Jump to content

Deep Gluteal Pain Syndrome

Original Editor - Mariam Hashem Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Lucinda hampton, Ewa Jaraczewska, Mandy Roscher, Tony Lowe and Tarina van der Stockt

Introduction

Deep gluteal syndrome (DGS) is an umbrella term for a group of conditions that produce pain, numbness or paraesthesia in the buttock, hip, or posterior thigh, with radiation/radicular pain in the sciatic nerve distribution.[1][2][3][4][5] The term DGS has been used synonymously with piriformis syndrome (i.e. sciatic nerve entrapment by the piriformis muscle),[6] but the concept has broadened to include sciatic nerve entrapment by various structures within the deep gluteal space, as well as conditions such as ischiofemoral impingement, proximal hamstring syndrome and pudendal nerve entrapment.[1][6]

Anatomy

The anatomical borders of the deep gluteal space are as follows:[6][7]

  • posterior: gluteus maximus
  • anterior: posterior acetabular column, hip joint capsule and proximal femur
  • lateral: lateral lip of the linea aspera and the gluteal tuberosity
  • medial: sacrotuberous ligament and falciform fascia
  • superior: greater sciatic notch
  • inferior: ischial tuberosity, where the proximal hamstrings tendon attaches

The deep gluteal space contains six small muscles, often referred to as the "deep six". These are piriformis, superior gemellus, obturator internus, obturator externus, inferior gemellus and quadratus femoris. Of these muscles, piriformis and quadratus femoris are the easiest to palpate.[4] The sciatic, superior and inferior gluteal, pudendal, and posterior femoral cutaneous nerves also pass through this space, as well as a number of vascular structures.[1]

DGS Clinical Presentation

DGS causes buttock or retro-trochanteric pain.[8] Patients might describe sciatic-type pain. Symptoms are usually unilateral, but they can be bilateral. Patients typically have pain with prolonged sitting (longer than 20-30 minutes). They may have pain with terminal hip extension during gait and present with an antalgic gait. They may also have neurological changes on assessment, severe night pain and disturbed sleep.[4]

Sciatic Nerve Entrapment

Sciatic nerve entrapment within the deep gluteal space is the prototypical presentation of DGS. The sciatic nerve exits the deep gluteal space underneath piriformis and passes over the obturator and gemelli complex. It is bounded medially by the ischial tuberosity and laterally by the lesser trochanter of the femur. Due to its position, it can be entrapped by multiple structures in the deep gluteal space, including piriformis, fibrous bands, the obturator-gemelli complex, vascular structures, and bursae.[4][6][9][8] Symptoms include buttock pain, pain with sitting, radicular pain, as well as paraesthesia, weakness and abnormal reflexes in the affected leg.[3]

Pudendal Nerve Entrapment

The sacrotuberous ligament runs from the posterior ilium, lateral sacrum and coccyx to the ischial tuberosity. The sacrospinous ligament lies deep to the sacrotuberous ligament and runs from the lateral margins of the sacrum and coccyx to the ischial spine. The pudendal nerve passes through the lesser sciatic foramen, the opening formed between these two ligaments.[10][11]

Thickening of these ligaments can entrap the pudendal nerve, a condition also referred to as Alcock canal syndrome or cyclist syndrome.[4] Alongside buttock pain, symptoms include sexual dysfunction, rectal pain, faecal incontinence, and urinary incontinence. Symptoms are typically aggravated by prolonged sitting. However, lying flat and sitting on a toilet seat often eases the pain by relieving pressure on the nerve.[4][12]

Ischiofemoral Impingement

Ischiofemoral impingement (IFI) is a relatively rare, but increasingly recognised cause of posterior hip and deep buttock pain. It is commonly linked to trauma and/or hip surgery.[13]

The ischiofemoral space is bordered by the ischial tuberosity and the lesser trochanter. Narrowing of this space can compress the nociceptive structures within it.[4][13][14][15]

IFI causes deep-seated buttock pain. It is often described as a deep ache. Pain sometimes radiates to the knee, posterior thigh, or groin, and it tends to be worse with terminal hip extension and adduction. Runners with IFI may find short strides more comfortable than long strides, as the ischiofemoral space narrows with hip extension and adduction. They may also present with facet-type pain at L3–L4 or L4–L5 due to the loss of hip extension, which can be mistaken for primary lumbar pathology.

MRI is considered the best way of confirming a diagnosis of IFI.[15] However, Gómez-Hoyos et al. (2016) validated two clinical tests for this condition: the ischiofemoral impingement test and the long-stride walking test.[16]

[17]
[18]


Hamstring Tendinopathy

The proximal hamstring tendon originates at the ischial tuberosity, in close proximity to the sciatic nerve. Proximal hamstring tendinopathy is caused by combined compressive and tensile loading of the tendon at the ischial tuberosity. It is common in distance runners and in athletes performing high-velocity sagittal-plane activities (such as sprinting or hurdling) or sports with quick direction changes (such as football and hockey). It can also be caused by deep hip flexion stretching activities (such as yoga, Pilates, dance, or gymnastics) and in sedentary individuals with prolonged sitting.[19]

Patients typically present with a history of a change in load, such as an increase in running volume, deadlifts or other flexion-based exercise, deep stretching, or prolonged sitting.[4] [19] Pain is deep and localised to the ischial tuberosity. It is typically aggravated by sitting (often described as sitting on a boggy mass), driving, lifting from a flexed position, and uphill running.[4] During running, peak hamstring force occurs in late swing, which helps explain why uphill running (with its increased hip flexion) is a common aggravating activity.

Because of the close anatomical relationship between the proximal hamstring tendon and the sciatic nerve, sciatic-type symptoms can co-exist with proximal hamstring tendinopathy. On examination, the slump test is usually positive and patients may have a positive straight leg raise. On palpation, a thickened, boggy mass can often be felt at the ischial tuberosity. Patients may report that sitting on a doughnut cushion eases symptoms by relieving pressure on the area.[4]

Load assessment tests can support the diagnosis. These tests progressively increase compressive and tensile load on the proximal hamstring tendon by increasing the hip flexion angle. Pain scores should increase with progressive loading across the following tests: single-leg bent-knee bridge, long-lever bridge, and arabesque. Initially, the movements can be performed slowly. If the patient remains asymptomatic, the speed can be increased. Further research is required to confirm the diagnostic accuracy of these tests. For more information on assessment, see: Proximal Hamstring Tendinopathy.

Examination

The clinical examination in suspected deep gluteal syndrome aims to rule out other sources of buttock pain, particularly lumbar spine pathology and intra-articular hip pathology, and to identify which structure within the deep gluteal space is generating symptoms. Many of the examination findings specific to each condition have been covered in the preceding sections.

Ruling Out Other Sources

Lumbar spine pathology should be ruled out first, as it is the most common alternative source of posterior buttock and leg pain. A full lumbar spine examination, including neurological screening, range of motion and provocation testing, is appropriate. For more information, see: Overview of Lumbar Spine Assessment.

The sacroiliac joint (SIJ) is often assessed using the sacroiliac joint special test cluster, but a more recent systematic review notes that test clusters are more useful for ruling SIJ pain out (92% certainty) than for ruling it in (35% certainty).[20] The Gillet (March) test and the active straight leg raise are also commonly used to assess pelvic load transfer, though a positive finding indicates failed load transfer rather than a specific structural source.

The FABER test, which takes the hip into flexion, abduction and external rotation, is also validated for SIJ dysfunction. However, because the sciatic nerve glides across the posterior border of the greater trochanter in this position, a positive FABER test may also indicate sciatic nerve pathology.[4]

EmbedVideo is missing a required parameter.

[21]

Intra-articular hip pathology can be assessed using total hip range of motion and the FADIR test. A negative FADIR helps to rule out intra-articular pathology, such as labral damage or hip osteoarthritis.

[22]

Differentiating Deep Gluteal Sources

The FADER test, performed with resisted internal rotation, can help differentiate between sources of lateral and deep buttock pain. Pain felt directly over the greater trochanter suggests gluteal tendinopathy. Pain felt deep in the buttock suggests irritation of the piriformis muscle or one of the other deep six muscles.

The combination of the seated piriformis stretch test and the active piriformis test has a reported sensitivity of 91% and specificity of 80% for sciatic nerve entrapment in the deep gluteal space.[23]

[24]

Neurological Findings

Patients with DGS may present with altered nerve conduction, changes in reflexes, motor weakness, and sensation changes. These findings overlap with lumbar spine pathology and do not in themselves differentiate the two.[25][4]

Palpation

Palpation is a valuable differentiating tool. Using the ischial tuberosity as a reference point, careful palpation of the surrounding structures can help localise the patient's pain and identify changes in soft tissue texture.[4][3]

Differential Diagnosis

Differential diagnosis in deep gluteal syndrome relies on recognising the clinical features that suggest one condition over another. The table below groups common clinical features and history points with the conditions they should prompt the clinician to consider. It is important to remember, however, that these conditions can co-exist.

Clinical feature Differentials to consider
Uphill running, deadlifts, lifting from flexion, sensation of sitting on a boggy mass Proximal hamstring tendinopathy, ischial bursitis
Radicular leg pain with hip flexion, positive neurodynamic tests, pain with prolonged sitting Sciatic nerve entrapment along the path of the nerve (including discogenic causes, the lumbar spine, deep gluteal space or elsewhere in the buttock)
Increased time on the bike, change in saddle, easing of pain on a toilet seat Pudendal nerve entrapment
Pain with hip extension or long strides Ischiofemoral impingement, lumbar spine, sacroiliac joint
History of trauma or hip surgery, pain with hip extension and adduction Ischiofemoral impingement
Limping after prolonged sitting Common in various conditions, including hamstring tendinopathy, gluteal tendinopathy, deep gluteal sources (piriformis, obturator/gemelli)

Management

Effective management of DGS depends on identifying which structure is generating symptoms, since condition-specific advice differs significantly. Patient education on the anatomy and likely source of symptoms is a key first step. Where there is chronic pain or a centrally mediated component, education should also address contributing psychological factors such as fear-avoidance and pain catastrophising. Load management forms the basis of conservative care across all DGS conditions.

General lifestyle factors that may contribute include weight, sleep, and smoking. Where these are relevant, they should be addressed alongside the specific management of the condition.

Condition-specific Advice

Proximal Hamstring Tendinopathy

Patients should avoid deadlifts and other flexion-based exercises, which compress both the hamstring tendon and the sciatic nerve at the ischial tuberosity. Hamstring stretches that straighten the leg at 90° of hip flexion should also be avoided, as they compress the hamstring tendon against the ischial tuberosity.

Sciatic Nerve Involvement

Driving position can be modified by moving the car seat closer to the steering wheel, reducing neural tension on the sciatic nerve. Runners with sciatic-type symptoms may find that reducing stride length helps.

Pudendal Nerve Entrapment

Patients with pudendal nerve symptoms, including sexual dysfunction, rectal pain, and faecal or urinary incontinence, should be referred to a pelvic health physiotherapist. Where hormonal or other gynaecological factors are clinically relevant, onward referral to a gynaecologist may also be appropriate.

Ischiofemoral Impingement

Runners with IFI symptoms may benefit from reducing stride length, as long strides narrow the ischiofemoral space.

Manual Therapy and Adjuncts

Myofascial release and other manual therapy techniques can be useful adjuncts to exercise and education, particularly for managing soft tissue thickening and pain in the deep gluteal region.[4]

Exercise Principles

Limiting exercise sessions to 15-20 minutes per day can support patient adherence to the programme.[4]

Stretching is generally avoided in the early phase of tendinopathy management to limit tensile or compressive loading on the tendon, and can be reintroduced as symptoms settle.[4]

For lower limb tendinopathy, pain should be kept to 4/10 or less during loading exercises. In addition, pain should not be worse 24 hours after exercise. Functional loading exercises (such as step-downs, single-leg squats, dynamic lunges, and split squats) should be pain-free, as pain during these may indicate movement compensation or medial collapse.[4]

Progressive loading should emphasise hip extensors, abductors, and lateral rotators. Gluteal strengthening exercises such as bird-dog, split squats and functional loading exercises may be included. Neurodynamic sliders for the sciatic nerve can be added where there is nerve involvement.[4]

Single Leg Squat 
Resisted bird-dog
Piriformis Stretching

When stretching piriformis with the hip flexed to 90°, the hip should be positioned in external rotation. This reflects piriformis's functional role: it acts as a hip external rotator below 45–60° of hip flexion, but switches to an internal rotator above 60°. Stretching in the wrong position will not effectively lengthen the muscle.[4]

When Conservative Management is Unsuccessful

For patients with severe pain or where conservative management is unsuccessful, image-guided anaesthetic or corticosteroid injections may be considered.[26]

Surgical options also exist, such as partial lesser trochanteric plasty for ischiofemoral impingement, and arthroscopic or endoscopic release of adhesions between the hamstring tendon and piriformis.[27][28][29]

References

  1. ↑ 1.0 1.1 1.2 Yoon YH, Hwang JH, Lee Hw, Lee M, Park C, Lee J, et al. Beyond nerve entrapment: a narrative review of muscle–tendon pathologies in deep gluteal syndrome. Diagnostics. 2025;15(19):2531.
  2. ↑ Kizaki K, Uchida S, Shanmugaraj A, Aquino CC, Duong A, Simunovic N, Martin HD, Ayeni OR. Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Apr 3:1-1.
  3. ↑ 3.0 3.1 3.2 Martin HD, Reddy M, Gómez-Hoyos J. Deep gluteal syndrome. Journal of hip preservation surgery. 2015 Jul 1;2(2):99-107.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 Bell-Jenje T. Differentiating Buttock Pain (Part 3). Plus Course, 2020.
  5. ↑ Reckling WC, Polly DW. Differential diagnosis of posterior buttock pain: a conceptual review based on topographic localization of pain, is it really the sacroiliac joint? Int J Spine Surg. 2025 Dec 11;19(S3):S85-S98.
  6. ↑ 6.0 6.1 6.2 6.3 Park JW, Lee YK, Lee YJ, Shin S, Kang Y, Koo KH. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. Bone Joint J. 2020 May;102-B(5):556-567.
  7. ↑ Martin HD, Shears SA, Johnson JC, et al. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthroscopy 2011; 27: 172–81
  8. ↑ 8.0 8.1 Yeo PY, Kasivishvanaath A, Pérez-Carro L, T J. Top ten causes of non-arthritic hip pain: A comprehensive review. World J Orthop. 2025 Jun 18;16(6):107397.
  9. ↑ Hernando MF, Cerezal L, Pérez-Carro L, Abascal F, Canga A. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal Radiol. 2015 Jul;44(7):919-34.
  10. ↑ Henyš P, Ramezani M, Schewitz D, Höch A, Möbius D, Ondruschka B, Hammer N. Sacrospinous and sacrotuberous ligaments influence in pelvis kinematics. J Anat. 2022 Oct;241(4):928-937.
  11. ↑ Giulioni C, Pitoni L, Fuligni D, Beltrami M, Passarella V, Palantrani V, et al. Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review. Investig Clin Urol. 2024 May;65(3):230-239.
  12. ↑ Fawaz R, Ltaief-Boudrigua A, Duraffourg M. Pudendal nerve entrapment syndrome: clinical features, diagnosis, and management. Pain Med. 2025 Jan 1;26(1):39-42.
  13. ↑ 13.0 13.1 Wu WT, Chang KV, Mezian K, Naňka O, Ricci V, Chang HC, et al. Ischiofemoral impingement syndrome: clinical and imaging/guidance issues with special focus on ultrasonography. Diagnostics (Basel). 2022 Dec 31;13(1):139.
  14. ↑ Gollwitzer H, Banke IJ, Schauwecker J, Gerdesmeyer L, Suren C. How to address ischiofemoral impingement? Treatment algorithm and review of the literature. Journal of Hip Preservation Surgery. 2017 Dec;4(4):289-98.
  15. ↑ 15.0 15.1 Sharma PK, Raja S, Jerosha S, Gr N. Ischiofemoral impingement syndrome, an unusual entity of hip pain: A case report and literature review. Radiol Case Rep. 2025 Jan 18;20(4):1893-1899.
  16. ↑ Gomez-Hoyos J, Martin RL, Schroder R et al. Accuracy of 2 clinical tests for ischiofemoral impingement in patients with posterior hip pain and endoscopically confirmed diagnosis. Arthroscopy 2016; 32: 1279–84
  17. ↑ The Physio Channel. Posterior Hip Impingement Test Video Demonstration. Available from: https://www.youtube.com/watch?v=qobPzFnhRY0 [last accessed 29/05/2026]
  18. ↑ ChiroUp. Long Stride Walking Test. Available from: http://www.youtube.com/watch?v=bO2FvbzdJH0 [last accessed 29/05/2026]
  19. ↑ 19.0 19.1 Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. Journal of orthopaedic & sports physical therapy. 2016 Jun;46(6):483-93.
  20. ↑ Saueressig T, Owen PJ, Diemer F, Zebisch J, Belavy DL. Diagnostic accuracy of clusters of pain provocation tests for detecting sacroiliac joint pain: systematic review with meta-analysis. J Orthop Sports Phys Ther. 2021 Sep;51(9):422-431.
  21. ↑ Ortho EVAL Pal With Paul Marquis PT. FABER/Patrick/Figure 4 Test-How to Perform it and What it Means! 2021 . Available from:https://www.youtube.com/watch?v=RMgaRoBg0do[last accessed 26/10/2022]
  22. ↑ How to do the FADIR hip impingement test . Available from:https://www.youtube.com/watch?v=PqgPWRqmQ_A[last accessed 22/10/2020]
  23. ↑ Martin HD, Kivlan BR, Palmer IJ, et al. Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal region. Knee Surg Sports Traumatol Arthrosc 2014; 22: 882–8.
  24. ↑ Sports Med Review. Active Piriformis Test (for Piriformis Syndrome). Available from: http://www.youtube.com/watch?v=-xUpSYQ8fpE [last accessed 29/05/2026]
  25. ↑ Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am 2004; 35: 65–71
  26. ↑ Filler AG, Haynes J, Jordan SE, et al. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine 2005; 2: 99–115
  27. ↑ Kay J, Morrison L, Fejtek E, Simunovic N, Martin HD, Ayeni OR. Surgical management of deep gluteal syndrome causing sciatic nerve entrapment: a systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2017 Dec 1;33(12):2263-78.
  28. ↑ Aguilera-Bohorquez B, Cardozo O, Brugiatti M, Cantor E, Valdivia N. Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: clinical results. Revista Española de Cirugía Ortopédica y Traumatología (English Edition). 2018 Sep 1;62(5):322-7.
  29. ↑ Elzeiny A, Giai Via R, Donis A, Erdmenger S, Giachino M, Aprato A, Massè A. Endoscopy for sciatic nerve entrapment in deep gluteal syndrome. A systematic review of literature. Eur J Orthop Surg Traumatol. 2025 May 31;35(1):223.
Retrieved from "https://www.physio-pedia.com/w/index.php?title=Deep_Gluteal_Pain_Syndrome&oldid=379637"