What If Your Thigh Pain Isn’t a Hamstring Strain and What to Do About It

Stay the CourseThe title of this post is purposefully reminiscent of one of our most popular articles on plantar foot pain. When Editor-in-Chief Bryon Powell came up with that title, I was at first critical of such an unrefined name. That is, until I realized how such wording helped many ailing, frustrated runners find the article. Indeed, a great number of runners are diagnosed with ‘plantar fasciitis’ yet:

  • Their injury doesn’t quite fit the mold of actual plantar-fascial pain; and/or
  • Their ‘plantar fasciitis’ fails to improve as a result of conventional treatment.

It was a powerful article and it continues to help folks today because it raised awareness to the notion that you can have pain in your foot from other structures other than the plantar fascia. This concept, called differential diagnosis, simply asks, “What else could it be?”

In that same vein, we now turn our attention to a long-overdue subject, hamstring pain. In this article, we talk about what it is and what else pain in your posterior thigh can be.

Hamstring Pain Defined

The hamstring is a muscle group on the posterior aspect of the thigh comprised of three muscles in parallel. Together they play mostly a supportive role while running, helping to:

  • Swing and drive-through a shortened leg when striding forward;
  • Slow the foot between the swing-through phase and landing;
  • Stabilize the leg during stance phase; amd
  • Extend the leg behind upon push-off.

In the efficient state, the hamstring seldom gets overworked, especially among trail and ultrarunners. When it does occur, the muscle can strain. This means that individual muscle fibers (out of many thousands) are torn. Mild strains occur when only a small number are torn. Moderate or severe strains occur when more numerous (or focal) fibers are torn. In severe (and very rare) cases, the entire muscle (across all the fibers) can tear.

A few factors can add excessive load to the hamstring. For trail and ultrarunners, these factors include:

  • Overstriding. When the foot swings and lands too far in front of the body’s center of gravity.
  • A ‘low-legged swing’: This is a failure to adequately lift the heel during swing through. This keeps the hamstring ‘long’ and tensioned. This often occurs when a trail and ultrarunner begins to ‘shuffle’ with insufficient knee and foot lift.
  • Deficient hip extension: If the hip joint (and its primary mover, the glutes) fails to extend efficiently, hamstring overuse may occur, trying to aid in push-off.

[Author’s Note: For a more detailed description of hamstring anatomy, physiology, and function for trail runners, see this article from several years ago.]

In this article, we focus on the other structures that can cause posterior thigh pain. Spoiler alert: there are a lot of structures that can cause pain in the hamstring region, an area that ranges from the posterior pelvis (buttocks) to the back of the knee. The posterior pelvis and thigh are a complex, busy area with many different muscles, tendons, ligaments, bones, joints, and nerves. Each of these groups, if irritated, can cause pain in the area.

Hamstring Pain Versus Something Else

First off, let’s distinguish between hamstring pain and pain from non-hamstring origins:

FactorHamstring InjurySomething Else
Focal pain and tensionYesNo
Radiating painNoYes (often whole leg, or includes buttocks, lateral knee, or lower leg)
Swelling and bruising presentYes (if severe)No
Pain at rest (sitting, lying down)Rarely (unless acute, severe)Yes
Responds to conventional treatment (RICE, massage, stretching, strength to hamstring muscle)YesNo
Healing time2-8 weeks (for mild to moderate)Indefinite

If your posterior thigh pain falls mostly into the ‘Something Else’ category, it is time to consider what other structures might be in play. But before we do, here are some key concepts to keep in mind about our bodies, in general, and the hip area, specifically:

The ‘Hips’ are a Mechanical System

I use a lot of automobile analogies, and I compare the leg, pelvis, and spine to these parts of a car:

  • The tire (leg)
  • The wheel or rim (pelvis)
  • The axle (sacrum)
  • The chassis (vertebral column)

Each part of this mechanical system must move efficiently. Problems arise when one component–or one side of the system–fails to move efficiently.

Posterior thigh pain can come from ‘tire-on-rim,’ ‘rim-on-axle,’ or ‘axle-on-chassis’ issues. So, whether your thigh pain is from a hamstring muscle or something else, the key to getting better is to restore efficiency to this system. Unfortunately, general muscle stretching, strengthening, or rest seldom corrects a mechanical dysfunction. Getting all the parts moving equally is crucial to recovery!

If Your Stride Lacks Efficiency, Anything Can (and Will Continue to) Hurt

Stride inefficiency can cause swing strain or landing stress–whether that occurs to the hamstring muscle; to hip, pelvic, or spinal joints; or to associated connective tissues or nerves. Too much stress and anything can hurt. Removing the source of the stress through stride optimization is paramount for sustained recovery.

Nerves Run from Head to Toe

The sciatic nerve–or all back and leg nerves for that matter–literally runs from head to toe. Our peripheral nerves begin in the brain, run down the entire length of the spine, go into the leg, and continue all the way down to the toes.

Any sort of tension or ‘pinch’ can cause a nerve to become painful. That pain can be localized to the pinch or it can radiate that pain up or down its length. Moreover, there can be multiple ‘pinch points’–areas of tension or motion restriction–that, when combined, break the threshold to create nerve pain. Lastly, nerve pain is often ‘sub-clinical’ to imaging, meaning that diagnostic imaging (x-rays or even MRIs) will fail to see any abnormality. A nerve can be tight and painful without being visibly pinched (let alone strained or torn).

As such, we runners and medical folk need to ‘think like a plumber or an electrician’ and recognize that a problem anywhere along the cord can cause an issue along its length. Thus, if you’re experiencing posterior thigh pain (and you think it could be nerve pain), then you or your medical provider must consider any dysfunctions from head (neck/cervical spine) to toe.

Common Sources of Posterior Thigh Pain

This is not an exhaustive list nor is this a complete how-to for diagnosing (let alone treating!) these conditions. The intent of this list is to merely generate awareness of what other structures can cause pain in the hamstring area. They are listed in order of what I find most commonly at my clinic.

Whole Hamstring Pain

These symptoms tend to affect large areas or lengths of the posterior thigh (which is often a key to differential diagnosis from a proper hamstring strain). The most frequent problem areas are:

  1. Sacroiliac joint dysfunction. The sacroiliac (SI) joint is where the rim meets the axle. It is a tough, stable area yet it also has to ‘spin.’ (Really, it rotates a small amount both in flexion and extension.) Pain can radiate from this area if this joint fails to move, or if it moves too much (because the opposite side fails to move). Here are some examples of what referred SI joint pain feels like. Severe SI joint pain often radiates down the entire posterior thigh. In some cases, it can also refer into the lateral calf.
  2. Sciatica. This is a blanket term for tension and irritation of the sciatic nerve, the large nerve that supplies the entire backside of the leg from the pelvis to the toes. Sciatica can result from any nerve-mobility problem in the spine or in the pelvis (and not necessarily due to compression by the piriformis muscle, a deep hip rotator that runs adjacent this nerve). Sciatic-nerve tension or irritation is generally experienced throughout the posterior leg and often has symptoms at rest, namely sitting (but sometimes also lying flat). Sciatic-nerve tension can be assessed by nerve mobility testing, which generally worsens if adding either foot or spine motion.

Upper Hamstring Pain

For more focal pain in the ‘hip,’ ‘butt,’ or ‘sit bone’ areas, the most frequent problem areas include:

  1. Sacroiliac joint dysfunction. The SI joint can refer pain focally to the upper hamstring and lower pelvis area, especially when the joint irritation is milder.
  2. Lumbar facet joint referral. This is more like ‘axle-on-chassis’ mechanics. The joints of the lumbar spine (chassis) and sacrum bone (axle) can cause referred joint pain. While sciatica (see below) tends to refer a great length down the leg, referred pain can mimic buttock or upper hamstring pain.
  3. Posterior hip impingement. This is a ‘tire-on-rim’ issue, where the back side of the ball-and-socket hip joint ‘pinches’ the joint capsule or other structures. This can cause hamstring-like referred pain.
  4. Obturator nerve or obturator internus muscle pain. Only recently have these structures–and their propensity for dysfunction–appeared on my clinical radar. The obturator nerve is a small branch nerve that comes from the lower spine. It innervates deep into the hip and pelvis as well as the medial thigh. When strained or irritated, both the obturator nerve and its namesake muscle, the obturator internus, can cause pain in the hamstring area.
  5. Honorable mentions: piriformis syndrome (another that is widely over-diagnosed) and cluneal nerve pain.

Lower Hamstring Pain

For focal pain at the bottom of the hamstring, where it attaches at the knee joint and lower leg, the most frequent problem areas are:

  1. Tibiofemoral (knee) joint pain. The knee joint is the articulation of the tibia (lower leg) and femur (thigh) bones. Significant irritation to this joint can refer pain to any side of the joint: front, inside, outside, and the back. Posterior joint pain can refer to the area behind the knee, around where the hamstrings attach to the knee and lower leg area.
  2. Others: pes anserine bursitis, popliteus, or plantaris muscle strain.

Conclusion

Being an effective medical professional doesn’t necessarily require a deep knowledge of orthopedics and sports medicine, precision hands-on skill, scientific protocol, or high-tech gadgetry. Instead, it lies in the accurate diagnosis of what is actually creating the pain. More often than not, such a discovery begins with the question of, “What else can it be?”

If you experience pain in your hamstring area, yet it fails to respond to conventional hamstring muscle treatment or is taking an inordinately long time to improve, it’s important to ask that all-important question and to consider these other structures.

Call for Comments

Have you experienced posterior thigh pain that you–and other medical professionals–thought was your hamstring, but it turned out to be something else? If so, what was your experience and treatment approach?

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 9 comments

  1. Trailmomma

    Dealing with this now. Have had Xrays, MRIs, Shockwave, Physical Therapy and most recently, PRP (Platelet Rich Plasma) injected into my high hamstring (where it attaches to the bum). You forgot ischial tuberosity as that can relate to the hamstring as well. My final diagnosis was a prior partial tear that I ran through (the injury happened in a bad pilates class – followed by continued running/training) and has resulted in tendinopathy. The most painful thing in the world, is sitting. This injury is a bummer of all bummers. You don’t realize how much one uses the hamstring in daily life. Bending over to tie your shoes, yoga, stairs – the hamstring is involved and the only thing to do right now, is to NOT stretch it as that is bad for any kind of tear. Hopefully the PRP works followed by some physical therapy to strengthen it and perhaps a gait analysis to ensure that my weak hip flexors don’t knock me off track later. Thanks for this article.Very timely for me.

  2. Ryan Whitehead

    An overlooked issue: high hamstring tendinopathy. See reference: https://www.sports-health.com/sports-injuries/leg-injuries/chronic-high-proximal-hamstring-tendinopathy

    I’ve suffered from this and it can radiate down the leg and generate considerable pain / discomfort at rest. Acute trauma can be a cause but, as I understand it, so can the other causal factors you noted. For me the path to recovery was PRP + long recovery (without a heavy training load and no intense work) followed by a lot of strengthening under eccentric load and work on form + range of motion.

    1. Trailmomma

      Ryan, that’s what I am dealing with right now. See my above comment. Ugh. It literally is a pain in the a$$ and super frustrating. I just had PRP done last week. The not running is killing me though.

      1. Joe Uhan

        Hey guys-

        Thanks for the comments.

        In my experience: real, actual proximal high hamstring tendinopathy is *exceedingly rare* (that’s not to say you guys aren’t experiencing it). Muscles and tendons heal. Chronic hamstring tendinopathy can occur, but it’s normally driven my a joint dysfunction were “things aren’t moving/aligned right” in the pelvis. This causes chronic/constant tension or overuse.

        So, if I can to quantify what I see clinically. Of all the distance runners with “hamstring [area] pain”:

        70% have no actual issue with the hamstring muscle or tendon (it, instead is SI joint, lumbar, hip joint, nerve, — all the things described above)
        25-29% have hamstring irritation driven by a pelvis/hip joint dysfunction (doesn’t move/align right)
        1% acute hamstring pathology.

        Should either of you fail to fully recover from your current issues, you need to first look into:

        A.) pelvic/hip alignment, or
        B.) structures and issues entirely non-hamstring.

        -Joe

        1. Ryan Whitehead

          Noted on rarity. Mine was only diagnosed via ultrasound after years of mis-diagnosis, so was merely looking out for those fringe cases.

        2. Trailmomma

          Thanks! Duly noted. I felt a “pop” taking a trial pilates class with a bad instructor. Lesson learned. But I don’t rule out that I may also have hip dysfunction or alignment issues as I lack flexibility on one side but the initial pain started with that class followed by not backing off in training at all. An MRI showed some tendinopathy in that area and an ultrasound before PRP also showed some … when I can, I am definitely going to look into possible form issues and weak glutes etc.

  3. Bethany Patterson

    Great post since I’ve been dealing with this issue since last November. Without insurance, I refuse to pay for an ortho visit to a doc who will just tell me to go to PT. I had an MRI done which showed nothing, no tear, no bursitis, no tendinopathy, nothing. Yet, I have this lingering pain on my sit bone which at times feels like sciatic type pain. From reading your description, mine almost sounds like joint dysfunction, but it’s never been an issue before now. This all came about after doing marathon training (I’m an ultrarunner trying to find some speed). I’ve been dealing with this since my marathon last fall and no real answers. I chalked it up to hamstring tendinitis or sciatica or piriformis, but nothing seems to help. So frustrating. How do you assess joint dysfunction or treat that? Rest didn’t help, slower running didn’t help, can’t stretch without pain, rolling, dry-needling etc have made it better but it’s still there. So frustrating!

    1. Joe Uhan

      Bethany-

      Thanks for sharing and sorry to hear about it!

      Self-assessment of joint mobility/symmetry is difficult, but that is why I wrote this series:

      https://www.irunfar.com/2017/01/performance-mobility-part-1-introduction-and-hip-mobility.html

      Start there. Go through all the metrics. The knee to chest and rotation metrics, in particular, may reveal a relevant imbalance. Beyond that, going to a really good, comprehensive PT is your best bet. Folks from this list are the very best in the country:

      http://www.naiomt.com/index.cfm?fuseaction=page.viewPage&pageID=770
      http://www.instituteofphysicalart.com/index.php/ipa/world/view/

      Good luck!

  4. Jeannie

    The “no” for radiating pain on a hamstring injury is not true. I tore my hamstring 3 years ago and had very significant radiating pain both down my leg and (more) around my hip. True, it was likely the sciatic nerve causing the radiating pain but it was triggered by the torn hamstring. After I had my surgery, my doctor (who is the Team physician for the Vikings) told me the sciatic nerve is frequently affected and involved with hammy injuries.

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