Deep Gluteal Pain Syndrome

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

Introduction

The gluteal/buttock area is complicated and hasn't been much explored in the literature. The symptoms are often diagnosed as Lumbar Radiculopathy and when not treated could be considered chronic pain.

Gluteal Pain Syndrome is often defined as pain or numbness in the buttock, the hip, or the posterior thigh with radiation or radicular pain in the Sciatic Nerve distribution.

Symptoms:

• Buttock/Gluteal pain and sometimes behind the greater trochanter.
• Pain is usually unilateral
• Patients usually struggle with prolonged seating for more than 20 or 30 minutes
• They also struggle with stride into a terminal extension
• They may limp
• They may have neurological changes in testing
• Severe night pain with disturbed sleep

Anatomy

The deep gluteal space is bounded superiorly by the Sciatic Notch, which includes Piriformis. Inferiorly, by the Ischial Tuberosity, which has the attachment of the Hamstring tendon. Laterally by the Linea Aspersa of the femur and the greater trochanter and medially by the Sacrotuberous ligament, which has yet another highly nociceptive structure.

Underneath the Glute Max and Med lie the "deep six" which include the Piriformis muscle, which attaches under the medial facet on the greater trochanter. And below the Piriformis muscle, are the small Obturators and Gemelli's. The Superior Gemelli, Obturator Internis, Inferior Gemelli and Quadratus Femoris.

You cannot palpate Obturator Externus directly, because that is on the ventral side. Of the ''deep six'', the two muscles that will be easiest for you to palpate are the Piriformis and the Quadratus Femoris.

The Sciatic Nerve exits underneath the Piriformis muscle where it becomes a possible source of entrapment.

The sciatic nerve lies over the Obturator and Gemelli complex then it sits laterally to the Ischial Tuberosity. And on top of the Ischial Tuberosity is the insertion of the Biceps Femoris, which then has fibres that intermingle and go proximally onto the Sacrotuberous Ligament. The Sciatic Nerve is bound on the medial side, by the Ischial Tuberosity and on the lateral side, by the lesser trochanter of the femur.

The Sacrotuberous and the Sacrospinous Ligaments are highly nociceptive and could be involved in the patient's presentation. On palpation, they could feel very thick. The Sacrotuberous Ligament comes from the Ischial Tuberosity and inserts onto the sacrum and the coccyx. The Sacrospinous Ligament lies at 90 degrees to it, deep to the Sacrotuberous Ligament and attaches onto the Ischial Spine. The Pudendal Nerve can become entrapped or adherent to one of these two ligaments. And if that happens, your patient could present with Pudendal Nerve entrapment. Pudendal Nerve entrapment could also be referred to as Alcock Canal Syndrome and the Cyclist Syndrome. Spending a long time on the bike can irritate the pudendal nerve and can be profoundly life-altering

Symptoms of the pudendal nerve include sexual dysfunction, rectal pain, faecal incontinence, urinary incontinence. Pain is aggravated by sitting and eased when they sit on a toilet seat as it's taking the entrapment or the pressure of the Pudendal Nerve.

Ischiofemoral Impingement

Ischiofemoral Impingement is first described in 1977 by a surgeon who often saw patients after hip surgery, including a total hip replacement. Where the patients had Sciatic pain radiating down their posterior leg and they complained of a deep buttock ache, especially when they had their hip in extension and adduction.

The anatomical region of the Ischiofemoral space is bound by the Ischial Tuberosity and the lesser trochanter. It is a very small space. Any thickening in that region, Quadratus Femoris, for example, or you get a bursal swelling in that region that can cause narrowing and can cause impingement on the nociceptive structures in that region.

Symptoms:

Deep-seated buttock pain. Patients might point deep to their buttock and describes it as a deep ache. If they're a runner they'll tell you that short strides are more comfortable than long strides. when the stride length increases, hip extension increases increase possibly adduction narrowing the]at space. Patients often have back pain due to the loss of hip extension, as a restriction, overcompensating by lumbar extension. They can present with facet type pain at L3/4, or L4/5. This cannot be confused with a primary lumbar problem. This is a primary Ischiofemoral problem with a secondary lumbar presentation.

Ischiofemoral Impingement pain is worse with terminal hip extension and adduction.

Hamstring tendinopathy

The insertion point of the Hamstring is on the Ischial Tuberosity, which is very close to the Sciatic Nerve is also in that region. This condition has different symptoms.

Patients have increased the loading of flexion. So they've maybe done deadlifts or some flexion activity, that is compressing the, or tensioning the Hamstring tendon on the Ischial Tuberosity.

Pain gets worse with sitting.

They may have worse pain running uphill when they flex their trunk, which is causing more compression on the Hamstring tendon, on the Ischial Tuberosity.

They can have pain with driving because the Sciatic Nerve is very closely related to the Hamstring tendon.

They might have a positive straight leg raise.

They will almost definitely have a positive slump, because it's very hard to differentiate out Sciatic Nerve path from this region from the Hamstring tendinopathy. And they really feel like they're sitting on a boggy mass. And they might feel like if they sit on a doughnut or something to take the pressure off that area, they feel a lot more comfortable.

And you'll often feel a thickening on palpation, if you feel around that Ischial Tuberosity, just lateral to the Ischium.

In all of the above conditions, patients can have positive neurodynamic tests as they experience pain with flexion and with terminal hip extension.

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