Getting to the bottom of buttock pain – Part 2
In this blog on causes of buttock pain, we'll turn our attention to soft-tissue and nerve sources of nociception in presentations of buttock pain. We'll also cover other sources of buttock pain not to be overlooked. In last month's blog we explored lumbar, SIJ and hip joint related buttock pain. If you missed the first blog, you might like to jump on over there to read the first instalment. Within that blog, you can also take a walk through the anatomy of the region in a short free video.
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Soft Tissue Related Buttock Pain
Myofascial structures are obvious sources of nociception in the buttock, which is abundant in muscles, tendons, bursae, ligaments and other fascial structures. The term ‘fascia’ includes all collagen rich structures such as tendons, ligaments, and all the connective tissues that surround and separate our muscles, nerves and organs1. While we are still in the infancy of our understanding of the role of fascia in pain states, it is well innervated, particularly in more superficial fascial sheets and should be considered as a possible source of nociception.
The features below are more specific to muscles and tendons but keep in mind the potential for more diffuse pain and spread of symptoms that might in some cases be related to fascial expansions rather than neurogenic mechanisms such as radicular pain. The research is growing in this field, so further clarity in the role of fascia should emerge over time.
Features of soft tissue related buttock pain
- Area of Pain:
- Pain is usually relatively localised to the nociceptive tissue
- Associated Symptoms:
- May be accompanying stiffness or weakness
- Aggravating Factors:
- Pain aggravated by activity/ loading of the specific tissue
- usually on initial loading after rest and
- on loading of the tissue beyond its level of load tolerance (dependent on local and central factors)
- Pain at rest usually only if
- acute/inflammatory condition or
- positional - relating to direct loading of tissues e.g. ischial pain in sitting with proximal hamstring tendinopathy
- Pain aggravated by activity/ loading of the specific tissue
- Easing Factors:
- Common to experience pain on initial activity that eases during warm-up and then may return if load tolerance level is reached during activity, or after cool-down.
- Rest generally eases pain, unless the condition is acute/inflammatory condition or the patient adopts a position of provocative load for the particular tissue
- History of Onset
- History usually reflects some form of overload
- Acute high-load trauma – history of injury or accident
- Fatigue overload – Abnormal stresses on normal tissues – increase in training volume or intensity
- Insufficiency overload – Normal stresses on insufficient tissues – the overload may not be initially apparent, but in deconditioned individuals and/or those with significant structural pathology, relatively low loads may result in overload and nociception
- History usually reflects some form of overload
- Patient Characteristics
- Muscular injury/overload is more common in active individuals
- Tendon conditions present in both active individuals (e.g proximal hamstring tendinopathy in runners) and older, deconditioned and/or sedentary individuals
- Tendon conditions are common in post-menopausal females
KEY IDENTIFIERS OF SOFT TISSUE RELATED BUTTOCK PAIN
Buttock pain is more likely to be related to muscles or tendons if:
- the pain is localised to a muscle or tendon
- the pain is aggravated by activity or specific loading of the tissue beyond its level of load tolerance
- the pain eases with rest and light activity, below load tolerance level
- there is an identifiable history of overload – acute, fatigue or insufficiency
Nerve Related Buttock Pain
Local nerves running through the buttock can also be responsible for both local and/or remote symptoms. The sciatic nerve is the largest and most recognised source of local nerve related buttock pain. Entrapment or irritation of the sciatic nerve as it passes through the buttock has been given many names, among them the more well recognised piriformis syndrome and deep gluteal syndrome (read more about syndromes of the buttock here).
Unfortunately, such terms are used to encompass myofascial and even referred sources of pain in some cases, doing little to enhance differential diagnosis, clinical reasoning and treatment planning. There are also a multitude of smaller local nerves that provide sensory and motor supply to tissues of the buttock. All of these nerves are capable of producing neuropathic pain. If you haven’t already refreshed your anatomy of the region, you can view the video in Part 1 of this blog to review the deep and superficial nerves of the buttock, but here is a summary graphic below.
Features of nerve related buttock pain
- Area of Pain:
- Area of nerve entrapment (nociceptive pain) and area of nerve supply (neuropathic pain)
- Sciatic entrapment/irritation (deep gluteal syndrome2) – mid and/or lower buttock pain +/- distal pain (sciatica) +/- lower back pain, but the buttock pain is usually the initial and worst area of pain.
- Cluneal nerves serve the skin of the buttock producing local pain
- As discussed in lumbar related pain, extra-territorial spread of symptoms may occur due to remote immune-inflammatory responses in the dorsal root ganglia and dorsal horn3. Patients with cluneal nerve entrapment have been reported to present with ‘sciatica-like’ symptoms, relieved by surgical release of cluneal nerve entrapment4.
- Nature of Pain:
- Often described as burning and/or sharp or shooting pain
- Also, may experience a deep ache, particularly with nerves within the deep gluteal space
- Associated Symptoms:
- Dysaesthesia/paraesthesia – tingling, change in sensation, itching/crawling sensations
- Altered temperature sensitivity (deficit in cold and/or warm detection5)
- Cramping in the buttock, posterior thigh and/or sometimes calf
- Gluteal weakness – may be pre-existing, pain inhibited or possible gluteal nerve injury
- Weakness of external rotators – may be pre-existing, pain inhibited or possible nerve injury
- Aggravating Factors:
- Sitting – tolerance is often limited to 30minutes or less
- Slump type postures or activities where nerves are on stretch or moving between structures in the buttock
- Cluneal nerve pain may be exacerbated by direct pressure (tight belt/pants) or stretch of the thoracodorsal/gluteal fascia through which the nerves transit to the skin
- Night time pain (and/or cramping)
- Gluteal and particularly deep rotator exercise (deep gluteal space entrapments)
- Easing Factors:
- Getting up and moving – from sitting and at night
- History of Onset
- May have history of trauma e.g. impact +/- haematoma to buttock, pelvic fracture
- Previous surgery or intramuscular injection into the buttock
- History of muscular overload of deep rotators – physical labour, gym/sport, trail running on uneven surfaces
- Patient Characteristics
- Variable
- Presentation may be influenced by other general health issues and psychological stressors
- Higher rates of neuralgia in those with connective tissue disorders6
KEY IDENTIFIERS OF NERVE RELATED BUTTOCK PAIN
Buttock pain is more likely to be related to local nerves if:
- the patient reports burning, sharp or shooting pain and/or itching/crawling skin sensations
- pain is associated with paraesthesia, numbness or altered mechanical and temperature detection
- poor sitting tolerance in the absence of focal ischial pain or back pain +/- development of distal symptoms while sitting
- night pain and/or cramping not significantly improved by change in position but improved by walking
- reports previous significant pain exacerbation following buttock massage and/or gluteal exercise
- pain response is often cumulative and delayed
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Other Causes of Buttock Pain
While the lumbar spine, SIJ, hip joint, soft tissues and nerves are the most common sources of nociception associated with buttock pain, it is important to be aware of those less common causes. Missing these may have substantial consequences for our patients, so we all need to ensure we listen and assess carefully.
Bony Sources of Buttock Pain
The other musculoskeletal structure within the buttock is of course, bone. Although relatively rare, be aware of the possibility of stress fractures of the pelvis, particularly the sacrum - commonly misdiagnosed as sacroiliac joint pain, or the ischiopubic ramus.
These will present most commonly as fatigue fractures in endurance runners, particularly females with Relative Energy Deficiency in Sports (RED-S) but can present in either sex, or as insufficiency fractures in older osteoporotic individuals. Onset of pain is usually rapid and significantly impedes activity, but sometimes symptoms may develop slowly and diagnosis can be delayed.
Ischial apophysitis or avulsion injury may occur in adolescents involved in sports with high hamstring loads e.g kicking sports or rapid acceleration. Remember that the ischial growth plates may not fully fuse until 25 years of age, so keep these diagnoses in mind even for athletes in their late teens and early 20's7.
Intrapelvic and Vascular Sources of Buttock Pain
The other adjacent region with potential referral sources is the intra-pelvic space. Pelvic pain is sometimes overlooked but particularly if your patient is female, some extra questioning around cyclical nature of pain, pelvic health and history is well warranted. Back, sacral and buttock pain are common areas of pelvic organ pain, or linked with prolapse, pain post prolapse surgery and with pelvic floor and related obturator internus dysfunction. Buttock pain may also arise due to either intrapelvic or extrapelvic vascular conditions. Pain associated with vascular structures is usually described as throbbing, pounding or pulsating.
Malignancy, Infection, Nociplastic Pain States and Systemic Causes of Buttock Pain
Systemic causes, nociplastic pain states and psychosocial contributors to any pain presentation should always be considered. There are also other processes that cause nociception within musculoskeletal structures, such as malignancy or infection, so questioning around general health is mandatory.
We have focused on nociceptive and neuropathic mechanisms for buttock pain, but I did want to highlight the need for early identification of spondyloarthropathies such as axial spondyloarthopathy and ankylosing spondylitis (AS). There is often substantial delay between onset of symptoms, diagnosis and management of AS, particularly in those who are HLAB27 -ve8. Awareness and screening is key to early diagnosis. Pain onset is usually in the 20's or 30's and patients report back and buttock pain with morning stiffness that lasts more than 30minutes, isn’t eased with rest but improves with activity and anti-inflammatory medication. While this diagnosis might come to mind more readily when assessing a male patient with these symptoms, sometimes it is overlooked in females due to other more common sources of pelvic pain. Make sure you consider this differential diagnosis in any such presentation, regardless of sex.
Use Paul Kirwan’s great SCREENDEM tool to check the clinical indicators:
- Skin - rash or psoriasis?
- Colitis or Crohns?
- Relatives – family history of inflammatory arthritis?
- Early Morning Stiffness?
- Eyes – has the patient had Uveitis (painful red eye with photophobia and blurred vision)?
- Nail involvement? Nail pitting, thickening or detachment
- Dactylitis? Sausage-like swelling of the fingers
- Enthesopathy? Pain at entheses - Achilles, plantar fascia and patellar most common
- Medication and Movement response? Pain reduced with movement and anti-inflammatories but not rest
Download your FREE 10-page eBook
Easily recognise the potential source of nociception or referral within the differential diagnosis of Buttock Pain, with this Free eBook.
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Are you after even more detail about buttock pain conditions, their pathoaetiology, assessment and management? You'll find plenty of evidence-based information and clinical pearls in my Lateral Hip & Buttock Pain course. Or join the video library for access to a growing techniques library of clinical tests and exercises.
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References
- Zügel, M., Maganaris, C., Wilke, J., Jurkat-Rott, K., Klingler, W., Wearing, S., Findley, T., Barbe, M., Steinacker, J., Vleeming, A., Bloch, W., Schleip, R. and Hodges, P., 2018. Fascial tissue research in sports medicine: from molecules to tissue adaptation, injury and diagnostics: consensus statement. British Journal of Sports Medicine, 52(23), pp.1497-1497.
- Martin, H., Reddy, M. and Gómez-Hoyos, J. (2015). Deep gluteal syndrome. Journal of Hip Preservation Surgery, 2(2), pp.99-107.
- Schmid, A., Hailey, L. and Tampin, B., 2018. Entrapment Neuropathies: Challenging common beliefs with novel evidence. Journal of Orthopaedic & Sports Physical Therapy, 48(2), pp.58-62
- Aota, Y., 2016. Entrapment of middle cluneal nerves as an unknown cause of low back pain. World Journal of Orthopedics, 7(3), p.167.
- Ridehalgh, C., Sandy-Hindmarch, O. and Schmid, A., 2018. Validity of Clinical Small–Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration. Journal of Orthopaedic & Sports Physical Therapy, 48(10), pp.767-774.
- Bénistan, K. and Martinez, V., 2019. Pain in hypermobile Ehlers‐Danlos syndrome: New insights using new criteria. American Journal of Medical Genetics Part A, 179(7), pp.1226-1234.
- Papastergiou, S et al, 2020. Apophysitis of the Ischial Tuberosity: A Case Report. Journal of Orthopaedic Case Reports, 10(1), pp.82-85.
- Deodhar, A., Mittal, M., Reilly, P., Bao, Y., Manthena, S., Anderson, J. and Joshi, A., 2016. Ankylosing spondylitis diagnosis in US patients with back pain: identifying providers involved and factors associated with rheumatology referral delay. Clinical Rheumatology, 35(7), pp.1769-1776.
