Buttock pain is common in runners and active people. It has many causes, including referred pain from the spine, sacroiliac joint arthritis, and sciatica. One cause is deep gluteal syndrome. How do we diagnose deep gluteal pain syndrome, and what treatments are available?
Deep gluteal syndrome is one of several causes of deep buttock pain.
What is deep gluteal syndrome?
Deep gluteal syndrome is the entrapment of the large sciatic nerve anywhere in the buttocks. The sciatic nerve enters the buttock under, through, or above the piriformis muscle — in one study, 80% of people had it passing under the piriformis. The nerve then runs over other buttock muscles behind the hip joint, before passing outside the hamstring tendons and sitting bone into the thigh.
Where does the sciatic nerve get trapped?
The nerve can be trapped anywhere from the lumbar spine to the back of the thigh. In a recent study, the commonest sites were beneath the piriformis muscle (68%), the sciatic foramen (6%), and the hamstring origin tendons (4%). Other sites include the quadratus femoris and deep gluteal muscles. Rare causes include pelvic growths and sacral stress fractures.
Clinical assessment of deep gluteal pain syndrome
Trapping the sciatic nerve usually causes buttock or posterior thigh pain, sometimes with nerve pain radiating down the leg (sciatica). Pain is typically worse with sitting and better with activity. Numbness and pins and needles can occur in the buttocks or back of the thigh.
Your doctor should examine the structures around the buttocks thoroughly to exclude pain referred from elsewhere.
Deep gluteal syndrome tests
Specific tests help. The seated piriformis stretch is often combined with the active piriformis test — reproducing pain suggests sciatic nerve entrapment. Palpating the piriformis, hamstring origin tendons, quadratus femoris, and sacroiliac joint gives further clues.
An MRI of the buttock is usually essential to confirm nerve entrapment — it may show nerve thickening or swelling of muscles such as the piriformis or quadratus femoris, and it excludes hip arthritis, SI joint arthritis, and lumbar spine entrapment. Nerve studies rarely diagnose it, but help exclude spinal trapping or inflammatory neuritis.
Other causes of buttock pain to exclude
- Referred pain from the lumbar spine
- Hip joint problems, such as hip impingement or early arthritis
- Sacroiliac joint injurie,s such as sacroiliitis or osteoarthritis
- Pelvic or abdominal disease — endometriosis, ovarian cysts, kidney stones, prostate cancer
How do we treat deep gluteal pain syndrome?
We stay. A physical therapist supervises a programme to strengthen the buttocks, hamstrings, and hip muscles, with hip and buttock stretches and nerve glides.
Nerve pain medication can reduce pain and improve rehab compliance — options include amitriptyline and duloxetine.
In complex cases, diagnostic ultrasound-guided injections help. Depending on the likely site, we target the piriformis, the hamstring origin tendon, the quadratus femoris, or the pudendal nerve. If a nerve is trapped by scar tissue, we can release it with nerve hydrodissection — a technique Dr Masci teaches across the UK and Europe.
Is surgery for deep gluteal syndrome a good option?
Sometimes. Some surgeons use keyhole surgery to explore and release the sciatic nerve. But surgery is unpredictable and could worsen the pain, so consider it only once all other treatments have failed.
Deep gluteal syndrome after hip replacement
Buttock pain can follow hip replacement. While it may relate to the prosthesis (incorrect positioning or loosening), some cases come from nerve trapping in scar tissue around the piriformis or hamstring tendons. The first step is an X-ray to confirm the presence of the prosthesis, sometimes accompanied by blood tests to exclude infection. Then work hard with your physiotherapist to rebuild hip strength. An MRI and, occasionally, ultrasound-guided injections can help.
Frequently asked questions about deep gluteal syndrome
What causes deep gluteal syndrome?
Anything that compresses or entraps the sciatic nerve in the buttock. The commonest site is the piriformis muscle; others include the hamstring origin tendon and the sciatic foramen.
Can a fall cause sciatica?
Yes. A fall onto the buttocks can cause a disc bulge that pinches a spinal nerve. It can also cause local swelling and bruising in the buttocks that directly irritates the sciatic nerve.
How is deep gluteal syndrome different from piriformis syndrome?
Piriformis syndrome is one type of deep gluteal syndrome, entrapment specifically by the piriformis. Deep gluteal syndrome is the umbrella term covering entrapment at any site in the buttock, including the hamstring tendons and quadratus femoris.
How long does deep gluteal syndrome take to recover?
It varies with the cause and severity. Many people improve over weeks to a few months with rehab and nerve medication. Injection or hydrodissection can speed things up in stubborn cases; surgery is a last resort.
Final word from Sport Doctor London about deep gluteal syndrome
Buttock pain can come from tendons, joints, or nerve trapping. Deep gluteal syndrome is a specific nerve cause — entrapment of the sciatic nerve in the buttock. For persistent buttock pain, see an experienced sports medicine doctor for an accurate diagnosis and plan.
To book a one-stop assessment with Dr Masci in London, contact the team here or call +44 (0) 203 488 0350.
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