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Getting to the ‘bottom’ of buttock pain can sometimes prove a diagnostic dilemma, due to the number of potential local sources of nociception and relative complexity in anatomical relationships within the posterior hip region. This is compounded by pelvic structures and more remote sources within the lumbar spine. Perhaps this conundrum sometimes leads health and exercise professionals to oversimplify buttock pain and the associated impairments.

The most common things that patients are told when attending for treatment of buttock pain:

  1. It’s related to your sacro-iliac joint (SIJ) - your pelvis is out of place
  2. Your glutes are overactive/underactive
  3. You have piriformis syndrome (a label often used for any pain in the mid-buttock region).

We owe it to those disabled by buttock pain, often unable to sit, sleep well or undertake physical activity, to expand our knowledge in this space, increasing awareness of a larger spectrum of possible diagnoses and their presentations – optimising your ‘Test Kit’ if you like. We are often focused on gathering tools for our treatment tool kit along our professional journey. However, the tools will only be effective if we have an understanding of the person we are treating and the mechanisms and impairments underpinning the condition with which they are suffering.

In a recent call-out to the Twitter community regarding what questions health professionals would like answered around buttock pain, ‘differential diagnosis’ was the overwhelming response and particularly, a starting point for this process. Arguably the journey to diagnosing buttock pain starts before we even walk in the room to greet our patient. We all need some sort of framework that contains a virtual directory of the potential sources of local nociception and more remote sources of pain referral, and a road map for how we might recognise these conditions.

Sources of Buttock Pain - Dr Alison Grimaldi Blog Graphic

The flowchart above outlines the primary musculoskeletal sources of buttock pain and a starting point for differential diagnosis of buttock pain. Keep in mind that particularly in older individuals or more chronic and/or severe conditions, there are often multiple co-existing sources of nociception. Being able to differentiate between tendon and bursal-related pain may not influence your ultimate treatment direction in most situations, but it’s good to start with a framework of possibilities, so you don’t forget that for example there are bursae sitting over the ischium and under the obturator and gluteal tendons, and that the sciatic nerve is only one of many that transit or reside within the buttock region.

Need a quick refresher of the anatomy of this region before we go on?

Watch this short free video, the introductory video from my Lateral Hip & Buttock Pain course. I'll walk you through the anatomy of the region so it's fresh in your mind.

Ready to jump in now? This blog will focus on patient presentation features of lumbar, SIJ and hip joint-related pain. As I started to write down the information, it became evident that I simply couldn't fit it all in one blog. So we'll start with the hardware and then in the next blog I will address soft tissue and peripheral nerve related buttock pain, and other non-musculoskeletal or nociplastic considerations.

Recognising Lumbar Related Buttock Pain

Lumbar Related Buttock Pain

The lumbar spine is a frequent source of buttock pain and should always be in the starting mix of diagnostic possibilities.  Buttock pain of lumbar origin is most commonly either related to neuro-compressive processes, such as radicular pain or stenosis or somatic referred pain from the lumbar intervertebral discs or facet (zygapophyseal) joints.

Features of lumbar related buttock pain

  • Area of pain:
    • Radicular pain often transits from the lower back, across the buttock and into the lower limb, but may present without back and or distal symptoms
    • Buttock pain associated with stenosis is generally in the mid to lower buttock regions
    • Both radicular and stenotic pain are frequently associated with leg and foot pain
    • Radicular pain may initially present in roughly dermatomal distribution but innervation overlap is common and with persistent pain, extra-dermatomal spread of symptoms may occur due to remote immune-inflammatory responses in the ipsilateral and then contralateral dorsal root ganglia and dorsal horns of the spinal cord
    • Bilateral symptoms may be due to central stenosis or mirror-pain in radicular presentations associated with immune-inflammatory response in the contralateral dorsal root ganglion and dorsal horn2
    • Facet related pain may extend down the posterior thigh but is generally more focal than neuropathic pain3
    • Disc and facet pain do not generally refer below the knee
  • Associated Symptoms:
    • +/- lower back stiffness
    • Paraesthesia or numbness linked with radicular pain or stenosis
    • NO paraesthesia or numbness when pain is referred from discs or facet joints
  • Aggravating Factors:
    • Aggravated by lumbar loading – lifting, bending, repeated lumbar movements
    • Stenotic pain gradually increases with duration of standing and walking1
    • Pain may also be exacerbated by sustained postures – sitting, standing
    • Facet related pain is often particularly exacerbated by sustained and dynamic extension
  • Easing Factors:
    • Sometimes eased by change in lumbar position or mid-range lumbar movement.
    • Stenotic pain is usually eased by sitting and lumbar flexion
    • Facet related pain is also reduced in more relaxed sitting positions
  • History of Onset
    • May be acute onset related to lumbar loading – forward leaning, lifting
    • Often intermittent or gradually progressive symptoms associated with more degenerative conditions
  • Patient Characteristics
    • The probability of disc related pain decreases as age increases, while the likelihood of facet related pain increases with age4.

KEY IDENTIFIERS OF LUMBAR RELATED BUTTOCK PAIN

Buttock pain is more likely to be related to the lumbar spine if:
  1. the buttock pain is associated with back pain and their behaviour is linked
  2. pain extends below the knee
  3. there is accompanying leg and/or foot tingling or numbness
  4. there are bilateral symptoms
  5. aggravating factors are related to lumbar loading – leaning/bending (e.g. vacuuming), lifting, repeated/end range lumbar motion, particularly if both back and buttock pain are exacerbated

BUT buttock pain without back or leg symptoms does not rule out the lumbar spine. Somatic referred pain may be more localised.

Recognising SIJ Related Buttock Pain

SIJ Related Buttock Pain

Unfortunately, sacroiliac joint dysfunction still appears to be grossly overdiagnosed and beliefs that are transferred to patients about instability and pelvic malposition are generally unhelpful and may often be harmful. Such approaches may delay patients seeking more evidence-based treatments or even when more appropriate treatment is suggested, ingrained beliefs around the need for regular pelvic ‘adjustment’ may prevent engagement with more active treatments and prevent optimal longer term outcomes.

However, it is also important not to ignore the sacroiliac joint and especially its associated ligaments as sources of nociception. True instability is rare but does occur and even in the absence of excessive mobility, symptomatic overload may occur. While the joint moves very little, it does need to transfer large loads between the lower limbs and trunk. Intrinsic muscle or movement/activity factors or other extrinsic factors may contribute to pelvic overload. It is essential for health professionals to both have a broader awareness of alternative diagnoses and mechanisms underlying buttock pain presentations and also to recognise the features of true SIJ related pain.

Features of sacroiliac joint related buttock pain

  • Area of pain:
    • Pain in the Fortin’s area, around the Posterior Superior Iliac Spine (PSIS)5, *inferomedial
    • May be associated pubic symphysis or groin pain
    • Sometimes patients report pain that extends from the Fortin’s area, down towards the medial ischium and through towards the groin
  • Associated Symptoms6:
    • Feeling of instability in single leg standing
    • Feeling of heaviness of the leg when lifting the leg, particularly the whole leg in supine
    • May report difficulty with initial weightbearing through affected side when rising to stand
  • Aggravating Factors:6
    • Pain and difficulty with load transfer through SIJ – moving from sit – stand, stance phase of gait, lifting into hip flexion, rolling in bed
    • Wide leg, split lunge or single leg function
    • Pain with sustained sitting
    • Supine leg loading tasks e.g. abdominal leg loading exercise may be provocative
  • Easing Factors:
    • Sometimes eased by sacroiliac belt, but this may also increase local pain
  • History of Onset
    • During pregnancy or post-partum, particularly with a history of a traumatic natural delivery
    • History of pelvic trauma – fall onto the ischium or a heavy impact through one leg, traction force through one leg (e.g. fall from horse and dragged via stirrup), slip into splits (forward or lateral)
  • Patient Characteristics
    • More common in females, particularly where trauma has not been involved
    • Those with connective tissue disorders such as hypermobile Ehlers Danlos Syndrome, may present with difficulties on load transfer across the pelvis, particularly in perinatal females

KEY IDENTIFIERS OF SACROILIAC JOINT RELATED BUTTOCK PAIN

Buttock pain is more likely to be related to the sacroiliac joint if:
  1. the primary area of pain is in the Fortin’s area, near the PSIS
  2. aggravating factors specifically recreate pain in the Fortin’s area around the PSIS (rather than pain in the mid-buttock region)
  3. the patient is female/perinatal/hypermobile or has a history of pelvic trauma

Note: consider Ankylosing Spondylitis for males in 20-40year old age group presenting with SIJ region pain – discussed in Part 2 of this blog, next month

Recognising Hip Joint Related Buttock Pain

Hip Joint Related Buttock Pain

Pain experienced in the mid-buttock region should immediately provoke suspicion of a hip joint condition. Hip osteoarthritis (OA) is more readily recognised in the older patient with an antalgic limp, associated groin pain and difficulty reaching their foot due to gradually progressive range restriction. However, younger patients or those with earlier disease may present with more subtle symptoms of intra-articular joint pathology.

While anterior bony impingement is now well recognised, posterior femoroacetabular impingement (FAI) and associated chondrolabral pathology are often overlooked. In addition, posterior laxity or instability of the hip joint remains underrecognised, particularly in those with ‘hip stiffness’ associated with anterior FAI. Anterior impingement at end range flexion and internal rotation results in a levering of the femoral head from the posterior aspect of the acetabulum. Focal instability and overload may also be related to bony undercoverage posteriorly associated with acetabular retroversion. More global hypermobility is usually due to some form of collagen disorder (Hypermobile Spectrum Disorder or hypermobile Ehlers Danlos Syndrome).

Features of hip joint related buttock pain

  • Area of pain7:
    • Buttock pain associated with hip joint conditions is usually experienced in the mid buttock region
    • Often accompanied by anterior hip/groin pain
    • +/or may present with referred pain to the anterior knee and anterolateral leg
  • Associated Symptoms:
    • Hip stiffness is a key sign of hip OA - difficulty reaching the foot of the painful side when dressing/difficulty manipulating shoes and socks1,8
    • Painful limp
    • Posterior instability - giving way, lack of stability or confidence when weightbearing in flexion +/- internal rotation
  • Aggravating Factors:
    • Deep flexion-squatting and sitting - mediated by depth of chair/amount of hip flexion – worse in low seats *car
    • Start-up pain and stiffness in hip OA– pain that occurs immediately on rising to stand and walk, but eases with continued walking (compared with lumbar stenotic pain that is less likely to occur on immediate standing/walking but tends to increase with time in standing/walking1)
    • Pain on weightbearing tasks - buttock pain usually on impact/loading phase, associated with anterior pain that occurs in hip extension, at end stance phase
    • Pain on weightbearing rotation - getting in/out of the car (stance leg), change of direction
    • Pain lifting the leg in/out of car
    • Posterior FAI symptoms may be aggravated by hip extension +/- external rotation.
  • Easing Factors:
    • Eased by changing hip loads – reducing hip flexion – sitting on higher seats, on edge of chair with knee hanging down, reducing impact activity and reducing hip extension e.g. reducing stride length in walking
  • History of Onset
    • May be associated with a single acute trauma involving impact through the foot or knee, hyperflexion or rapid/forceful rotation
    • More often gradual onset or associated with an increase in volume or intensity of activity
  • Patient Characteristics
    • Older age groups - suspect hip OA especially if accompanied by gradually increasing stiffness
    • Risk of hip OA increased with family history of OA, previous trauma, childhood hip disorders (Perthes, Slipped Capital Femoral Epiphysis, Dysplasia) and known Cam morphology (FAIS)
    • Posterior instability - increased risk in those with known acetabular dysplasia, collagen disorders (hypermobility), or anterior bony impingement.

KEY IDENTIFIERS OF HIP JOINT RELATED BUTTOCK PAIN

Buttock pain is more likely to be related to the hip joint if:
  1. the pain is in the mid-buttock region at the posterior aspect of the joint
  2. there is associated anterior hip/groin or knee pain (not explained by a local knee condition)
  3. there is accompanying range restriction – difficulty reaching the foot/manipulating shoes and socks
  4. mid buttock and anterior hip pain are provoked by deep hip flexion and/or repeated hip extension (e.g. walking fast or on a treadmill).

So far we've covered characteristic patient presentation features of lumbar, SIJ and hip joint-related buttock pain. These are 3 major differential diagnoses when assessing a patient with buttock pain. But there are other important potential sources of nociception - soft tissues and peripheral nerves, as well as additional systemic and nociplastic considerations. We'll cover these in part 2 of this blog - sign up to the newsletter at the bottom of this page if you want to make sure you don't miss the remaining information.

Can't wait till next month's blog?

Sign up here for the newsletter and receive an infographic covering the key features of all sources discussed in both blogs, to assist you in optimising your differential diagnosis of buttock pain today.

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.

Out soon!
Dr Alison Grimaldi on the PhysioNetwork Podcast

References

  1. Rainville, J., Bono, J., Laxer, E., Kim, D., Lavelle, J., Indahl, A., Borenstein, D., Haig, A. and Katz, J., 2019. Comparison of the history and physical examination for hip osteoarthritis and lumbar spinal stenosis. The Spine Journal, 19(6), pp.1009-1018
  2. 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
  3. Gellhorn, A., Katz, J. and Suri, P., 2012. Osteoarthritis of the spine: the facet joints. Nature Reviews Rheumatology, 9(4), pp.216-224.
  4. Laplante, BL., Ketchum, JM. and Saullo, TR., 2012. Multivariable analysis of the relationship between pain referral patterns and the source of chronic low back pain. Pain Physician, 15, pp. 171-178.
  5. Fortin, J., Aprill, C., Ponthieux, B. and Pier, J., 1994. Sacroiliac Joint: Pain referral maps upon applying a new injection/arthrography technique. Spine, 19(13), pp.1483-1488.
  6. Vleeming, A., Albert, H., Östgaard, H., Sturesson, B. and Stuge, B., 2008. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), pp.794-819.
  7. Lesher, J., Dreyfuss, P., Hager, N., Kaplan, M. and Furman, M., 2008. Hip Joint Pain Referral Patterns: A Descriptive Study. Pain Medicine, 9(1), pp.22-25.
  8. Fearon, A., Scarvell, J., Neeman, T., Cook, J., Cormick, W. and Smith, P., 2012. Greater trochanteric pain syndrome: defining the clinical syndrome. British Journal of Sports Medicine, 47(10), pp.649-653.

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