Two years ago I was halfway up a long forested climb in the Rhodope mountains when I felt it — that deep, dull ache right under my sit bone, the one that sharpens every time you sit on a hard chair, drive a car, or push uphill. I knew exactly what it was before I even stopped to stretch. Proximal hamstring tendinopathy. The injury I had warned my callanetics students about a hundred times. The injury I had rehabbed in clinic, back when I was still seeing children with cerebral palsy and the occasional adult runner who wandered in for help.
And there I was, a physiotherapist and ultra runner, dragging my own leg back down the trail thinking: alright, time to take my own advice.
This is the progression that got me back. Not in two weeks. Not in a month. But back — properly, with no flare-ups, ready for long days on technical ground.
What proximal hamstring tendinopathy actually is
The proximal hamstring tendon attaches at the ischial tuberosity — your sit bone. When that tendon gets irritated from too much load too fast, or from repetitive compression (think sprinting, hill running, deep hinging, or sitting on hard surfaces for hours), it grumbles. Then it complains. Then it stops you from running.
The classic signs:
- Deep, localized ache right at the sit bone, sometimes radiating down the back of the thigh
- Worse with sitting, especially on firm surfaces
- Worse with running uphill or accelerating
- Stretching often feels good in the moment and worse the next morning
- Stiffness first thing in the morning that eases as you move
That last point is important. Tendons don't behave like muscles. They don't want to be stretched — they want to be loaded, in the right dose, at the right tempo, in the right direction. The whole rehab story is about respecting that.
Why most runners get this wrong
The first mistake is rest. Total rest weakens the tendon further and you come back to running with a tendon that handles even less load than before. The flare-up is then bigger.
The second mistake is stretching. Stretching a compressed, irritated tendon against the bone it sits on is exactly the mechanism that drove the problem. It feels nice for thirty seconds and feeds the cycle.
The third mistake is foam rolling the tendon directly. The muscle belly, fine. The attachment point, no.
The fourth mistake — and this is the one I see most often in runners I coach — is skipping straight to deadlifts because someone on the internet said heavy slow resistance fixes tendinopathy. It does. But not in week one. If your tendon is reactive, heavy loading too early just adds fuel.
The progression matters. Each phase earns the next.
Phase 1: Isometrics — calming the tendon down
In the first 1–2 weeks, the only goal is to reduce pain and reintroduce gentle load. Isometric holds are the tool. They give you analgesia (real, measurable pain reduction for hours afterwards) and they start loading the tendon without movement that compresses it.
My go-to: long-lever glute bridges, held.
Lie on your back, heels far from your hips so the hamstring is doing most of the work (not the glutes). Lift into a bridge and hold. Five reps of 45 seconds, with 2 minutes rest. Done daily, sometimes twice a day. Pain during the hold should sit around a 3/10 — uncomfortable but tolerable. If it spikes higher, bring the heels in closer.
You can also do isometric hamstring curls against a wall, or single-leg bridges if the double-leg version is too easy. The principle is the same: load without movement, sustained, repeated.
By week two you should notice morning stiffness easing and pain on sitting reducing. That is your green light to phase two.
Phase 2: Heavy slow resistance — building the tendon back
This is where the actual remodeling happens. Tendons respond to high load applied slowly. The protocol I followed (and the one supported by good evidence) is 3 sessions per week, 4 sets of 6–8 reps, with each rep performed at 3 seconds down and 3 seconds up. Heavy enough that the last rep is genuinely hard.
My two main exercises in this phase:
Romanian deadlifts. Hinge at the hips, knees soft but not bending, bar travels close to the legs. Feel the load in the upper hamstring near the sit bone. Start lighter than you think. I started with 20 kg and it was plenty.
Single-leg hip thrusts. Shoulders on a bench, foot planted, drive up through the heel. These hit the hamstring attachment beautifully and expose any side-to-side weakness — and there is always a side-to-side weakness in runners.
I spent six weeks in this phase. Some weeks I added a single-leg cable pull-through or a Nordic hamstring lower. Mostly I just kept adding small amounts of weight. Boring. Effective.
This is also where I started paying serious attention to the daily life pieces that nobody talks about. Sitting on a hard chair for three hours undoes a good rehab session. I bought a wedge cushion for my desk, took standing breaks every 40 minutes, and stopped sitting cross-legged on the floor while reading bedtime stories to my younger son (he was not thrilled, we compromised on standing-while-reading).
Phase 3: Energy storage — preparing the spring
Tendons in running are springs. They store and release energy. The previous phases built the tendon up but didn't teach it to spring. Skip this phase and your first hill run will flare you up.
Here the tempo changes. Hinges are performed at speed. Step-ups become explosive. I added:
- Tempo Romanian deadlifts — 1 second down, fast up, lighter weight
- Single-leg hops — first in place, then forward, then for distance
- Sprint-pattern A-skips and B-skips on a soft surface
This phase took me about three weeks. The honest truth: it was scary. After two months of careful, slow loading, suddenly bouncing the tendon felt risky. It wasn't. The previous work had earned it.
If you have read my piece on peroneal tendinopathy rehab, the energy-storage logic is identical — the tendon must be reintroduced to the demand it will face in sport, gradually, before you ask it to do the real thing.
Phase 4: Return to running
Walk-run intervals on flat ground first. One minute running, two minutes walking. Build to continuous easy running before you touch hills. Hills are the boss-level test for the proximal hamstring because they ask for hip extension under load with the trunk forward — the exact compression position that irritates the tendon.
My return-to-running rule: pain during the run can be a 2/10 maximum, must not increase as the run progresses, and must be back to baseline within 24 hours. If any of those three conditions fail, I drop back to the previous week's volume.
Took me about five weeks of structured return-to-run before I trusted technical trails again. First proper ultra back was eight months after the original flare-up.
How HYKLE products fit into the recovery routine
A good rehab is more than the exercises. It's the hours between sessions — how you sit, how you recover, what you wear on your feet, how you support circulation in a leg that has been holding tension for months. This is where I leaned on the products Deso and I have built at HYKLE, because they solved the daily-life problems my rehab needed solved.
Post-session circulation. After heavy hinge sessions and after every return-to-run, I pulled on my HYKLE Compression Socks for the rest of the evening. Graduated compression up the calf helps venous return, reduces the heavy-leg feeling, and meant I woke up the next morning with less posterior chain stiffness. James, one of our customers, put it well: "Comfortable compression state was maintained through all the day's activities." That has been my experience too. On long travel days to races I switched to the HYKLE Compression Stockings with Zipper — easier on, easier off in an airport bathroom, same compression where I needed it.
Footwear that doesn't aggravate the tendon. Stiff, heavily cushioned shoes with a big heel-to-toe drop change how your hamstring loads during gait. A more natural foot position with proper toe splay lets the posterior chain work the way it was built to. I wore HYKLE Barefoot Shoes around the house and for short walks in the early weeks, then progressed to using them for daily errands once I was running again. For colder months I switched to HYKLE OptiWarm Barefoot Shoes so I could keep walking outdoors without going back to bulky boots.
The sit-bone problem. Prolonged sitting is the silent saboteur of PHT rehab. If you also have any lower-back component (and many runners with PHT do), the HYKLE Sciatica & Lower Back Support Brace gives you something to use on long driving days when standing breaks are not an option. It positions the pelvis better and unloads the area.
These are not replacements for the rehab. They are the supporting cast that makes the lead actor — the loading progression — actually possible across a real life with work, kids, and travel.
Daily life pieces nobody puts in the rehab protocol
A few things I learned the hard way:
- Driving position matters. A reclined seat with the pelvis tucked under is a recipe for sit-bone compression. Sit upright, use a small wedge if your seat has a hard edge.
- Yoga is not always your friend. Forward folds, pigeon pose, and seated hamstring stretches are exactly the compression positions that drive PHT. Skip them during rehab. Strengthening replaces stretching here.
- Sleep position. I slept with a pillow between my knees for the first few weeks, which kept the pelvis neutral and the hamstring quiet overnight. Similar logic to what I wrote about in best sleeping positions for sciatica.
- Hill walking before hill running. Power-hiking with poles is a great bridge between phase 3 and phase 4. It loads the hamstring under hip-extension demand without the impact.
- Gluteus medius matters. A weak hip stabilizer changes pelvis position in stance and compresses the proximal hamstring more. If you haven't read it, the gluteus medius work I wrote about belongs in your weekly routine for life, not just during rehab.
The honest timeline
People want to hear six weeks. Real PHT rehab is three to six months for most runners, sometimes longer if it has been ignored. The good news is that with a proper progression, the tendon comes back stronger than it was before — I have personally pushed bigger weekly volumes and bigger climbs since this injury than I did before it.
The trap is impatience. Skip phase one because it feels too easy, you stall. Skip phase three because deadlifts felt like enough, you flare on your first hill. Each phase earns the next.
Closing thoughts and where to start
If you are reading this with a deep ache under your sit bone, start tonight. Five long-lever glute bridges, 45-second holds. Tomorrow morning, notice whether your morning stiffness changed. That small signal tells you the tendon is listening.
Get the surrounding pieces in place too. The recovery routine matters more than people admit. At HYKLE we build the products I actually use on my own legs between training sessions — the HYKLE Compression Socks for after every loading day, the HYKLE Barefoot Shoes for daily wear that doesn't fight your gait, and the support pieces for the sitting hours that quietly undo good rehab. Everything comes with our 90-day test-and-return guarantee, because the only way to know if something works for your body is to use it on your body. Questions about sizing or which sock compression to start with, our team at support@hykle.com is the one I trust with my own students.