Proximal Hamstring pain

Another request from a friend - this time with a pain in the bum!

Now this condition is quite interesting (I think).  And I have my own theories, developed in clinic with my patients, about this type of problem.

Firstly I think I need to make clear that we are not talking about acute (sudden onset) tears of the hamstrings here - so if anyone has this problem and it came on suddenly with severe pain in their posterior, upper thigh, then this is not relevant to that problem - that is likely a hamstring tendon tear rather than the condition which I would like to consider which is 'proximal hamstring tendinopathy'.

Proximal hamstring tendinopathy means 'damage/disease of the hamstring tendon where it attaches at the pelvis'.  The hamstrings attach at the ischial tuberosity which is the bony lump in your bum that you pretty much sit on. The hamstrings include: the biceps femoris (long head only attaches at the ischial tuberosity), semimembranosus and semitendinosus.  The key action of the hamstrings are to act as antagonists of the quads muscles - particularly acting eccentrically to decelerate the extension of the leg at the knee during e.g. running.  They kick in just prior to the foot striking the ground and it is at this point that the hamstrings are most at risk of tearing (but this is getting off the subject).

So - why pain in the bum?  Well, as with all tendons in the body, the hamstring tendons are subject to load and can become degenerate or tendinopathic (ie injured!).  And rather than a more acute injury, they can be subject to repetitive strain which can result in the more chronic or slow onset pain and disability that athletes recognise as their 'pain in their bum'.  Again, as with many slower onset type problems (e.g. achilles tendinopathy, plantar fasciitis, patellar tendinopathy), initially you can train through the problem with minimal upset to training.  But gradually the symptoms become more significant to the point where they affect performance and function.

The treatment of hamstring tendinopathies traditionally tend to rely on eccentric hamstring training (nordic curls, hamstring bridging, swiss ball hamstring roll outs, romanian dead lifts) and I would certainly recommend that anyone with proximal hamstring tendon pain start undertaking these kinds of exercises.  My personal opinion though is that one of the underlying reasons for proximal hamstring problems is, in some patients, the positioning of the pelvis and the quality of the patient's lumbosacral control (pelvic/core stability).

In situations where the patient has poor lumbosacral control with poor core/pelvic stability, the patient has to use something to stabilise the pelvis in order to allow the force from the movement of the legs to be transmitted up the body to the trunk and in so doing, move it forward.  One method that can be adopted is the 'posterior pelvic tilt'.  This is where the pelvis is tucked under and held in this position.  This is achieved by contracting rectus abdominus and the glutes and the proximal hamstrings start to become involved in the process of stabilising the pelvis.  And this is not a role that they were designed for and thus they are loaded in an abnormal way.

As an aside from this, with the rectus abdominus being used to stabilise the pelvis, breathing can be affected and with the glutes being used for stability purposes, the stride length and power can be affected - and in this way the running style becomes less efficient as well.

So to rectify this, it is not only important to strengthen the hamstrings but it is also important to stretch off the abdominals, stretch off the glutes (I think I may have blogged about this just recently - but try doing a full squat whilst concentrating on really sticking your bum out - i.e. squat right down so your bum is almost on the floor with your heels on the ground - you may have to hold onto a table for support.  You should feel the stretch in your glutes.  If you don't, then concentrate again on sticking out your bum or tilting your pelvis 'anteriorly' or forward.), stretch the hamstrings (foot on a low chair/table and straighten the leg - no need to lean right over the leg, just tilt the pelvis anteriorly/stick your bum out) and then work on your pelvic and core control whilst learning good lumbosacral control - again, the lumbar spine should have a natural curve to it - it should sit in slight extension - it should not be flat.

In summary:
1) stretch - full body - see my previous blog - but concentrating particularly on abdominals and glutes.
2) stretch off the hamstrings (as above)
3) work on good lumbosacral control - knowing how to hold your pelvis when you are performing activity.
4) work on good glute strength/core strength/pelvic control.

In some situations I have been known to inject the proximal hamstring origin with steroid, but without any of the above adjustments the pain is highly likely to return.  The steroid is just a very good pain reliever....but not permanent.

I hope this vaguely makes sense.  Again, no randomised controlled trials, but observations and opinion.