Hamstring Pain: A Physical Therapist’s Guide
As a physical therapist, I see hamstring pain or back of the thigh pain quite often. It affects runners, active adults, weekend athletes, and even people who spend most of their day sitting. Many patients tell me the same thing: “I didn’t do anything. It just started hurting.” But the truth is, hamstring pain is rarely random. It is almost always the result of patterns that have been building over time.
Sometimes the pain is actually from the sciatic nerve, but today, I want to break down why hamstring injuries happen, how the anatomy plays a role, and what you can do to recover and prevent the discomfort from coming back.
Understanding Your Hamstrings: The Real Anatomy Behind the Pain
The hamstrings are a group of three muscles located on the back of your thigh. They attach at the top of your pelvis at a bony point called the ischial tuberosity and anchor below the knee on the tibia. I often tell patients to think of the hamstrings like a hammock. They span across two major joints. They do not connect to the femur bone the way people assume. Instead, they float behind it like “hamhocks”.
This placement makes them responsible for both hip extension and knee bending. Because they work across two joints, they take on more strain when other muscles are not doing their job.
Why Hamstring Strains Happen
Hamstring strains are usually small microtears in the muscle. These tears heal by creating scar tissue. And here is the important part: scar tissue never completely goes away. It is part of the healing process, but it also changes how the tissue moves. Over time, this can set someone up for new pain or recurring injuries in other parts of the body.
Here are the most common contributing factors I see:
1. Weakness in the Front of the Hip and Core
This is the number one cause of hamstring issues in the clinic. When the hip flexors, deep core, or glute muscles are weak or underused, the hamstrings step in to do work they were never designed to do. They become overactive and overloaded. And usually it’s the opposite front hip, that is weak, from the injured hamstring.
2. Too Much Sitting
Prolonged sitting shortens the hip flexors and places the hamstrings on stretch for hours at a time. This is one of the reasons my patients, Sean and Eric, developed long-standing hamstring discomfort. They were both active, but their day-to-day sitting setup was working against them.
3. Scar Tissue From an Old Injury
Once you strain a hamstring, the scar tissue that forms can change the way the muscle functions. Even if you feel “healed,” the tissue may not move as smoothly as before. This can cause future issues such as:
- Lower back pain
- SI joint dysfunction
- Foot and calf tightness
- Upper back or shoulder pain due to compensation
Craig is a great example of this. He had scar tissue from a past surgery of his femur, and years later, his hamstring and low back pain were still connected to that old healing pattern.
4. Poor Movement Patterns
If the glutes are not firing correctly or the core is not stabilizing well, the hamstrings try to compensate. This often leads to the classic “pulled hamstring” during running or bending forward.
What Hamstring Pain Feels Like
Hamstring pain can show up in several ways:
- A dull ache in the back of the thigh
- Sharp pain when bending forward
- Pain while sitting
- Discomfort when walking uphill
- Tightness that never seems to go away
- A pulling sensation during running
It is also very common to feel pain right where the hamstring attaches at the sit bone, known as proximal hamstring tendonopathy. This is differentiated from a typical hamstring pain as it is very persistent and can take a long time to rehab and heal, especially with prolonged sitting and can be felt during activities like putting on shoes or pants.
Why Hamstring Pain Can Lead to Other Problems
Because your hamstrings attach at the pelvis, an irritated or tight hamstring can alter pelvic alignment. This affects the SI joint, lumbar spine, and even the upper body, as well as stresses the sciatic nerve leading to sciatica. For example:
- Sean developed SI joint dysfunction over five years.
- Craig developed ongoing low back pain from old scar tissue.
- Brendan experienced upper back and shoulder pain from poor compensation.
- Eric had persistent hamstring pain because the underlying weakness was never addressed.
Your hamstrings never work alone. When they are stressed, everything up and down the chain needs attention.
How a Physical Therapist Differentiates Hamstring Pain vs. Sciatic Nerve Pain
When someone comes in with pain in the back of the thigh, my first job as a physical therapist is to figure out what’s actually causing the pain. Back-of-the-leg pain is often labeled a “hamstring issue,” but that isn’t always the full story.
Sometimes the pain is coming from the hamstring muscle itself, and other times it’s related to irritation of the sciatic nerve — or a combination of both.
To determine the difference, I look at why the pain is there. Is the sciatic nerve being irritated in the lower back? Is pelvic alignment or muscle tension in the buttocks placing pressure on the nerve? Is old scar tissue or tight fascia in the back of the thigh restricting how the nerve or muscle moves? Or is this truly a hamstring strain without any nerve involvement at all?
These distinctions matter because hamstring pain and sciatic nerve pain require very different treatment approaches. Stretching a nerve irritation can make symptoms worse, while strengthening the right areas and improving movement patterns often brings relief. A thorough evaluation allows us to treat the source of the pain instead of guessing based on symptoms alone.
1. Whole Body Evaluation
I look at the hips, low back, pelvis, core, feet, and gait patterns to determine if the hamstring is the victim or the source.
2. Manual Therapy
This may include Integrative Manual Therapy, soft tissue work, myofascial release, or gentle mobilization to reduce scar tissue restrictions and improve movement.
3. Strengthening the Right Areas
This usually includes:
- Glutes
- Deep core
- Hip flexors
- Calves and feet
- Multifidi and spinal stabilizers
When these muscles do their job, the hamstrings finally stop overworking.
4. Teaching Better Movement Patterns
This includes:
- How to bend forward without straining
- How to sit and stand with good alignment
- How to walk and run with balanced mechanics
Tip: When bending forward, whether you are seated to tie your shoes or standing to put on your pants, adjust your pelvis position by either flattening your low back or arching your low back. Use whichever direction allows you to do the activity without increasing your hamstring pain.
Even small adjustments can make a big impact.
5. Progression Back to Activities
Once pain and movement improve, we rebuild strength, flexibility, and load tolerance so you can return to running, strength training, or daily activities with confidence.
When to Seek Help For Hamstring Pain
You should get evaluated if:
- Pain has lasted more than two weeks
- You keep “pulling” your hamstring
- You have pain near the sit bone when sitting
- You have low back or SI pain along with the hamstring pain
- You feel a sudden pop or cannot walk normally
Hamstring issues rarely get better with stretching alone. Proper treatment requires improving strength, alignment, and mechanics from the pelvis all the way down to the feet.
Final Thoughts
Hamstring pain is common, but it is not something you have to live with. When you understand the anatomy and the whole-body mechanics behind the strain, recovery becomes much clearer. If you have been dealing with persistent hamstring discomfort, a whole-body
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