By Dr. Shane Drakes
Pain in the buttock region may not be as common as in other areas of the musculoskeletal system but in some cases it can be severe enough to affect sitting, walking or running and negatively affect a person’s quality of life.
The buttock region extends from the iliac crest (the top of the pelvic bones) to the gluteal folds (the where the buttock ends and the back of the thigh begins). As with all other areas of the musculoskeletal system, the buttock is made up of bones and joints, ligaments which assist with stability, muscles which allow for movement and nerves which provide power to the muscles and sensation to the skin. The bones of the buttock region are the pelvic bones and the sacrum and coccyx which form the lower segment of the spine. The sacrum is joined to the pelvic bones on each side at the sacroiliac (SI) joints. The stability of the SI joint is maintained by strong ligaments in the region. The muscles of the buttock include the three gluteal muscles which are closer to the surface and the deeper muscles which rotate the thigh outwards and help to keep the hip joint stable. The tendons of the hamstring muscles are also attached to the pelvis. The sciatic nerve is a major nerve in the lower limb and this passes through the buttock on the way to the thigh, leg and foot.
Common causes of buttock pain include:
- SI joint dysfunction
- Hamstring tendon origin pain
- Piriformis conditions
- Referred pain from the lumbar spine
SI joint dysfunction refers to either restricted or excessive mobility of the joint. This causes stress on the surrounding structures. Risk factors for development of this condition include:
- Muscle imbalance around the hip
- Leg length discrepancy (one leg longer than the other)
- Biomechanical abnormalities in the lower limbs
Patients with this condition have buttock pain that feels deep, possibly pain with ascending/descending stairs and tenderness over the joint. The pain can travel down into the thigh in some cases. Pregnant women are at increased risk of SI joint dysfunction as a result of hormones causing the surrounding ligaments to relax.
The hamstrings originate from the ischial tuberosity and this is a possible source of pain. In adults, an injury to the tendon at the origin may occur after an acute tear or as a result of overuse. The severity can range from minor tendon tears to the tendon being torn from the bone. In adolescents, a similar injury can result in an avulsion fracture (piece of bone being pulled off) if severe. This occurs because the bones are not fully fused in this age group and the tendon is stronger than the bone. An injury at this site results in buttock pain which may extend into the back of the upper thigh, with worsening with sitting, standing or attempting to walk.
The piriformis muscle starts at the sacrum and attaches to outer part of the upper femur (thighbone). It rotates the thigh outward and helps to maintain hip joint stability. It can be affected by trauma, overuse in repetitive, vigorous activities such as long-distance running and prolonged sitting. Conditions affecting this muscle include strain and piriformis syndrome. In the latter condition, other symptoms include numbness, tingling or a burning sensation in the back of the thigh and leg. These symptoms occur as a result of compression of the sciatic nerve by the piriformis, as a result of an enlarged muscle or abnormal path travelled by the nerve.
In some patients, buttock pain is a result of pain referred from the lumbar spine. The source may be the joints in the lower spine or a herniated disc which may be pushing on a nerve root. In such a case, there will also likely be other symptoms such as back pain, numbness, tingling or burning pain in the leg or weakness of the leg. These other symptoms may be made worse by adopting particular postures.
Appropriate management of buttock pain requires a thorough evaluation to diagnose the cause of the pain. This includes a good history and proper physical examination. In some patients, imaging studies such as x-rays, ultrasound or MRI may be required to help confirm the diagnosis. In patients who have a herniated disc with nerve damage, nerve conduction studies and electromyography will be needed to confirm the presence and severity of the nerve damage. The rehabilitation specialist possesses the knowledge and skills to accurately diagnose the source of the pain and arrange appropriate treatment. This will usually include physical therapy/therapeutic exercises and pain management using oral or injected medications. Patients with herniated discs causing nerve compression or patients with severe hamstring injuries may require referral for surgery.
Get evaluated if you have buttock pain that is not resolving so you can start your journey back to optimal physical function.
(Dr. Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at firstname.lastname@example.org.)