Let’s Chat About That Pain in Your Butt

How Your Hamstrings May Be the Culprit

Over the past month, I have had quite a few people walk into the clinic complaining about an annoying pain in their butts. No, they are not talking about their mom, husband, dog or children, but actual pain in the bottom that bothers them when they wake up in the morning, sit, run, go up a hill, bend over, kick a ball, sit on the john, etc.  It tends to be quite deep and achy, aggravating and limiting, and can sometimes hurt with or without movement. The true definition of a “royal pain in the butt”.  

So, folks, let us chat about this a little more. Dr. Google sometimes tells people it could be their lower backs or their sciatic nerves (and it could be), but for those who really do some digging, the phrase Proximal Hamstring Tendinopathy may pop up. Three words, representing what may be the true cause of your pain in the butt. (Does the red circled area in the picture to your right look familiar? That is the proximal hamstring tendon. It is basically right at the base of your buttocks.)

Tendinopathy can often be a catch-all term for any pathology that has to do with a tendon. Sometimes, it is used for pain that has been occurring for > 3 months. Well, for ease of explanation, I am going to use two different classifications (thanks, Jill Cook!) to describe tendinopathy. Have you had this pain awhile and it just will not go away, or it waxes and wanes a bit? You might have what we consider reactive-on-degenerative tendinopathy. If the onset of this pain is new and comes on after a known event, we tend to call it reactive tendinopathy.  

So, why does it happen? Across the board, whether reactive-on-degenerative or reactive, it is most likely related to a load management problem. Sometimes, it is due to lack of activity, sometimes, it is simply too much too fast (let’s just say I’ve seen this injury in couch potatoes, elite athletes, and weekend warriors). For those experiencing chronic discomfort or pain, the activity you are doing is either too much or too little for what your tendon needs. For those who have experienced an onset after an activity, more than likely, you did too much than what your tendon could handle at that very point in time.

*Quick Sidebar: I know that the term degenerative can be scary. However, something being termed degenerative does not necessarily mean that it is a never-ending problem, nor does it necessarily mean it is associated with pain. There are many studies out there showing people having degenerative tendons with no pain. Just think about that! More than likely, this is where monitoring your workloads really matters!

So, if this pain exists what can you do about it? The answer is: modify your activity and progressively load your musculature within a monitored pain framework. A progressive loading strategy moving from isometrics to slow & heavy resistance training is the only way to have tendons make adaptations to meet the requirements of human movement. We cannot just expect to rest, ice, and stretch to get pain to dissipate, especially with tendon pain! On a side-note, repeated stretching of a high-hamstring tendinopathy or any tendon problem can actually make it worse.

Tendons like activity. They like to be loaded and they do not necessarily like to sit idle. Their properties drive them to stiffen when irritated, especially with a lack of activity. So, load your hamstrings within a 0-4 (maybe 5) pain range, and proceed if the pain does not continue to increase and returns to baseline within ~36 hours. Side note: you should not be limping or have any compensatory changes in movement after loading (running, weightlifting, walking, etc.).

There is a lot that goes into rehabilitating a proximal hamstring tendinopathy or really any tendon injury. If I can offer several words of advice, find someone to guide you and do not give up. These injuries can be frustrating and take time, but you CAN get back to doing what you love. That actual pain in your butt can go away!

Stay tuned to the video below, as I will go over some general exercises, I give to people suffering from PHT. And as always, if you have any questions, do not hesitate to reach out.

Ashley Witson, PT, DPT