Have you ever experienced a dull ache or sharp pain in your lower buttock, especially during activities like running or sitting for extended periods? If so, you might be dealing with proximal hamstring tendinopathy, commonly referred to as a real "pain in the butt."
This condition is more common than you might think, particularly among athletes and physically active individuals. The hamstring tendon, located at the sit-bone, acts as a crucial connection between your muscles and bones, providing stability and support during movement. But like any hardworking component of the musculoskeletal system, it can be prone to overuse or strain, leading to discomfort and reduced performance.
Addressing proximal hamstring tendinopathy requires more than just rest and recovery. Understanding the underlying causes, symptoms, and appropriate treatment options is essential for managing pain and preventing further injury.
What is proximal hamstring tendinopathy?
Proximal hamstring tendinopathy, also known as high hamstring tendinopathy or hamstring origin tendinopathy, is a condition characterised by pain and irritation of the hamstring tendons where they attach to the ischial tuberosity (the "sit bone") of the pelvis.
Normally, tendons are designed to withstand significant loads. However, when the hamstring tendons are subjected to excessive or repetitive strain, especially with high-intensity activities or sudden increases in activity, they can develop tendinopathic changes.
This can lead to a cascade of changes that impact the tendons loading capacity and potentially even structural changes that can ultimately cause pain and dysfunction. It's often an overuse injury that develops gradually over weeks or months.
Common causes of proximal hamstring tendinopathy
Proximal hamstring tendinopathy is frequently seen in athletes, particularly:
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Runners: especially long-distance runners, sprinters, and those who run uphill or downhill.
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Athletes involved in activities with repetitive hip flexion or kicking, like dancers, soccer players, and hurdlers.
- Activities involving deep hip flexion and loading, such as deep squats, lunges, and deadlifts.
It can also affect non-athletes due to prolonged sitting, especially on hard surfaces, which can compress the tendon.
Other contributing risk factors for proximal hamstring tendinopathy
- Sudden increases in training volume or intensity
- Poor warm-up or recovery methods
- Muscle imbalances (e.g., weak glutes or tight quadriceps)
- Lack of flexibility
- Fatigue
- Previous hamstring injuries
- Age (more common in middle-aged and older athletes)
Common symptoms of proximal hamstring tendinopathy
The main symptom of proximal hamstring tendinopathy is a dull, deep pain or aching in the buttock, specifically at the top of the hamstring where it meets the sit bone. This pain may:
- Worsen during or after activities like running, lunging, squatting, or cycling
- Be aggravated by prolonged sitting, especially on hard surfaces
- Extend down into the hamstring muscle
- Initially appear a short time after exercise and settle down, but as the condition progresses, pain may occur during and after activity
- In some cases, lead to sciatica-like symptoms down the leg if the sciatic nerve becomes irritated due to its proximity to the affected tendon
Physiotherapy treatment for proximal hamstring tendinopathy
1. Load management and activity modification
Identify and minimise aggravating activities such as prolonged sitting, deep hip flexion (squats, lunges), and running. Modify sitting with cushions, adjust seat height, and take standing breaks. Engage in cross-training activities like swimming or cycling.
2. Progressive loading exercise program
This involves a gradual capacity increase in the tendon:
- Stage 1: Isometric hamstring loading to decrease pain and activate muscles. Includes isometric leg curls and bridge holds, aiming for 5 repetitions of 30-45 seconds at a moderate effort.
- Stage 2: Isotonic hamstring loading with limited hip flexion focuses on restoring strength with exercises like single-leg bridges and prone leg curls, 3-4 sets of 6-15 reps.
- Stage 3: Increased hip flexion exercises like hip thrusts and Romanian deadlifts prepare for functional movements.
- Stage 4: Energy storage and release
Loading includes plyometric exercises for high-speed activities. Gradually increase intensity, speed, and complexity, mimicking the demands of the desired activities.
3. Addressing biomechanical deficiencies
Strengthening glutes and improving lumbopelvic stability is essential.
4. Adjunct therapies
Manual therapy, ice/heat treatments, acupuncture, shockwave therapy, and guided injections may assist with pain and inflammation.
Final thoughts
Proximal hamstring tendinopathy can be a chronic condition, meaning it often lasts for months, and sometimes even longer, especially if not managed properly. Tendons heal slowly.
The pain can sometimes be mistaken for other conditions like sciatica (due to the sciatic nerve's proximity), piriformis syndrome, or lower back issues, leading to delayed or incorrect treatment.
If you are experiencing symptoms of proximal hamstring tendinopathy, seeking professional medical advice is the best first step. Proximal hamstring tendinopathy can be a stubborn condition to resolve, often requiring patience and consistent adherence to a rehabilitation program.
Book an appointment with one of our highly qualified physiotherapists at Enhance Physio before starting a rehabilitation program. We can advise you on the best course of action for your condition.
