Buttock Pain and High Hamstring Tendinopathy

Pain deep in the buttocks or upper back-side of the thigh can be due to tendon injury near the origin of the hamstring muscle off of the ischial tuberosity. That is the name of the bone which bears body weight in the seated position. It is an injury we see in mid to long distance runners, yoga practitioners, and occasionally non-athletic individuals who have been injured by improper chiropractic adjustments or physical therapy.

Occasionally the damage to the tendon in chronic cases can be severe enough to cause irritation of the nearby sciatic nerve, thus producing symptoms of referred pain down the entire back of the leg which are more typically associated with herniated lumbar disks. The pain is typically worse when the patient is seated on a hard surface, and after running, especially at faster speeds. There can be pain at rest in severe cases. The bent knee stretch test is applied for the diagnosis of this condition with the patient lying supine. The hip and knee are first maximally flexed towards the patient’s chest, and then the knee is extended gradually. Pain at the origin of the hamstring on that side which reproduces the patient’s pain is diagnostic. Additionally, prolotherapists rely on direct thumb pressure over the proximal hamstring tendon in the buttocks, the so called “jump sign” to reproduce the pain, localize the injury, and determine the best treatment. Direct firm pressure on affected areas causes the patient to “jump’ because of accentuation of the pain. Finally, injection of a local anesthetic solution into the tendon-bone junction of the affected hamstring tendon can cinch the diagnosis by immediately eradicating all evidence of pain at rest or with motion or sitting.

There are several other conditions that can produce a similar symptom complex. Herniated lumbar disks and sacroiliac ligament strain both refer pain into the deep buttock area. Spasm of the pyriformis muscle is another common condition in athletes, and in older individuals metastatic cancer to the bone, and pelvic stress fracture must also be considered. Fortunately, all of these conditions except for the latter two will respond to appropriately applied Prolotherapy, but making the differential diagnosis is critical in order to achieve the most rapid response. When necessary, X-rays, bone scan, or MRI imaging is ordered.

Prolotherapists approach the treatment of high hamstring tendinopathy much differently than most orthodedists and team or family physicians. Ice and anti-inflammatory drugs (which, by the way, are not particularly effective in this condition anyway) are never recommended. We also never inject steroids, which is another favorite of orthodox physicians despite the fact that long term outcome is clearly not improved by this approach, and there are possible cadverse complications. Since steroids can weaken tendons, care should be taken to avoid injecting them directly into the tendon. This is far different than prolotherapy injections, which are safe and all the more effective when injected directly into the site of the tendinopathy. The pelvis must be properly aligned, so chiropractic intervention is requested when indicated. As I mentioned above, I have seen some cases of high hamstring tendinopathy arise from over-exuberant chiropractic adjustments, so be careful who adjusts you. Maintaining flexibility of both hamstrings is also important, and so is strength training. The former is accomplished with stretching, while the latter with double leg isometric bridge exercises. With the patient on his back, he activates the abdominal muscles to raise his pelvis while maintaining neutral position and alignment of the shoulders, hips, and knees. Hold this position for 10 seconds and then lower the pelvis back to the floor. Progression of this exercise requires lifting and extending one foot off the ground, and/or placing the arms across the chest. In the early weeks of treatment, pool running rather than track running is advisable to decrease impact trauma, but mobility should be maintained as much as possible.

Prolotherapy injections are definitely the fastest route to recovery from high hamstring tendinopathy. The only possible danger from prolo for this disorder is the proximity of the hamstring tendons to the sciatic nerve, but proper experience and technique will always avert any problems in this regard. Should the nerve ever be touched by the slowly advancing prolo needle (a precautionary measure on the prolotherapist’s part), there will be a quick electrical sensation down the leg. As the needle is withdrawn or redirected, any discomfort will be mild and temporary. Return to full athletic activity is speeded up by “prolo,” and it is the only treatment of all available that actually stimulates the body to heal the damaged and painful area, for permanent relief, via the deposition of additional tissue strengthening collagen which becomes an intrinsic part of the tendons treated, restoring strength, elasticity, and functionality.