What is that pain in my butt when I run? Hamstring Tendinopathy
WHAT IS THAT PAIN IN MY BUTT WHEN I RUN?
HAMSTRING TENDINOPATHY
A tendinopathy where the hamstring (muscle at the back of the thigh) inserts into the ischial tuberosity (your sitting bone) in the pelvis. For a greater understanding into tendonopathy and what they are read about it HERE in an earlier post from physiotherapist Lindsay Young.
WHO SUFFERS FROM IT?
Generally middle and long distance runners can suffer from proximal hamstring tendinopathy. Sprinters are more likely to suffer mid hamstring injuries (tears) at the myotendinous junction, and less likely to suffer an overuse injury such as the development of a tendinopathy (1).
HOW DO I KNOW I HAVE IT?
Signs include experiencing a pain deep in the buttock or thigh which may worsen with acceleration during a run or running at higher speeds than used to. Some people may experience sciatic like symptoms due to the sciatic nerve running close to the tendon. Pain with sitting and difficulty stretching the hamstring (eg leaning down to pick something up, sitting with legs outstretched) may be uncomfortable (2)
HOW IS IT ASSESSED BY A PHYSIOTHERAPIST?
- Palpation – your physiotherapist will feel the area of pain
- Hamstring length – your physiotherapist will want to know how tight your hamstring is (this may be tested using a straight leg raise or bent knee test) and will compare it to your unaffected side
- Neural involvement – your physiotherapist will assess whether there is any neural involvement eg sciatic nerve which could be adding to your pain
- Your physiotherapist may request some imaging to be performed (3)
WHAT IMAGING (SCANS) MAY BE USEFUL?
Ultrasound scan or MRI will show changes to the tendon at the ischial tuberosity (insertion point) of the tendon typical of a tendinopathy.Changes can include an infiltration of fluid into the tendon, fluid (oedema) at the tendon/bone junction, and in chronic cases the infiltration of blood vessels (neo-vasculariation).
WHAT ELSE COULD IT BE?
Other injuries which can present similarly to proximal hamstring tendinopathy include:
- Proximal hamstring tear (as mentioned above, more common in sprinters, more acute injury)
- Lower back; depending on the structure involved (disc, facet joint, ligament or muscle) and what level affect the lower back can refer into the buttock and posterior thigh
- Ischiogluteal bursitis
- Apophysitis (in children/teens where the growth plates have not yet closed, this area can become irritated)
- Avulsion (hamstring tendon detached from its insertion-point – also more likely in children)
- Piriformis syndrome
WHAT CAN A PHYSIOTHERAPIST DO?
- Manual therapy (hands on treatment) for soft tissue release –this may include massage, trigger point release, PNF stretching (contract/relax), and/or dry needling.
- Home exercise program focused on stretching and strengthening the hamstrings eccentrically (view video HERE) as well as core strengthening. If you need some great ideas for core strengthening – check out this exercise (video HERE).
- Assess your running technique. If you live on the Gold Coast or in QLD our RUN101 WORKSHOPS are an ideal way of getting professional feedback on your running technique. Furthermore step 2 in Brad Beer’s Amazon Bestselling book ‘You CAN Run Pain Free!’ focuses on running technique (‘Run With Great Technique’)-you can get the book HERE.
- Assess strength and length of other areas which may be affecting the kinetic chain/your side of pain (eg quadriceps, calf, thoracic spine)-and correct with manual therapy and exercise prescription.
WHAT IF PHYSIOTHERAPY DOESN’T RESOLVE MY PAIN?
In some cases, proximal hamstring tendinopathy will not fully resolve with physiotherapy and active rehabilitation. In these cases an ultrasound guided corticosteroid injection may be of use to reduce pain and improve the patient’s ability to perform active rehabilitation/exercise program(4) (a steroid injection does not mean rehabilitation is over, it is to reduce pain so rehab and return to running can be progressed) or in some cases surgery to remove scar tissue from tendon and from around sciatic nerve is required. Alternately PRP injection therapy is currently a popular treatment modality for recalcitrant tendon problems such as long standing proximal hamstring tendinopathy-read about it HERE.
Emily Georgopoulos (APAM)
PAIN-FREE. PERFORM. PROLONG.
REFERENCES:
1. Fredericson M, Moore W, Guillet M, Beaulieu C. High hamstring tendinopathy in runners: meeting the challenges of diagnosis, treatment, and rehabilitation. Phys Sportsmed. 2005;33:32-43.
2. Puranen J, Orava S: The hamstring syndrome: a new diagnosis of gluteal sciatic pain. Am J Sports Med 1988;16(5):517-521.
3. Cacchio A, Borra F, Severini G, Foglia, A ,Musarra F, Taddio N, De Paulis F. Reliability and Validity of Three Pain Provocation Tests Used for the Diagnosis of Chronic Proximal Hamstring .Tendinopathy Br J Sports Med. 2012;46(12):883-887.
4. Sofka CM, Collins AJ, Adler RS: Use of ultrasonographic guidance in interventional musculoskeletal procedures: a review from a single institution. J Ultrasound Med 2001;20(1):21-26.
