stretch such as a high kick or the splits. It often forces you to stop.; Hamstring tendinopathy
Usually no single moment. It creeps in over weeks, often after adding hills, speed work or lunges, or after a change to a more sitting-heavy routine.
Where it hurts: Hamstring strain
Along the muscle at the back of the thigh, most often the outer hamstring (biceps femoris), tender over a length of the muscle rather than at one point. Strains from a deep stretch can sit higher, close to the sitting bone.; Hamstring tendinopathy
One spot on the sitting bone (the ischial tuberosity), low in the crease of the buttock. You can usually put one finger on it, and it may ache down into the upper back of the thigh.
Bruising: Hamstring strain
Can come out over the next day or two at the back of the thigh. A pop right at the sitting bone with large bruising, a gap you can feel or trouble walking is a different injury: see the warning signs below.; Hamstring tendinopathy
Not a feature of tendinopathy. Bruising points to a tear or another injury.
Sitting: Hamstring strain
Not usually the main complaint. A fresh strain high in the thigh can be sore to sit on, but that tends to ease as it heals.; Hamstring tendinopathy
Often the worst part of the day. Hard seats, long drives and desk work press on the tendon at the sitting bone, and shifting your weight, a cushion or perching on the edge of the seat may ease it.
Walking and running: Hamstring strain
Often a limp at first, with pain when striding out or bending the knee. Walking normally comes back first, then easy jogging, then speed.; Hamstring tendinopathy
Walking is usually comfortable. Running uphill or fast hurts most, often more later that day or the next morning, while easy, flat running may be manageable.
Stretching: Hamstring strain
In the early, painful weeks, forceful stretching that brings on the pain is avoided; range comes back with comfortable movement and gradually progressed loading.; Hamstring tendinopathy
Deep toe-touch stretches often aggravate it, because they add pressure at the sitting bone to the stretch. Easing off them while it settles may help.
Over the following weeks: Hamstring strain
Usually worst in the first days, then improving week by week as walking, jogging and strength come back.; Hamstring tendinopathy
Goes up and down with load. It flares after hills, speed work or a long sit and settles when that load drops, but it can drag on for months if the load does not change.
Typical recovery time: Hamstring strain
As a guide, 2 to 3 weeks back to sport for a mild (grade 1) strain, 4 to 8 weeks for grade 2, and 3 to 6 months for a complete tear. Strains that reach into the tendon or sit close to the sitting bone tend to take longer.; Hamstring tendinopathy
Usually measured in months. A staged program may run 3 to 6 months or longer, and sitting comfort, strength and faster running can improve at different rates.

What I check in person to separate them

These are the clinical tests I actually run in the first visit. You cannot do them all on yourself reliably, but understanding what they look for helps explain how an in-person exam narrows them down.

Pressing along the hamstring and on the sitting bone
Tenderness over a length of the muscle at the back of the thigh points to a strain, and how long the tender area is gives me one clue to how long recovery may take. Tenderness in one spot right on the sitting bone points to the tendon.
Bending the knee against resistance, with the hip in different positions
A fresh strain is painful, and often weak, when the hamstring works against resistance. With tendinopathy, the effort brings on the familiar pain at the sitting bone.
Bent-knee stretch and Puranen-Orava tests
These stretch the hamstring in set positions and can bring on the familiar sitting-bone pain of tendinopathy. They were tested in athletes with long-standing tendinopathy and athletes without it, not in fresh strains, so where the pain is felt and how it started matter as much as the result.
Checking for a gap and marked weakness after a pop
When there was a pop near the sitting bone, I feel for a gap where the tendon attaches and check for marked weakness and heavy bruising. Any of these raises concern that the tendon has pulled off the bone, and I refer you urgently rather than start a rehab plan.
Nerve tension tests, including the slump test, and a back check
Pain at the back of the thigh can also come from the lower back or the sciatic nerve. If the slump test brings on the pain and moving the neck changes it, the nerve is likely involved, and I look at the back before treating the hamstring.

Which pattern fits you better?

Plain-language routing. This is not a diagnosis, and real patients often sit between the two, but the language below is a reasonable starting point.

More likely

Hamstring strain

Your pattern more likely fits a hamstring strain if it started at one moment you can name: a sharp grab or pull at the back of the thigh while sprinting, accelerating, kicking or reaching into a fast stretch, often bad enough to stop you. Walking and striding out hurt for the first days, the sore area runs along the muscle at the back of the thigh, bruising may come out over the next day or two, and it improves week by week as loading builds. If the pain is right at the sitting bone after a pop, with large bruising, a gap or trouble walking, check the warning signs below first.

Read the hamstring strain page

More likely

Hamstring tendinopathy

Your pattern more likely fits proximal hamstring tendinopathy if there was no single moment of injury and the pain crept in over weeks, sits in one spot on the sitting bone, and is worst on hard seats, on long drives or at a desk. Hills, speed work, lunges, deep squats and toe-touch stretches bring it on, often more later that day or the next morning. There is no bruising, and it goes up and down with load rather than steadily healing.

Read the hamstring tendinopathy page

If you still cannot tell

The two can blur. Strains from a deep stretch sit close to the sitting bone, a partial tear of the upper tendon can sit alongside tendinopathy, and a sore tendon is sometimes treated for months as a tight or strained hamstring. A short in-person assessment can narrow it down. I take the story of how it started, press along the muscle and on the sitting bone, test strength with the hip and knee in different positions, and run the bent-knee stretch tests. I also check the lower back and the sciatic nerve, since both can send pain into the back of the thigh. I cannot order imaging; when imaging would change the plan, such as a possible tear near the sitting bone or a recovery that is not following the expected pattern, I flag it to your family doctor or a sports medicine physician and refer you.

When both are going on

They share the same muscle and tendon, so they can travel together. A strain close to the sitting bone can take months to recover, and while it does, sitting and stretching can stay sore, much as they do with tendinopathy. Someone with an irritable tendon can also strain the muscle during a sprint. Both plans rest on hamstring strength work built up step by step; what differs is the starting point, how quickly it progresses, and how much attention sitting, stretching and speed need. When both are in play, I protect the newer injury first and build toward the loading the tendon needs.

When to see a doctor first

A sudden pop or tearing feeling at the sitting bone during a sprint, slip, or forced split, often with large bruising down the back of the thigh, a gap you can feel, or difficulty walking. Possible proximal hamstring avulsion (the tendon pulled off the bone). Get an urgent surgical opinion within days, through your family doctor, a sports medicine physician or emergency. Not every avulsion needs surgery, but if repair is chosen it is easier when done early.
Sudden sharp pain at the sitting bone in a teenager during sprinting, hurdling or kicking. Possible avulsion of the growth plate at the sitting bone. Stop sport, keep weight off the leg, and get it checked today with an X-ray.
New trouble starting to pass urine or feeling it pass, new loss of bladder or bowel control, new numbness between the legs or around the back passage, new loss of genital sensation or sexual function, or severe or rapidly worsening weakness in both legs. Go to emergency now. These can be signs of cauda equina syndrome.
Calf swelling, warmth or tenderness after the injury or a spell of reduced activity. Same-day medical assessment to rule out a blood clot in the leg (deep vein thrombosis).
Sudden shortness of breath or chest pain, coughing up blood or feeling faint, especially with a painful or swollen calf. Go to emergency now, or call 911. A clot that has travelled to the lungs (pulmonary embolism) needs to be ruled out.
Numbness or tingling spreading down the leg or into the foot, without weakness. Can be checked at your physiotherapy assessment; see your family doctor if it is spreading or getting worse.
A new foot drop (the foot catches or slaps when you walk), or weakness in the leg that is getting worse. Same-day medical assessment.

Questions patients ask about telling these apart

I felt a sharp grab at the back of my thigh while sprinting. Is that a strain or the tendon?

That is the typical story of a strain: a sudden grab or pull mid-sprint that often makes you stop, most often in the outer hamstring muscle. Tendinopathy does not usually start with one moment; it builds over weeks with running, hills or sitting. The exception to watch for is a pop or tearing feeling right at the sitting bone, especially in a slip or forced split, with large bruising, a gap you can feel or difficulty walking. That can be the tendon pulling off the bone (an avulsion) and needs an urgent surgical opinion within days, through your family doctor, a sports medicine physician or emergency.

Is a high hamstring strain the same as high hamstring tendinopathy?

No, although they hurt in the same area. 'High' only means close to the sitting bone. A high hamstring strain is a sudden injury there, often from a deep stretch with the hip bent and the knee straight, such as a high kick or the splits. Studies of these stretching-type strains found the injury close to the sitting bone, often in the upper tendon of one hamstring muscle, and recovery took months for many. High hamstring tendinopathy, also called proximal hamstring tendinopathy, has no single moment of injury: it builds over weeks with load and is often worst when sitting. How it started is usually what separates them.

It hurts to sit. Does that mean tendinopathy rather than a strain?

It leans that way, but it does not settle it. Pain on hard seats, long drives and desk work, right on the sitting bone and building over weeks, is typical of tendinopathy, because sitting presses on the tendon where it attaches. A fresh strain high in the thigh can also be sore to sit on for a while, but it started with a clear moment and usually eases as it heals. If sitting pain comes with numbness, tingling or weakness spreading down the leg, check the warning signs on this page first.

Should I stretch it?

Not hard, for either one. In the early, painful weeks after a strain, I avoid forceful stretching that brings on the pain and use comfortable movement and gradually progressed loading instead. With tendinopathy, deep toe-touch stretches often aggravate the tendon, because they add pressure at the sitting bone to the stretch, so I reduce their range or pause them for a while. Both plans lean on hamstring strength work built up step by step rather than on stretching.

Do I need an MRI to tell them apart?

Usually not. The story of how it started and the examination separate them in many cases. In a study of 180 male athletes with sudden pain at the back of the thigh, adding a magnetic resonance imaging (MRI) scan to the history and examination barely improved the estimate of their return to sport. That study was about predicting recovery after a strain rather than telling a strain from tendinopathy, but it shows how much the history and examination already tell. Imaging matters when the tendon may have pulled off the bone, when a complete tear is suspected, or when recovery is not following the expected pattern. I cannot order imaging; when imaging would change the plan, I flag it to your family doctor or a sports medicine physician and refer you.

How long does each take to recover?

A strain is usually measured in weeks. As a guide, a mild (grade 1) strain takes 2 to 3 weeks to return to sport, grade 2 usually 4 to 8 weeks, and a complete tear 3 to 6 months; strains that reach into the tendon or sit close to the sitting bone tend to take longer. Tendinopathy is usually measured in months, and a staged program may run 3 to 6 months or longer. For both, return is guided by meeting set checks, such as strength and running without symptoms, rather than by the calendar. A previous hamstring strain is one of the clearest risk factors for another, so strength work and a gradual return to fast running carry on after the pain settles (Green et al., 2020).

Evidence this page draws on

Sources I lean on when separating these two conditions in clinic.

In 18 elite sprinters followed after a first hamstring strain while sprinting in competition, the main injury was in the outer hamstring muscle (the long head of biceps femoris) every time. Injuries that reached the upper tendon, or sat closer to the sitting bone on examination and imaging, took longer to get back to the previous level of performance.

Askling CM, Tengvar M, Saartok T, Thorstensson A. "Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings." Am J Sports Med 2007; 35(2): 197-206.

PubMed 17170160

In 30 people from 21 sports whose hamstring strain happened in a position combining a deep hip bend with a straight knee, every injury sat high in the back of the thigh close to the sitting bone, and most involved the upper tendon of one hamstring muscle (semimembranosus). Nearly half gave up their sport, and for the 16 who returned, the typical time back was 31 weeks, ranging from 9 weeks to 2 years.

Askling CM, Tengvar M, Saartok T, Thorstensson A. "Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport." Am J Sports Med 2008; 36(9): 1799-1804.

PubMed 18448581

In 180 male athletes examined within five days of sudden pain at the back of the thigh, how bad the worst pain was, having to stop within five minutes, the length of the tender area and pain when bending the knee against resistance were each linked with the time to return to sport. Adding a magnetic resonance imaging scan barely improved that estimate. Return times varied widely, and the authors found no reason for a routine scan after a sudden hamstring injury.

Wangensteen A, Almusa E, Boukarroum S, et al. "MRI does not add value over and above patient history and clinical examination in predicting time to return to sport after acute hamstring injuries: a prospective cohort of 180 male athletes." Br J Sports Med 2015; 49(24): 1579-1587.

PubMed 26305004

A clinical review describes proximal hamstring tendinopathy as deep buttock pain where the hamstrings attach to the sitting bone, affecting athletes and non-athletes, often long-standing and limiting sport and daily life. Evidence on its diagnosis and management is limited, and principles established for Achilles and patellar tendinopathy appear to apply but are less well documented for it.

Goom TS, Malliaras P, Reiman MP, Purdam CR. "Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management." J Orthop Sports Phys Ther 2016; 46(6): 483-493.

PubMed 27084841

A review of upper hamstring injuries reports that tendinopathy and partial tears can often be managed without surgery, with surgery kept for cases that do not respond. Complete tears managed without surgery often left weakness, reduced function and a poor return to sport, while surgical repair can give good strength and function, and early repair is preferred over a delayed one. A later randomised trial in adults aged 30 to 70, summarised below, found non-surgical care no worse than surgery for function at two years.

Degen RM. "Proximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries." Curr Rev Musculoskelet Med 2019; 12(2): 138-146.

PubMed 30806898

In 92 athletes, half with long-standing proximal hamstring tendinopathy, three tests that stretch the hamstring to bring on pain at the sitting bone (the Puranen-Orava, bent-knee stretch and modified bent-knee stretch tests) gave consistent results between and within examiners and identified the condition moderately to highly well, the modified bent-knee stretch test best. The authors advise using them alongside other measures, such as imaging.

Cacchio A, Borra F, Severini G, et al. "Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy." Br J Sports Med 2012; 46(12): 883-887.

PubMed 22219215

A 2024 trial in Sweden and Norway randomised 119 adults aged 30 to 70 with a hamstring avulsion (tendon pulled off the sitting bone) to surgery or non-surgical treatment. At two years, function with non-surgical care was no worse than after surgery, and there were fewer adverse events (3 against 9).

Pihl E, Laszlo S, Rosenlund AM, et al. "Operative versus Nonoperative Treatment of Proximal Hamstring Avulsions." NEJM Evid 2024; 3(8): EVIDoa2400056.

PubMed 39023393

In 100 people with proximal hamstring tendinopathy treated in primary care physiotherapy practices, six sessions of individualised physiotherapy or of shockwave, both with the same advice and education, gave similar results for overall change and function over a year.

Rich A, Ford J, Cook J, et al. "Physiotherapy Compared With Shockwave Therapy for the Treatment of Proximal Hamstring Tendinopathy: A Randomized Controlled Trial." Am J Sports Med 2025; 53(14): 3396-3407.

PubMed 41243328

A review of 78 studies covering 71,324 athletes found that a history of hamstring strain raised the risk of another (risk ratio 2.7), more so when it was recent (4.8), and the authors named older age and a previous strain as the strongest risk factors.

Green B, Bourne MN, van Dyk N, et al. "Recalibrating the risk of hamstring strain injury (HSI): A 2020 systematic review and meta-analysis of risk factors for index and recurrent hamstring strain injury in sport." Br J Sports Med 2020; 54(18): 1081-1088.

PubMed 32299793

Book an assessment

If this page has helped you narrow things down, or if it has left you wanting a proper exam, I see patients at Endorphins Health & Wellness Centre in Burlington. Direct insurance billing is available, and a physician referral is not required.

4631 Palladium Way, Unit 6Burlington, ON L7M 0W9
(905) 634-6000Direct billing. No referral needed.

Burlington hours

Endorphins Health & Wellness Centre

4631 Palladium Way

Monday: 1:30 to 7:00 PM
Tuesday: 3:30 to 8:00 PM
Thursday: 1:30 to 8:00 PM

Headon Physio

1387 Walkers Line

Wednesday: 2:00 to 7:00 PM
Friday: 1:00 to 7:00 PM

PhysioMax Wellness

1035 Brant Street

Tuesday: 11:00 AM to 2:30 PM
Saturday: 12:00 to 3:00 PM

Book an Initial Assessment