Massage therapy · Kitchener–WaterlooBiceps Femoris Tendinopathy

Biceps femoris tendinopathy is an overuse problem affecting a tendon of the biceps femoris, one of the hamstring muscles along the back of the thigh. The biceps femoris has two heads (starting points) and one main attachment at the bottom, so tendon pain can occur in one of two places: just under the buttock, where the long head attaches to the "sitting bone" of the pelvis (ischial tuberosity), or at the back and outside of the knee, where the tendon attaches to the top of the fibula (the thin bone on the outside of the lower leg) (Koolmees et al., 2025). Tendon pain under the buttock is often called proximal (upper) hamstring tendinopathy (Grimaldi et al., 2024). Tendinopathy at the knee end is much less common (Koolmees et al., 2025).

Tendinopathy used to be thought of as a chronic inflammation, but it is now understood mainly as a tendon problem caused by more load (use) than the tendon can cope with, rather than inflammation (Grimaldi et al., 2024).

Biceps Femoris Tendinopathy Anatomy

The biceps femoris has two heads. The long head starts at the sitting bone (ischial tuberosity) at the bottom of the pelvis, just under the buttock. The short head starts from a ridge on the back of the thighbone (femur) called the linea aspera, and does not reach the buttock. The two heads join and run down the outer side of the back of the thigh, and the tendon attaches to the outer side of the top of the fibula (the fibular head), with a small slip to the tibia (shin bone) (Koolmees et al., 2025).

How to Treat Biceps Femoris Tendinopathy

1. Identify which activity is causing the problem, and reduce or change it. Remember that this is an overuse injury, so it's likely to be the activity you do most regularly. Managing the load on the tendon is a key part of treatment (Grimaldi et al., 2024).
2. Avoid positions that squash (compress) the tendon. If your pain is under the buttock, positions where the hip is bent a long way, such as deep hamstring stretches, can press on the tendon and irritate it (Grimaldi et al., 2024). Avoid hamstring stretches until I advise otherwise.
3. Strengthening exercises. Progressive strengthening exercises are the main treatment, and they are usually started early, alongside managing the load on the tendon (Grimaldi et al., 2024). I can build you a strengthening programme that suits you, with hands-on work and advice on managing load to go with it. See the My Approach tab for how I work.
4. Don't sit for extended periods of time. Sitting, especially on a hard surface, can irritate the pain under your buttock (Grimaldi et al., 2024). Using a cushion may help. Get up and move regularly.
5. If your pain is at the back and outside of the knee, come and see me or your family doctor or nurse practitioner for an assessment. This is usually managed with rest and physical therapy (Koolmees et al., 2025).

Tips

• A snapping or clunking feeling at the outside of your knee when you bend it or squat should be checked by me or your family doctor or nurse practitioner, as the tendon can snap over the top of the fibula (Koolmees et al., 2025).
• Start gentle strengthening early, with my guidance, rather than waiting until the pain has gone completely (Grimaldi et al., 2024).
• If you want to go back to sport, ask me for some dynamic and functional strengthening exercises.
• Tenderness and pain under the buttock or along the outside of the knee may be a sign of biceps femoris tendinopathy, but other problems can cause pain in these areas too, so get it assessed.
• If you get pain under your buttock while running, sprinting or sitting, you should be checked for hamstring tendinopathy.

Hamstring tendon pain usually comes from asking the tendon to handle more load than it's ready for. My aim is to calm it down, then build its strength back up gradually so it copes with sitting, running, lifting and sport again.

I start by assessing where your pain is, under the buttock or at the outside of the knee, and testing your hip and knee movement, hamstring strength and how the tendon responds to load. Other problems can cause pain in both places, so this also tells us whether you should see your family doctor or nurse practitioner.

Calming It Down

• Cutting back the activities that flare it, rather than stopping everything
• Avoiding positions that squash the tendon, such as deep hamstring stretches and long sitting on hard surfaces
• Pain-free holds early on, such as pressing your heel down into the floor or holding a bridge
• Warm or cool applications in the clinic, and I'll show you how to use ice safely at home

Hands-On Treatment

• Myofascial and trigger point work through the hamstrings and the rest of the leg to ease tension pulling on the tendon
• Once it's less irritable, cross-fibre work on stuck-down spots near the tendon
• Gentle mobilisation of stiff nearby joints, such as the hip and low back, with no quick thrusts
• Work around the buttock and hip only with your informed consent and a signed consent form

Building Strength

1. Grimaldi, A., Mellor, R., Nasser, A. et al. (2024) 'Current and future advances in practice: tendinopathies of the hip', Rheumatology Advances in Practice, 8(2), rkae022. doi: 10.1093/rap/rkae022
2. Koolmees, D.S., Klott, J.D., Poppe, T.R. and Bernholt, D.L. (2025) 'Distal hamstring injuries and disorders', Journal of the American Academy of Orthopaedic Surgeons: Global Research & Reviews, 9(9), e25.00248. doi: 10.5435/JAAOSGlobal-D-25-00248