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Atlas · Thigh

Hamstrings

The hamstrings group includes semitendinosus, semimembranosus and biceps femoris. Posterior-thigh pain after sprinting differs from gradual sitting-bone tendon pain and from lumbar or sciatic symptoms. Examination should identify the relevant component region and loading pattern before choosing rehabilitation.

Hamstrings
Body region
Thigh
Trigger points
3
documented in this muscle
Common symptoms
3
patterns cataloged
Contributors
3
Factors to assess

Muscle overview

Symptoms and first steps

Practical first steps

  • After an acute injury, reduce forceful stretching and high-speed loading until the injury is assessed.
  • Keep tolerable walking and introduce graded strength appropriate to the presentation.
  • For proximal tendon pain, reduce painful sitting compression and deep hip-flexion demand temporarily.

When to seek assessment

  • Sudden severe hip/groin pain after a fall, inability to bear weight, fever or a hot swollen joint needs urgent assessment.
  • New progressive leg weakness, saddle numbness or loss of bladder/bowel control needs emergency assessment.
  • Arrange assessment for persistent unexplained night pain, significant trauma, a growing mass or symptoms that do not track movement/load.
  • A sudden pop near the sitting bone with marked bruising, weakness or difficulty walking needs prompt assessment for a significant tear or avulsion.

Record whether pain is lateral or medial and whether it is proximal tendon, belly or distal tendon. The short head of biceps femoris crosses only the knee; the other principal hamstring components also cross the hip.

Examination, palpation and treatment evidence

Illustrated overview

Hamstrings

Blue highlights the muscle. Crosses mark representative trigger-point sites; shaded areas show possible referred pain. These examples do not correspond one-to-one with the numbered points below. Patterns vary and cannot diagnose the cause of pain.

Illustrated overview

Hamstrings · Anatomy and referred pain 1

Representative source regions. The illustrated markers and pain pattern are not individual assignments to the numbered trigger points.

Open full-size image

Trigger points

1. TrP1

Location. Lateral posterior-thigh region, corresponding broadly to biceps femoris; head not established by the legacy marker

Trigger point map
Hamstrings — Trigger point mapOpen full-size image

Shared diagram of this muscle region; it may show several trigger points.

Referred pain map
Hamstrings — Referred pain mapOpen full-size image

Regional muscle reference; this is not an individual map of the selected numbered trigger point.

Pain referral. Back of thigh, back of knee, buttock

Pain Pattern

  • Back of thigh
  • Back of knee
  • Buttock
  • Posterior thigh

What This Pain Feels Like

A lateral posterior-thigh ache or pulling symptom can occur during knee flexion, hip hinging or running. A sudden sprint injury, focal tendon pain and neurological radiation require different assessment paths.

What Patients Report

  • Pain in back of thigh
  • Pain behind knee
  • Tight hamstrings
  • Pain when running
  • Sitting discomfort

What Makes It Worse

  • Running
  • Sprinting
  • Bending forward
  • Sitting
  • Kicking
  • Accelerating
Browse related exercises (18)

Symptoms patients report

Posterior-thigh pain during running or knee flexion A sudden sprint/stretch event suggests an injury; gradual pain needs review of load and competing causes.

Proximal sitting-bone pain Pain during sitting, deeper hip flexion or running can support a tendon presentation when examination agrees.

Weakness, stiffness or reduced stride tolerance Record force, comfortable range and the running demand that fails rather than relying on a feeling of tightness.

Contributors to assess

High-speed running or sudden lengthening load Acceleration and sprint exposure, kicking or an unexpected slip can create an acute injury.

Return to sport before capacity is restored Ordinary walking may recover before high-speed and long-length force production.

Repeated proximal-tendon compression/loading Deep hip flexion and prolonged sitting may be provocative in an assessed proximal tendinopathy; indiscriminate stretching can aggravate it.

For clinicians and supervised training

Clinical reference

The three retained point records do not provide a validated map for every hamstring component. Tightness on a toe-touch or pain down the thigh does not by itself identify a hamstring muscle source.

Anatomy and palpation

Anatomical relationships

Semitendinosus and semimembranosus run from the ischial tuberosity toward the medial tibia. Biceps femoris long head shares a proximal origin with semitendinosus and joins the short head, which arises from the femur, toward the fibular head. All flex the knee; the proximal hamstrings also extend the hip.[1][2][3][4]

  • Ischial tuberosity is the proximal tendon origin region.
  • Semitendinosus is the more cord-like distal medial tendon; semimembranosus is broader/deeper.
  • Biceps femoris tendon approaches the fibular head laterally.

Nearby structures. The sciatic nerve travels near the proximal hamstrings; adductor magnus lies anterior/medial. The common fibular nerve is close to the fibular neck, and major vessels/nerves occupy the popliteal fossa.

Palpation

Patient position. Prone or side lying with the hip and knee supported; explain consent and draping for proximal thigh/ischial contact.

Find the landmarks

  • Ischial tuberosity
  • Medial and lateral posterior-thigh bellies
  • Distal medial tendons and fibular head

Examination sequence

  1. Inspect for bruising and ask about the injury event before resisted testing.
  2. Identify medial and lateral tendons during gentle knee flexion, then relax and assess the accessible belly along the symptomatic component.
  3. Compare proximal tendon-region tenderness with belly tenderness; avoid deep pressure into the sciatic pathway or popliteal fossa.

Document the findings

  • Familiar pain, focal injury-region sensitivity and load-related weakness documented by component region.
  • Palpation cannot determine complete tear extent or exclude neurological pain.

Limits and precautions

  • Avoid vigorous pressure or stretching during a new tear/hematoma.
  • Do not repeatedly press on a proximal tendon already aggravated by sitting compression.
[5][3][1]

Examination and tests

2

Resisted knee flexion at different knee angles[5]

Assess posterior-thigh force and symptom location without immediately exposing an acute injury to maximal long-length load.

Position
Prone with the thigh supported; begin with the knee comfortably bent.
Technique
Apply gradual resistance to knee flexion and record pain/force. If tolerated, compare a less-flexed knee position and the opposite side. Record medial versus lateral and proximal versus distal symptoms.
Positive finding
Familiar pain or reproducible force loss, particularly with increasing length demand.
Interpretation
Guides the initial loading range and progression; marked acute weakness or proximal pain after a pop needs injury review.
Limitations
Several knee flexors contribute. Foot rotation does not reliably isolate one hamstring and pain inhibits effort.

Active knee extension and proximal loading comparison[5][6]

Assess length tolerance and distinguish a posterior-thigh restriction from proximal tendon or neural symptoms.

Position
Supine with the hip supported in a comfortable flexed position, initially below a painful end range.
Technique
Slowly straighten the knee actively while holding the thigh position. Record the angle, familiar pain and whether it is proximal tendon, belly or radiating. A clinician can compare a controlled hinge or sitting-compression response when proximal tendinopathy is suspected.
Positive finding
Reproducible limitation, familiar posterior-thigh pain or a proximal tendon-loading pattern.
Interpretation
Use as a baseline with strength and history; sitting/compressive and tensile symptoms together may support a tendon presentation.
Limitations
Neural sensitivity and hip/back disease can alter the result. Do not force a stretch or perform repeated provocative tests after an acute tear.

Distinguishing other causes

Acute hamstring strain or proximal avulsion[5]

Findings that matter. A sudden sprint/stretch event, pop, bruising and force loss, especially near the sitting bone.

Next step. Assess severity and walking; urgent specialist assessment/imaging when a substantial proximal avulsion is suspected.

Proximal hamstring tendinopathy[6]

Findings that matter. Gradual localized sitting-bone pain with sitting, running and deep hip-flexion load.

Next step. Examine proximal tendon loading/compression and design a tendon-specific plan; symptoms alone are not a diagnostic gold standard.

Lumbar radiculopathy or sciatic neural pain[8]

Findings that matter. Radiation, numbness, reflex change or weakness not limited to painful knee flexion.

Next step. Perform neurological and back assessment and escalate progressive deficits.

Adductor magnus or hip/ischial-region disease[5]

Findings that matter. Posteromedial pain with adduction, deep hip pain with rotation or focal bony symptoms.

Next step. Examine neighboring adductor, hip and bony structures rather than assuming every posterior-thigh symptom is hamstring-related.

Treatment selection and progression

Exercise and rehabilitation

Progressive hamstring strength across lengths[5][6]

Consider when. A graded rehabilitation plan after clinical assessment of injury or persistent loading pain.

Start with tolerable heel-dig isometrics or a short-lever bridge, then knee-flexion and hip-hinge resistance. Add controlled lengthening exercises and greater hip-flexion range according to the diagnosis and capacity.

Dose and review
A clinician sets the initial effort, range and recovery; no single Nordic or stretching dose suits every injury stage.
Progression
Progress resistance, length and speed separately and reassess before high-strain long-length work.
Stop or reassess
Stop for a new sharp pain, pop, bruising or deteriorating walking.
Evidence and limits
The hamstring-strain guideline supports staged strengthening and running for athletic injury. Proximal tendon pain requires additional attention to compression tolerance.

Exercise and rehabilitation

Staged return to running and sprinting[5]

Consider when. Daily function and initial strength work are tolerated and the injury is appropriate for running progression.

Restore easy running first, then gradually increase speed, acceleration and the actual sport demands. Combine running with strength work rather than substituting endless stretching for capacity.

Dose and review
Use supervised, recoverable exposures; progression depends on strength and response, not an automatic return date.
Progression
Include repeated high-speed and sport-specific tasks before unrestricted return when those are required.
Stop or reassess
Stop for sharp pain, altered stride or a decline in next-day function.
Evidence and limits
A criteria-based running/strength approach is supported for hamstring strain; it is not a validated deactivation protocol for atlas points.

Self-care and activity

Manage compression in proximal tendon pain[6]

Consider when. Assessed proximal hamstring tendinopathy, particularly with sitting and deep-flexion symptoms.

Use a seat/support that reduces direct sitting-bone pressure, vary prolonged sitting and temporarily limit deep hip-flexion loading. Restore that range gradually within the strength program.

Dose and review
Start from a comfortable sitting/activity threshold and review the following-day response.
Progression
Add deeper hinges, lunges and longer sitting as symptoms and capacity permit.
Stop or reassess
Reassess new bruising, marked weakness, constant night pain or neurological change.
Evidence and limits
The 2025 PHT trial used condition-specific education and graded care; this applies to the tendon presentation, not all posterior-thigh muscle pain.

Clinician-delivered care

Shockwave for persistent proximal hamstring tendinopathy[6]

Consider when. Confirmed persistent proximal tendon pain when a patient and clinician consider a noninvasive procedure after discussing active rehabilitation.

Treat the clinically assessed proximal tendon region and agree on goals such as sitting or running. The clinician selects the device/course and reviews response; do not target a generic posterior-thigh map.

Dose and review
The 2025 trial used four weekly shockwave treatments within six clinical visits over 12 weeks. This describes the study, not a universal prescription.
Progression
Review meaningful function at roughly 4–12 weeks and later durability before extending treatment.
Stop or reassess
Stop and review an unexpected significant flare, new neurological symptoms or new injury signs.
Evidence and limits
In 100 adults with proximal hamstring tendinopathy, shockwave and individualized physiotherapy did not differ in primary outcomes at 4, 12, 26 or 52 weeks. Both received advice; no sham arm. This supports a discussed alternative, not superiority or evidence for hamstring MPS.

Clinician-delivered care

PRP or whole blood for proximal hamstring tendon pain[7]

Consider when. Chronic proximal hamstring tendinopathy when an injection is being discussed after a defined active rehabilitation trial and review of tendon injury severity.

Confirm the tendon diagnosis and consider the prior loading response, sitting tolerance and imaging findings. Discuss ultrasound-guided tendon fenestration with PRP or whole blood as an option with uncertain added benefit, alongside continued or revised rehabilitation.

Dose and review
The small trial used one ultrasound-guided fenestration and injection for each treated hip, with review at 2, 6 and 12 weeks and six months. Agree the review schedule before proceeding.
Progression
Track sitting tolerance, running and a hip-function measure. Review whether any benefit carries into loading before considering further procedures.
Stop or reassess
Reassess new weakness, spreading numbness or a substantial tear before treatment. Following injection, fever, increasing redness or rapidly worsening pain requires prompt review.
Evidence and limits
The study analyzed 15 people and 17 hips; both injection groups also received tendon fenestration. PRP and whole blood did not significantly differ at six months for clinical outcomes or tendon appearance. There was no sham, fenestration-only or rehabilitation-only comparator, so the added effect of the injectate remains uncertain. This evidence concerns chronic tendon disease, with tears greater than 50% excluded.

Reassessment and follow-up

  • Repeat knee-flexion force, active length tolerance and the same running or sitting task.
  • Document component and tissue region rather than counting tender points.
  • Require recovery of the actual speed/load demand, not pain-free walking alone.

Evidence and sources

  1. University of Washington Muscle Atlas: Semitendinosus

    2026 · Institutional anatomy reference

    Undated anatomy page, verified September 2026; the year records this review. Supports attachments and actions, not diagnostic accuracy of palpation or a trigger-point map. No atlas illustration reproduced.

  2. University of Washington Muscle Atlas: Semimembranosus

    2026 · Institutional anatomy reference

    Undated anatomy page, verified September 2026; the year records this review. Supports attachments and actions, not diagnostic accuracy of palpation or a trigger-point map. No atlas illustration reproduced.

  3. University of Washington Muscle Atlas: Biceps femoris long head

    2026 · Institutional anatomy reference

    Undated anatomy page, verified September 2026; the year records this review. Supports attachments and actions, not diagnostic accuracy of palpation or a trigger-point map. No atlas illustration reproduced.

  4. University of Washington Muscle Atlas: Biceps femoris short head

    2026 · Institutional anatomy reference

    Undated anatomy page, verified September 2026; the year records this review. Supports attachments and actions, not diagnostic accuracy of palpation or a trigger-point map. No atlas illustration reproduced.

  5. Hamstring Strain Injury in Athletes

    2022 · Clinical practice guideline

    Sports-related hamstring injuries; staged strengthening and running differ from treatment of proximal tendinopathy and lumbar referred pain.

  6. Physiotherapy Compared With Shockwave Therapy for the Treatment of Proximal Hamstring Tendinopathy: A Randomized Controlled Trial

    2025 · Randomized trial

    100 adults with proximal hamstring tendinopathy; physiotherapy versus shockwave with advice in both arms. No primary-outcome difference at 4, 12, 26 or 52 weeks; no sham group. This is tendon evidence, not hamstring muscle MPS evidence.

  7. Ultrasound-Guided Intratendinous Injections With Platelet-Rich Plasma or Autologous Whole Blood for Treatment of Proximal Hamstring Tendinopathy: A Double-Blind Randomized Controlled Trial

    2015 · Small randomized active-comparator trial

    17 patients enrolled; 15 patients/17 hips analyzed after failure of at least six weeks of conservative care. Both groups received ultrasound-guided tendon fenestration, then PRP or whole blood. No significant six-month between-group clinical or tendon-appearance difference; one earlier IHOT-33 comparison differed. No sham, fenestration-only or rehabilitation-only group.

  8. Low back pain and sciatica in over 16s: assessment and management

    2020 · Clinical guideline

    Regional back/leg assessment and active care; does not identify an individual hamstring from tenderness or establish a hamstring-specific exercise dose.

Associated Trigger Points