I’ve been training and competing the last three years in speed walking. Then last month, I started to have buttock pain whenever I try to increase my pace. It’s sharp pain and there’s tenderness right over the sit bone. Sometimes it goes all the way down to the middle of my thigh (on the back side). What could be causing this and what can I do for it?

You may have a condition called hamstring syndrome or proximal hamstring syndrome. Proximal just refers to the fact that the problem (and the symptoms) occur at the top of the hamstring muscle rather than down at the bottom where it inserts into the knee area.

The proximal (upper portion) hamstring muscle attaches to the ischial tuberosity. The ischial tuberosity is the part of the pelvic bone that we sit on — otherwise referred to as the sit bone. With proximal hamstring syndrome, the sciatic nerve becomes tethered or attached by adhesions or scar tissue to the hamstring muscle. There may be a specific (hamstring) injury that led to the start of this problem. Or the symptoms may have developed slowly over time creating a chronic problem of hamstring tears with scarring and eventual tethering.

But there are other possible causes of buttock pain such as piriformis syndrome, hamstring tears, or sciatica. You will need to see an orthopedic surgeon to get a definitive diagnosis. The surgeon takes a careful history and performs an exam to make the diagnosis. Usually, the pain pattern of proximal muscle syndrome is slightly different from these other conditions. There is pain in the buttock that goes down the leg toward the back of the knee. When the examiner presses on the ischial tuberosity, it reproduces the pain or is tender.

Sitting or stretching the hamstrings also brings on the painful symptoms. This pattern is different from a hamstring tear where the pain is more in the muscle belly or the piriformis syndrome where the tenderness is deep in the buttock muscles. Weakness of the hamstring muscle is also common with proximal hamstring syndrome. The athlete is unable to run at full speed — or even increase the pace in that direction.

Nerve conduction tests were not always helpful. The results are just as likely to be positive or negative in patients with proximal hamstring syndrome. A better test is performed with the patient prone (face down). Strength of the hamstring muscle is tested with the knee bent to 30 degrees and compared with the same strength test at 90 degrees. Severe weakness with the knee flexed at 30 degrees (compared with normal strength at 90 degrees) is a good test for this problem.

Once an accurate diagnosis has been made, then a plan of care can be determined. Usually, conservative (nonoperative) care is advised before considering anything more invasive such as surgery.