Is your sitting-bone pain sciatica or the hamstring tendon?

Both can cause pain in the buttock and the back of the thigh that is worse with sitting, and hamstring tendon pain at the sitting bone can be mistaken for sciatica. Sciatica usually comes from an irritated nerve root in the lower back, so the pain tends to travel down the leg, often below the knee, and can come with numbness, pins and needles or weakness. Proximal hamstring tendinopathy is a load problem in the tendon where the hamstrings attach to the sitting bone, so the pain sits in one spot and is brought on by sitting on it and by loading the hamstring, without nerve symptoms. One is a nerve sending pain down the leg; the other is a tendon hurting where it attaches.

Written by Kareem Hassanein, Registered Physiotherapist. Burlington, Ontario. This is a guide, not a diagnosis. An in-person exam usually narrows it down, though the two can overlap and some cases need imaging or a second look.

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Other Comparisons

Condition A

Sciatica

Nerve root compressions and radiculopathyRead the full sciatica page Condition B

Proximal Hamstring Tendinopathy

Pain at the sitting bone where the hamstring tendons attach, often worse with sitting, hills and runningRead the full hamstring tendinopathy page

Side by side

The patterns that separate sciatica from hamstring tendinopathy in clinic. Read across each row and compare.

Aspect	Sciatica	Hamstring tendinopathy
Where it hurts	From the lower back or buttock down the leg, often below the knee into the calf or foot. The leg pain is often worse than the back pain, and many people can trace a line down the leg.	One spot on the sitting bone (the ischial tuberosity), low in the crease of the buttock. It can ache into the upper back of the thigh but does not usually travel below the knee.
The lower back	Back pain often comes with it or came first, though some people have little, and back positions change the leg symptoms: bending and long sitting for many people, standing and arching back for some.	The back is usually not part of the story, and moving the back on its own changes little. Bending forward with straight knees can still hurt at the sitting bone, because it stretches the hamstring.
Numbness, pins and needles or weakness	Often present, typically in a strip of the leg or foot supplied by one nerve root (a dermatome), sometimes with weakness in particular muscles or a reduced reflex. Weakness that is getting worse, or a foot that catches or slaps, needs a same-day medical check.	Not typical. If they appear, the lower back or the sciatic nerve beside the tendon is more likely involved and needs checking.
Coughing, sneezing or straining	Can send a jolt of pain down the leg, because they briefly raise the pressure on an irritated nerve root.	Usually makes no difference to the pain.
Sitting	Long or slumped sitting often builds the leg symptoms, and getting up and moving tends to help. Some people are worse standing or walking instead.	Hard seats press directly on the tendon at the sitting bone, so the pain stays in that one spot. Shifting your weight, a cushion that spreads pressure or perching on the edge of the seat may ease it.
Activity and exercise	Bending and lifting often aggravate it, while short walks often help. A hamstring stretch can bring on the leg symptoms, because it also stretches the nerve.	Running uphill or fast, lunges, deep squats and toe-touch stretches bring on the sitting-bone pain, often more later that day or the next morning. Easy walking is usually comfortable.
Lifting the straight leg	Lifting your straight leg, or sitting slumped and straightening the knee, often brings on the familiar leg pain, and moving the ankle or the neck can change it.	The same test may pull at the sitting bone, but moving the ankle or the neck usually does not change it. Stretch tests done with the knee bent often bring on the familiar sitting-bone pain.
How it starts and settles	Often after bending to lift something, or building over a few days. Many people see meaningful improvement within 4 to 6 weeks and recover within about 3 months without surgery.	Usually creeps in over weeks after more hills, speed work or sitting. Recovery is usually measured in months, and a staged loading program may run 3 to 6 months or longer.

Where it hurts: Sciatica
From the lower back or buttock down the leg, often below the knee into the calf or foot. The leg pain is often worse than the back pain, and many people can trace a line down the leg.; Hamstring tendinopathy
One spot on the sitting bone (the ischial tuberosity), low in the crease of the buttock. It can ache into the upper back of the thigh but does not usually travel below the knee.
The lower back: Sciatica
Back pain often comes with it or came first, though some people have little, and back positions change the leg symptoms: bending and long sitting for many people, standing and arching back for some.; Hamstring tendinopathy
The back is usually not part of the story, and moving the back on its own changes little. Bending forward with straight knees can still hurt at the sitting bone, because it stretches the hamstring.
Numbness, pins and needles or weakness: Sciatica
Often present, typically in a strip of the leg or foot supplied by one nerve root (a dermatome), sometimes with weakness in particular muscles or a reduced reflex. Weakness that is getting worse, or a foot that catches or slaps, needs a same-day medical check.; Hamstring tendinopathy
Not typical. If they appear, the lower back or the sciatic nerve beside the tendon is more likely involved and needs checking.
Coughing, sneezing or straining: Sciatica
Can send a jolt of pain down the leg, because they briefly raise the pressure on an irritated nerve root.; Hamstring tendinopathy
Usually makes no difference to the pain.
Sitting: Sciatica
Long or slumped sitting often builds the leg symptoms, and getting up and moving tends to help. Some people are worse standing or walking instead.; Hamstring tendinopathy
Hard seats press directly on the tendon at the sitting bone, so the pain stays in that one spot. Shifting your weight, a cushion that spreads pressure or perching on the edge of the seat may ease it.
Activity and exercise: Sciatica
Bending and lifting often aggravate it, while short walks often help. A hamstring stretch can bring on the leg symptoms, because it also stretches the nerve.; Hamstring tendinopathy
Running uphill or fast, lunges, deep squats and toe-touch stretches bring on the sitting-bone pain, often more later that day or the next morning. Easy walking is usually comfortable.
Lifting the straight leg: Sciatica
Lifting your straight leg, or sitting slumped and straightening the knee, often brings on the familiar leg pain, and moving the ankle or the neck can change it.; Hamstring tendinopathy
The same test may pull at the sitting bone, but moving the ankle or the neck usually does not change it. Stretch tests done with the knee bent often bring on the familiar sitting-bone pain.
How it starts and settles: Sciatica
Often after bending to lift something, or building over a few days. Many people see meaningful improvement within 4 to 6 weeks and recover within about 3 months without surgery.; Hamstring tendinopathy
Usually creeps in over weeks after more hills, speed work or sitting. Recovery is usually measured in months, and a staged loading program may run 3 to 6 months or longer.

What I check in person to separate them

These are the clinical tests I actually run in the first visit. You cannot do them all on yourself reliably, but understanding what they look for helps explain how an in-person exam narrows them down.

Neurological screen (reflexes, strength and feeling)
I test the knee and ankle reflexes, the strength of muscles each nerve root supplies (such as lifting the big toe or rising onto the toes), and feeling in the leg and foot. Clear changes in a nerve-root pattern point to the spine. With hamstring tendinopathy, these are usually normal.
Straight leg raise and slump test, with the neck or ankle moved
Both put tension on the nerve and stretch the hamstring at the same time. In a cadaver study, bending the ankle up changed the strain on the sciatic nerve without changing it in the hamstring, and in pain-free volunteers, moving the neck changed thigh pain without changing hamstring muscle activity. These are useful clues, not proof of where your pain comes from. If your familiar leg pain comes on and changes with those moves, the nerve is the more likely source. They change what people without pain feel too, so what counts is your own familiar pain. A pull only at the sitting bone that does not change points toward the tendon.
Back movements, sometimes repeated
If bending or arching the lower back changes the leg pain, or repeated movements draw it back up toward the spine, the back is likely involved. With tendon pain at the sitting bone, back movements on their own change little.
Pressing on the sitting bone
Pinpoint tenderness right where the hamstrings attach points to the tendon. The buttock can be tender with sciatica too, so I read tenderness alongside the nerve tests rather than on its own.
Bent-knee stretch and Puranen-Orava tests
Stretching the hamstring with the knee bent, in set positions, often brings on the familiar sitting-bone pain in tendinopathy. In a study of athletes, these tests gave consistent results between examiners and helped separate long-standing tendinopathy from no tendinopathy.
Hamstring load tests, such as a single-leg bridge or resisted knee bending
These make the hamstring work hard. Pain at the sitting bone with the effort points to the tendon, and I read the result alongside the nerve tests.

Which pattern fits you better?

Plain-language routing. This is not a diagnosis, and real patients often sit between the two, but the language below is a reasonable starting point.

More likely

Sciatica

Your pattern more likely fits sciatica if the pain started in or alongside your lower back and travels down the leg, often below the knee into the calf or foot, with numbness, pins and needles or weakness. Coughing, sneezing or straining can send it down the leg, and back positions change it: bending and long or slumped sitting for many people, standing and walking for some. Bending to lift something, or a few days of building back and leg pain, is a common start.

Read the sciatica page

More likely

Hamstring tendinopathy

Your pattern more likely fits proximal hamstring tendinopathy if the pain sits in one spot on the sitting bone, hard seats and long drives are the worst part of the day, and running uphill or fast, lunges, deep squats and toe-touch stretches bring it on. There is no numbness, pins and needles or weakness, coughing and sneezing make no difference, and moving your back does not change it. It usually crept in over weeks after more hills, speed work or sitting.

Read the hamstring tendinopathy page

If you still cannot tell

These can be hard to separate on your own, partly because 'sciatica' is often used for any pain at the back of the leg, and no single test settles it. A short in-person assessment can narrow it down. I start with the lower back and a check of reflexes, strength and feeling, then run the nerve tension tests and see whether moving your neck or ankle changes the symptoms. Then I press on the sitting bone and load the hamstring in the positions that bring on tendon pain. If the nerve checks are clear and loading the hamstring brings on your familiar sitting-bone pain, the tendon moves up the list; if there are nerve signs, I work out where the nerve is being irritated, whether in the back or near the sitting bone, and tendon and nerve problems can occur together. Some cases need reassessment as they respond. Imaging is usually not needed to start treatment. I cannot order imaging; when imaging would change the plan, I flag it to your family doctor or a sports medicine physician and refer you.

When both are going on

Both can be present at once. The sciatic nerve runs close beside the hamstring attachment at the sitting bone, so an irritable tendon can sometimes irritate the nerve as well, and a back with a past disc episode can sit alongside a tendon overloaded by running or sitting. When both seem to be in play, I work out which one is driving most of your symptoms and treat that first. Treating only the tendon when the back is driving the leg pain, or the reverse, tends to stall progress.

When to see a doctor first

New trouble starting to pass urine or feeling it pass, new loss of bladder or bowel control, new numbness between the legs or around the back passage, new loss of genital sensation or sexual function, or severe or rapidly worsening weakness in both legs. Go to emergency now. These can be signs of cauda equina syndrome.
Sudden unexplained weakness or numbness in an arm or leg, even if it improves. Call 911 now. This can be a stroke. Do not wait for a physiotherapy appointment.
A new foot drop (the foot catches or slaps when you walk), weakness in one leg that is getting worse, or pain that suddenly starts down both legs or spreads from one leg to both. Same-day medical assessment.
Fever or feeling generally unwell with back and leg pain. Same-day medical assessment.
Fever with back pain and new weakness, confusion, or feeling very unwell. Go to emergency now.
Back pain in someone who has or has had cancer, with shooting leg pain, new weakness or numbness, difficulty walking, or a bladder or bowel change. Go to emergency now. The spinal cord or nerves may be under pressure.
New back pain, or back pain that is getting worse, in someone who has or has had cancer. Same-day medical review; tell them about your cancer history.
Unexplained weight loss, or constant pain at night that does not ease with rest. See your family doctor before starting physiotherapy.

Questions patients ask about telling these apart

My doctor said sciatica, but the pain is right on my sitting bone. Could it be the hamstring tendon?

It could. 'Sciatica' is often used for any pain at the back of the leg, and pain from the hamstring attachment on the sitting bone was described decades ago as a sciatica-like buttock pain. Pain that sits in one spot on the sitting bone, is worst on hard seats, flares with hills, speed or lunges, and comes without numbness, pins and needles or weakness leans toward the tendon. Pain that runs below the knee with nerve symptoms leans toward the back. A focused examination can usually tell them apart.

Does pain below the knee mean it is sciatica?

It shifts the odds toward the nerve. In a study of people seeking primary care for back-related leg pain, pain below the knee, leg pain worse than back pain, a positive nerve tension test and a measurable change in nerve function on examination were the four findings kept in a scoring tool built to identify sciatica. Hamstring tendon pain usually stays at the sitting bone and the upper back of the thigh. It is a pattern, not a rule, so I check it on examination.

Why does sitting hurt with both?

For different reasons. With the tendon, the chair presses directly on the hamstring attachment at the sitting bone, so hard seats are worse, the pain stays in one spot, and shifting your weight or a cushion that spreads pressure may ease it. With sciatica, long or slumped sitting keeps the irritated nerve under stretch, so the leg symptoms build the longer you sit, and getting up and moving often helps. Some people with sciatica are worse standing or walking instead.

Should I stretch my hamstrings?

Not hard while either is sore. Deep toe-touch stretches can aggravate an irritable hamstring tendon, because they add pressure at the sitting bone to the stretch. With sciatica, a hamstring stretch also pulls on the irritated nerve and can bring on the leg symptoms; gentle nerve gliding exercises, which slide the nerve back and forth without holding it on stretch, may help instead. If a stretch brings on your familiar pain or sends symptoms further down the leg, ease off it.

Do I need an MRI to tell them apart?

Usually not to start treatment, because the history and examination separate them in many cases. For sciatica, a magnetic resonance imaging (MRI) scan is usually kept for warning signs, weakness that keeps getting worse, or symptoms that are not improving, where a scan would change the plan, and scans often show disc changes in people without pain. For the tendon, imaging helps when a tear is suspected or progress stalls. I cannot order imaging; when imaging would change the plan, I flag it to your family doctor or a sports medicine physician and refer you.

How long does each take to settle?

Many people with sciatica see meaningful improvement within 4 to 6 weeks and recover within about 3 months without surgery, though leftover symptoms can take 3 to 6 months to settle fully. Hamstring tendinopathy is usually measured in months, and a staged loading program may run 3 to 6 months or longer. For either, I reassess the plan if progress stalls rather than push on.

Evidence this page draws on

Sources I lean on when separating these two conditions in clinic.

In 394 people seeking primary care for back-related leg pain, a simple scoring tool built to identify sciatica (nerve root pain) kept four findings in both versions tested: pain below the knee, leg pain worse than back pain, a positive nerve tension test, and a measurable change in nerve function on examination (a neurological deficit).

Stynes S, Konstantinou K, Ogollah R, et al. "Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain." PLoS One 2018; 13(4): e0191852.

PubMed 29621243

A Cochrane review of 19 studies found that, in people seen for back surgery, the straight leg raise was positive in most of those with a disc pressing on a nerve root but also in many without one. Single findings such as weakness, reflex changes or reduced feeling were poor at identifying it on their own, combining findings did better although few studies tested combinations, and the results may not apply outside surgical settings.

van der Windt DA, Simons E, Riphagen II, et al. "Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain." Cochrane Database Syst Rev 2010; (2): CD007431.

PubMed 20166095

In 92 athletes, half with long-standing proximal hamstring tendinopathy, three tests that stretch the hamstring to bring on pain at the sitting bone (the Puranen-Orava, bent-knee stretch and modified bent-knee stretch tests) gave consistent results between and within examiners and identified the condition moderately to highly well, the modified bent-knee stretch test best. The authors advise using them alongside other measures, such as imaging.

Cacchio A, Borra F, Severini G, et al. "Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy." Br J Sports Med 2012; 46(12): 883-887.

PubMed 22219215

An early series of 59 patients treated with surgery described pain over the sitting bone that spread down the back of the thigh, brought on by sitting, stretching the back of the thigh and running fast, as a new diagnosis of sciatica-like buttock pain, which the authors called the hamstring syndrome. They proposed that tight tissue where the hamstrings attach to the sitting bone was the cause; a surgical series without a comparison group can suggest a cause but cannot confirm it.

Puranen J, Orava S. "The hamstring syndrome. A new diagnosis of gluteal sciatic pain." Am J Sports Med 1988; 16(5): 517-521.

PubMed 3189686

A clinical review describes proximal hamstring tendinopathy as deep buttock pain where the hamstrings attach to the sitting bone, affecting athletes and non-athletes, often long-standing and limiting sport and daily life. Evidence on its diagnosis and management is limited, and principles established for Achilles and patellar tendinopathy appear to apply but are less well documented for it.

Goom TS, Malliaras P, Reiman MP, Purdam CR. "Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management." J Orthop Sports Phys Ther 2016; 46(6): 483-493.

PubMed 27084841

In 11 legs from 6 cadavers, bending the ankle up during a straight leg raise stretched and moved the sciatic nerve in the upper thigh at every hip angle tested, while the strain in the hamstring muscle beside it (biceps femoris) did not change. The authors suggest the move can help separate a nerve source from a muscle source of pain at the back of the hip.

Bueno-Gracia E, Pérez-Bellmunt A, Estébanez-de-Miguel E, et al. "Differential movement of the sciatic nerve and hamstrings during the straight leg raise with ankle dorsiflexion: Implications for diagnosis of neural aspect to hamstring disorders." Musculoskelet Sci Pract 2019; 43: 91-95.

PubMed 31374476

In healthy young adults held in the slump position, lifting the head reduced the pain felt at the back of the thigh by 40 percent on average, while hamstring muscle activity did not change, which suggests the neck movement acts on the nerve rather than the hamstring.

Lew PC, Briggs CA. "Relationship between the cervical component of the slump test and change in hamstring muscle tension." Man Ther 1997; 2(2): 98-105.

PubMed 11485360

In 88 people without symptoms, adding the neck or ankle move changed how far the knee or hip could go during the slump and straight leg raise tests, so a change on its own is a normal response, and the authors advise taking that into account when reading the tests.

Herrington L, Bendix K, Cornwell C, et al. "What is the normal response to structural differentiation within the slump and straight leg raise tests?" Man Ther 2008; 13(4): 289-294.

PubMed 17395520

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Sciatica

Proximal Hamstring Tendinopathy

Side by side

What I check in person to separate them

Neurological screen (reflexes, strength and feeling)

Straight leg raise and slump test, with the neck or ankle moved

Back movements, sometimes repeated

Pressing on the sitting bone

Bent-knee stretch and Puranen-Orava tests

Hamstring load tests, such as a single-leg bridge or resisted knee bending

Which pattern fits you better?

Sciatica

Hamstring tendinopathy

If you still cannot tell

When both are going on

When to see a doctor first

Questions patients ask about telling these apart

My doctor said sciatica, but the pain is right on my sitting bone. Could it be the hamstring tendon?

Does pain below the knee mean it is sciatica?

Why does sitting hurt with both?

Should I stretch my hamstrings?

Do I need an MRI to tell them apart?

How long does each take to settle?

Evidence this page draws on

Treatments that commonly sit inside either plan

Book an assessment