The pain shows up in a very specific place. Deep under the buttock, right where the sit bone is. It hurts when you drive long distances, when you sit on a hard chair through a meeting, when you bend down to tie your shoes, and — the reason most runners finally pay attention — at the bottom of every stride when you push the pace or run downhill.
This is proximal hamstring tendinopathy. The hamstring tendon attaches directly onto the sit bone (the ischial tuberosity), and when that attachment gets irritated, it becomes one of the most stubborn injuries a runner can deal with. I've worked through it myself, I've coached callanetics students through it, and I've watched too many runners make it worse by doing the one thing that feels intuitive: stretching.
Here is the protocol I actually use, stage by stage, with the reasoning behind every choice.
Why Stretching Makes It Worse
The hamstring tendon wraps around the sit bone. When you hinge forward into a deep hamstring stretch — toe touches, seated forward folds, the classic "foot up on a bench" runner stretch — you compress the tendon against the bone. Compression on an already-irritated tendon is the exact mechanical input that drives the pain cycle.
This is why so many people limp along for months. They feel tightness, they stretch, the pain spikes the next day, they assume they need to stretch more. The tendon doesn't need lengthening. It needs load — the right kind, in the right amount, at the right time.
If you want the broader context on how I personally rebuilt back to ultra trails after dealing with this, I wrote about my own progression in Proximal Hamstring Tendinopathy: The Rehab Progression That Got Me Back to Ultra Trails. The article below is the cleaner clinical version — the framework I'd hand to anyone starting from zero.
The Four Stages at a Glance
You move through stages based on symptom response, not the calendar. A reasonable range is 2–6 weeks per stage, but I've seen runners spend three months in stage 2 and others fly through. The body decides.
Pain Monitoring: The Rule That Governs Everything
Before any exercise, you need a rule. Mine is simple:
- Pain during the exercise stays at or below 3/10
- Pain the next morning is no worse than baseline
- If both conditions are met, you progress. If not, you scale back.
This rule is non-negotiable. Tendons respond to load, but they punish overshoot 24 hours later, not in the moment. Trust the morning, not the workout.
Stage 1: Isometric Holds (Weeks 1–3, Usually)
Isometric contractions — holding a muscle under tension without moving — have a quiet analgesic effect on irritated tendons. They give you load without the compression risk of stretching and without the range-of-motion demands you're not ready for yet.
The starter set:
1. Long-lever bridge hold
Lie on your back, heels on the floor, legs almost straight (slight knee bend, maybe 20 degrees). Press your heels down and lift your hips. Hold.
- 5 holds × 30–45 seconds
- 60 seconds rest between holds
- Once daily, can go to twice daily if symptoms allow
2. Single-leg bridge hold (progression)
Same setup, one leg only, opposite leg lifted slightly off the floor.
- 5 holds × 20–30 seconds each side
- Add when bilateral version feels easy and morning pain is stable
3. Wall hamstring isometric
Sit on a chair, heel pressed into a wall in front of you, knee bent to about 90 degrees. Push the heel into the wall as if trying to drag it back toward you.
- 5 holds × 30–45 seconds per leg
- This is gold for targeting the proximal tendon specifically
Progress out of Stage 1 when:
- You can complete the single-leg bridge hold for 5×30 seconds with pain ≤2/10
- Sitting tolerance has improved (e.g., 30+ minutes without sharp pain)
- Morning stiffness is mild
Stage 2: Heavy Slow Resistance (Weeks 3–8)
This is where actual tendon remodeling happens. Heavy slow resistance — meaning controlled, moderate-to-heavy loading with a slow tempo — is the most evidence-supported intervention for chronic tendinopathy.
Tempo matters. I cue 3 seconds down, 1 second pause, 3 seconds up. The slowness keeps you honest about form and creates the time-under-tension that the tendon adapts to.
The Stage 2 exercises (3 sessions per week, 48 hours between):
1. Romanian deadlift
Hip hinge with dumbbells or a barbell, hamstrings loaded through a controlled range. Stop short of feeling a stretch at the sit bone — about three-quarters of full range is the right starting point.
- Week 1: 3 × 12, moderate weight
- Week 2: 3 × 10, increase load
- Week 3: 4 × 8, heavier
- Week 4+: 4 × 6, heavy
2. Single-leg hip thrust
Upper back on a bench, one foot on the floor, drive through the heel. The lower position reduces compression on the proximal tendon, which is why I prefer this over a single-leg deadlift early in stage 2.
- 3 × 10 per leg, building load weekly
3. Nordic hamstring curl (eccentric only, partial range to start)
Kneel with feet anchored, lower your torso forward under control. Catch yourself with your hands before any pain provocation. Range increases as tolerance increases.
- 3 × 5, very slow eccentric (5+ seconds down)
Progress out of Stage 2 when:
- You can perform Romanian deadlifts at a load roughly equal to your bodyweight (or your own meaningful benchmark) for 4×6 with pain ≤2/10
- Hill walking and stair climbing are pain-free
- The hamstring feels strong and stable, not "guarded"
Stage 3: Energy-Storage Loading (Weeks 6–12)
Strength is not the same as spring. Running asks the hamstring to absorb load and return it fast — a different demand than slow heavy lifting. Skipping this stage is the single most common reason runners re-injure when they try to come back.
Energy-storage exercises reintroduce stretch-shortening cycle work. They should feel like effort, but the morning rule still applies.
Three sessions per week, 48 hours apart:
1. Single-leg deadlift to step-up
Hinge into a single-leg deadlift, then drive up onto a step. The transition trains hamstring-to-glute timing.
- 3 × 8 per leg
2. A-skips and high-knee marches
Start with marches, progress to skips. Begin on flat ground, 20–30 metres at a time.
- 4 × 30 metres, building over two weeks
3. Lateral and forward bounds
Sub-maximal effort. Land softly. Quality over distance.
- 3 × 6 bounds per direction
4. Hill walking with high knees
A gentle incline (5–8%). Walk briskly with exaggerated knee drive.
- 3 × 1 minute
This stage often overlaps with the start of stage 4. You don't need to fully exit one before testing the next.
Stage 4: Return to Running
Here's where patience pays off or destroys the rehab. The hamstring tendon is most vulnerable during the late swing phase of running — when the leg is extending forward and the hamstring is decelerating it before foot strike. Speed and downhills amplify this. Both come last.
The progression I use:
Week 1: Walk-run intervals on flat ground. 1 minute run, 2 minutes walk. Total run time: 10 minutes. Two sessions.
Week 2: 2 minutes run, 1 minute walk. Total run time: 15 minutes. Two to three sessions.
Week 3: Continuous easy running. 20 minutes flat. Two to three sessions.
Week 4: Continuous running, 25–30 minutes. Introduce one session with very gentle rolling terrain.
Weeks 5–6: Build volume by no more than 10% per week. Easy pace only.
Week 7+: Reintroduce one element at a time — first a slightly faster paced session (strides, not intervals), then short hill repeats (uphill effort, walk down), then proper tempo work, then downhill running last.
Downhill running is the final test. If you can run a moderate descent at a steady pace with no provocation the next morning, you're back.
For circulation support on those early easy recovery runs — especially if you're someone who feels heavy-legged after sitting at a desk all day — a pair of HYKLE Compression Socks can take the edge off lower-leg fatigue. They don't treat the tendon itself, but for the long, slow comeback miles, less peripheral fatigue means better form, and better form means less compensation up the chain.
Common Mistakes I See Constantly
Stretching to "loosen" the tightness. It's not tightness. It's a protective response to an irritated tendon. Stretching feeds the problem.
Skipping stage 1 because isometrics feel too easy. They're not meant to feel hard. They're meant to calm symptoms and prime the tendon for what's coming. Three weeks of disciplined isometrics is worth more than three months of guessing.
Foam rolling the sit bone. Direct compression on the tendon attachment is the same mechanical error as stretching. Foam roll the belly of the hamstring if you must, never the upper attachment.
Returning to running on a hilly route. Flat ground first. Always. Hills — both up and down — are stage 4 late-phase territory.
Ignoring the hip and pelvis. The hamstring doesn't work in isolation. Weak glute medius and poor pelvic control overload the hamstring every single stride. If you haven't addressed hip stability, you're rehabbing one tendon while leaving the cause untouched. I'd pair this protocol with the work in Gluteus Medius Exercises That Actually Fix Hip Stability.
When to See Someone in Person
This protocol works for the majority of proximal hamstring tendinopathies. It will not work if:
- The pain is sharp, bruised, or came from a single traumatic event (think tear, not tendinopathy)
- There's neural pain radiating down the leg in a sciatic pattern
- Six weeks of disciplined stage 1 produces zero improvement
In those cases, get assessed in person. Imaging may be warranted, and the rehab framework may need to be adjusted.
The Summary I'd Tape to Your Wall
Sit-bone pain in runners is rarely a stretching problem. It's almost always a loading problem — too much, too fast, in a position the tendon couldn't handle. The way out is the same as the way in: load, but smarter. Start with isometrics to calm it. Build with heavy slow resistance. Add spring with energy-storage work. Return to running on flat ground first, downhills last. Respect the morning-after rule, and let the tendon set the pace.
The runners who recover fully are the ones who treat this as a 3-month project, not a 3-week one. The ones who push through usually end up doing the same protocol six months later, having lost a season instead of a few weeks.
Be patient with the sit bone. It rewards patience like almost no other tendon in the body.