When can barely sit at your desk or in the car due to buttock pain, signs likely point to proximal hamstring tendinopathy (PHT), “a condition involving often painful changes in the hamstring tendons where they attach to the pelvis,” according to Sports Physiotherapist Andrew Stephens of Olympic Park Sports Medicine Centre.
“There are not many other conditions that cause such strongly localised ‘Sitting Bone’ pain, Stephens, physiotherapist for the AFL umpires said. “Patients will often say, “I literally can’t sit down for more than 20 minutes.”
What’s the cause?
Increasing age, hormonal changes at menopause, genetics and family history can all play a role in the development of PHT, which is generally a “later life condition,” Stephens said. While these intrinsic factors can’t be altered, we can change extrinsic factors such as training errors - the reason why gym buffs, sports or running enthusiasts and older athletes commonly develop PHT.
“Even a small change in your workout routine can have big consequences,” and can set off PHT, Stephens said. “If you start running and hitting the gym at the same time, this doubles the demand on your hamstring tendons, leaving you vulnerable to breakdown”.
Significant compressive loads on the tendons can occur with the sudden addition of deep and heavy squats or dead-lifts in the gym, with lunging or hill running, or with strong hamstring stretching.
“PHT can be difficult to diagnose: some low back and hip conditions may refer pain to the region and also be aggravated by sitting. Tendons require their own unique treatment regime that focuses on load and exercise self-management.”
Treatment dos and don’ts
If the hamstring tendons are the source of the pain then there are a few rules to follow:
Firstly, don’t rest completely in hope that the pain will pass with time; choosing rest over rehab will only reduce the ability of the tendon to take the load, said Stephens, who recommends the addition of a progressive weighted hamstring strengthening program.
“Exactly which hamstring exercise is best in each phase of rehabilitation is individual to each person, the location and extent of the pathology, and as a result requires careful selection” Stephens said.
“Current research suggests that exercise is one of the few well-researched ways to rehabilitate the tendon, with the guidance of a sports physiotherapist. Often the patient will start with a simple daily home-based exercise program, and progress to a gym-based program.” The aim of rehab is to gradually improve the tendons’ ability to take on more load, and without the patient experiencing buttock pain.
Massage is another don’t. “Active rehabilitation works better than passive treatments like massage for PHT,” Stephens stressed, referring to “the world-renowned tendon research” by physiotherapist Associate Professor Peter Malliaras (Monash University) and Professor Jill Cook (La Trobe University).
The recovery period can be as long as “three to six months, depending on case-severity and how hard the patient is trying to train,” Stephens said.
“If they have PHT and they’re playing or umpiring football mid-season, or they’re training for a marathon, recovery will be slower,” Stephens said.
Older age can also slow the recovery process. Stephens suggests as much as ten per cent of the AFL umpires he is currently working with have PHT.
“Experienced field umpires are often in their 40s and umpiring every weekend, and they’re often a good 10 to 20 years older than the players running around”
Ultimately, perseverance with your individualised rehabilitation program is key for recovery, Stephens said.
And if you do have that literal “pain in the butt” but have not yet sought treatment, it’s probably time to see a reputable sports physiotherapist so that you can be pain-free sooner rather than later, and so you don’t inadvertently make this debilitating musculoskeletal condition worse.
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