Question
I am 32 and have been running for several years.  Jogging became running.  I did a marathon once and several 10K.  I get a pain right on the butt bone.   Sitting is painful and I have to do it a lot at work.  The otrhopedist took xrays and said everything is normal then sent me to PT. I've tried sitting on a tennis ball to massage the area but that doesn't work.  My physical therapist has me stretching my hamstrings and piriformis, and I get electric stim and and also do some exercises for the legs.  This has been six months.  It used to get a little better then it comes back.  Now it hurts every time I run and sitting is a problem.  What else should I do?  

Answer
Samantha,

I see this quite often.  For many it is treatable and resolvable.  Your story is quite familiar, as many have tried the "sitting on the tennis ball" thing (which doesn't work).  First, for most cases of "Runners Butt," the problem is the hamstring tendon where it attaches to the bottom-most bone of your pelvis, called the ischial tuberosity.   The ischial tuberosity is the bone you sit on.  It is a connection point for the hamstring, and it also has attachments close by from the tendons of the deep hip rotator muscles.  Maybe you've heard of the piriformis muscle, which is one of six hip rotators.  There also are small fluid-filled bursas around this region of the buttock, one of which is adjacent to the deep hip rotators (the obturator externus muscle).   Lastly, there is a web of connective tissue, fascia, that helps sling all this together.   That was part 1, the general anatomy of the area.  Here's part 2: if it's your hamstring tendon causing your buttock pain, than odds are the tendon is in a state of degeneration.  This is called tendinopathy.  It's not tendinitis, as it is usually not an inflammatory situation, but rather a situation where the substance of the tendon breaks down.  This renders the tendon with swiss cheese-like holes that fill in with crud.  As the internal "matrix" of the tendon degenerates, it becomes a painful tendon.  This "crud," or granulomatous tissue, can also develop around the perifery of the tendon.   This is the classic "runners butt" situation.  Stretching, ice/heat, e-stim, and sitting on a tennis ball will not make this go away.  Before I tell you what does, you have to understand that there are other conditions that cause buttock pain.   That little hip rotator muscle also has a tendinous attachment to the ischium, and there is a bursa there, too, that can become inflammed (the obterator externus bursa).   Buttock pain can also come from an arthritic hip joint, but since the x-rays were normal we'll assume you do not have hip joint arthrosis (degeneration).   Buttock pain can come from a disc herniation in the lumbar spine, where the disc itself will refer to the buttock, or the nerve that exits the spine gets irritated from the disc and causes referred pain into the buttock.  Usually with nerve irritation there is pain into the groin and thigh and/or into the leg.  If you find a good sports chiropractor, they will go through each of these systems/regions and attempt to pinpoint the source of the pain.   A simple hamstring isometric strength test can be the simplest first place to start.  If you get a jolt of pain, odds are it's the hamstring tendon or the tendon's attachment site at the iscial tuberosity (the anatomic zone of tendon attachment to bone is called the "enthesis").    Research shows that the way to change the anatomy of the degenerated tendon involves direct contact and transverse frictioning massage.  Metal works better than a fat finger to do this, and thus the Graston Technique (tm) is the best method to address this (see www.grastontechnique.com).   In conjunction, you need to exercise the region and you should do so with both eccentric and concentric rep's - go slowly up and down - doing single leg deadlifts, single leg dips, and wide stance squats.   You can see a graphic of 1-leg deadlift via www.coreessential.biz (go to exercises).   Some people respond to therapeutic ultrasound over the tendon, and it is considered reasonable to do ultrasound before the Graston Technique.   If your problem is not at the hamstring, but rather in he deep gluteal muscles e.g. hip rotators, then the soft tissue methods must be targeted to that muscle/tendon group.  There are other forms of soft tissue treatment, such as active myofascial release or active release technique (where you move your leg and hip through a range of motion while the practitioner presses with thumbs into the gluteal tissue, for example).  A complicating factor for the hamstring tendon is if it has a tear.  Runners butt people with a tear do not seem to get resolve like others.  MRI should be used if you don't get resolve of your condition, or if it doesn't change at all after about 6-10 treatment sessions.   Lastly, chiropractic joint manipulation to the pelvis and hips may further aid a healing response by creating better joint movement and better muscular responsiveness.   The latter term is an entirely different topic and I can go on at length on it.  Suffice it to say that the sports chiropractor will likely look at your knees and ankles as they are part of a "kinetic chain" that links to your butt...   You can find practitioners via www.grastontechnique.com  and www.acbsp.com    

I hope this was helpful.  

Dr. G
www.drgillman.com