Finally Solving the Chronic Hamstring Pain Dilemma
If you've had hamstring pain for more than 3 months, it's probably more than just the hamstring
Let me guess.
You’ve had pain in the bottom of your buttock and in the middle of the backside of your thigh for several months.
The pain is worse when you are running fast or uphill, and it can get pretty sharp. The pain is bad enough that it shuts you down and you can’t push through it.
Sitting on hard surfaces isn’t fun and can make your whole leg from your glutes to your lower thigh ache.
You’ve been stretching, massaging, and heating your hamstrings until they are nearly mush, but your leg doesn’t seem to care. Massage therapy, chiropractors, physical therapists, and acupuncture hasn’t led to any lasting help.
What is the DEAL?! And how do I know exactly what you’re experiencing?
No, I haven’t been stalking you on Strava or Instagram. Your hamstring-cursing twins just seem to frequent my clinic.
First, you should know that your pain isn’t coming from just your hamstring. If it was, your thigh muscles and tendons would be happily propelling you through miles of blissful, painless running by now.
What Came First, the Back or the egg…I Mean Leg
Let’s get straight to it.
When you can’t seem to shake chronic hamstring pain, you’re likely missing the key ingredients to solving the problem: your nerves and your low back.
I see three common patterns that lead to this chronic hamstring dilemma:
You have a previous or current history of low back or referred lumbar (you would say “sciatica”) pain. If this lingers long enough we’ll see gluteal amnesia creep in. Yes your glutes can imitate Jason Bourne: after suffering pain or trauma to the low back, they might completely forget who they are and what they’re good at.
Why does this happen? That could be too long of a post, but the short answer is because of the nerves that tell the glutes to fire. All three of your glute muscles need clear signals from at least the L5 and S1 nerve roots, which also happens to be the region of the lumbar spine under the most load. Thus, the discs at L5 and S1 are commonly stressed and causing your back or referred leg pain.
If the discs at L5 and S1 aren’t happy, leading to chemical inflammation to gather around the nerve roots, the ability of those nerves to work perfectly can be hindered. Thus, your glutes don’t fire as strongly as needed. But something has to take up the slack so that your hip remains stable every time your foot hits the ground. That role will shift to either the hip adductors, flexors, or hamstrings.
If your hamstrings take that load they likely won’t be able to handle the extra burden for too long. This will lead to injury and pain coming from the hamstring tendons or muscles. Now you have local hamstring pain in addition to back pain or an additional pain in your hip and thigh that is referring from the low back…you follow?
The second pattern I see is easier to understand and unfortunately is quite self inflicted. You have been feeling like your hamstrings are getting really tight. So you turn to the obvious solution…stretch them until you’re feeling looser than Gumby! Except there is one problem. You don’t actually know what you’re stretching.
This is where you say, “Of course I know what I’m stretching, I’m stretching my hamstrings!” Mmm. Probably not. Let’s run through a quick little test.
Get into a hamstring stretch position. Something similar to this:
Image Credit: Popsugar Fitness Get to where you first feel a good stretch in the back of your thigh. Now pull your toes up toward you. Did the stretch intensity change in the back of your thigh or in your back? Relax your toes back down. Now flex your chin down to your chest. Did that change the stretch feeling?
If your stretch didn’t change at all when you moved your toes or your head, congratulations, you probably are just stretching the hamstrings. You can Gumby it up if you really want to. If the stretch DID change when you moved your head and toes, I have one question for you. Why? Do your hamstrings attach to your feet or to your head?
Of course not. What does run all the way from your head to your foot and often doesn’t like to be stretched? Your spinal cord and nerves.
Your hamstrings are feeling tight because there is something making your nerve roots at the lumbar spine a little aggravated. Usually a minor disc irritation at L4, L5, or S1 is to blame. So you decide to stretch, stretch, stretch those hamis. But you’re actually just pulling on already annoyed nerves.
You may feel initial relief when you stretch, but you’re just kicking the tightness and pain down the road. The more you stretch your nerves, the tighter you’ll be later and the more likely you’ll actually increase your pain and problems for weeks and sometimes months to come.
A third possible pattern is you initially injure your hamstring and then decide to stretch your hamstrings as part of your rehab. That’s a VERY bad idea. Your hamstring rehab will take much longer plus you might trigger that same nerve irritation we just talked about it pattern 2.
Time for Some Examples
At this point you may be wondering how I came up with these wacky theories, and what physical therapist doesn’t like stretching? Before you call for a mutiny on this newsletter, I’ll present some case studies for you.
2 Years of Hamstring Pain
When Geraldine (made up name as always) told me she had been having hamstring pain for 2 years I already knew we were looking for something more than just the hamstring.
Her pain started when she tried to run faster than usual to compete with a friend at the end of a long run. She felt a pull and pain in the back of her thigh and lower buttock that immediately ground her to a halt. If she had left it alone, the hamstring muscle and tendon would have likely healed just fine in a matter of weeks and that would have been the end.
But she decided to book a one way trip to Stretch Town! It happens to be our favorite town at Zona because people always come out of that town needing our help. But that’s an aside!
Geraldine’s pain progressed to an aching pain that would radiate from the bottom of her right glute down her thigh and toward the back of the knee. She came to me worried she would never be able to run again. Ever. She was terrified and feeling near hopeless.
Her exam showed typical signs of nerve irritation with a positive straight leg raise and slump, neural mobility sign, and quick hamstring cramping with resisted strength testing.
Did we solve her pain? Of course. If we didn’t I wouldn’t be putting it in here now would I?
The first most crucial aspect of her home plan: STOP STRETCHING!
Sidelying manual traction on her low back really helped reduce her hamstring pain, in addition to sitting nerve glides and teaching her how to brace properly to take load off of her low back.
Once she was able to run we also noted that she tried to run fast she tended to lean back and land a little further in front of her body. This means more load to the hamstrings and low back. So we addressed that problem.
In 3 visits over 3 weeks she was back to running over 6 miles with zero hamstring pain. She nailed her home plan and healed fast. That was over 2 years ago and she’s never had any problems since. With the right diagnosis, pain should go quickly in most cases.
Elite Runner. 10 Years of Pain with No Help.
Let’s make these next cases a lot quicker. Cliff notes version on 1.5x playback speed.
Stacy is an elite competitive runner who has had all sorts of medical staff try to resolve her hamstring pain for the last 10 years but with no change. Her pain is most pronounced when running fast on flat ground.
She also had the same nerve tests show up positive and pain with resisted hamstring tests. But the resisted hamstring tests and running both had much less pain when we treated her low back and nerves. Glute activation was also a crucial part of her home plan that really improved her pain with running over the long term.
She was a classic pattern 1 case. Long term low level back irritation leading to gluteal amnesia and eventually cascading to an overloaded and pained hamstring and nerve root.
Treat the back. Treat the nerve. Treat the hamstring. Problem solved.
Pulled Hamstring? Maybe More
6 months before seeing me, Randi heard a sickening pop in her thigh during a workout. Before that happened, she had been feeling like her hamstrings were always tight so she regularly engaged in stretching marathons. But they still felt so tight!
Now her hamstrings (and nerves) had responded in protest and declared they would take such punishment no longer. She’s a pattern 2 friend. Tight hamstrings from back irritation led to stretching which led to bigger problems.
Her pain was now at its worst when running, deadlifting, and sitting on hard surfaces. She too had pain with all the nerve and resisted hamstring testing.
We had to treat the hamstring tendon itself, but also needed nerve glides, recovery for the low back, and NO STRETCHING!
Randi now runs, deadlifts, and sits on hard high school bleachers to her greatest content.
Great, Other People Got Rid of Their Hamstring Pain. What About Me?
Okay, I know you could read stories of other people getting out of pain all day, but maybe you want some advice for your own pain. I suppose that’s reasonable.
The most crucial aspect of resolving any pain is getting an accurate diagnosis of what is causing your pain. If you have chronic hamstring pain, meaning pain in the back of your thigh or at the bottom of your glutes, here are some hints that your back and/or nerves may also be contributing:
The pain has been lingering for more than 8 weeks, especially if the pain is getting worse.
Your pain is in two different spots, like the middle of the back of your thigh and the bottom of your glutes.
If you feel like both hamstrings have felt really tight in recent months or years no matter how much stretching you’ve done.
If you have a history of back pain or previously have experienced “sciatica” symptoms with shooting, nerve-like pain in your glute and down into your thigh or lower.
If you feel like you can never get your glutes burning when you do exercises that make everyone else’s glutes burn.
Your pain increases or lingers AFTER exercise.
Your pain increases with sitting.
These are possible hints that you are experiencing hamstring AND nerve or low back symptoms, and your pain will only resolve once we treat it all.
Let’s roll through another bullet list of possible treatments to attempt. I would suggest only implementing 1-2 into your home plan at a time so you can know what is helping or not helping.
I would also suggest you find something that triggers your pain, like a hamstring bridge or a straight leg raise test. Try a treatment, then retest that painful movement to find what treatment helps best. Then prioritize using that treatment in your home plan:
No matter where your pain is coming from, for the love of all that is your hamstring health, STOP STRETCHING your hamstrings.
If you have pain right at the base of your glute, that pain could be coming from your hamstring tendon. You’ll want to either foam roll that area or GENTLY sit on a lacrosse ball and massage across the tendon for 3-4 minutes at a time.
Before any exercise or running especially, perform banded side steps or clamshells or anything that gets the side of your glutes burning. And we’re talking SPICY burn. You’re using reciprocal inhibition to temporarily take a little stress off the hamstrings.
If you suspect you have some nerve involvement, try a few different nerve glides, standing or sitting.
If you suspect some low back involvement, you’ll want to learn how to properly brace your core to best stabilize your spine, move like an athlete all day, and start lying down for 5 minutes after you exercise or sit for a long time (Recovery position. More on this in future posts).
These bullet lists should at least give you a good starting point to better understand where your hamstring pain is really coming from and how to start resolving it.
Whew, okay. That felt a little long. I’ve seen this problem enough that I wanted to make sure it was well addressed here to give you hope and some direction. As always, if you need further guidance, you can always schedule a free phone consultation with any of our Zona physical therapists.
Enjoy the extra time you now have since you won’t be stretching your hamstrings for 37 hours each day!