Deep Gluteal Pain Syndrome
Introduction[edit | edit source]
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[1].
Symptoms[1]:
- 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[edit | edit source]
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[edit | edit source]
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[edit | edit source]
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[edit | edit source]
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.
