Buttock pain is a real pain in the arse. The main two causes of buttock pain are referred pain from the lumbar spine (lower back) or tendinopathy of the hamstring. The latter is what this article is going to talk about.
What is it?
The hamstring muscles are a group of three muscles at the back of the thigh. They attach on to your sitting bones (the ischial tuberosity) at one end and below the knee at the other. They’re main role is flexion (bending) of the knee) but they are also involved in hip extension (backward movement). As per all muscles as they attach on to bone, they become tendons. Tendons are elastic structures that allow load / or energy to be stored and subsequently transferred between muscle and bone to allow movement.
Where the tendons insert on to your sitting bones is an area that sometimes becomes painful. This is known as proximal hamstring tendinopathy (PHT). In these cases the hamstring tendon has become intolerant to load. This often is due to physiological changes within the tendon meaning it is unable to work as effectively. Equally however there is often some changes of the nervous system meaning that pain comes on to protect you but sometimes this can be overprotective. This is known as sensitisation. Most often it is a combination of the two.
To further complicate things there may also be some subsequent irritation to what is known as a bursa. Bursae are a little sacs of fluid which lay between muscles, ligaments and bones. They act to reduce friction between structures and often problems with the bursa co-exist with tendon problems.
Symptoms
Proximal hamstring tendinopathy usually presents with pain which is localised to the bony bit on your bottom (the ischial tuberosity). It is worsened when sitting (especially on hard surfaces) or when walking or running (especially uphill). Other things that may aggravate include deep lunges / deep squats or stretching of the hamstrings. This is because all these things add a tensile or compressive load to the tendon, the worst ones often combine the two.
Causes
It is often caused when there is sudden change to the amount of work the tendon is expected to do. This may be a change in training for example taking up yoga or doing more or deeper lunges/squats. It may be you have increase the amount you are running or have taken up hill running. It may be you are just sitting for longer periods. Sometimes however there is not this acute change and it just represents a slow overuse type of problem.
Management
Regardless of the cause the management is largely the same and it is the same for the management of other tendon problems. It needs to be carefully but progressively loaded. One research paper has suggested a three stage approach and this is something that I have used well in patients with this condition.
The approach they advocate is to start with isometric exercises i.e. long static holds. These are graded upwards so they become progressively harder. When this improves one can move on to the second stage where we start to load the hamstrings in a hip neutral position. This means we add tensile load but minimal compressive load. Then in stage three we start working the hamstrings in positions of increasing hip flexion so that that we combine compressive and tensile loads.
Other activities can be continued provided that we don’t overload the tendons, therefore they may need to be modified. Tendons can be fickle beasts and if we overload them we can set things back rather quickly. That said total rest is not recommended as activities are likely to be more painful when we restart them.
Optimal rehab takes about three months but can be longer and is sometimes shorter. This is dependent on how long the problem has been there and how carefully we apply load. The aim of rehab is to have effects both on the physical properties of the tendon but also the sensitivity of the tendon to load. Interestingly studies have shown that improvements can be made with no changes to the tendons make-up. This shows the importance of the sensitivity aspect of these problems.
The bottom line (sorry!)
Proximal Tendinopathy is an issue leading to pain in the buttock (s). It responds well to a graded loading program. Get in contact if you feel you have this problem and we can talk you how we can get you back to doing the things you enjoy or need to do.