Running related injuries are most commonly overuse in nature secondary to repetitive microtraumas in the lower quarter. Patient’s often describe a training error where their training volume exceeded their tissue’s ability to positively adapt to the load. Buttock pain is less common complaint among runners, but can significantly limit an athlete’s ability to train and compete. The most common reason for buttock pain is referral from the lower lumbar spine, but local tissues should also be considered as pain generators. In runner’s complaining of sit bone pain, buttock pain, or high hamstring pain two competing diagnoses should examined.
The hamstring muscle originate from the sit bone at the bottom of our pelvis before spanning along the back of the thigh and inserting into the knee joint. As a two joint muscle they actively extend the hip and flex the knee as they shorten, but also control the motions of hip flexion and knee extension through a lengthening contraction. Runners average 1,000-2,000 steps per mile and these repetitive forces drive the common overuse patterns in the hamstring and buttock. Symptoms at their insertion into the pelvis can drive two main diagnoses, hamstring syndrome and hamstring tendinopathy. Although these two conditions appear similar on the surface experienced clinicians can tease them apart through a thorough history and clinical examination.
Hamstring syndrome occurs secondary to irritation of the sciatic nerve as it crosses the sit bone near the origin of the biceps femoris hamstring muscle. Affected individuals often describe a history of a prior hamstring injury, past or current history of low back pain, and are currently a sprinter, jumper, or distance runner. Patients describe a gradual onset of symptoms and worsening of symptoms with prolonged stretching. Importantly, hamstring syndrome worsens with hamstring stretching secondary to the neural nature of symptoms. In addition, injured runners will describe pain with sitting. On clinical examination they have pain with resisted knee bending and passive hamstring stretching with ankle bending (dorsiflexion). Conversely, resisted hip extension on their stomach is often pain free since the sciatic nerve is not compressed against the sit bone.
Injured runners are advised to work with a Physical Therapist for treatment of this condition. Treatments may include activity/load management strategies, implementation a wedge for sitting, manual therapy to the lower quarter and most importantly exercises to address impairments in the lower quarter. Runners should avoid hamstring stretching in favor of neural flossing exercises and begin to perform hip extension/glut maximus and hamstring strengthening.
Hamstring tendinopathy occurs secondary to repetitive microtraumas at the hamstring origin on the sit bone. The imbalance between tendon breakdown with running and inadequate tissue recovery weakens the tendon structure leading to pain, weakness, and loss of function. Runners describe pain along the buttock, centered at the sit bone, but have a few key differences from hamstring syndrome. Often these patients do not have pain while sitting. On clinical examination, pain is elicited with hamstring resistive testing in all positions including sitting and laying on their stomach. Treatments should include activity/load management strategies, running gait retraining, manual therapy to the lower quarter, and importantly concentric and eccentric strengthening of the hamstring and glut musculature.