Proximal hamstring tendinopathy; expert physiotherapists' perspectives on diagnosis, management and prevention

Key points

1. 01All experts used a combination of patient interview findings and clinical load-based tests to diagnose PHT, not a single test
2. 02Progressive hamstring loading starting in near-neutral hip positions was the cornerstone of rehabilitation for all respondents
3. 03Passive interventions such as injections and surgery were not recommended by any expert physiotherapist
4. 04Sitting pain was noted to often take over a year to resolve and frequently lagged behind functional recovery
5. 05Prevention of recurrence relied on long-term continuation of hamstring and kinetic chain strengthening alongside workload management

How it was conducted

Design

Qualitative study using semi-structured interviews with expert physiotherapists

Participants

13 expert physiotherapists (14 contacted, 1 declined due to illness); all male; average clinical experience not fully stated but minimum 5 years required

Geographic spread

Australia (majority), Ireland, New Zealand, Qatar, and Scotland

Inclusion criteria

Registered physiotherapists with PHT experience, Masters or PhD qualification, minimum 5 years experience

Analysis

Qualitative content analysis with two independent researchers using NVivo; interviews continued until data saturation

Primary outcome

Expert perceptions on assessment, management, and prevention of PHT, organised into categories and sub-categories

What they found

• All 13 experts used a combination of patient interview and clinical examination to diagnose PHT
• All experts reported insidious onset associated with increased mechanical load through the proximal hamstring tendon
• Four experts (percentage not fully stated in text) reported symptoms primarily at the hamstring insertion, sometimes spreading down the hamstring but not past the knee
• Evidence-based pain provocation tests (Puranen-Orava, bent-knee stretch, modified bent-knee stretch) have moderate to high sensitivity (range not fully stated) and specificity (range not fully stated) for detecting MRI-defined tendinopathy, but were only used by a small percentage of the physiotherapists interviewed
• MRI structural changes in the proximal tendon are present in approximately 55% and 78% (mean age not reported) of asymptomatic people imaged
• All experts prescribed progressive load-based hamstring exercise from early to late-stage management
• No expert referred patients for platelet-rich plasma or corticosteroid injections
• Most experts noted rehabilitation typically required 3 to 6 months; sitting pain often took over a year to resolve
• Cortisocteroid injection has been shown in retrospective studies to result in greater than 50% of patients not achieving long-term symptom resolution

Limitations

• Only expert physiotherapists were interviewed, which may bias results toward non-invasive interventions and underrepresent perspectives on injection or surgical management
• The majority of experts (54%) were from Australia, which may limit external validity to other healthcare contexts
• This is qualitative expert opinion, not a controlled trial, so findings reflect clinical consensus rather than empirical evidence of treatment effectiveness
• Sample size of 13 experts limits the range of perspectives and generalisability

Why it matters

For patients

People with persistent deep buttock or ischial pain should expect a thorough clinical assessment using multiple movement tests rather than imaging alone, and should prepare for a graduated rehabilitation program lasting several months.

For clinicians

Expert consensus supports a clinical reasoning approach combining history and progressive load-based provocation tests for diagnosis, followed by education and graded hamstring and kinetic chain loading avoiding early hip flexion, with no role for routine injection referral.

For readers

This study fills a gap in the absence of high-quality RCT evidence for PHT by capturing expert consensus, providing a basis for developing and testing structured management protocols.