| Age / Sex | 35-year-old male |
| Activity Level | Competitive runner, half-marathon and marathon distances |
| Primary Complaint | Deep ache at the right ischial tuberosity (sit bone) worsening with speed work and prolonged sitting |
| Duration of Symptoms | 18 months, failed multiple return-to-running attempts |
| Previous Treatments | Rest, hamstring stretching, eccentric loading program, dry needling, PRP injection |
| Diagnosis | Proximal hamstring tendinopathy with anterior pelvic tilt and lumbar hyperlordosis creating chronic tendon compression |
Background
This 35-year-old competitive runner had been dealing with what he described as a deep, nagging ache in his right sit bone for a year and a half. It started during a speed work session and never fully resolved. He could run easy miles with manageable discomfort, but any attempt at tempo runs or intervals would flare it up for days. Sitting at his desk for more than 45 minutes made it worse. Even driving became uncomfortable.
He had tried everything the running community recommended: Nordic hamstring curls, progressive loading protocols, and extensive stretching. A PRP injection provided modest improvement for about two months before plateauing. His sports medicine doctor warned that proximal hamstring tendinopathy can take years to resolve and suggested he consider scaling back his running goals. He was not willing to accept that answer.
Assessment Findings
The proximal hamstring tendon was tender and thickened on palpation, consistent with chronic tendinopathy. But the critical finding was his pelvic position. He had a pronounced anterior pelvic tilt with lumbar hyperlordosis, which places the ischial tuberosity in a position where it compresses the proximal hamstring tendon against the bone during hip flexion. Every time he sat down, bent forward, or drove his leg through the running stride, the tendon was being pinched.
AiM gait analysis showed he was overstriding with insufficient hip extension on the right side, creating excessive hamstring loading at the wrong phase of the gait cycle. DNS assessment revealed poor diaphragmatic function and a core stabilization pattern that relied on back extensors rather than the deep stabilizing system, perpetuating the anterior pelvic tilt.
Treatment Protocol
Phase 1 Weeks 1-3 | Focused shockwave therapy (F-ESWT) to the proximal hamstring tendon to stimulate healing in the chronic tendinopathy. DNS breathing and core retraining to reduce anterior pelvic tilt and decompress the ischial tuberosity. Chiropractic pelvic alignment. Cessation of hamstring stretching (which was compressing the tendon further). |
Phase 2 Weeks 3-5 | Continued F-ESWT. AiM gait retraining to correct overstriding and improve hip extension timing. Progressive hamstring loading in positions that avoided tendon compression. DNS-based single-leg stability work. Running resumed at reduced volume with gait corrections. |
Phase 3 Weeks 5-7 | Speed work reintroduced progressively. Full running volume restored. Independent maintenance program for pelvic alignment and gait mechanics. |
Progress Timeline
| Months 1–8 (Pre-Treatment) | Rested and began hamstring stretching and eccentric loading program under PT guidance. Tried dry needling for pain relief. Eventually received a PRP injection — mild improvement but symptoms returned with running. Searched for a more comprehensive rehab approach. |
| ▸ Treatment at City Integrative Rehabilitation | |
| Week 1 | First F-ESWT session. Stopped stretching hamstrings. DNS breathing retraining initiated. Sitting comfort improved within days of pelvic correction work. |
| Week 2 | Sitting for over an hour without pain for the first time in months. Pelvic tilt visibly reduced. Second F-ESWT session. |
| Week 3 | Resumed easy running with gait corrections. No sit bone pain during or after 4-mile runs. |
| Week 5 | Running 25 miles per week with tempo segments. AiM gait corrections holding well. Tendon no longer tender on palpation. |
| Week 7 | Full training volume restored including intervals and tempo runs. Completed a 13-mile long run with no hamstring symptoms. Cleared for half-marathon preparation. |
Outcome
After 18 months of failed treatments, this competitive runner was back to full training in seven weeks. The missing piece was recognizing that his proximal hamstring tendinopathy was being perpetuated by a structural problem: anterior pelvic tilt was compressing the tendon against the ischial tuberosity with every stride and every time he sat down. Focused shockwave therapy stimulated tendon healing, DNS core retraining corrected the pelvic position, and AiM gait analysis fixed the stride mechanics that were overloading the hamstring. Critically, stopping the aggressive hamstring stretching that previous providers had prescribed removed a major source of tendon compression.
This case study represents a real patient treated at City Integrative Rehabilitation. Details have been modified to protect patient privacy. Individual results may vary.