High Hamstring Tendinopathy
Symptoms of High Hamstring Tendinopathy
High Hamstring Tendinopathy gives you pain in the lower buttock on the part of the pelvic bone you should be sitting on. This part of the bone is called the ischial tuberosity. The pain in the buttock has been described as very sharp or like a toothache all the time. There doesn’t seem to be any inflammation in the ischial tuberosity although it’s painful to pressure, most notably sitting.
When I had this I wasn’t able to sit comfortably for about 6 months. The pain I had when driving was almost unbearable, but this was at the extreme end.
Contraction of the hamstring muscles causes pain in the buttock as does a hamstring stretch. Standing does not cause pain buttock although a slight pull may be noticed in the back of the knee on the outside. Tightness may also be noticed in the upper hamstrings.
Testing for High Hamstring Tendinopathy
There are a number of tests that can be done to help in the diagnosis of high hamstring tendinopathy. Some can be done on your own. Others will need assistance, or better still have them done by a skilled and experienced sports therapist.
Testing involves putting the hamstring under tension and trying to compress the tendon This is to reproduce your pain or in some cases slightly increase it. Different variations may be used to increase the stress, stretch or compression on anatomical structures in the area.
It is worth bearing in mind that there are a number of conditions that can cause deep buttock pain. Here’s a list of other conditions that can mimic hamstring tendinopathy and give deep buttock pain.
The 5 Causes of High Hamstring Tendinopathy
A quick search of the internet reveals that there are 5 main causes for high hamstring tendinopathy. The reasons or main causes associated with the onset of your deep buttock pain are;
The most commonly written about on the internet, because this is the most researched! Specifically with middle or long distance runners, but it can happen to anyone. Instead of calling it an overuse injury (which it is), its proper name is a Reactive tendinopathy, because it reacted to use
The common factor seems to be change that happens too soon or too fast for your ability to adapt or cope. Examples could be, changes in exercise (more walking, lifting heavier weights (shopping could be included here!) cycling and running more too).
Running and cycling faster or doing more hills are other examples. Even something as simple as changing the way you carry load may be enough to make your hamstring tendon symptomatic. So going from shopping bags to a rucksack or vice-versa may be a cause pain to start.
After back pain
This seems to be due to the pain irritating the sciatic nerve, The cause of the sciatica nerve irritation doesn’t appear to be indicated
This may be due to general sensitisation or “adhesions” to the sciatic nerve
Traumatic or sudden onset
Possibly due to a slip or slide and sudden contraction of the biceps femoris pulling and irritating the tendon and where it attaches to the bone. There also seems to be where the fibrosis or sticking of the sciatic nerve to the muscle occurs.
Other Causes of High Hamstring Tendinopathy
While these other factors can be thought causes I feel its also useful to think of them of as maintaining factors too.
Adhesions between the sciatic nerve and one of the hamstring muscles.
The fascia covering the hamstrings is scarred and bound to other structures and as a result may inhibit sciatic nerve function, and also shorten the range of motion in the hip, thigh and buttock area.
Gluteal weakness or lack of strength in other core muscles have been found in some studies.
This is maybe causing overuse of the hamstring muscles as your body struggles to stabilise your pelvis. This lack of stabilty and subsequent hamstring overuse then becomes a problem as our routine changes leading to high hamstring tendinopathy.
There is a link between diabetes/insulin sensitivity and obesity. Insulin sensity/diabetes causes changes in the tendon matrix increasing the likelihood of tenodonitis. If you add the increased load that someone with obesity has, it’s not hard to see how this will quickly push this into a reactive tendinopathy.
As there is a link between obesity and diabetes, you can win in two ways by starting to modify your diet and lose weight.
It may also be good to speak to your Doctor to see if any other help or support is available.
Management of High Hamstring Tendinopathy
This has changed substantially from when this post was initially written.
I initially recommended ice and anti-inflammatory medication for this, but following the British Medical Journal article I now recommend the opposite HEAT and no anti-inflammatory medication, as it’s thought that these can stop the healing process and prolong the pain
The first goal is to stop further sensitivity, so I may suggest reducing, changing, or even stopping potential causes and irritants initially.
Cutting back or modifying exercise, reduce sitting (try standing, kneeling or even laying down)
Next, deal with any active inflammation. Icing is no longer suggested, but gentle movement that doesn’t stretch or compress the tendon can be of benefit around the insertion and tendon may help in the short term
I prefer heat on the muscle belly feels good and may help release any tightness in the muscle itself.
Anti-inflammatory medication has been suggested in the acute stages, but discuss this with a health professional as there is some disagreement on anti-inflammatory medication. Some fairly common conditions can also make non-inflammatories a no-go medication
In the early stages do not stretch the hamstring muscles, as this will pull on the tendon and further irritate it. I found foam rolling ineffective and the compression of the tendon will probably make it worse.
Get it examined so it can be diagnosed so that appropriate active management and treatment for the correct stage of the tendinopathy can begin as quickly as possible as this may shorten the duration of the condition.
Kinesiotaping and massage can help reduce pain and sensitivity. which will allow you to do your home rehab/treatment to help get you back to your life and activities quicker
Treatment of High Hamstring Tendinopathy
Treatment of high hamstring tendinopathy is best thought of as going through a series of steps, with goals and outcomes wanted for each step.
treatment by me is always based on the needs of you as an individual patient based on the stage of your tendon problem and the treatment step we are in.
Because of that, it is hard to give a definitive treatment guide with times for each stage. During treatment, each step will overlap, but thinking of them as individual step can help me treat you and for you to manage your condition.
The first step of High Hamstring Tendinopathy treatment is to start managing the load. This has to include educating you about your problem so you can understand what’s happening, and why it needs to managed ad treated this way. It helps stop you making the mistake of, “just testing it”.
I often look for ways to stop further irritation of the area, and if possible keeping you doing the activities you love. As an example it may be possible to keep on running, if we can decrease, weight, speed, distance and any hills.
The second step is to find ways to decrease pain and sensitivity. This may involve massage and other techniques to the muscles, rather than the tendon.
but as you’re an individual I’ve found that rather than using a one size fits all protocol or exercise sheet I’ll use some of the methods or rationale detailed below.
The third step is about increasing load to the muscle and tendon in a sensible way to allow you get back to what you want to do.
Sometimes we may have to look at movement re-training to make sure what you’re doing isn’t irritating your tendon.
Over-striding when you run has been suggested as something that needs addressed and that muscles are being recruited correctly and that they’re strong enough.
If you run or play a particular sport the load and way that load is applied will may be different to allow you to return to play/running and reduce the risk of boom-bust scenarios.
Back pain and sciatica link
To manage the potential link between low back pain and sciatica nerve, treatments I have in the past have included soft tissue techniques to the Iliolumbar Ligament, Lumbar Erector Spinae, and Multifidus. Sometimes manipulation on the lumbar spine may be necessary although articulation can be used instead. Also soft tissue to the gluteal area and the deep hip rotators (piriformis and its relationship with the sciatic nerve deserve extra attention), but taking care to avoid the ischial tuberosity and the proximal part of the hamstrings
Soft Tissue approach to High Hamstring Tendinopathy.
As part of the second step I will often use various soft tissue techniques including massage when treating the hamstrings. Other ways of treating could include cupping, and instrument assisted soft-tissue massage (IASTM for short). IASTM would include ART and Graston techniques, but there is no, one better way of doing IASTM..
The techniques chosen depend on the goals for that particular stage of treatment. I normally take care to not stress or tension the upper hamstring tendon until the later stages of treatment.
As you start to improve and your capacity for movement improves I’ll start to bring in one or two appropriate exercises and progress (or regress) them for where you are on the pain/recovery line.
High hamstring Tendinopathy is a debilitating condition that can affect many aspects of your life. Simple things that we take for granted such as sitting down and eating a meal to leisure activities like running can become excruciating. I don’t want that to happen to you.
Not only have I treated numerous people with high hamstring tendinopathy, I’ve suffered from it as well. I understand the frustration that it can give, so aim to get you back to your normal activities as quickly as possible. I have the experience to diagnose, treat and also advise on a rehabilitation program to try and stop it from reoccurring.
Please note. I can’t give a diagnosis online, If you live or work in the Glasgow area it may be an idea to book an appointment. Click to book an appointment now.
Where possible all links are to free to access versions.
Lempainen L, Johansson K, Banke IJ, et al. Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy. Muscles Ligaments Tendons J. 2015;5(1):23-28
Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challanges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.
Tom Goom. Proximal hamstring tendinopathy – a case study…me The Running Physio
Alison Grimaldi. Physio edge podcast, Hamstring tendinopathy with dr Alison Grimaldi. Physio edge 11