Proximal hamstring tendinopathy – a common cause of butt pain in runners

This condition can literally be a pain in the butt. As if it’s not enough that it can stop you running, it can also cause a lot of discomfort when sitting. The funny thing about sitting is that you don’t realise how much you do it until it becomes painful. In this article I explain why runners develop proximal hamstring tendinopathy and what you can do to get rid of it.

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In this article:

• The anatomy of the hamstrings

• Where you feel your pain

• What causes proximal hamstring tendinopathy?

• What are the symptoms of proximal hamstring tendinopathy?

• How do you get rid of it?

Here's a livestream video I did about this topic:

The anatomy of the hamstrings

Your hamstrings are made up of 4 muscles. They all come together at the top of your thigh and attach with a shared/conjoined tendon to your sit-bone (ischial tuberosity) on your pelvis. Two of the hamstring muscles (semitendinosus, semimembranosus) run more towards the inside and back of your thigh and the other two (long head and short head of biceps femoris) more towards the outside of the back of your thigh.

Where you feel your pain

Proximal hamstring tendinopathy develops where the hamstrings’ shared tendon attaches to your sit-bone and you tend to feel the pain in that area. It can sometimes cause a bit of buttock pain as well as pain lower down in the thigh, but the majority of the pain is usually around your sit-bone area.

Other conditions like sciatic nerve irritation and muscle tears can feel very similar and it’s always worth having your injury diagnosed by a healthcare professional.

What causes proximal hamstring tendinopathy?

Whenever your hip is flexed (like when you sit or when you run) the tendon is compressed against your sit-bone. This is normal and usually not a problem.

If, however, this compression force is excessive, it can injure your tendon and cause tendinopathy. Examples include things like:

• If you sit for very long periods on a hard chair or in a position that stretches the hamstring (like when you drive a car). Sitting in itself is not a problem – it’s the length of time your do it for and what type of surface you sit on that can cause injury.

• Training error is a very common cause. For instance, if you suddenly increase your training to include a lot of forceful hamstring contractions with your hip in flexion (hill running, sprinting, jumping, hurdles or lunging).

• Excessive passive stretching of the hamstring can also cause trouble. For example deep hamstring stretches in yoga and pilates that are held for a long time.

Conditions like the hormonal changes during the menopause, diabetes, high cholesterol and inflammatory arthritis can also affect your tendons’ health and make them more susceptible to developing tendinopathies.

What are the symptoms of proximal hamstring tendinopathy?

All tendinopathies can be roughly divided into two stages namely the reactive stage and the more settled/less painful stage.

A reactive tendinopathy is usually extremely painful and the pain is easily aggravated through normal daily activities. For proximal hamstring tendinopathy the main aggravating activities are usually sitting (because of the direct compression on the tendon) and any activity that involves deep flexing of the hip like stretching the hamstring or running.

I find it useful to think of a reactive tendon as an angry baby that is just waiting to throw its toys out of the cot. The slightest thing can set the pain off.

When a tendinopathy is more settled and out of the reactive phase, you may find that there is a warm-up effect when you do activities. For example that it hurts at the beginning of a run, but that the pain then goes away only to return again towards the end of the run or somewhere in the next 24 hours.

Part of the reason why it can be so tricky to recover from ongoing proximal hamstring tendinopathy is because you won’t always feel pain while you’re doing the activity so it’s easy to overdo things. It may only be the next morning that you realise that you’ve overdone things and set yourself back.

How do you get rid of it?

There are 2 main things that you have to do to get rid of proximal hamstring tendinopathy:

1. Reduce ALL of the aggravating activities to a level where it does not stir your pain up

This does not mean that you have to avoid them – you just have to adapt them to a level that works for you. Take sitting for instance, placing a soft pillow under your thighs so that your sit-bone does not take any pressure can be very effective – I explain this in more detail in the video.

If your tendon is in the reactive phase, you may have to take some time out from running. But if it’s in the more settled phase you may be able to continue running as long as you adapt your running for example to running on flat ground and keeping your strides short. There are loads of different ways in which you can adapt your running, work postures, sitting and other exercise and your physio will be able to help you with this.

This memory foam cushion can help to reduce the pressure when you're sitting or driving.

2. You have to slowly strengthen the tendon

When you have a tendinopathy, your tendon loses some of its strength and the cells and fibres inside the tendon changes shape. You can change your tendon back into a strong healthy tendon by doing a carefully graded strength training programme.

The exercises has to be set at the right level for you, otherwise you may make your injury worse. This process is not a quick fix and can take between 3 and 6 months depending on your specific case. I explain this all in a bit more detail in the video.

When your tendon is in the very sensitive reactive phase, exercises like isometric glute bridges can work well to calm the pain down, but if you tried to do a movement like a lunge you may find that it makes your pain worse. This is because the tendon undergoes more compression during the deep flexion movement of a lunge. As your tendon recovers, it will gradually handle exercises like lunges better.

Let me know if you have any questions. Would you like a treatment programme for your hamstring tendinopathy? I do online physio consultations via video call. During the session I’ll get you to perform a full battery of tests which allows me to design a programme that is at the right level and intensity for you.

Best wishes

Maryke

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram.

References:

1. Brukner P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon)

2. Goom TS, Malliaras P, Reiman MP, et al. Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy 2016;46(6):483-93.