Proximal hamstring tendinopathy usually causes a localized, deep ache at the sitting bone that rises when the hamstring is loaded in hip flexion. Sciatic nerve pain is more often burning, electric or tingling, tends to travel down the leg, and is reproduced by tests that tension the nerve rather than tests that load the tendon. Both can hurt near the sitting bone and both can be aggravated by sitting, so the distinction comes from where the pain is, what it feels like, how it responds to tendon loading and how it responds to neural testing. The two can also coexist.
Where does proximal hamstring tendinopathy hurt?
The hamstring tendons attach to the ischial tuberosity, the bony point you sit on. Proximal hamstring tendinopathy typically manifests as deep buttock pain at that common hamstring origin. People usually point to one spot low in the buttock, sometimes with an ache spreading a short way into the upper back of the thigh.
The pain tends to behave like other tendon pain. It is often stiff at the start of activity, may ease once warmed up, and can be worse later or the next day after a heavy session. Hills, speed work, lunges, long strides and deep forward bending are common aggravators. It is load-related: walking on flat ground may be comfortable while running uphill is not.
What does sciatic nerve pain feel like?
Sciatic nerve pain describes symptoms along the course of the sciatic nerve. People often describe burning, electric, shooting or deep aching pain, sometimes with tingling or numbness. Symptoms commonly travel down the back of the thigh and may continue below the knee into the calf or foot.
The source can be a lumbar nerve root or the sciatic nerve itself in the deep gluteal space. Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space. Its causes include the piriformis and other short external rotators, fibrous bands, ischiofemoral pathology and hamstring conditions. The difference between a lumbar root problem and deep gluteal entrapment is covered in deep gluteal syndrome vs. lumbar radiculopathy.
Why do both hurt near the sit bone?
Anatomy explains most of the overlap. As the sciatic nerve leaves the deep gluteal space, it passes just lateral to the ischial tuberosity, close to where the hamstring tendons attach. An irritated tendon and an irritated nerve can therefore produce pain within a few centimeters of each other, and patients often cannot tell which one they are feeling.
Pain location still helps. Tendon pain is usually focal at the attachment. Nerve pain is more often diffuse, may be felt along a line down the leg, and is less tied to one tender point.
Why does sitting aggravate both?
Sitting is a common complaint in both conditions, for different reasons.
- Tendon: the proximal hamstring tendon is exposed to both tensile load and compression near the ischial tuberosity. Sitting, particularly with the hip deeply flexed, compresses the tendon against the bone. In an irritable tendon this can provoke pain without any exercise.
- Nerve: sitting places pressure on the deep gluteal region, and hip flexion increases tension on the sciatic nerve. An irritated or entrapped nerve may respond with buttock pain, leg symptoms or tingling.
Because sitting aggravates both, it does not separate them on its own. What happens during sitting is more useful: a focal ache at the sitting bone points toward the tendon, while spreading leg pain, burning or numbness points toward the nerve.
How does tendon loading change symptoms?
Tendon pain responds to how much load the hamstring is taking, especially in hip flexion. Graded tasks, such as a single-leg bent-knee bridge, a long-lever bridge, an arabesque or a single-leg deadlift, increase hamstring demand step by step. If the familiar sitting-bone pain rises as the task gets harder, that supports a tendon source.
Specific pain-provocation tests are also used. In a study of 92 athletes, the Puranen-Orava, bent-knee stretch and modified bent-knee stretch tests showed high reliability between examiners and moderate-to-high validity for proximal hamstring tendinopathy, with the modified bent-knee stretch test performing best. The authors still recommended combining the tests with other measures rather than relying on any one of them.
Expert physiotherapists interviewed in a 2021 study similarly described diagnosis as a clinical reasoning process built on the patient interview and load-based provocation tests.
How does neural testing change symptoms?
Neural tests tension or slide the sciatic nerve while keeping the hamstring load similar. The straight-leg raise and the slump test are common examples. Adding ankle dorsiflexion or neck flexion at the end of the test increases tension on the nerve without changing hip position. If that reproduces or increases the familiar buttock or leg symptoms, a neural component becomes more likely. If the pain stays the same and only the back of the thigh feels tight, the tendon or muscle is a more likely source.
A neurologic screen of strength, reflexes and sensation helps identify nerve-root involvement, which changes the pathway.
What can palpation tell you, and what can't it?
Pressing on the ischial tuberosity often reproduces tendon pain, and that is useful information. It does not settle the diagnosis on its own. The nerve lies close by, the area is deep under the gluteus maximus, and pressure can be uncomfortable even in people without a tendon problem. Palpation is most useful combined with the location of symptoms, the response to loading and the response to neural testing.
Can proximal hamstring pathology irritate the sciatic nerve?
In selected patients, yes. Fibrous structures associated with the proximal hamstring tendons can restrict the sciatic nerve in selected patients, a presentation surgeons have called hamstring syndrome. In one series, surgeons treated 16 patients with 22 operations to release tight fibrous structures associated with the hamstring tendons near their origin, reporting complete relief in 11 cases, good relief in 8 and fair relief in 3. Another series of 47 releases in 44 high-level athletes reported average pain falling from 6.5 to 2.0 on a 10-point scale.
These are retrospective surgical case series in carefully selected patients. They show that the tendon and nerve can interact, not that most high hamstring pain is a nerve problem. Surgical biopsies from another series of proximal hamstring tendinopathy found typical features of tendinosis in all 15 specimens examined, which supports the view that the core problem in most cases is in the tendon itself. Fibrous entrapment of the sciatic nerve more broadly is discussed in can fibrous adhesion entrap the sciatic nerve?
When should lumbar radiculopathy be considered?
A lumbar nerve root should be considered when leg pain is worse than buttock pain, symptoms travel below the knee, back movement or coughing changes the leg symptoms, or there are changes in strength, reflexes or sensation. Progressive weakness, numbness in the saddle area, or new bladder or bowel changes need urgent medical assessment.
When does MRI or ultrasound help?
Imaging is usually not needed to make the initial diagnosis. It becomes more useful when a tear or avulsion is suspected, the diagnosis is unclear, neurologic findings are present, or symptoms do not improve as expected.
MRI findings need careful interpretation. In a study of 118 pelvic MRIs, more than 90% of proximal hamstring tendons showed increased internal T1 or T2 signal, and this was not associated with symptoms. Larger tendon size, ischial tuberosity edema and feathery signal around the tendon were more closely related to symptoms. A crescent-shaped high-signal area at the tendon-bone junction, called the sickle sign, indicates a partial-thickness tear.
Can tendon pain and nerve entrapment coexist?
Yes. A sensitive tendon and an irritable nerve can occur together, especially in long-standing cases. When both are present, treatment usually addresses the tendon's load tolerance and the nerve's sensitivity together rather than choosing one explanation. That is why we test the tendon, the nerve and the lumbar spine separately at the first visit.
How Novo approaches deep buttock pain
We take a detailed history, test tendon loading and provocation, perform neural and neurologic testing, screen the hip, deep gluteal space and lumbar spine, and review previous imaging. Treatment follows the diagnosis. See how we approach proximal hamstring tendinopathy and sciatica and sciatic nerve entrapment, read the proximal hamstring shockwave evidence review, or book a new patient exam.
References
- Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(6):483-493. PMID 27084841. (link)
- Cacchio A, Borra F, Severini G, et al. Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. British Journal of Sports Medicine. 2012;46(12):883-887. PMID 22219215. (link)
- Nasser AM, Pizzari T, Grimaldi A, et al. Proximal hamstring tendinopathy: expert physiotherapists' perspectives on diagnosis, management and prevention. Physical Therapy in Sport. 2021;48:67-75. PMID 33378733. (link)
- De Smet AA, Blankenbaker DG, Alsheik NH, Lindstrom MJ. MRI appearance of the proximal hamstring tendons in patients with and without symptomatic proximal hamstring tendinopathy. American Journal of Roentgenology. 2012;198(2):418-422. PMID 22268187. (link)
- Kizaki K, Uchida S, Shanmugaraj A, et al. Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020;28(10):3354-3364. PMID 32246173. (link)
- Saikku K, Vasenius J, Saar P. Entrapment of the proximal sciatic nerve by the hamstring tendons. Acta Orthopaedica Belgica. 2010;76(3):321-324. PMID 20698451. (link)
- Young IJ, van Riet RP, Bell SN. Surgical release for proximal hamstring syndrome. American Journal of Sports Medicine. 2008;36(12):2372-2378. PMID 18818432. (link)
- Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. American Journal of Sports Medicine. 2009;37(4):727-734. PMID 19218559. (link)
- Sheean AJ, Arner JW, Bradley JP. Proximal hamstring tendon injuries: diagnosis and management. Arthroscopy. 2021;37(2):435-437. PMID 33546782. (link)
