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Yoga Anatomy

Proximal Hamstring Tendonitis: How to Avoid This Common Yoga Injury

Sometimes called “yoga butt,” Proximal Hamstring Tendonitis can hinder your life and practice. Here’s how to prevent it from happening to you and your students.

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Several years ago, I was into aerial dance, which is the beautiful—and challenging—act of lifting, twirling, and hanging from colorful silks while posing like you’re a Cirque du Soleil dancer. One afternoon during a two-hour practice session, after the flying portion of class, we were stretching on the mat. While I was in full splits, my instructor placed his hands on my hips and adjusted (or rather manhandled) my position. One moment my left hip bone (the iliac, to be precise) was behind my right hip. The next, my hips were forcibly shoved side-by-side. Since my hips were on the ground, they were unable to modify around that pull, resulting in a dramatic tugging on my right hamstring and a shearing force applied to that tendon where it connects to the bone. Yikes.

The resulting pain wasn’t instant. But it did become relentless. I experienced a nagging, recurring ache just under my right sit bone for the better part of two years. Even today, that pain is present each time I move too quickly into a hamstring stretch or forward bend.

What most likely happened that day is one of my hamstring tendons suffered a partial tear. The resulting chronic pain I experienced is known as proximal hamstring tendonitis (PHT or tendinopathy for short), also commonly referred to as “yoga butt.” It can be caused by repetitive overuse, forcing a stretch when the muscle is “cold,” or by a jarring force (caused here by my aerial teacher’s so-called “adjustment”). While runners and athletes often experience this type of chronic injury, it is also common in populations who regularly and deeply stretch the hamstrings, like yogis. This explains why PHT is also known as yoga butt—not to be confused with a sculpted backside.

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The function and anatomy of the hamstrings

The hamstrings are a group of muscles that are key players in flexing (bending) your knee during yoga and extending your hip (taking your leg away from your body, such as in the back leg when you are in a lunge). It is highly involved not only in athletic endeavors but in everyday walking. Because of this, just about anyone can suffer from inflammation of a hamstring tendon.

There are three hamstring muscles, and each connects to the skeleton at the ischial tuberosity (which is lovingly and seemingly ubiquitously referred to in yoga classes as the “sit bone”). By design, the hamstring tendons are quite thick and strong in order to connect muscle to bone securely. However, they also serve as a bottleneck, since they connect the large muscles of the thighs at a relatively pinpointed location on the skeletal structure. That’s part of the problem.

Tendons are not as vascular as muscles, meaning that they do not have as many blood vessels. That’s good news in that it makes these connective tissues stronger. However, it’s bad news in terms of healing, because they recuperate at a much slower rate than muscular tissue.

Diagram of the hamstrings to explain the affected areas with yoga butt
(Photo: (Photo: shutterstock.com/Hank Grebe))

When you feel the stretch in the center of your thigh—the “belly” of the hamstring—that’s a good thing. However, when you feel a tug only at the sit bone, the value of that stretch comes into question. Luckily, with some awareness of biomechanics and movement theories, you can continue to refine your practice to be safer in the long term.  Yoga poses that stretch the hamstrings include forward bends such as Uttanasana (Standing Forward Bend), Parsvottanasana (Pyramid Pose), Paschimottanasana (Seated Forward Bend), and Upavistha Konasana (Wide-Angled Seated Forward Bend).

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What is yoga butt?

Yoga butt, or tendonitis of the proximal hamstring, typically presents as an ache or recurring pain deep in the gluteal region. While anyone can experience it, the prevalence of yoga butt in yoga students is undeniable. It makes sense. Yoga’s tendency to move the body and stretch in several directions means that you may initially notice an ache while practicing. Additionally, when you try to force poses in yoga, or practice without a proper warmup, it can actually cause injuries in susceptible bodies.

To be fair, there are several different potential causes of pain in this region, including piriformis syndrome, a hamstring tear, or the numbing or tingling sensation of a pinched nerve, explains Dr. Loren Fishman, an MD at Prema Yoga Institute and the author of Healing Yoga. Each of these conditions should be approached with a different healing modality. Rather than self-diagnose (as I confess I did), always consult with a healthcare professional if you experience pain, so you can discern the source and understand how to address it.

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How to prevent—and recover from—yoga butt

With some awareness of biomechanics and sound movement theories, it is possible to refine your practice to help prevent yoga butt. If you’re experiencing pain, and the cause is tendonitis, specifically yoga butt, there are certain modifications you can make in your practice to ensure you don’t aggravate the inflammation. Additionally, safe cueing can (in theory) help prevent yoga butt in students.

Don’t rush (or skip) your warmup

It’s critical to warm up the muscles before asking—or demanding—that they lengthen. The science of stretching reveals a relationship between your muscles and spinal cord that’s designed to protect your muscles. When the length or tension in a muscle changes abruptly, the muscle spindle—a receptor located in the belly of a muscle—immediately sends a message to the spinal cord, which in turn signals the muscle to contract. This not only leads to a lack in range of motion, but if the hamstrings contract while you’re trying to stretch them too quickly, some of that tension could travel to the tendons, causing connective tissue strain. This could lead to yoga butt.

Conversely, when we gradually increase stress on the muscles and connective tissue through slow or passive stretching (i.e., Uttanasana or Standing Forward Bend with the knees generously bent), then the muscle will naturally respect its limits. As a vinyasa and slow flow teacher, I rely heavily on slow, accessible, and repetitive movements in a warm-up to safely prepare the muscles for lengthening. This approach can prevent injury in the tendons. If you’re in recovery from yoga butt, moving slowly and mindfully gives you time to listen to and respect your body’s response.

How to: Begin your practice or class with actions that slowly bend and straighten your knee and gradually introduce length into the hamstrings (ie, Low Lunges).

Normalize using equipment

The word “props” implies that you need support. I prefer to say “equipment,” a term I’m borrowing from my co-teacher Jon Witt. I bring blocks under the hands in a Low Lunge warmup before directing a student to inhale and lengthen their front leg towards a Parsvottanasana (Pyramid Pose), then exhale and bend again in a slow flow. If blocks aren’t available, a stack of books works well. Even using the directive to “lengthen” the leg instead of “straighten” can subtly empower students to be more engaged in the process of stretching rather than fixated on “straight” as the endgame.

Person in Warrior III variation with blocks
(Photo: Andrew Clark; Clothing: Calia)

I also find that using blocks on their highest level under the fingertips in Virabhadrasana III (Warrior III Pose) gives students a chance to see how equipment can refine their alignment and contribute to their strength. The blocks can be a steadying tool for the standing leg, which requires that the hamstrings lengthen. Students are encouraged to avoid locking out the knee by keeping a slight bend in the standing knee.

Modify your expectations (and your cues)

With a few adjustments, teachers can adjust the words they use to cue students to become generally safer in a group yoga class. Although there is an extreme amount of biodiversity in the human body, particularly in the hips, these tried-and-true tips are valuable for most bodies:

Slightly bend the knees during forward fold transitions

In the classic Surya Namaskar A (Sun Salutation A), you move from arms over your head (Urdhva Hastasana or Upward Salute) to folding forward at your hips (Uttanasana or Standing Forward Bend). If your knees are locked or hyperextended, this hinges the movement right across the sit bones area—at the very point where the hamstring connectors bottleneck at their origin—and there is a pull at both ends of the hamstrings. This tension can become even more strained if the practitioner tends to flare out the seat and/or arch the lower back in a “swan dive.” All of these actions stretch, or potentially strain, what’s called the “posterior chain,” which is the long myofascial line of muscles and connective tissue in our back body.

Instead, have that  famous “microbend” in the knees while folding. When teaching, I discuss keeping the knees active – not locked, not deeply bent, but active –  so that the legs are engaged in the pose.

Engage the quadriceps

Another way to allow the hamstrings as a group to stretch and lengthen is to recruit their agonist, or opposing muscle group. When you extend (straighten) your front knee in a pose such as Utthita Trikonasana (Triangle Pose), the opposing muscle group to the hamstrings is the quadriceps. If the nervous system suspects you might lose your balance, it will instinctively contract muscles, such as the hamstrings, even when you’re actively lengthening them. That transfers more tension to the tendons. But when the nervous system knows that something is holding you up—in this case the quads when engaged in a triangle pose—then the hamstrings get the hint and lengthen.

How do you engage the quads or cue students to do so? Lift your kneecaps towards your hips.

(Photo: Andrew Clark)

Make it easy for the hamstrings tendon

One thing that helped my recovery was finding ways to release the hamstrings without exerting any pulling or tugging on the proximal tendon.

One approach taken by movement pros and therapists is to wrap a TheraBand or yoga strap just below the crease of the seat before practicing forward bends. A less-intense modification you can try is to roll a hand towel and, before practicing a seated forward bend such as Janu Sirsasana (Head-to-Knee Forward Bend), place the roll at the top of your thigh just below your seat. You can play with the amount of pressure by modifying how thick the towel roll is. This tourniquet effect is thought to prevent the tendon from lengthening any more as you lean forward. This way, the lengthening is constrained to the muscle—which was made to lengthen—while giving the connective tissue time to rest.

A person demonstrates a variation of Head-to-Knee Pose with blankets under her bottom and knees
You can use towels or blankets to support you in Janu Sarasana (Head-to-Knee Forward Bend) to protect your tendon.
(Photo: Eleanor Williamson)

Personally, I have found that this technique brings a similar feeling as that of a good massage, and when I release the towel out from under me, I sense a warm flow through the area. Generally speaking, blood flow and synovial fluid movement in the area around a recovery are considered beneficial to the healing process (after your caregiver has cleared you for movement, of course!). Applying gentle pressure to tissue and then releasing it may increase blood flow in the area much like in a massage.

 

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The importance of building strength to avoid yoga butt

We’ve discussed how to modify the stretching aspect of the physical practice of yoga, but asana is also a mindful act of strengthening in which we learn to bear and lift our body weight, and to relate to the earth in ways that can build phenomenal strength in our tissues.

“Within the scope of teaching yoga, two general rules of thumb are good to keep in mind. The first is that strengthening an area of generalized pain (as opposed to passively stretching) can often work wonders,” explains Jesal Parikh, who teaches anatomy at Prema Yoga Institute. “And the second is that pain is complex. Our specialty as yoga teachers is in offering holistic mind-body practices that can go a long way in addressing the varied factors that go into how and why we feel pain.” First, let’s look at how to specifically strengthen this line, then review  yogic mindfulness practices that help manage sensation during recovery.

Strength-building opportunities in asana

There are many subtle changes you can make within your asana practice to engage—and thereby strengthen— the hamstrings. Some of the below suggestions also target the glutes, which are key synergists in hip extension:

A person demonstrates Salabhasana (Locust Pose) in yoga
(Photo: Andrew Clark; Clothing: Calia)

Ṣalabhāsana (Locust Pose)

Keep your legs straight and the big toes touching each other. You do not need to lift the legs much at all to feel this!

Person in Warrior III modification with a chair
(Photo: Andrew Clark; Clothing: Calia)

Vīrabhadrāsana III (Warrior III Pose)

Internally rotate the lifted leg by turning your inner thigh towards the ceiling. Lift the back heel so it is parallel with the glutes.

A person demonstrates High Lunge in yoga
(Photo: Andrew Clark; Clothing: Calia)

Vīrabhadrāsana I (Warrior I Pose), Anjaneyasana (Low Lunge), and High Lunge

Press your front heel down into the mat and isometrically draw it back to feel if the glutes engage more.

Woman demonstrating Chair pose
Clothing: Calia (Photo: Andrew Clark)

Utkatasana (Chair Pose)

You knew this was coming! Try sitting your seat back and down as far as you can in the pose without letting your knees jut in front of your ankles. Think of wrapping the deep muscles around your sit bones. This wrapping action feels like you’re making a fist around your sit bones.

Woman in Bridge pose
(Photo: Andrew Clark; Clothing: Calia)

Setu Bandha Sarvangasana (Bridge Pose)

Play with grounding your heels firmly down and isometrically drawing them either towards your seat or towards one another. Feel what action best turns on the glutes in your body.

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How mindfulness may help you mitigate your yoga butt pain

During all of the above, keep your breath deep and consistent to release unnecessary tension. The breath is the bridge to mindfulness in postures, and a physiological fast track to down-regulating our nervous system.

As Jesal reminds us, yoga is a holistic practice. Mindful movement, yoga nidra, and meditation are all used by practitioners to listen to and manage sensations. Consider integrating yoga nidra into your practice—taking time to scan the body, observe, and release any unnecessary tension. Contemplative practices like yoga nidra and yin can only help in the healing process, awakening the Parasympathetic Nervous System response known as “rest, digest, and heal.”

My teachers always reminded me that we are not our pain—any more than we are our worst moments. In the yoga philosophy of the Yoga Sutras, it is taught that our true nature is something far more lasting than our passing thoughts. Keep practicing mindfulness or meditation, in any form, including those moments where you do not yet see the results of your practice.

About our contributor

Dana Slamp, C-IAYT, ERYT500, is a certified Ayurvedic yoga therapist and the founder of Prema Yoga Institute in New York City and online. She studied with Dr. Marc Halpern, Guru Dharam, LAcc, Leslie Kaminoff, Gurmukh, Yogi Charu, and more. Dana’s love of yoga is boundless and extends across therapeutic techniques like yoga nidra and restorative.