Buttock pain is a common presentation in people who are active in running and sports. There are multiple causes of buttock pain, including referred pain from the spine, sacroiliac joint arthritis and sciatica. We term one cause of buttock pain as Deep gluteal syndrome. How do we diagnose Deep gluteal syndrome, and what treatments are available?
What is deep gluteal syndrome?
The deep gluteal syndrome is trapping of the large sciatic nerve anywhere in the buttock. The sciatic nerve enters the buttock under, through or above the piriformis muscle. In one study, 80% of people had a sciatic nerve passing under the piriformis muscle. The nerve then passes over other buttock muscles behind the large hip joint. Finally, the nerve tracks outside the hamstring tendons and the sitting bone before passing into the thigh.
Where is the sciatic nerve getting trapped?
The sciatic nerve can get trapped in any position from the lumbar spine to the back of the thigh. In a recent study, the most common sites of sciatic nerve trapping are beneath the piriformis muscle (68%), sciatic foramen (6%), and hamstring orion tendons (4%). Other sites of trapping include the quadratus femoris and deep gluteal muscles. Rare cases include pelvic growths or tumours and sacral stress fractures.
Clinical assessment
Trapping of the sciatic nerve into the buttock usually presents pain in the buttock or back of the thigh +/—nerve pain in the leg (often known as sciatica pain). Generally, pain is worse with sitting and better with activity. Sometimes, numbness and pins and needles occur in the buttock or back of the thigh.
It is essential that your doctor thoroughly examines the structures around the buttock to exclude causes of buttock pain from other areas.
Other causes of buttock pain
It is essential to exclude other causes of buttock pain, including:
- Referred pain from the lumbar spine
- Hip joint pathologies such as hip impingement or early arthritis
- Sacroiliac joint injuries such as sacroiliitis or osteoarthritis
- Diseases in the pelvis or abdomen, such as endometriosis, ovarian cysts, kidney stones and prostate cancer
Deep gluteal syndrome tests
Specific tests are helpful when used in an examination. For example, the seated piriformis stretch is often combined with the active piriformis test. The reproduction of pain while performing these tests suggests sciatic nerve trapping. In addition, palpation of the structures around the buttock, such as the piriformis muscle, hamstring origin tendons, quadratus femoris, and sacroiliac joint, can give clues to the likely source of pain.
In most cases, an MRI scan of the buttock is essential to confirm evidence of nerve trapping. Some of the findings in nerve trapping include thickening of the nerve or swelling and enlargement of the muscles, such as the piriformis or quadratus femoris. MRI excludes other causes of buttock pain, such as hip joint arthritis, sacroiliac joint arthritis, and nerve trapping from the lumbar spine.
Studies to test sciatic nerve function are rarely diagnostic. However, nerve studies helps to exclude nerve trapping from the spine or other causes of nerve swelling, such as inflammatory neuritis.
Deep gluteal syndrome treatment
Generally, we recommend simple treatment first. You should see a physical therapist to supervise a programme to strengthen the buttock, hamstring, and hip muscles. Other therapies include hip and buttock stretching exercises and nerve stretches.
Sometimes, medication for nerve pain can reduce pain intensity and improve rehab compliance. Examples of medicines used for deep gluteal syndrome include amitriptyline and duloxetine.
In complex cases, diagnostic injections using ultrasound guidance can be helpful. Depending on the potential site of nerve trapping, injections targeting the piriformis muscle, hamstring origin tendon, quadratus femoris, or pudendal nerve may be proposed. Occasionally, if we think a nerve is trapped by scar tissue, we can try to release it from the surrounding tissue.
Is surgery for deep gluteal syndrome a good option?
Sometimes. Some surgeons use key-hole surgery to explore the sciatic nerve and release the nerve. However, surgery is unpredictable and could worsen your pain. As such, you should only consider surgery once all other treatments have failed.
Deep gluteal syndrome after hip replacement
Pain in the buttock can occur after hip replacement surgery. While post-operative buttock pain might be related to problems with the replacement (such as incorrect positioning or loosening), some cases could be related to nerve trapping in the buttock. A trapped nerve can be secondary to scar tissue formation around the piriformis muscle or hamstring origin tendons.
The first step in assessing buttock pain after surgery is to get an X-ray to confirm a correct prosthesis. Sometimes, we perform blood tests to exclude occult infection. Then, it would be best if you worked hard with your physical therapist to rebuild strength in your hip. In some cases, an MRI may be helpful. Occasionally, ultrasound-guided injections may assist in reducing pain and improving exercise therapy.
Final word from Sportdoctorlondon about deep gluteal syndrome
Pathologies, including tendonitis, joint degeneration or nerve trapping, can drive buttock pain. Deep gluteal syndrome is a different cause of nerve trapping in the buttock. If you have persistent buttock pain, you should see an experienced sports medicine doctor for a correct diagnosis and treatment plan.
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