Nerve Pain in Hamstring?

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Docs weigh in on whether sciatic pain causing persistent ache in hamstring

Member Question

I have been a runner and triathlete for more than 15 years. In the past 3 years, I've noticed an increase in an annoying pain that I think might be related to the sciatic nerve. I used to think it was a tight hamstring, but sports massage therapists could never seem to work it out, no matter how hard they dug at it. The pain is dull and feels like it is in the head of the hamstring muscle. I have zero mobility problems and it doesn't seem to get any worse.

I have a feeling it's a nerve problem, not a muscle problem. It has come on as I've hit 40 years old and life has gotten busier, resulting in less-than-ideal training, while still trying to race triathlons at least once per year. The pain comes on as soon as I start a run, and will sometimes ache in the evening after I've run in the morning. It's not a big problem, but I'd love to find a way to relieve the discomfort, or at least reassure myself I'm not doing permanent damage. I've been training the same way with essentially the same equipment for years, just less consistently in the past 3 years. I also have a documented "hip drop" on the right side at the moment of heel strike, which was revealed in a gait analysis. I run in minimalist shoes and ride a tri bike. I'm 5'3" and weigh about 118 lbs. I've had two children, the most recent born 10 years ago.

Answer by James Suchy, MD and Caitlyn Mooney, MD
Members, AMSSM

There are several causes of pain in the area of your hamstring. A thorough physical exam and history by a physician will likely be beneficial to help differentiate between the potential causes. As massage therapists often do not address the underlying causes of hamstring pathology, I think it’s still very possible that the pain you are experiencing is from your hamstring, based on the location and that it’s exacerbated by running, a hamstring dominant activity. The term “hamstrings” actually refers to three muscles on the back of the leg: biceps femoris, semitendinosus, and semimembranosus. These muscles form attachments between the pelvis and the lower leg, acting as the primary muscle force in knee flexion (bending) and hip extension (pushing the thigh backwards relative to the pelvis). Other muscles, including the glutes and piriformis, are in the same area and could also cause your pain. Below I’ll highlight some possible cause of your pain: chronic hamstring tendinopathy, biomechanical imbalance (i.e. hip drop), and sciatica.


Chronic Hamstring Tendinopathy


Acute hamstring muscle strains and tears often have a clear onset and inciting event just prior to the symptoms starting. When hamstring pain is more gradual, achy, and vague over a long period of time, one must consider chronic tendinopathy or muscle inflammation. The upper attachment point of the hamstring muscle is at the ischial tuberosity (sit bones) which is the site where runners can develop chronic proximal (high) hamstring tendinopathy. Those with proximal hamstring tendinopathy complain of ongoing pain in buttocks region that is worsened by repetitive activity like running. Pain may even radiate down the length of the hamstring muscle. Other exacerbating factors include pain with sitting, which places additional pressure on your sit bones, or when bending at the hip, which stretches your upper hamstring muscle. You mentioned that the pain begins when you start running, but does it get better throughout the run or worsen? In the case of tendinopathy I would expect that pain to worsen such that you might not be able to complete some of your faster-paced runs.

In terms of diagnosis, MRI is the best imaging modality to identify hamstring pathology. Treatment is tricky, as strengthening, flexibility exercises, and massage have not been proven to be highly effective, although can be attempted for several months along with ice/heat, rest, and NSAIDS (if deemed safe for you to use by your physician). Another treatment option is extracorporeal shock-wave therapy (ESWT) that delivers an electrical charge that breaks up scar tissue and improves circulation, theoretically promoting healing. If these options fail, then corticosteroid injections and biologic treatments such as PRP injections are the next steps prior to surgery.


Biomechanical Imbalance and Hip Drop


Biomechanical imbalance occurs when the musculoskeletal system is misaligned either in static postures or kinetic movement. Biomechanical imbalance can occur almost anywhere within the body. In response to the imbalance, the body develops compensatory patterns that make up for areas of muscle weakness or tightness. Greater levels of stress will be placed on certain muscle, bones, and joints to make up for deficiencies in other areas. This compensation works in the short term, allowing you to run or perform your physical activity. But over a long period of time, joints wear faster and muscles are more easily strained due to unnaturally high stresses placed upon them.

Hip drop is a particularly well-known biomechanical imbalance that develops in some runners. Hip drop is noticeable during the stance phase of running, when body weight is being supported on one side, and the opposite hip drops down in relation to the weight-bearing side. Hip drop is best visualized when observing a runner from behind. This commonly occurs because of hip muscle weakness in the weight-bearing leg. The abnormal angle created between the femur and pelvis of the weight-bearing side puts additional pressure on the hamstrings and surrounding muscles to compensate. It’s entirely possible that your chronic hamstring pain could be the direct result of your hip drop.

You can talk to a physical therapist or athletic trainer about exercises you can do to improve hip drop and correct the biomechanical imbalance that is placing the additional strain on your hamstring muscles. To get you started, I’ll explain a functional exercise meant to mimic the running motion. This exercise is performed while standing on a single leg, similar to the running stride, and therefore will translate into the greatest improvement in your actual running form. Try single leg squats on a bench or box. Form is important to prevent injury and reinforcement of incorrect movement. Do this exercise in front of a mirror and make sure your knee stays in line with your foot and your hips stay level with each other. Once you master this squatting movement, you can add a hip abduction movement (lift the non-weight-bearing leg to the outside) at the top of the squat motion. Gradually increase the number of reps as tolerated. These exercises will improve your leg muscle’s ability to work in unison.


Sciatica


Sciatica similarly can cause pain in the back of the leg. Sciatica essentially means pain caused by irritation, inflammation, or irritation of the sciatic nerve. People usually experience a nerve-type pain, or neuropathy, that feels like a tingling, needle-like discomfort or numbness that can start in the rear glutes or upper hamstring and radiate down the back of the leg and into the foot. Most people with sciatica will also have lower back pain since the cause of the sciatica originates there. Sciatica in and of itself is a set of symptoms and not a diagnosis. In other words, the sciatic nerve becomes irritated, but sciatica can result for many reasons including a herniated lumbar disc (gel-like cushion between vertebrae herniates against the nearby sciatic nerve root), piriformis syndrome (piriformis hip muscle overlying sciatic nerve spasms and tightens over the nerve), among others. Knowing the likely cause of sciatica is important because it dictates the specific therapy exercises that will provide the most relief. A doctor or physical therapist should be able to assess this.

Based on the description provided I can’t definitely say you are experiencing sciatica. A special test that doctors use to evaluate for sciatica is called the straight leg raise test. This test can be performed at home with the help of a partner, and may reveal the cause of your pain. Lie down flat on your back. Have your partner lift the leg of your affected side up and towards your body, while you keep your leg straight. Depending on your hamstring flexibility, you will naturally feel a stretching sensation in your hamstring. This is normal. Most people with sciatica will experience a re-elicitation of their nerve pain somewhere between 30-70 degrees of elevation relative to the ground. This test is not the be-all end-all and should be evaluated in conjunction with the rest of your history and physical exam. Again, seeing a doctor to rule in or out sciatica is preferable.


Summary


Often times, acute and chronic muscle pains can be relieved with the proper type and quantity of physical therapy and other conservative measures (rest, heat/ice, Tylenol/NSAIDS). It’s always best to talk with your doctor about what is best for your condition. If your pain persists despite this, an MRI would be the next step to make a definitive diagnosis and ensure no other causes of your pain. I hope this information helps you along the road to recovery and best of luck with your future triathlon endeavors.




James Suchy, MD
UC Irvine
Co-author: Caitlyn Mooney, MD




Reference:
Fields, K. B., Copland, S. T., & Tipton, J. S. (n.d.). Hamstring muscle and tendon injuries. Retrieved February 21, 2017, from http://www.uptodate.com/contents/hamstring-muscle-and-tendon-injuri...

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date: February 28, 2017

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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