A Real Pain In The Butt: How To Treat ‘Sit Bone’ Pain
Why does my butt hurt so much?
There are lots of things that are a pain in the butt: a flat tire, that pile of laundry that’s sitting in the corner of your bedroom, being forced to listen to the same episode of Cocomelon you’ve already heard a dozen times this week.
Then there’s a literal pain in your butt – something I treat patients for every week as a chiropractor in Brookfield.
Butt pain can come in different forms: sharp shooting pain, tight muscular pain, irritating burning pain at your sit bones. But no matter what kind of pain you’re experiencing down there, you probably want it gone ASAP.
Today we’re going to talk about that last kind of pain – pain at your ‘sit bones‘ – and how to make it stop.
So-called ‘sit bone pain’ is typically deep, annoying and located directly over the ischia – close to where the buttock meets the back of the upper thigh – and it usually gets worse during activities like walking hills, running and/or prolonged sitting or driving.
In most cases, this deep buttock pain is due to either trauma or biomechanical stress where the hamstring tendon attaches to your pelvis. The medical term for it is ischial bursitis or hamstring tendinopathy, depending on the structure we’re talking about (which term you use really doesn’t matter, as they almost always occur together).
What’s bursitis (and what’s tendinopathy)?
So what is bursitis? Bursitis is inflammation of the bursa sacs, which provide a cushion for the muscles, and tendons near your joints. In this case, we’re talking about the bursas that cushion your hamstrings.
Your hamstrings run from just behind your knee, up along the back side of your upper leg and towards your pelvis.
One branch of the hamstring muscle attaches to the upper thigh bone (or femur). The other continues up underneath your glute muscles, with the tendon of the muscle attaching to the pelvis at the ischium (specifically, bony protrusions on the ischia called the ischial tuberosities). Your ischia (or sit bones) are what support most of your weight while sitting.
There are bursa sacs that rest under your hamstring tendons where they glide over the ischia, helping reduce friction between the tendon and the bone. Anything that puts extra tension or stress on the muscle can cause rubbing – and inflammation – of both the bursa and the tendon.
Sometimes the sciatic nerve, which passes close to the ischial tuberosity, can become irritated as well, resulting in pain that radiates down the back of your leg.
Other common symptoms of ischial bursitis/hamstring tendinopathy include:
• Pain when stretching the hamstrings.
• Pain worsening gradually over time.
• Pain aggravated by prolonged sitting, especially on hard surfaces.
Isolating the cause of your butt pain
MRI imaging is the gold standard for diagnosing ischial bursitis and hamstring tendinopathy, as it can spot tendon thickening, tearing, inflammation, and swelling at the ischial tuberosity. They can also rule out stress fractures, septic infections and gout crystal deposits. But a much simpler – and less expensive – way to test if these structures are the source of your problem is a standing or reclined hamstring stretch test.
To perform a standing hamstring stretch test, prop one foot up on a surface that’s a little lower than your hip, such as a chair or bench. Flex your foot towards your body. To increase the stretch, lean forward at your hips.
To do a reclined hamstring stretch test, lie on your back. Raise one leg as high as you can, keeping your pelvis flat on the ground. Hold your lower thigh and pull your leg toward your head.
While they’re not perfectly reliable clinical tests, high hamstring or buttock pain with either of these movements is a good indicator of ischial bursitis and/or hamstring tendinopathy. If these hamstring stretch tests don’t elicit pain, it’s possible that the source of the problem is something totally different.
A host of other musculoskeletal injuries can cause deep buttock pain – including piriformis syndrome, muscle strains, a sacral stress fracture, or pain radiating from low back injuries – so it’s worth checking with your doctor to get a definitive diagnosis.
How do you treat sit bone pain?
Ischial bursitis and hamstring tendinopathy cab be a challenge to treat and can cause frustrating, long-term interruptions to your normal life. Early diagnosis and treatment are critical for getting out of pain fast.
The good news is that surgery is rarely required. And considering the average recovery time for hamstring tendinopathy surgery is five months and can take up to 12 months to fully heal, that’s a relief for everyone looking to bounce back quickly.
So how do you get rid of bursitis (and hamstring tendinopathy)?
Unsurprisingly, Johnny Knoxville’s preferred method of managing bursitis isn’t one that’s recommended by doctors.
3 Steps to relieving sit bone pain
Fixing this problem is a three-part process: 1.) reducing the acute inflammation, 2.) fixing pelvic alignment to reduce tension on the hamstring, and 3.) breaking down any scar tissue and/or fibrous adhesions within the muscle and tendon.
If you’re only addressing the acute inflammation (with ice, NSAIDs, or corticosteroid injections) or going wild on your hamstrings with myofascial release work, but ignoring the altered biomechanics that are putting abnormal tension on the hamstrings in the first place, you’ll never actually eliminate the problem permanently.
Conversely, if you’re just correcting pelvic alignment without addressing the soft tissue damage already done, you’ll always have some degree of chronic hamstring tendon inflammation to deal with.
Disclaimer: This is not a substitute for medical care. Please consult a doctor or healthcare professional to get a medical diagnosis, rule out any serious complications and get advice on a treatment plan for your particular condition before beginning any self-treatment described here.
Reducing acute inflammation
Naturally, the first step is going to be stopping any activity that causes pain or exacerbates it. That usually means biking, running and kickboxing workouts are off-limits for at least a few weeks.
Applying ice or cold packs to the area can help reduce inflammation, along with over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen or ibuprofen. If your pain is really severe, your doctor might recommend a corticosteroid injection directly into the inflamed bursa. Extracorporeal shockwave therapy is also an option if more conservative approaches fail.
But keep in mind that these are adjunct therapies. This means they should not be seen as a stand-alone but used alongside treatment that’s actually correcting the cause.
Once you’ve got the acute pain calmed down, it’s time to tackle the real problem.
Your hamstrings themselves aren’t the problem
Personal trainers, chiropractors and physical therapists all love to prescribe hamstring stretches. Because who doesn’t have tight hamstrings?
But in one of the few comprehensive reviews on treating ‘sit bone pain’, Standford researchers found it was far better to drop the hamstring stretches and instead focus on correcting pelvic tilt to fix the cause of what’s putting tension on the hamstrings instead.
You can stretch your hamstrings until the cows come home, but the fact is that ‘tight hamstrings’ are almost always due to a pelvic positioning issue, not a ‘muscle length’ issue. In fact, aggressive stretching can actually make ischial bursitis and hamstring tendinopathy worse.
Due to the way they attach to the pelvis, the most common reason that hamstrings become stretched is a forward-tilting pelvis – also known as anterior pelvic tilt (APT). Anterior pelvic tilt is an extremely common postural problem caused by a lack of anterior core control and glute activation.
Fun Fact: Muscles will involuntarily contract when stretched due to some handy dandy sensory receptors known as muscle spindles. So, if you’ve developed a wicked case of APT and your hamstrings get put on stretch, they respond by contracting to protect themselves.
Correcting anterior pelvic tilt and stabilizing your pelvis long-term requires a combination of both manual joint manipulation (aka chiropractic treatment) alongside targeted, progressive glute/core exercises. That means adding to your workouts:
Lower ab and external oblique work: Think planks and side planks. Avoid crunches/sit-ups/v-ups, which put stress on vulnerable structures in your lower back.
Hip extension/hip hyperextension work: This includes hip bridges, lunges, and front squats.
Stabilization work: Anything that forces your body to stabilize through the torso (planks, pallof presses, and unilateral work) are all good choices.
Breaking down scar tissue and promoting healing
Finally, you’ll want to utilize myofascial release massage, ART, or Graston Technique (all part of what we do at Ascent Chiropractic) to break down any existing scar tissue or fibrous adhesions, promoting healing of the soft tissues that make up the hamstring tendon.
Be cautious, though: any kind of myofascial work should focus on the muscle and tendon and avoid direct compression on the ischial tuberosity – you don’t need any additional irritation there.
Brookfield Chiropractor Ascent Chiropractic
While what we do at Ascent Chiropractic to correct ischial bursitis and hamstring tendinopathy isn’t necessarily a quick fix – you can generally expect about 8-12 weeks for full recovery of chronic cases – it’s a solution that gets rid of pain naturally (and permanently). And it’s a solution that allows you to return to all the activities that you love in life, even the high-impact, high-intensity ones.
Ready to get started? To make an appointment at Ascent Chiropractic, call 262-345-4166 or schedule an appointment with our online scheduling app.