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

DGS has three characteristics:

: (1) non-discogenic, (2) sciatic nerve disorder, and (3) nerve entrapment in the deep gluteal space. In the diagnosis of DGS

Examination:

we found fve diagnostic procedures: (1) history taking, (2) physical examination, (3) imaging tests, (4) response-to-injection, and (5) nerve-specifc tests

For that reason the term ‘deep gluteal syndrome’ instead of ‘piriformis syndrome’ is now preferred to describe the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve

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.

A history of repetitive Hamstring loading with hip flexion, such as with uphill running or picking up boxes, or maybe they moving house. Then we think it could be a reactive Hamstring tendon, or possibly bursitis. Similarly, if they feel like they're sitting on a boggy mass, along with that history that I've just described to you think Hamstring tendinopathy or bursitis.

Sciatic Nerve

Pain radiating down their leg with hip flexion or with a neurodynamic test.

Could be from the deep gluteal space or discogenic pathology.

Pain with increased time on a bike, change of saddle, and sitting on a toilet seat eases, think Pudendal Nerve entrapment

Pain with hip extension or long-striding, think Ischiofemoral impingement, or Sacroiliac joint pathology or lumbar spine.

History of trauma or hip surgery, pain with extension after hip arthroscopy or a hip replacement could be Ischiofemoral Impingement.

Pain with sitting for a while and getting up with limp could be different things a Hamstring tendon problem, Gluteal tendinopathy, Obturator-Gemelli insertional tendinopathy. That sort of limping after you get up from prolonged sitting is a very common symptom of that entire buttock area, including the lateral hip.

Examination

Lumbar spine pathology has to be ruled out. Palpation it, but see if you can rule out your lumbar spine pathology. Tests of the pelvic girdle type or SI-joint type pain, such as the March test and the active straight leg raise test.

The problem is that no studies have ever been done, as yet, looking to see what happens in somebody with deep gluteal pain when you perform an active straight leg raise test, and you provide force closure or compression by approximating the ASIS or the PSIS. A positive March test or active straight leg raise test, indicate poor motor control and failed load transfer, but don't rule out the source of the patient's presentation.

The total arc of motion of the hip, FADIR test to rule out OA. FADIR. A negative FADIR can rule out intra-articular pathology of the hip, such as labral damage or osteoarthritis of the hip.

The FABER test is validated for SI-joint dysfunction. A positive Faber test, remember also that when you do that test the Sciatic Nerve glides across the posterior border of the greater trochanter in that position. So a positive test could actually implicate Sciatic Nerve path.

FADER, FADER with a resisted internal rotation could be positive in somebody with Gluteal tendinopathy, Piriformis or a deep buttock symptom. Pain felt directly on the greater trochanter could be more Gluteal tendinopathy. Pain deep in the buttock is more likely to be compression or tendinopathy or irritation around the Piriformis muscle or some of the deep six.

Patients with Deep Gluteal Pain Syndrome, you can have altered nerve conduction tests. So you can have changes in reflexes, motor weakness, and sensation changes. So those tests again, will not help you differentiate out lumbar spine from the buttock.

Palpation can be extremely helpful. The referred symptoms can be confusing because there's an overlap around all these nociceptive structures. But your palpation skills can help you differentiate out more of an Obturator-Gemelli primary problem. Pain at the posterior hip Versus Gluteal tendinopathy.

The worst pain would be on the superior aspect of the greater trochanter versus Hamstring tendinopathy where you would palpate a boggy mass around the Ischial tuberosity itself.

So if you can become familiar with the anatomy, it will mean that your palpation skills may add value when you assess using all the clinical pictures that we've discussed.

Management

Try and make as clear a diagnosis as possible, because you can see that the symptomatology can be so different.

Patient education, show them the anatomy, the structures that could be causing their symptoms and try and get them to understand the possible pathogenesis of their condition.

If I think there's chronic pain or central mediated component,

I'll educate them on that and discuss things such as fear-avoidance or catastrophisation as appropriate.

Advise the patient on the management of the condition.

Hamstring tendinopathy:

Avoid deadlifts and other exercises that compress the Hamstring tendon, and the Sciatic Nerve.

Avoid Hamstring stretches such as straightening the leg at 90 degrees of hip flexion, because that's going to compress the Hamstring tendon onto the Ischial tuberosity.

Sciatic Nerve involvement and you have positive neurodynamic tests, you can advise the patient:

Put the car seat closer to the steering wheel when driving to take that neural tension off the Sciatic Nerve.

If they're a runner and they have pain with hip extension, you may instruct them to reduce their stride length to relieve those symptoms.

If they have Pudendal Nerve type symptoms, you may refer the patient to a woman or men's health physiotherapist to assist you with the symptoms such as rectal pain or faecal incontinence or urinary incontinence, for example.

And if they are a female and they're over 50, you may refer them to the gynaecologist to assist their hormonal status.

And if you think that they are overweight, you may discuss weight management or a healthy lifestyle with the patient.

You may discuss sleep hygiene as a good seven to eight hours of sleep can really be helpful.

And you may discuss the risk factors of smoking and all the other ancillaries that you need to you look at to try and get the best outcome with these patients.

Myofascial release can be helpful with these patients. It can be a very helpful manual therapy type tool in conjunction with the appropriate rehabilitation and advice.

But good palpation skills in this region are helpful diagnostically and can really help release thickened areas, especially around the Sacrotuberous Ligament or Sacrospinous Ligament.

Exercises

Try and limit the exercises to 15 or 20 minutes a day to improve your compliance and your adherence

And certainly, for tendinopathy in the short-term, avoid stretching and compressive or tensile loading until the symptoms reduce then you can introduce those type of exercises to their programme.

Tendinopathy rule of thumb is that you shouldn't really push tendon pain to more than a four out of ten pain and no worse at 24 hours afterwards. And those are recognised tendinopathy principles for the lower limb. It's different for the upper limb. So for the lower limb, no more than a build-up to a four out of ten pain. However, if your patient is performing a functional loading exercise, such as a step-down or one-legged squat, a dynamic lunge, for example, a split squat. Then no pain should be allowed at that, while doing that exercise. Because pain during a functional loading exercise may imply that the patient's biomechanics are incorrect and they're going into medial collapse. So be very cautious of that.

Piriformis is a hip abductor and external rotator below 45 to 60 degrees of hip flexion. Once it goes above 60 degrees of hip flexion, Piriformis becomes an internal rotator. So if you want to stretch Piriformis with the hip at 90 degree, the hip needs to be at an external rotation position, not internally rotated. So understand the anatomy so you can specifically direct your stretches to the structures that are, you are trying to target. So Piriformis becomes an internal rotator once the hip is flexed to 60 degrees or more.

Neurodynamic gliding techniques, such as a Sciatic Nerve slider.

Gluteal strengthening and buttock strengthening such as bird-dog, split squats, and functional loading exercises.

Progressive loading with emphasis on hip extensors, abductors and lateral rotators as a general rule.

Sometimes with these patients, the pain is just so severe, the Sciatic Nerve referral and the radicular pain is unbearable and we aren't getting a good outcome with good conservative measures. And for some of these patients, then an image-guided anaesthetic block or steroid might be effective. Some of the surgeons are now doing rhizotomies on these regions, which can be effective.

Some surgeons are doing partial lesser trochanteric plastics for Ischiofemoral Impingement.

Arthroscopic or endoscopic releases of adhesions between Hamstring tendons, or of the Piriformis tendon as it relates to the Sciatic Nerve. So there are some surgical options that have been recognised.

Graphs from slides

Table:

•History of repetitive hamstring loading with hip flexion (Reactive hamstring tendon, bursitis)

•Uphill running

•Deadlifts

•Picking up boxes / other loading flexion activity

•Feels like is sitting on a boggy mass (Reactive hamstring tendon, bursitis)

•Pain radiates down leg with hip flexion (Sciatic N – from buttock or discogenic?)

•Increased time on the bike / change in saddle (Pudendal N)

•Sitting on a toilet seat eases (Pudendal N)

•Pain with hip extension or long strides (IFI, lumbar facet, SIJ)

•History of trauma or hip surgery (IFI)

•Limping after prolonged sitting (GT , obturator / gemelli tendinop)

•Lumbar spine pathology ruled out

•No studies relating March test to DGS

•No Studies relating ASLR test to DGS

•Test Hip Total arc of motion (TAM) to differentiate from intra-articular hip.

•FADIR: A negative test rules OUT OA hip

•FADER-Resisted isometric IR

•Pain deep buttock, not lateral hip

•FABER

•Sciatic Nerve glides across posterior border of greater trochanter.

•Pain with resisted hamstring tests

•Ischiofemoral impingement test

•+ Slump test

•Possible  abnormal reflexes or motor weakness

•+ Nerve Conduction test, MRI

•Palpation – site of pain assists diagnosis as well as palpable feeling of tissue swelling

•

Research:

https://link.springer.com/article/10.1007/s00256-020-03519-4

https://academic.oup.com/jhps/article/4/4/289/4100564

https://journals.lww.com/jaaos/Abstract/2018/09010/Current_Concepts_Review__Evaluation_and_Management.2.aspx

https://www.jospt.org/doi/full/10.2519/jospt.2016.5986

https://journals.lww.com/acsm-csmr/fulltext/2017/05000/rehabilitation_and_prevention_of_proximal.15.aspx