Differentiating Buttock Pain and Sacroiliac Joint Disorders

Original Editors - Jessie Tourwe

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

What Is Causing the Pain?

The diagnosis of Gluteal or buttock pain is complicated due to the overlapping symptoms of many conditions such as :

• Radicular pain from Lumbar spine origin
• Sciatic nerve entrapment
• Obturator internus/gemellus syndrome
• Piriformis Syndrome
• Quadratus femoris/ischiofemoral pathology
• Problems at the hamstrings
• Gluteal muscles disorders

There are no fixed guidelines for the diagnosis of buttock pain.

The complicated anatomy of the Sacroiliac joint, the Lumbar spine and the buttock area makes the differential diagnosis of pain and dysfunction a challenging task.

It is also difficult to use objective assessment measures to differentiate the source of the problem. Imaging such as MRI scans provides valuable information but can often mislead the management since the findings are not always consistent with LBP history and symptoms.

Anatomy

The Sacroiliac joint is the joint connection between the spine and the pelvis formed by the fusion of the three bones of the pelvis: the ilium, ischium, and pubic bone. The sacroiliac joint has different functions:

• Load transfer between the spine and the lower extremities
• Shock absorption
• Converts torque from the lower extremities into the rest of the body.

This region is surrounded by and covered with the dorsal sacral nerve, the iliolumbar ligament, the dorsal sacral ligaments, the erector spinae fascia, which is part of the thoracolumbar fascia and makes palpating specific structures difficult.

The subgluteal space is located between the middle and deep gluteal aponeurosis layers. It contains Superior/Inferior gluteal nerves, blood vessels, Ischium, Sacrotuberous/sacrospinous ligaments, Sciatic nerve and Piriformis.

The piriformis muscle is innervated by the branches of the L5, S1, and S2 spinal nerves.

The sciatic nerve has a complicated relationship with the piriformis muscle, passing above, below and through the muscle before and after dividing.

Considerations

When a patient presents with persisting chronic pain that is not responding to treatment, biopsychosocial factors are often thought to be the reason for chronicity. The development of chronic pain might have been the result of catastrophisation and fear avoidance as a result of a missed primary structural pain.

Impingement of the sciatic nerve occurs mostly in the deep gluteal space and around the piriformis muscle than in the lumbar spine level.

Differential Diagnosis

Ruling Out the Lumbar Spine

Red Flags are serious pathologies and should be spotted on the first contact.

Spondyloarthropathies and other inflammatory conditions at the lumbar spine level could possibly refer pain to the buttock area. Patients with Ankylosing spondylitis or Reiter's syndrome may present with inflammatory bowel diseases, such as Diverticulitis or Chrohn's disease, prolonged severe morning stiffness, bilateral enthesopathies such as Achilles tendinopathy or Plantar fasciitis.

Gynaecological problems, potential infectious diseases, possible malignancies and patients not responding to physiotherapy management can possibly reflect the presence of serious pathologies.

Buttock pain can be caused by a referred pain from the lumbar spine in the respective dermatome, A study by Eubanks reported significant improvement in buttock pain following facet joint block.

History	Physical Examination	Range of Sensitivity/Specificity
Low back pain Pain may radiate down to the leg Electric character of pain Sitting, standing, changing posture, coughing or sneezing may exacerbate pain	Lasegue sign (or Straight Leg Raise test) Inverted lasegue sign (or Cross Straight Leg Raise test) Femoral nerve stretch test Slump test Bowstring sign Trendelenburg test (L5 radiculopathy) Sensory deficits Motor deficits Altered reflexes

Ruling Out the Sacroiliac Joint

The thoracolumbar fascia, sacroiliac joint, Gluteus max, Gluteus minimus, Piriformis, Obturator Externus and Internus, Gemelli's Superior and Inferior, ischio-gluteal bursa, the long dorsal ligament, sacrotuberous ligament, sacrospinous ligament and the posterior capsule of the hip are all nociceptive structures that can trigger posterior hip pain.

Numerous neural structures can also be involved such as the dorsal sacral nerve, the lumbosacral plexus, including the sciatic nerve and the pudendal nerve which can be highly implicated in sexual dysfunction and pelvic floor dysfunction.

Any pain from the sacroiliac joints or the surrounding myofascial, nerve or neural structures, connective tissues and ligament structures is considered Sacroiliac dysfunction.

This pain could be gradual, due to maladaptive postures, seronegative spondyloarthropathies, osteoarthritis, pregnancy-related pain, or sudden often due to sudden movement, strain or trauma, for example, missing a step or unilateral loading with a twist which can be accompanied by a click. Pain can refer to the pubic symphysis, the groin, the coccyx , and the posterior thigh.

Symptoms vary from difficulties with standing, walking, walking up the stairs, squatting getting out of the car, turning in bed which causes sleep disturbance.

Psychosocial factors can influence the presentation and the symptoms.

Other associated symptoms: pelvic organ dysfunction, such as urinary incontinence, prolapse, or constipation and sexual dysfunction, It can also be associated with respiratory distress such as aberrant breathing patterns. There is some suggestion of links of the lateral erector spinae, such as iliocostalis linking T12 to L1 down onto the sacrum.

Special Tests

March test was validated by Hungerford in 2004. The validation study was published before much was known about other nociceptive structures or pathological structures in the lumbar spine or in the buttock. The March test is a load transfer test of the ability of the pelvic girdle to transfer a load when lifting the opposite leg, A positive test however doesn't show where the failure of load transfer happened (on which level).

Active straight leg raise test. Is used clinically to isolate the sacroiliac joint however, it's not specific and cannot be relied on in determinning the cause of the pain. The active straight leg raise test is a validated test but doesn't rule out other pelvic girdle dysfunctions

Same applies to Laslett's composite tests and tests that are based on palpation or positional faults

The one-legged squat test, femoral glide test. passive accessory tests: AP glide and the longitudinal glide to assess stability at the joint. However, these tests are unvalidated but you can compare glide within the same patient between the right and left sides.

The Pelvic joint compression with the use of a sacroiliac belt can be very helpful to help control and increase force closure across that lumbar-pelvic area.

Imaging

X-rays don't rule out which tissue is involved.

Sacroiliac Joint Infiltration can ease the symptoms when injecting an anesthetic, it doesn't differentiate what the pathological structure is.

Management

The language we use is important. Diagnosing the joint as locked, out of alignment, or positional fault which is not supported by evidence. Patients often develop fears and anxieties in response to the beliefs explained by the physiotherapists and consequently catastrophise their symptoms. of the patient.

A suggested alternative is explaining the symptoms to the patient using motor control examples, for example, here is a little bit of less control around this region and we need to restore it.

Ruling Out Deep Gluteal pathology

Gluteal Tendinopathy is characterized by chronic, intermittent pain over the buttock and lateral aspect of the thigh.

Symptoms are mainly located in the inferior gluteal aspect '' retro-trochanteric'' between the ischial tuberosity and the surrounding structures radiating onto the back of the greater trochanter.

The pain might also be originating at the lesser trochanter which could possibly reflect ischio-femoral impingement,

The definition of greater trochanteric pain syndrome has now been expanded upon to include the insertional region of the Gemelli's and the Obturators.

Patients with Gluteal tendinopathy present with sleep disturbance and difficulties with physical activity and quality of life affected similarly to those awaiting a hip replacement for severe osteoarthritis (Angie Fearon). Up to 70% of people suffering from gluteal tendinopathy are menopausal or peri-menopausal females so it's important to rule out gynaecological pathologies.

Pain can refer to the groin, the coccyx, the anterior thigh, the lateral thigh around the sacroiliac joint, the buttock and down to the insertion of the iliotibial tract on the proximal tibia which makes it more difficult to differentiate it from SIJ.