Hamstring - dog 01

Biceps Femoris Tendonitis: The Forgotten Hamstring

The truth is….athletes “pull” muscles. That is something everyone is at risk for with an active lifestyle. Biceps femoris tendonitis is typically an injury resulting from overuse or over stretching of the biceps femoris tendons of the most lateral hamstring on the back of the thigh.

The two most common locations for pain with this injury are at the ischial tuberosity, just below the buttock, or along the palpable tendon near the outside of the knee 2-4 inches above the joint. In other words, at the tendons at the top of the muscle or the longer tendon just below the muscle.

These are the locations of the tendons responsible for connecting the biceps femoris muscle to your pelvis and shin bones. Repeated injuries involving the muscle itself can create a chronic inflammation of the tendons and their enclosed sheath.  This is commonly referred to as a form of tendonopathy.

Tendonopathy is a general term used to describe a combination of ailments. It is often associated with repeated micro tearing and inflammation of a tendon and it’s surrounding sheath. Athletes of all ages and sports are prone to tendonopathies of all three (3) hamstring muscles.

The biceps femoris is one of those hamstring muscles.  It is located at the posterior thigh and moves down the back-outside of the upper leg where it inserts just below the lateral knee. This muscle assists in flexion or bending of the knee, extension of the hip and some rotation of hip movement while the knee is in a bent position.

Avoiding the complicated science behind the reasoning, the biceps femoris is very important for acceleration and deceleration with all running and jumping activities. Injuries involving any of the hamstring tendons or muscle bellies are painful and can easily take up to 4-6 weeks to properly heal.

Signs & Symptoms of Biceps Femoris Tendonitis

  1. Pain or tenderness just under the buttock or at the back-outside corner of the knee with motion.
  2. Palpable swelling and tenderness just under the buttock or at the outside of the knee.
  3. Increased pain with active or resistive flexion (bending) of the knee.
  4. Inability to perform simple exercises without pain anywhere along the length of the lateral hamstring. These activities include running, stair climbing, forward bending with the knees straight while reaching for your toes, pulling the knees towards the chest and backward walking.
  5. It is not unusual to feel a “squeaking” within the distal tendon sheath with slow active knee bending.
  6. Pain with lateral or external rotation of the foot and shin while sitting with the knee bent.

Professional Treatment for Biceps Femoris Tendonitis

  1. Immediately stop activity and apply compression to the area.
  2. Avoid all hamstring stretches for at least 4 days. (Trust me on this one…I’ve learned this valuable tip the hard way!)
  3. Apply ice packs to the lateral knee and/or back of the thigh for 15 minutes every hour.
  4. During and after every ice treatment, apply compression to the involved tendon and the hamstring muscles in that region of the hip/thigh/knee.
  5. When resting, elevate the affected lower limb to minimize swelling.
  6. Avoid prolonged sitting.
  7. Three days after you are able to walk pain free, initiate an easy stretching and non-running exercises plan.
  8. After three days of pain-free stretching and functional athletics, progress as tolerable with strengthening and running activities.  The two key variables at this point to avoiding a setback are Progression & Common Sense

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Are you certain of the diagnosis of biceps femoris tendonitis and do you have any other concerns with my injury?
  2. Are other hamstring muscles, nerves or tendons damaged?
  3. How long can I expect for this injury to properly heal?
  4. Do you suggest that I visit a physical therapist for a comprehensive rehabilitation program?

Elite Sports Medicine Tips from Mike Ryan

  • Check your strength – It would be beneficial to you to consult a physical therapist during your down time. Getting a professional option on your lower extremity strengthen might shed some light on why you got injured in the first place.
  • Stretch it out – Promise yourself that when you recover from this injury, you will spend 5-10 minutes stretching every day.
  • Ice – Regular application of ice on the biceps femoris muscle belly and the involved tendon will help control the inflammation.
  • Take your time – When returning to your sport, take your time. Stretch properly and gradually build up the intensity of your activities.
  • Pay attention – After returning to your workouts, monitor the hamstring signs and symptoms.  If it gets cranky, return to rest, ice aggressively, STOP stretching and try again in two days.
9 replies
      • sarah
        sarah says:

        Hi Mike,
        Ive seen two sports therapists and an osteopath who all have differing opinions. I think i have what you have described but after 4 months of compete rest, ice, stretch etc it is still no better and i cannot walk any distance pain free. Any help would be much appreciated
        Thank you 🙂

        • Mike Ryan
          Mike Ryan says:

          I’m sorry to hear this Dawn while I hear this story way too often. My suggestion is to take a broader look at your issue. “Why is my hamstring sore?” is the question and many times I find the real reason to be quite obvious. The real problem is either above (hip, low back or groin) or below (knee, foot mechanics or big toe stiffness) the hammy.
          In other words, your hamstring may be the RESULT of a biomechanics abnormality with a chronic compensation pattern when you walk.
          Get with a great runner-oriented PT who can do a thorough biomechanics eval to find that reason(s) and to put your rehab plan back on-track so you stop wasting your time and $$.

  1. Peter
    Peter says:

    I have had this injury for about 3 years, gone for steriod injection and physio without success. I’ve even had PRP suggested but I declined.

    Would surgery help ?

    • Mike Ryan
      Mike Ryan says:

      You, your doctor and your therapist need to look above and below the pain for the real source of the problem. Put on your detective hat and find the reason(s) why that side of your body is moving different from the painfree side. Sometimes it’s very simple like a shorter leg while other times it’s deeper like an arthritic hip. Go find the real problem and the hamstring issue will be the easy part.

  2. Nathan
    Nathan says:

    Hi Mike i have a pain below the outside of my left knee almost where the calf muscle starts. Its causing me pain when playing soccer, and particularly when I bend at the knee I can not get very far without pain. My hamstring flexibility also seems to have suffered. Would this be bicep femoris tendinitis? Hope you can help. Thank you

    • Mike Ryan
      Mike Ryan says:

      It could be but the area you describe is also an upper outer calf tendon. The hamstring crosses the knee from above and one of the two calf (Gastroc) muscles crosses the knee from below. Get with your PT or certified athletic trainer for a full eval. Especially look at: hamstring flexibility, calf flexibility, leg length,ITB symptoms and knee cartilage involvement.
      Keep me posted Nathan. Thanks for sharing my info with others.


Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *