Proximal hamstring pain is a common overuse tendon injury where pain is felt at the top of the hamstrings and buttock crease, where the hamstring tendon attaches onto the sit bone. It is often mis-diagnosed as sciatica which leads to treatments that do not address the true root of the problem.
What causes proximal hamstring pain?
There are three main forces that cause aggravation to the proximal hamstring tendon - stretch, compression, and loading. Changes in these forces can lead to a change in the balance of ‘WEAR’ and ‘REPAIR’ processes in the tendon. These tendon changes are then often accompanied by pain which then affects performance, function and activity levels.The gradual nature of its onset is often why it gets ignored or undiagnosed for longer periods of time compared to an acute muscle injury for example.
Sudden change in training load or intensity
Changes in bike set-up or a new bike - especially dropping front end, longer stem, or starting riding a TT or tri bike for the first time
Change in saddle
Previous hamstring muscle injury
Hamstring inflexibility (especially when combined with a riding position that lies beyond current flexibility capacity)
Hamstring / Gluteal muscle weakness
What are the symptoms?
The number one symptom that riders complain of is pain in their sit bone when sitting on a harder surface, often needing to shift their weight to the unaffected side.
Bending over to touch the floor will often bring strong if not sharp pain right at the top of the hamstrings where they attach onto the sit bone.
Riding on the drops or in a more aero position will create pain on the affected side.
Test your straight leg raise (below) - lying on your back, keeping your knee straight, lift one leg up as high as you can, now compare to the other leg. The affected side will normally be limited and painful compared to the other side.
How can I manage Upper hamstring pain?
Minimise time spent sitting, in particular on harder surfaces. If this is unavoidable (e.g. at work) then try putting a softer cushion on top of the chair (make sure you adjust your chair height accordingly to accommodate the height from the cushion).
Avoid stretching the hamstring. This is often tempting as the hamstring muscles may feel ‘tight’ but in most cases this sensation is owing to the irritation at the tendon and applying further stretch has been found to aggravate the healing tendon.
Reduce riding intensity and duration. This will reduce the workload on the hamstrings.
Try riding on the hoods rather than the drops.
If you are also a runner / triathlete then running is also not recommended in the early stages as it places stretch, compression, and load on the hamstring and its tendon.
Physiotherapy / Exercise
There is good evidence to support the use of a guided, structured and progressive loading programme. The key to these programmes is progressive use of high loads in specific exercises. A specialist physiotherapist will be able to guide you with this. Book a Physiotherapy consultation
In addition to focused work on the hamstrings there are often areas of weakness in the surrounding muscles. A well structured rehab programme needs to include work on these areas also, with particular attention to the gluteals, lower abdominals, core, and lower back muscles.
Sports Massage Cyclists will often describe that they have pain and tightness further down in their hamstring muscles and around their buttock muscles. Sports massage can assist in alleviating some of this discomfort and works very well in conjunction with a loading programme.
It is possible to achieve some of this benefit by using either a foam roller or lacrosse ball to apply some massage to the affected areas but be careful not to apply pressure directly over the tendon and attachment to the sit bone.
Reaching forward excessively to the bars or having to drop lower than your flexibility will allow can increase tension on the hamstring tendons.
Saddle height being set too high will contribute to some of the problems noted above with reach and drop but can also place excessive stretch on the hamstring purely based on demand and over-extension at the bottom of the pedal stroke.
A saddle that doesn’t fit well to the anatomy and shape of your pelvis can start to cause pain quite quickly - a particularly common problem is a saddle that is too wide which then presses into the sit bone during riding.
There is a growing body of evidence supporting the use of shockwave therapy for a multitude of tendon problems. I have written a separate blog piece about shockwave if you would like to read more about it.
It can be very effective at assisting both in terms of pain relief and kick starting the tissue healing process in proximal hamstring tendon problems.
Steroid injections have been used successfully to ease pain and inflammation associated with this condition but the long term impact of corticosteroid injections around tendons is questioned. There is research that indicates a link between steroid injections and future tendon ruptures but this has yet been fully established.
What else could it be?
Sciatic Nerve Entrapment
Referred pain (spinal, sacroiliac joint)
Hip joint arthritis
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