Identifying the difference between focal or referred posterior thigh pain is critical in developing the appropriate management strategy. Jo Brown explores posterior thigh pain and helps clinicians to determine when a hamstring injury may be a canary in the coal mine for nerve entrapment.
Hamstring injuries account for approximately 12% of all reported sporting injuries. In sprinters, the incidence is as high as 29%, with a recurrence rate of 32%(1). Hamstring injuries present in one of two ways, complete or partial tear during high-speed running or under acute stretch, which commonly occurs in dancers. In addition, the hamstrings often get blamed for pain that is not all their fault. Therefore, accurate diagnosis is imperative in the appropriate management of these cases. The athlete’s history provides many clues to a non-hamstring origin of pain. The broad spectrum of etiological factors for posterior thigh pain includes acute trauma, iatrogenic inflammatory conditions, infectious diseases, vascular abnormalities, and gynaecologic and other space-occupying lesions. Furthermore, clinicians must rule out lumbosacral pathology and other intrapelvic lesions in athletes with sciatic nerve symptoms(2).
A comprehensive subjective examination should guide differential diagnosis between an actual hamstring injury and alternate causes of posterior thigh pain (see table 1)(3).
Hamstring strain |
Referred pain |
Sudden or severe pain |
Sudden or gradual tightness/pain |
Disabling- mobility affected |
Athletes complain of a ‘cramp’ or ‘twinge’ |
Decreased strength/stretch |
Athletes may be able to walk or jog pain-free |
Marked focal tenderness |
Often non-specific tenderness |
Possible local bruising/hematoma |
Slump often positive |
Possible lumbar and SIJ signs |
May have lumbar signs, and gluteal palpation may reproduce pain |
Clinicians must be cautious when assessing athletes when differentiating between a local strain and referred pain. For example, elite runners commonly complain of a ‘cramp’ or ‘twinge’ that clinicians may consider a low-grade strain. However, some diagnostic distinctions include gradual onset, no focal point of tenderness, and unaffected gait or jogging(4). Accurate differential diagnosis and management require an in-depth anatomical understanding of the posterior thigh region.
Sciatica is a colloquially used term to collectively describe the posterior leg pain syndrome caused by the compromised sciatic nerve. However, specific pain patterns exist for different levels of entrapment. Previously known as piriformis syndrome, sciatica is the entrapment of the sciatic nerve as it passes between the piriformis and deep hip rotators. In addition, it is often associated with trauma and limited sitting tolerance(5).
The next level of entrapment is ischiofemoral impingement. This occurs as the nerve gets compressed between the lateral ischial tuberosity and the lesser trochanter at the level of quadratus femoris (and other deep rotators). Athletes may report pain while walking, particularly in mid- to terminal stance(6). As the sciatic nerve clears the pelvis, it can become entrapped by the proximal or distal hamstrings(7). Therefore, clinicians should maintain a high index of suspicion, particularly when the athlete has a history of hamstring injuries. In addition, possible partial avulsion or thickening of the hamstring at any point may entrap the sciatic nerve(8,9). The Straight Leg Raise and Slump tests assess the neurodynamic status of the sciatic nerve.
Historically, clinical symptoms associated with piriformis syndrome were thought to be caused by prolonged and excessive contraction of the piriformis muscle. However, now we have a better understanding of hip kinematics and anatomy. As a result, the clinical evaluation has evolved, and thus the understanding of sciatic nerve mechanics. In addition, other areas within the deep gluteal space have now been identified(10). Although piriformis syndrome is still widely used, these observations led to the introduction of the term deep gluteal syndrome (DGS). It better distinguishes the pathophysiology and clinical symptoms of hip, buttock, and thigh pain and radicular pain caused by non-discogenic and extra pelvic entrapment of the sciatic nerve and its branches.
Early descriptions of sciatic nerve irritation were attributed to the anatomic relationship between the piriformis muscle and the sciatic nerve. On the other hand, DGS may be associated with radicular-type pain due to a non-discogenic sciatic nerve entrapment in other structures within the subgluteal space (see figure 1)(11).
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