Proximal hamstring and gluteal tendinopathy are common musculoskeletal conditions that affect individuals of all ages. These are also very common injuries experienced by runners. Surprisingly to some, research consistently shows that women are more likely to experience these injuries than men. Despite extensive studies on musculoskeletal health, the reasons for this gender difference remain multifaceted. A variety of factors—from anatomical and biomechanical differences to hormonal influences—contribute to why women are more susceptible.

Anatomical and Biomechanical Differences

Several studies point to anatomical and biomechanical factors as key contributors to women’s heightened risk of proximal hamstring and gluteal tendinopathy. A systematic review by Alfredson et al. (2018) found that women generally have wider pelvic structures than men, which can result in altered hip mechanics. Specifically, wider hips cause a greater degree of hip abduction and external rotation during movement. This altered positioning places more strain on the gluteal tendons and the proximal hamstrings, potentially leading to tendinopathy over time.

Moreover, a study by Faber et al. (2018) highlighted that women tend to have a greater Q-angle, which is the angle between the hip and knee. This change in alignment also contributes to increased mechanical stress on the lower limbs, which can affect the function of the hamstrings and gluteal tendons.

Muscle Imbalances and Strength Deficits

Women often exhibit a greater tendency toward certain muscle imbalances, including weaker hamstrings in relation to quadriceps strength. Research shows that a weaker hamstring can fail to adequately control the movement of the leg during dynamic activities, creating additional stress on tendons in the posterior chain (gluteals, hamstrings, calves). This weakness is noted by Khan et al. (2014), reporting that muscle imbalances in women can increase the likelihood of developing tendinopathies in key muscles like the hamstrings and glutes.

In contrast, men tend to exhibit greater overall strength, especially in the posterior chain, which may provide them with a greater protective buffer against tendon injuries. However, this difference isn’t just about raw strength but also about how efficiently those muscles engage during movement. Women’s glutes, in particular, may not activate optimally, leading to an over-reliance on the hamstrings and contributing to tendon overload.

Hormonal Influences

One of the most intriguing explanations for why women are more prone to tendinopathy involves hormonal fluctuations. The role of estrogen and progesterone in tendon health has been widely studied. In particular, Paoloni et al. (2019) conducted a systematic review of tendinopathy research and noted that female athletes often experience a higher incidence of tendon injuries during certain phases of their menstrual cycle, specifically the luteal phase, when estrogen and progesterone levels are high.

These hormonal fluctuations may cause tendons to become more elastic and prone to injury, as tendons naturally undergo changes in collagen composition throughout the menstrual cycle. This increased laxity can predispose women to tendon damage and inflammation. Hormones like estrogen and progesterone have also been shown to affect tendon healing processes, potentially prolonging recovery times or making the tendons more susceptible to chronic injuries like tendinopathy.

Age-Related Factors

Aging also plays a role in tendon degeneration, and women may be more vulnerable to tendinopathies as they age. According to Dean et al. (2020), as women enter menopause, the decline in estrogen levels contributes to a reduction in tendon collagen content and structural integrity. This can further increase the likelihood of tendon injuries in the hamstrings and glutes.

Proximal hamstring and gluteal tendinopathy in women is a complex issue, shaped by various anatomical, biomechanical, hormonal, and age-related factors. Research has shown that anatomical differences, such as wider pelvises and greater Q-angles, contribute to altered mechanics and tendon strain. Furthermore, muscle imbalances, particularly in the hamstrings, and hormonal changes during menstruation and menopause, further heighten the risk for women. Understanding these factors and how they intersect is key to developing prevention and rehabilitation strategies tailored to women’s unique needs, especially those who are active.