Symptoms and Diagnosis
The hallmark symptom is deep, aching pain at the ischial tuberosity (the bony prominence you sit on) that worsens with prolonged sitting, uphill running, lunging, and hip flexion under load. Patients often describe difficulty sitting comfortably and may shift weight to the unaffected side. Pain may radiate into the posterior thigh, and there is often tenderness on direct palpation of the ischial tuberosity.
Diagnosis is clinical, supported by MRI showing tendon thickening, signal changes at the ischial tuberosity, and peritendinous edema. Ultrasound can demonstrate tendon thickening, neovascularization (on Doppler), and bursal fluid. I use musculoskeletal ultrasound in the office for real-time assessment and to guide treatment precisely to the tendon-bone junction.
Why Tendinopathy Is Difficult to Treat
Limited healing capacity of tendons. Tendons heal slowly. Their blood supply is limited compared to muscle, and the enthesis (tendon-bone junction) is a biomechanically complex transition zone from flexible tissue to rigid bone. Physical therapy with eccentric loading exercises is the first-line treatment and can be effective, but many patients with established tendinopathy plateau-the tendon cannot remodel adequately without additional biological support.
Steroid injection around the hamstring origin provides short-term relief but carries significant risk: corticosteroids weaken tendon tissue and have been associated with hamstring tendon rupture. For this reason, I do not use steroid injections for proximal hamstring tendinopathy.
Dr. Crane's Regenerative Approach
Regenerative injection therapy for high hamstring tendinopathy delivers concentrated biological repair signals directly to the degenerative tendon tissue, stimulating tenocyte proliferation (the cells that produce tendon collagen), promoting organized collagen synthesis, and modulating the neovascular and neurogenic pathways that produce pain. I use ultrasound guidance to target the tendon-bone junction precisely, focusing on the most degenerated regions.
The enthesis - the tendon attachment point where the tendon transitions to bone through a fibrocartilaginous zone - often requires targeted treatment. Regenerative approaches can stimulate an inflammatory-proliferative cascade at this junction, promoting fibrocyte activity and strengthening the entheseal attachment.
Rehabilitation is essential alongside regenerative treatment. We coordinate with physical therapists to implement a progressive loading protocol: isometric loading initially, progressing to eccentric loading, and finally sport-specific loading. The regenerative treatment provides the biological resources; the rehabilitation provides the mechanical stimulus for organized tissue remodeling.
What to Expect
Activity modification during the treatment period is important-we reduce sitting time, avoid aggravating activities, and implement a graded loading protocol. We monitor progress through pain assessment and functional measures.