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? 

We define deep gluteal syndrome as trapping the large sciatic nerve anywhere in the buttock. The sciatic nerve enters the buttock either under, through or above the large piriformis muscle. In a cadaver 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 ischial tuberosity (sitting bone) before passing into the thigh.

Where is the sciatic nerve getting trapped? 

buttock anatomy

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 ususally presents with 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.

Generally, it is essential that your doctor thoroughly examines the structures around the buttock, such as the lumbar spine, sacroiliac joint and hip, to exclude causes of buttock pain from these areas.

Other causes of buttock pain

It is essential to exclude other causes of buttock pain, including:

Deep gluteal syndrome tests

Specific tests are helpful when used in combination with a general examination. For example, the seated piriformis stretch is often combined with the active piriformis test. Reproduction of pain while performing these tests suggests sciatic nerve trapping. In addition, careful 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 or nerve trapping.

In most cases, an MRI scan of the buttock is essential to confirm evidence of nerve trapping in the buttock. 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 (nerve conduction studies) are rarely diagnostic. However, it 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 conservative treatment first. You should see a physical therapist who can supervise a programme of strengthening the muscles in the buttock, hamstring and hip. Other therapies include hip and buttock mobility exercises and neural 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 cases resistant to conservative measures, diagnostic injection 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 a nerve hydro dissection to release the nerve from surrounding tissue. Examples include the sciatic nerve at the piriformis or the pudendal nerve near the sitting bone.

Is surgery for deep gluteal syndrome a good option? 

Sometimes. Some surgeons use key-hole surgery to explore the course of the sciatic nerve and decompress the nerve if they find possible trapping sites. However, surgery in this area is unpredictable and could worsen your pain. As such, we suggest you only consider surgery once all other treatments have failed, including several injections.

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 prosthesis (such as incorrect positioning or loosening), other 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 the correct placement of the 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 glutes, hamstring and hip flexors muscles. In cases of intractable pain, an MRI may be helpful to highlight possible pain drivers in the buttock or lower lumbar spine. Occasionally, ultrasound-guided injections may assist in reducing pain and improving exercise therapy.

Final word from Sportdoctorlondon about deep gluteal syndrome

Various pathologies, including tendonitis, joint degeneration or nerve trapping, can drive buttock pain. Deep gluteal syndrome encompasses different causes 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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