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Differentiating Buttock Pain and Sacroiliac Joint Disorders

Original Editors - Jessie Tourwe

Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Tarina van der Stockt, Lucinda hampton and Ewa Jaraczewska 

Introduction

Buttock pain has many potential sources, including the lumbar spine, the sacroiliac joint (SIJ), the deep gluteal space (including the sciatic and pudendal nerves and the deep hip lateral rotators), the lateral hip tendons at the greater trochanter, the posterior hip joint capsule, and surrounding ligaments and bursae. The overlap in symptoms between conditions can make differential diagnosis challenging.[1]

This page focuses on SIJ dysfunction and the broader process of differentiating sources of buttock pain. Related Physiopedia pages cover gluteal tendinopathy and deep gluteal syndrome in greater depth.

Differential Diagnosis

Accurate differential diagnosis requires clinicians to systematically assess potential sources of buttock pain. The conditions discussed in this page are presented in the order they are typically considered: first, screening for serious pathology via red flags, then working anatomically through the lumbar spine, the sacroiliac joint, the lateral hip, and the deep gluteal structures.

Where chronic pain features are present, it should not be assumed that the structural source has been correctly identified. Psychological factors such as fear-avoidance and catastrophising can develop secondary to a missed primary source of pain. The clinician should continue to look for and address primary contributors alongside psychological factors.[2]

Red Flags

Red flag features that should prompt consideration of serious pathology include:[2][3]

  • Malignancy: history of cancer, unexplained weight loss, pain at rest or at night, reduced appetite, fatigue, fever, progressive symptoms
  • Fracture: significant trauma, prolonged steroid or immunosuppressant use, age over 50-70, previous fracture, female gender, low body weight, structural deformity, or minor trauma in an at-risk individual
  • Infection: fever, corticosteroid use or immunosuppression, intravenous drug use, pain at night or at rest, tenderness over the spinous processes
  • Cauda equina syndrome: new-onset saddle anaesthesia (perineal numbness), bladder or bowel dysfunction, progressive neurological deficit
  • Inflammatory pathology (e.g. ankylosing spondylitis, reactive arthritis): prolonged morning stiffness, bilateral enthesopathies, associated inflammatory bowel disease
  • Other serious pathology: gynaecological symptoms suggestive of pelvic pathology
  • Failure to respond to appropriate management

Lumbar Spine Conditions

Lumbar spine pathology should always be considered as part of the differential diagnosis. The lumbar nerve roots from L3 to S2 can refer pain to the buttock. Lumbar disc pathology and facet joint dysfunction are also potential sources of buttock pain.[4] Features suggesting a lumbar source include radicular pain in a dermatomal distribution, shooting or electric shock-like pain, pain aggravated by sitting, standing, posture change, coughing or sneezing, and positive neurodynamic findings (such as a positive straight leg raise, slump test, or femoral nerve tension test). Sensory, motor, or reflex changes in a dermatomal or myotomal pattern also suggest lumbar nerve root involvement.[5]

See Overview of Lumbar Assessment for more information. Please watch the following videos if you would like to recap the straight leg raise and slump tests.

[6]
[7]

Sacroiliac Joint Dysfunction

SIJ dysfunction is the focus of this page and is covered in more detail than the other differentials. SIJ dysfunction refers to pain arising from the SIJ itself or the surrounding myofascial, neural, connective tissue and ligament structures. A more recent framing, "SIJ complex pain", recognises that pain may originate from the joint itself (intra-articular) or from the surrounding dorsal ligaments and extra-articular structures.[8] It is reported that 15–30% of patients with back pain predominantly below L5 have SIJ dysfunction.[8]

Anatomy

The sacroiliac joint is a large diarthrodial joint that connects the spine and the pelvis.[9] It is formed by the sacrum and the innominate bone on each side. Each innominate is formed by the three bones of the pelvis: the ilium, ischium, and pubic bone.[10]

The sacroiliac joint transfers load between the spine and the lower extremities and absorbs shock.[11][12][13] Multiple surrounding structures contribute to sacroiliac joint function and stability, including the dorsal sacral nerve, the iliolumbar ligament, the dorsal sacral ligaments, and the erector spinae fascia (part of the thoracolumbar fascia). The density of these overlying structures means that direct palpation of the sacroiliac joint itself is not possible.[2]

[14]

Onset and History

SIJ pain can develop gradually or suddenly. Gradual onset is more typical of maladaptive postures, spondyloarthritis, osteoarthritis, or pregnancy-related pain.[15] Sudden onset typically follows a specific event, such as missing a step or unilateral loading combined with rotation, sometimes with an audible click at the time of injury.[2][16]

Clinical Presentation

Patients with SIJ pain experience unilateral or bilateral pain below L5, typically without numbness or paraesthesia. Pain is often diffuse across the buttock region, and may extend between the iliac crest superiorly, the gluteal fold inferiorly, the pubic symphysis and groin anteriorly, and the coccyx and the posterior thigh posteriorly.[2] Patients report difficulty with weight-bearing activities, including standing, walking, climbing stairs, squatting, getting out of a car, and turning in bed.[16] Sleep can be disturbed by pain on turning. Psychosocial factors can influence the presentation and severity of symptoms.[2]

Special Tests

Individual SIJ tests have limited diagnostic reliability when used in isolation.[17] Across the evidence, specificity is generally lower than sensitivity. This means that a negative test result is more useful for ruling SIJ pain out than a positive result is for confirming it.[8]

Provocation Test Clusters

Combining provocation tests into clusters improves diagnostic accuracy compared with using individual tests. Commonly used clusters include Laslett's cluster of provocation tests (distraction, compression, thigh thrust, sacral thrust, and Gaenslen's) and the cluster of van der Wurff (distraction, compression, thigh thrust, Gaenslen's, and FABER (Patrick's).[18] However, a 2021 systematic review by Saueressig et al., endorsed by recent multispecialty consensus guidelines, found that even with cluster testing, diagnostic certainty remains limited.[18][8] A positive cluster result gives only around 35% post-test probability of correctly identifying SIJ pain, while a negative cluster result gives around 92% post-test probability of correctly ruling SIJ pain out. Cluster testing is therefore most useful for ruling out the SIJ as the source of pain, rather than confirming it.[18]

Load Transfer Tests

The March test (also called the Gillet or the Stork test) and the active straight leg raise (ASLR) test assess pelvic load transfer rather than SIJ pain provocation. A positive result on either test indicates impaired load transfer through the pelvic girdle, but does not localise the cause to a specific structure. These tests are best understood as an assessment of motor control and pelvic stability.[2]

Imaging

Imaging has limited utility in diagnosing mechanical sacroiliac joint pain, as structural changes on imaging do not reliably correlate with symptoms. Radionuclide bone scans, CT, and MRI all have inadequate sensitivity for identifying mechanical SIJ pain.[8]

However, imaging is essential for excluding other pathology, including inflammatory sacroiliitis, infection, fracture, and malignancy. MRI is the reference standard for identifying SIJ involvement in spondyloarthritis; it has a sensitivity of over 80% for chronic sacroiliitis, and is part of the diagnostic criteria for axial spondyloarthritis.[8][19][20]

Intra-articular anaesthetic injection of the sacroiliac joint remains the diagnostic reference standard for SIJ pain, although it has significant limitations. A reduction in pain following injection supports the SIJ as a source of symptoms, but the test is associated with both false-positive and false-negative results.[8]

Gluteal Tendinopathy

Gluteal tendinopathy is a common cause of lateral hip and buttock pain. Pain is typically localised to the lateral hip over the greater trochanter and may radiate down the lateral thigh, but it can also refer to the groin, coccyx, anterior thigh, buttock, and the region around the sacroiliac joint — overlapping considerably with SIJ pain. Patients often report difficulty sleeping on their affected side and pain with weight-bearing activities, such as walking, climbing stairs, and rising from sitting.[2]

Gluteal tendinopathy is most common in middle-aged and post-menopausal women. Hormonal status may be a contributing factor and should be considered as part of the broader clinical picture. This is also true of younger females returning to exercise post-partum: drops in oestrogen levels during breastfeeding can temporarily affect tendon function.[21]

Palpation of the greater trochanter is highly sensitive. When the area is non-tender, it is considered the best individual test for ruling out gluteal tendinopathy. However, asymptomatic individuals can also be tender on palpation, so palpation should not be used in isolation to confirm a diagnosis of gluteal tendinopathy. Combining palpation with active loading of the abductors (using either resisted hip abduction or the 30-second single leg stance test) improves diagnostic accuracy.[8]

For more information on assessing and managing this condition, see: Gluteal Tendinopathy.

Deep Gluteal Syndrome

Deep gluteal syndrome (DGS) is an umbrella term for conditions producing buttock pain from non-discogenic entrapment of the sciatic nerve in the deep gluteal space, along with related conditions such as ischiofemoral impingement, proximal hamstring tendinopathy, and pudendal nerve entrapment.[22][23] The sciatic nerve can be entrapped in the deep gluteal space, making DGS an important consideration in the differential diagnosis of buttock pain. It is considered the prototypical and most common presentation of DGS.[24][25]

For more information on the assessment and management of DGS, see Deep Gluteal Syndrome.

Summary Table

This table summarises the key clinical features of specific conditions to assist in differentiating between different causes of buttock pain.

Differentiating Sources of Buttock Pain
Condition Key distinguishing features
Lumbar pathology Pain may radiate in dermatomal pattern; aggravated by Valsalva manoeuvres (coughing, sneezing); neurological deficits in a dermatomal/myotomal pattern; positive neurodynamic tests
Sacroiliac joint dysfunction Pain located below L5, posterior to the PSIS; difficulty with transitional movements (getting out of car, turning in bed); gradual onset or specific inciting event, such as fall, twist; no neurological deficit
Gluteal tendinopathy Focal tenderness over the greater trochanter; pain lying on the affected side; pain with single-leg loading (stairs, standing on one leg); pain radiating down the lateral thigh
Deep gluteal syndrome Deep buttock pain (not lateral); pain aggravated by prolonged sitting; sciatic-type radiation, often with positive neurodynamic tests; can also present with pudendal nerve symptoms, hip extension/adduction provocation (ischiofemoral impingement), or ischial tuberosity pain (proximal hamstring tendinopathy)

Resources

References

  1. ↑ Carro LP, Hernando MF, Cerezal L, Navarro IS, Fernandez AA, Castillo AO. Deep gluteal space problems: piriformis syndrome, ischiofemoral impingement and sciatic nerve release. Muscles, ligaments and tendons journal. 2016 Jul;6(3):384.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Bell-Jenje T. Differentiating Buttock Pain and Sacroiliac Joint Disorders. Physiopedia Plus Course, 2020.
  3. ↑ Farley T, Stokke J, Goyal K, DeMicco R. Chronic low back pain: history, symptoms, pain mechanisms, and treatment. Life (Basel). 2024 Jun 27;14(7):812.
  4. ↑ Jin Q, Chen L, Wu K, Feng Z, Yuan Y, Wang Y. Buttock pain in lumbar disc herniation: clinical characteristics, risk factors, and surgical outcomes. J Neurosurg Spine. 2025 Mar 14;42(5):572-578.
  5. ↑ Zibis AH, Mitrousias VD, Klontzas ME, Karachalios T, Varitimidis SE, Karantanas AH, Arvanitis DL. Great trochanter bursitis vs sciatica, a diagnostic–anatomic trap: differential diagnosis and brief review of the literature. European Spine Journal. 2018 Jul 1;27(7):1509-16.
  6. ↑ Physiopedia. Straight Leg Raise Test Explained. Available from: https://www.youtube.com/shorts/_4gfl6Wwl9M [last accessed 2/6/2026]
  7. ↑ Physiopedia. The Slump Test explained, by Physiopedia Plus. Available from: https://www.youtube.com/shorts/pChzhDCifzw [last accessed 2/6/2026]
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 McCormick ZL, Hurley RW, Anitescu M, Bhaskar A, Bhatia A, Cassidy RC, et al. Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group. Reg Anesth Pain Med. 2025 Nov 29:rapm-2025-107387.
  9. ↑ Cohen S., Steven P., Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis and treatment, IARS, November 2005, volume 101, issue 5, pp 1440-1453
  10. ↑ Dutton M. Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York: McGraw Hill, 2008.
  11. ↑ Sacroiliac Joint. Physiopedia Page (last accessed 20/09/2020) Available from: https://physio-pedia.com/Sacroiliac_Joint#cite_note-Dutton-2
  12. ↑ Kiapour A, Joukar A, Elgafy H, Erbulut DU, Agarwal AK, Goel VK. Biomechanics of the sacroiliac joint: anatomy, function, biomechanics, sexual dimorphism, and causes of pain. Int J Spine Surg. 2020 Feb 10;14(Suppl 1):3-13.
  13. ↑ Waldman LE, Maluli I, Moon CN, Skalski M, Matcuk GR. Sacroiliac joint dysfunction: anatomy, pathophysiology, differential diagnosis, and treatment approaches. Skeletal Radiol. 2025 Jun;54(6):1195-1213.
  14. ↑ SI Joint Anatomy, Biomechanics & Prevalencet . Available from:https://www.youtube.com/watch?v=D6NTMgWCSaU[last accessed 21/09/2020]
  15. ↑ Newman DP, Soto AT. Sacroiliac joint dysfunction: diagnosis and treatment. Am Fam Physician. 2022 Mar 1;105(3):239-245.
  16. ↑ 16.0 16.1 Buchanan P, Vodapally S, Lee DW, Hagedorn JM, Bovinet C, Strand N, et al. Successful diagnosis of sacroiliac joint dysfunction. J Pain Res. 2021 Oct 8;14:3135-3143.
  17. ↑ Telli H, Telli S, Topal M. The Validity and Reliability of Provocation Tests in the Diagnosis of Sacroiliac Joint Dysfunction. Pain Physician. 2018 Jul;21(4):E367-E376. PMID: 30045603.
  18. ↑ 18.0 18.1 18.2 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.
  19. ↑ Diekhoff T, Lambert R, Hermann KG. MRI in axial spondyloarthritis: understanding an 'ASAS-positive MRI' and the ASAS classification criteria. Skeletal Radiol. 2022 Sep;51(9):1721-1730.
  20. ↑ Horbal N, Aouad K, Baraliakos X, Ziade N, Maksymowych WP. Update of imaging in the assessment of axial spondyloarthritis. Best Pract Res Clin Rheumatol. 2025 Sep;39(3):102064.
  21. ↑ Grimaldi A, Ganderton C, Nasser A. Gluteal tendinopathy masterclass: Refuting the myths and engaging with the evidence. Musculoskelet Sci Pract. 2025 Apr;76:103253.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
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