Why do I have a pain in the buttock?

Buttock pain can be such a pain, accurately diagnosing it and treating it can also be challenging as there are various things that can be causing the pain. These include:

• Referred pain from the lower back
• Sacroiliac joint pain
• Hamstring tendinopathy
• Deep gluteal pain syndrome

Referred pain from the lower back

It’s quite common for joints that are aggravated in the lower back to refer into the buttock area. We term this somatic referred pain. It is often not accompanied by any neurological changes such as pins and needles or numbness. It is common that when we assess the back it will show something like a sore joint when pressed on that refers to the buttock area, or if it’s an irritated nerve it may also refer further down the leg when we do a nerve stretch test called a straight leg raise. A lot of these episodes of back and buttock pain settle down with time, some treatment and home exercises, however if they are not an MRI is required to establish the source of pain.

Sacroiliac joint pain

In my personal experience I see a lot of patients with lower back and buttock pain that have been diagnosed with sacroiliac joint (SIJ) dysfunction or sacroiliitis. However, this is most often not the case. SIJ pain is common during pregnancy and post-partum, and after falls on the buttock but in most other cases the SIJ is not the driving factor, and we need to rule out hamstring tendinopathy and deep gluteal pain syndrome. A good assessment can establish if the SIJ is the painful area or an MRI can rule out any inflammatory problems in the joint.

Hamstring tendinopathy

This is pain in the buttock crease in response to exercise and from prolonged sitting. As with all tendons there may have been an increase in activity levels be it running or walking, and this puts load through the tendon from which it fails to adapt and becomes painful. We think that compressive load of the tendon against the bone on the deep surface of the tendon is a driving factor. Tension load running downhill is also detrimental. It may be stiff and sore first thing in the morning and then have a warmup effect where it seems to feel a bit better, only for it to stiffen up again on inactivity.

We can ultrasound scan the tendon to see if it looks healthy or degenerative to help diagnose the problem. All tendon injuries need to be managed with a decrease in the offending load and strengthening exercises. We have a 4-stage hamstring tendinopathy programme at Wandsworth Physiotherapy that we can guide you through. A great adjunct to treatment is shockwave therapy and we mostly see that 6 sessions is required alongside the strengthening exercises. Other treatment may include PRP injections to help regenerate the aggravated tendon.

Deep gluteal pain syndrome

This was previously referred to as “piriformis syndrome”. There is great debate in the medical circles as to whether this condition actually exists or if the pain is coming from elsewhere. What we currently think we know is that buttock pain, that is not coming from the lower back, SIJ or hamstring tendon, may be coming from the piriformis in only 25% of cases. The sciatic nerve comes out under the piriformis muscle in most people and a strong and enlarged muscle in some people can irritate the nerve causing deep buttock pain.

However, it could also be irritated by other muscle such as obturator internus or quadratus femoris. We can ultrasound scan the deep buttock muscles to see if any of these are enlarged or compressing the sciatic nerve. Dry needling the area under US guidance can help to reduce muscle size and tension to offload the nerve. In some case injecting steroid or Botox under US guidance has been shown to work.

Finally there are other causes of deep buttock pain such as irritation of the pudendal nerve, ligamentous instability or even endometriosis that can be causing symptoms and if physiotherapy is not working we may need to refer you out for further investigation.

What do I need to do to resolve my buttock pain?

If you are suffering deep gluteal pain and it’s not back pain or SIJ pain it’s best to have an ultrasound scan to image the hamstring tendon and deep gluteal muscles from which we can inform which treatment modality is required.