Other potential causes for PHT pain with Aidan Rich

overlooked, but they can have serious consequences if left untreated, so it’s crucial to differentiate them from proximal hamstring tendinopathy (PHT). In this article, we’ll explore some other potential causes for lower buttock pain, their characteristics, and how they differ from PHT. We’ll also discuss diagnostic tests and imaging options for each condition.

Proximal Hamstring Tendinopathy (PHT): A Brief Overview

Before delving into other potential causes for lower buttock pain, let’s briefly discuss PHT. Proximal Hamstring Tendinopathy is a condition that primarily affects athletes, especially runners and cyclists. It involves the tendons connecting the hamstring muscles to the sitting bone, leading to localized pain at the base of the pelvis.

Other Potential Causes for Lower Buttock Pain

While PHT is a common cause of lower buttock pain, there are other conditions that can mimic its symptoms. Here are some differential diagnoses to consider:

1. Sciatic Nerve Irritation

  • Sciatic nerve irritation is relatively rare but can cause lower buttock pain.
  • Symptoms may include radiating pain down the back of the thigh, calf, or foot, which differs from the localized pain in PHT.
  • Diagnostic tests include MRI scans to identify fluid accumulation around the sciatic nerve and neurodynamic tests like the straight leg raise to assess nerve involvement.

2. Ischiofemoral Impingement

  • Ischiofemoral impingement is a lesser-known condition where the thigh bone compresses against the ischium or sitting bone.
  • Pain is often felt during hip extension, such as when the leg moves behind the body.
  • Tests like the long stride walking test or passive hip flexor stretches can help diagnose this condition, as pain occurs during specific movements associated with ischiofemoral impingement.

3. Deep Gluteal Muscle Tear

  • Deep gluteal muscle tears are relatively uncommon and can be challenging to diagnose due to the small size of these muscles.
  • Patients may experience pain after running or extended physical activity, often without a clear history of injury.
  • Tests and palpation can help identify tenderness in the affected muscles, although diagnosis can be challenging.

4. Bony Stress Reaction or Stress Fracture

  • Stress fractures are more common in long-distance runners, particularly female athletes.
  • Symptoms may include limping, pain at rest, and night pain.
  • A detailed history, physical examination, and palpation of the affected area can help differentiate between stress fractures and PHT.
  • Diagnostic imaging such as MRI scans is the primary method for confirming a stress fracture.

Diagnostic Tests and Imaging

Each of these potential causes for lower buttock pain may require different diagnostic tests and imaging:

  • Sciatic Nerve Irritation: MRI scans can reveal fluid accumulation around the sciatic nerve, while neurodynamic tests like the straight leg raise can help assess nerve involvement.
  • Ischiofemoral Impingement: Diagnostic tests may include the long stride walking test and passive hip flexor stretches to identify pain during specific movements related to ischiofemoral impingement.
  • Deep Gluteal Muscle Tear: Diagnosis often relies on a detailed history and palpation of the affected muscles.
  • Bony Stress Reaction or Stress Fracture: MRI scans are the primary imaging method for identifying stress fractures in the hip area.

Differentiating PHT from Complete Ruptures

One critical aspect of understanding PHT is differentiating it from complete hamstring ruptures. Complete ruptures typically involve a sudden event, often with a memorable moment when the injury occurred. For example, someone might recall slipping and feeling a sharp pain in their hamstring while walking the dog. This type of rupture usually results in dramatic bruising and is characterized by a rapid onset of symptoms.

In contrast, PHT typically presents with a more gradual onset of lower buttock pain. The pain often intensifies gradually and may be related to activities like stretching or forceful movements. In some cases, water skiing injuries have been associated with PHT, particularly due to over-stretching and muscle contractions. While complete ruptures are characterized by a distinct moment in time, PHT is a slower-developing condition.

Partial Tears and Tendon Health

When it comes to PHT, partial tears of the hamstring tendon are not uncommon. MRIs often reveal partial ruptures in individuals with PHT, and it raises questions about the health of the tendon before the injury. Can a healthy tendon rupture, or does it require a pre-existing condition?

Most individuals with PHT and partial tears show significant degenerative changes in the tendon when examined through MRIs. However, many of them have no prior history of pain in that region. This phenomenon is not exclusive to PHT; similar trends are observed in conditions like Achilles tendon ruptures, where individuals may have no history of pain but still exhibit significant tendinopathy or degenerative changes in the tendon.

This suggests that pain might be protective, signaling to the body to offload the tendon and use it less for powerful, explosive movements. It also indicates that tendon pathology might exist even before the symptoms appear.

Referred Pain from the Sacroiliac Joint

Another aspect that can make diagnosing PHT challenging is the possibility of referred pain from the sacroiliac joint (SIJ). The SIJ is where the sacrum meets the pelvis, and it is a relatively stiff joint with limited mobility. Pain from the SIJ can mimic PHT symptoms and may be more commonly associated with vague, fleshy buttock pain.

Various tests, such as Laslet’s test, can help diagnose SIJ pain by reproducing the symptoms through specific movements or compressing the joint. Pregnant individuals often experience SIJ pain, and it can be exacerbated by activities that load the joint, like twisting or sitting.

Referral from the Lower Back

Lower back issues can also refer pain to the buttock region, potentially leading to misdiagnosis or confusion. There are two primary categories of referred back pain: somatic pain, arising from joints in the back (e.g., facet joints), and pain resulting from sciatic nerve irritation due to disc protrusion or disc extrusion in the lower back.

Specific tests, like compressing or pushing on the facet joints, can help identify somatic pain. Sciatic nerve irritation usually presents with nerve-related symptoms, such as burning, tingling, and sometimes radiating pain down the leg.

The relationship between lower back pain and PHT is complex. While it is essential to explore the connection between the two, it can be challenging to differentiate between them solely based on symptoms. However, observing the relationship between the two conditions and their response to treatment can provide valuable insights.

Hip Joint Pathology

Although relatively rare, hip joint pathology can masquerade as PHT. Conditions like hip joint osteoarthritis, labral tears, or femoroacetabular impingement (FAI) typically cause groin pain. However, they may sometimes manifest as deep buttock pain, especially when activities that load the hip joint exacerbate the symptoms. Movements like getting in and out of a car or rolling over in bed can intensify the discomfort.

False Positives in Imaging

One challenge in diagnosing PHT is the possibility of false positives in imaging studies. An MRI may show changes in the hamstring tendon, such as thickening, but these findings do not always correlate with the presence of symptoms. A study involving individuals with no symptoms found that a significant percentage had tendon thickening, raising questions about the accuracy of relying solely on imaging for diagnosis.

The key takeaway is that imaging is a piece of the diagnostic puzzle, but it must be considered in conjunction with other clinical factors, including the patient’s history, pain location, and physical examination.

Ongoing Research Studies

To improve the understanding and management of PHT, ongoing research studies are crucial. Associate Professor Patrick Weinrauch at La Trobe University in Melbourne, Victoria, Australia, is involved in two significant research projects focused on PHT.

Study 1: Isotonic vs. Isometric Exercise

The first study aims to compare the effects of isotonic exercise (typical strength exercises) and isometric exercise (holding a heavy weight without muscle shortening) on individuals with PHT. The study will investigate how these exercises influence pain levels, strength, and sitting-related symptoms in PHT patients. If you’re in Melbourne, Victoria, Australia, and interested in participating, you can contact Patrick Weinrauch for more details.

Study 2: Physiotherapy vs. Shockwave Therapy

The second study is a more extensive trial involving 50 participants. It will compare the effectiveness of physiotherapy, including education, advice, and a progressive strength program, to shockwave therapy for PHT treatment. The goal is to determine which treatment approach is more beneficial for individuals with PHT. This study is anticipated to begin recruiting participants within the next three to six months.

Both studies offer PHT patients an opportunity to contribute to research that can improve the diagnosis and management of the condition. The treatments in these trials are provided at no cost to participants.


While proximal hamstring tendinopathy (PHT) is a common cause of lower buttock pain, it’s essential to consider other potential diagnoses, as they may require different treatment approaches. Differential diagnosis, appropriate tests, and imaging can help healthcare professionals accurately identify the underlying condition and provide suitable treatment. If you’re experiencing persistent lower buttock pain that doesn’t respond to typical treatments for PHT, consult with a healthcare provider to explore these other possibilities and receive proper care.

Proximal hamstring tendinopathy can be a challenging condition to diagnose and manage, given its potential overlap with other musculoskeletal issues and the limitations of imaging. Ongoing research studies like the ones led by Associate Professor Patrick Weinrauch aim to provide valuable insights into the most effective approaches for diagnosing and treating PHT.

Accurate diagnosis, often requiring a comprehensive evaluation by a skilled healthcare professional, is crucial for developing an appropriate management plan. By differentiating PHT from other conditions and considering a combination of factors, including clinical history and imaging, patients can receive the best possible care to alleviate their symptoms and return to an active, pain-free lifestyle