Top 5 Running Injuries: Proximal Hamstring and Buttock Pain
Updated: Apr 17, 2020
Over the past month, we have been reviewing the most common running related injuries we see in our clinic. If you missed the prior posts, you can find an outline of what causes running injuries, as well as detailed review of Achilles/posterior tibialis pain, and iliotibial band syndrome.
This installment in the series is all about a pain in the butt--literally. This is a topic near and dear to my heart, as I experienced this injury of both my left and right leg while running track in high school. I vividly remember that aching, pulling sensation that not only plagued my workouts, but made sitting in class almost unbearable. I spent many hours sitting on ice packs, trying out new kinesiotape techniques, and wrapping an ACE wrap tightly around my thigh to distract me from the underlying discomfort. Looking back, I wish I could have counseled my younger self to go to a PT, get a correct diagnosis, and do strengthening exercises, but of course I didn’t know any better.
All of that is to say, I’m excited to provide you with information on the causes, prevention, and treatment of this pain in the butt. However, you’re on your own if this happens to be due to a spouse, work, or children.
(insert sitcom laughter here)
The first step to treating buttock pain is to understand and correctly diagnose the origin of the pain. Pain in this location can be caused by a tendon issue of the proximal hamstring (where it attaches on the pelvis, or sit bone), the gluteal, deep hip, or pelvic floor muscles, or the lumbar spine. While a Physical Therapist can easily differentiate between these conditions with a thorough physical exam, I’ll highlight some key differences.
High Hamstring tendinitis/tendinopathy: This is characterized by localized pain over the tendon as it inserts on the pelvis. You will be able to reproduce the pain with either foam rolling the area or applying deep pressure near the sit bone. SItting, particularly on hard surfaces, will be uncomfortable. While running, the pain will be worse while running uphill or at a faster pace. You may also have pain if you “kick” off your shoes (requiring you to “pull up” using your injured leg). The pain will be achy and a “pulling” sensation, which intensifies with activity and is alleviated by rest. This is the condition that will be targeted in the "treatment" portion of this article.
Other myofascial pain: If your buttock pain is originating from the surrounding musculature, there will be an absence of point tenderness of the proximal hamstring, and the pain may be more diffuse and difficult to pinpoint. It may even feel deep in the hip joint or pelvis. Sitting may or may not be painful, however there is a high probability of stiffness of the hip and buttock area following periods of prolonged sitting. The discomfort is less predictable while running, and may be aggravated at all speeds and up/down hill. It is more common for this to be asymptomatic at the beginning of a run and gradually increase at a certain distance.
Lumbar spine radicular pain: This condition will have a different type of pain compared to those described above. The pain will be “burning” in nature, and may extend mid-thigh or past the knee. The pain will change with the position of your back, more commonly increasing with bending forward, however it is possible that the pain can increase with other positions as well. The pain may be predictably worse in the morning, improving with movement and then increase again with sitting/inactivity. Concomitant lower back pain may or may not be present.
Symptoms of a pelvic, sacral, or femoral stress fracture include: diffuse, vague glute pain that escalates to sharp in nature with weightbearing, deep lateral hip pain, and difficulty hopping/weightbearing on the injured leg. In this case, quick diagnosis is key to prevent serious injury and therefore protracted recovery. This should be assessed by a physician as soon as possible.
What causes it?
While there are a multitude of factors that can cause buttock and hamstring pain, we often notice a common pattern clinically. Runners who struggle with this often “overstride”, or contact the ground too far in front of the body. This forces the hamstring to work harder to move your body over that planted foot, and the glute is unable to fire in this position. Even in the absence of overstriding, many runners are unable to utilize their hips properly, using the hamstring and/or lower back muscles for hip extension.
Weakness of the pelvic girdle and abdominal muscles can also contribute to this problem, as poor endurance and strength of these muscles leads to an inability to maintain optimal pelvic position over the course of a run, with the risk for injury increasing with distance ran.
As is the case with most running injuries, this can be caused by a sudden change in volume or intensity of training, inadequate recovery between workouts, training errors, poor training and/or daily nutrition, and high life stress, among other factors.
How do you prevent and treat it?
Specifically for high hamstring injuries, eccentric loading of the tendon is important to encourage tissue remodeling, healing, and to strengthen the area. Some examples of eccentric exercises are shown below. The key is to emphasize the “lengthening” portion of the exercise, while the knee is straightening.
While the hamstring and surrounding areas may feel tight, stretching the area may actually make the problem worse. Improving hip mobility through dynamic and rotational movement will help decrease that sense of tension without stressing the unhealthy tissue. Use a foam roller or tennis/lacrosse ball (or really any device that my patients lovingly refer to as “muscle torture”) to eliminate trigger points and tight areas of the hips, hamstring, and low back.
As mentioned above, overactivity of the hamstring and lumbar paraspinals and underactivity of the glute max is a big issue for runners with hamstring injuries. Fixing this can be a tricky endeavor, as the muscle firing pattern is deeply engrained and it can be tough to rewire without external cuing or feedback. Intentional exercise is key, and this is where a PT or strength coach can be invaluable. I wrote about glute activation and how to address it here. It may also be beneficial to slightly increase your running cadence (~5-10% above your natural rhythm), as this will encourage you to hit the ground closer to your body and avoid overstriding.
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