DIFFERENTIAL

DIAGNOSIS
OF BUTTOCK
PAIN

An easy-to-follow guide designed to help you

better recognise the potential sources of
nociception or referral within the differential
diagnosis of Buttock Pain.

d r a l©i Dr
s oAlison
n g rGrimaldi
i m a l d2021
i.com
 DIFFERENTIAL DIAGNOSIS
OF BUTTOCK PAIN
dralisongrimaldi.com

Getting to the ‘bottom’ of buttock pain can sometimes prove a diagnostic

dilemma, due to the number of potential local sources of nociception and
relative complexity in anatomical relationships within the posterior hip
region. This is compounded by pelvic structures and more remote sources
within the lumbar spine.

We all need some sort of framework that contains a virtual directory of the
potential sources of local nociception and more remote sources of pain
referral, and a road map for how we might recognise these conditions.
Often the best approach is to simply think of what structures are in the
area or are likely to refer into the area, then look for the mechanisms.
Clarity around diagnostic terms can come later.

Other Sources of Buttock Pain

Lumbar Related Pain Local Sources of Nociception

0
Radicular Discs & Joints Soft Local Bone
& Stenotic Facet joints Tissues Nerves

SIJ Hip

0
Ligaments Muscles Tendons Bursae Fascia

Ha
First step is what structure/s and then, why – biopsychosocial drivers. The patient is a goldmine of information for directing
your physical examination and ultimately informing your differential diagnosis. The following information can all be gathered
from the patient interview, so listen carefully for the patterns that might assist in differentiating local and remote sources of
nociception associated with buttock pain.

The lumbar spine is a frequent source of buttock pain and should always be in the

LUMBAR starting mix of diagnostic possibilities in your differential diagnosis of buttock pain.
Buttock pain of lumbar origin is most commonly either related to neuro-compressive

RELATED processes, such as radicular pain or stenosis or somatic referred pain from the lumbar
intervertebral discs or facet (zygapophyseal) joints.

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KEY FEATURES OF LUMBAR RELATED BUTTOCK PAIN

Area of pain:
Radicular pain often transits from the lower back, across the buttock and into the lower limb,
but may present without back and or distal symptoms
Buttock pain associated with stenosis is generally in the mid to lower buttock regions1
Both radicular and stenotic pain are frequently associated with leg and foot pain
Radicular pain may initially present in roughly dermatomal distribution but innervation
overlap is common and with persistent pain, extra-dermatomal spread of symptoms may
occur due to remote immune-inflammatory responses in the ipsilateral and then contralateral
dorsal root ganglia and dorsal horns of the spinal cord.

Bilateral symptoms may be due to central stenosis or mirror-pain in radicular presentations associated with immune-
inflammatory response in the contralateral dorsal root ganglion and dorsal horn
Facet related pain may extend down the posterior thigh but is generally more focal than neuropathic pain
Disc and facet pain do not generally refer below the knee

Associated Symptoms: Easing Factors:

+/- lower back stiffness Sometimes eased by change in lumbar position or mid-
Paraesthesia or numbness linked with radicular range lumbar movement.
pain or stenosis Stenotic pain is usually eased by sitting and lumbar
NO paraesthesia or numbness when pain is flexion
referred from discs or facet joints Facet related pain is also reduced in more relaxed sitting
positions
Aggravating Factors:
Aggravated by lumbar loading – lifting, bending, History of Onset
repeated lumbar movements May be acute onset related to lumbar loading – forward
Stenotic pain gradually increases with duration leaning, lifting
of standing and walking1 Often intermittent or gradually progressive symptoms
Pain may also be exacerbated by sustained associated with more degenerative conditions
postures – sitting, standing
Facet related pain is often particularly Patient Characteristics
exacerbated by sustained and dynamic The probability of disc related pain decreases as age
extension increases, while the likelihood of facet related pain
increases with age.

The 2 major joints within the pelvis that may give rise to buttock pain associated with local
JOINT nociception, are the sacroiliac joints and the hip joints. Unfortunately, sacroiliac joint
dysfunction still appears to be grossly overdiagnosed and beliefs that are transferred to
RELATED patients about instability and pelvic malposition are generally unhelpful. However, it is also
important not to ignore the sacroiliac joint and especially its associated ligaments as
sources of nociception.

KEY FEATURES OF SACROILIAC JOINT RELATED BUTTOCK PAIN

Area of pain:
Pain in the Fortin’s area, around the Posterior Superior Iliac Spine (PSIS), *inferomedial
May be associated pubic symphysis or groin pain
Sometimes patients report pain that extends from the Fortin’s area, down towards the
medial ischium and through towards the groin

Associated Symptoms:
Feeling of instability in single leg standing
Feeling of heaviness of the leg when lifting the leg, particularly the whole leg in supine
May report difficulty with initial weightbearing through affected side when rising to stand
Aggravating Factors:
Pain and difficulty with load transfer through SIJ – moving from sit – stand, stance phase of gait, lifting into hip
flexion, rolling in bed
Wide leg, split lunge or single leg function
Pain with sustained sitting
Supine leg loading tasks e.g. abdominal leg loading exercise may be provocative

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KEY FEATURES OF SACROILIAC JOINT RELATED BUTTOCK PAIN - CONTINUED

Easing Factors:
Sometimes eased by sacroiliac belt, but this may also increase local pain

History of Onset
During pregnancy or post-partum, particularly with a history of a traumatic natural delivery
History of pelvic trauma – fall onto the ischium or a heavy impact through one leg, traction force through one leg
(e.g. fall from horse and dragged via stirrup), slip into splits (forward or lateral)

Patient Characteristics
More common in females, particularly where trauma has not been involved
Those with connective tissue disorders such as hypermobile Ehlers Danlos Syndrome, may present with difficulties
on load transfer across the pelvis, particularly in perinatal females

Pain experienced in the mid-buttock region should immediately provoke suspicion of a

HIP JOINT hip joint condition in your differential diagnosis of buttock pain. Hip osteoarthritis (OA) is
more readily recognised in the older patient with an antalgic limp, associated groin pain

RELATED and difficulty reaching their foot due to gradually progressive range restriction. However,
younger patients or those with earlier disease may present with more subtle symptoms
of intra-articular joint pathology.
While anterior bony impingement is now well recognised, posterior femoroacetabular impingement (FAI) and associated
chondrolabral pathology are often overlooked. In addition, posterior laxity or instability of the hip joint remains
underrecognised, particularly in those with ‘hip stiffness’ associated with anterior FAI. Anterior impingement at end range
flexion and internal rotation results in a levering of the femoral head from the posterior aspect of the acetabulum. Focal
instability and overload may also be related to bony undercoverage posteriorly associated with acetabular retroversion.
More global hypermobility is usually due to some form of collagen disorder (Hypermobile Spectrum Disorder or
hypermobile Ehlers Danlos Syndrome).

KEY FEATURES OF HIP JOINT RELATED BUTTOCK PAIN

Area of pain:
Buttock pain associated with hip joint conditions is usually experienced in the mid buttock
region
Often accompanied by anterior hip/groin pain
+/or may present with referred pain to the anterior knee and anterolateral leg

Associated Symptoms:
Hip stiffness is a key sign of hip OA - difficulty reaching the foot of the painful side when
dressing/difficulty manipulating shoes and socks
Painful limp
Posterior instability - giving way, lack of stability or confidence when weightbearing in flexion
+/- internal rotation
Aggravating Factors:
Deep flexion-squatting and sitting - mediated by depth of chair/amount of hip flexion – worse in low seats *car
Start-up pain and stiffness in hip OA– pain that occurs immediately on rising to stand and walk, but eases with
continued walking (compared with lumbar stenotic pain that is less likely to occur on immediate standing/walking
but tends to increase with time in standing/walking1)
Pain on weightbearing tasks - buttock pain usually on impact/loading phase, associated with anterior pain that occurs
in hip extension, at end stance phase
Pain on weightbearing rotation - getting in/out of the car (stance leg), change of direction
Pain lifting the leg in/out of car
Posterior FAI symptoms may be aggravated by hip extension +/- external rotation.

Easing Factors:
Eased by changing hip loads – reducing hip flexion – sitting on higher seats, on edge of chair with knee hanging
down, reducing impact activity and reducing hip extension e.g. reducing stride length in walking

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KEY FEATURES OF HIP JOINT RELATED BUTTOCK PAIN - CONTINUED

History of Onset
May be associated with a single acute trauma involving impact through the foot or knee, hyperflexion or
rapid/forceful rotation
More often gradual onset or associated with an increase in volume or intensity of activity

Patient Characteristics
Older age groups - suspect hip OA especially if accompanied by gradually increasing stiffness
Risk of hip OA increased with family history of OA, previous trauma, childhood hip disorders (Perthes, Slipped Capital
Femoral Epiphysis, Dysplasia) and known Cam morphology (FAIS)
Posterior instability - increased risk in those with known acetabular dysplasia, collagen disorders (hypermobility), or
anterior bony impingement.

Myofascial structures are obvious sources of nociception in the buttock, which is

SOFT abundant in muscles, tendons, bursae, ligaments and other fascial structures. The term
‘fascia’ includes all collagen rich structures such as tendons, ligaments, and all the
TISSUE connective tissues that surround and separate our muscles, nerves and organs1. While
we are still in the infancy of our understanding of the role of fascia in pain states, it is well

RELATED innervated, particularly in more superficial fascial sheets and should be considered as a
possible source of nociception.

KEY FEATURES OF SOFT TISSUE RELATED BUTTOCK PAIN

Area of Pain:
Pain is usually relatively localised to the nociceptive tissue

Associated Symptoms:
May be accompanying stiffness or weakness

Aggravating Factors:
Pain aggravated by activity/ loading of the specific tissue
usually on initial loading after rest and
on loading of the tissue beyond its level of load tolerance (dependent on local and
central factors)
Pain at rest usually only if
acute/inflammatory condition or
positional - relating to direct loading of tissues e.g. ischial pain in sitting with proximal hamstring tendinopathy

Easing Factors:
Common to experience pain on initial activity that eases during warm-up and then may return if load tolerance level is
reached during activity, or after cool-down.
Rest generally eases pain, unless the condition is acute/inflammatory condition or the patient adopts a position of
provocative load for the particular tissue

History of Onset
History usually reflects some form of overload
Acute high-load trauma – history of injury or accident
Fatigue overload – Abnormal stresses on normal tissues – increase in training volume or intensity
Insufficiency overload – Normal stresses on insufficient tissues – the overload may not be initially apparent, but in
deconditioned individuals and/or those with significant structural pathology, relatively low loads may result in overload
and nociception

Patient Characteristics
Muscular injury/overload is more common in active individuals

O
Tendon conditions present in both active individuals (e.g proximal hamstring tendinopathy in runners) and older,
deconditioned and/or sedentary individuals
Tendon conditions are common in post-menopausal females

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SOFT TISSUES OF THE BUTTOCK

Superficial
Thoracodorsal
Fascia EO
IO

GMed
GMax
Gluteal
Fascia

AM
ST

SM BFLH

EO: External Oblique AM: Adductor Magnus

IO: Internal Oblique SM: Semimembranosis
GMed: Gluteus Medius ST: Semitendinosis
GMax: Gluteus Maximus BFLH: Biceps Femoris Long Head

Deep

Quadratus Lumborum

Gluteus Medius
Piriformis
Gluteus Minimus
Superior Gemellus
Gluteus Medius &
Minimus Tendons Obturator Internus
Inferior Gemellus
Subgluteus Quadratus Femoris
Maximus & Obturator
Medius Bursae Internus
Proximal hamstring
tendons
Ischiogluteal Bursa Obturator Internus
Bursa (deep to OI)

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Local nerves running through the buttock can also be responsible for both local and/or

NERVE remote symptoms. The sciatic nerve is the largest and most recognised source of local
nerve related buttock pain. Entrapment or irritation of the sciatic nerve as it passes

RELATED
through the buttock has been given many names, among them the more well
recognised piriformis syndrome and deep gluteal syndrome

KEY FEATURES OF PERIPHERAL NERVE RELATED BUTTOCK PAIN

Area of Pain:
Area of nerve entrapment (nociceptive pain) and area of nerve supply (neuropathic pain)
Sciatic entrapment/irritation (deep gluteal syndrome) – mid and/or lower buttock pain +/- distal
pain (sciatica) +/- lower back pain, but the buttock pain is usually the initial and worst area of
pain.
Cluneal nerves serve the skin of the buttock producing local pain
As discussed in lumbar related pain, extra-territorial spread of symptoms may occur due to
remote immune-inflammatory responses in the dorsal root ganglia and dorsal horn. Patients
with cluneal nerve entrapment have been reported to present with ‘sciatica-like’ symptoms,
relieved by surgical release of cluneal nerve entrapment.

Nature of Pain:
Often described as burning and/or sharp or shooting pain
Also, may experience a deep ache, particularly with nerves within the deep gluteal space

Associated Symptoms:
Dysaesthesia/paraesthesia – tingling, change in sensation, itching/crawling sensations
Altered temperature sensitivity (deficit in cold and/or warm)
Cramping in buttock/posterior thigh and/or sometimes calf
Gluteal weakness – may be pre-existing, pain inhibited or possible gluteal nerve injury
Weakness of external rotators – may be pre-existing, pain inhibited or possible nerve injury

Easing Factors:
Getting up and moving – from sitting and at night

Aggravating Factors:
Sitting – tolerance is often limited to 30 minutes or less
Slump type postures or activities where nerves are on stretch or moving between structures in the buttock
Cluneal nerve pain may be exacerbated by direct pressure (tight belt/pants) or stretch of the thoracodorsal/gluteal
fascia through which the nerves transit to the skin
Night time pain (and/or cramping)
Gluteal and particularly deep rotator exercise (deep gluteal space entrapments)

History of Onset
O May have history of trauma e.g. impact +/- haematoma to buttock, pelvic fracture
Previous surgery or intramuscular injection into the buttock
History of muscular overload of deep rotators – physical labour, gym/sport, trail running on uneven surfaces

Patient Characteristics
Variable
Presentation may be influenced by other general health issues and psychological stressors
Higher rates of neuralgia in those with connective tissue disorders.

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NERVES OF THE BUTTOCK

Superficial

SCN's
MCN's

PFCN

ICN's

SCN’s: Superior Cluneal Nerves

MCN’s: Middle Cluneal Nerves
ICN’s: Inferior Cluneal Nerves
PFCN: Posterior Femoral Cutaneous Nerve

Deep

SGN

nOI SN
PN
IGN nQF

PR

PFCN

SGN: Superior Gluteal PFCN: Posterior Femoral Cutaneous

IGN: Inferior Gluteal PR: Perineal Ramus
SN: nOI: nerve to Obturator Internus
Sciatic
nQF: nerve to Quadratus Femoris
PN: Pudendal

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Now that you have a good idea of what structures may be involved in your patient’s buttock pain, you can apply physical
tests to confirm or refute your hypothesis and assess impairments to be addressed within the rehabilitative process.
It is also important to note that systemic causes, non-nociceptive or nociplastic pain states and psychosocial contributors
to any pain presentation should always be considered. There are also other processes that cause nociception within
musculoskeletal structures, such as malignancy or infection, so questioning around general health is mandatory.

Additional conditions not to be missed: Spondyloarthopathies (*Ankylosing Spondylitis), Polymyalgia, Stress

Fractures (*sacrum, femoral neck, ischiopubic ramus), ischial apophysitis/avulsion, bone/joint infections,
avascular necrosis of the femoral head, malignancy.

While the lumbar spine, SIJ, hip joint, soft tissues and nerves are the most common
OTHER sources of nociception associated with buttock pain, it is important to be aware of those
less common causes. Missing these may have substantial consequences for our
SOURCES patients, so we all need to ensure we listen and assess carefully.

Bony Sources of Buttock Pain

The other musculoskeletal structure within the buttock is of course, bone. Although relatively rare, be aware of the
possibility of stress fractures of the pelvis, particularly the sacrum - commonly misdiagnosed as sacroiliac joint pain, or the
ischiopubic ramus.
These will present most commonly as fatigue fractures in endurance runners, particularly females with Relative Energy
Deficiency in Sports (RED-S) but can present in either sex, or as insufficiency fractures in older osteoporotic individuals.
Onset of pain is usually rapid and significantly impedes activity, but sometimes symptoms may develop slowly and
diagnosis can be delayed.
Ischial apophysitis or avulsion injury may occur in adolescents involved in sports with high hamstring loads e.g kicking
sports or rapid acceleration. Remember that the ischial growth plates may not fully fuse until 25 years of age, so keep
these diagnoses in mind even for athletes in their late teens and early 20's7.

Intrapelvic and Vascular Sources of Buttock Pain

The other adjacent region with potential referral sources is the intra-pelvic space. Pelvic pain is sometimes overlooked but
particularly if your patient is female, some extra questioning around cyclical nature of pain, pelvic health and history is
well warranted. Back, sacral and buttock pain are common areas of pelvic organ pain, or linked with prolapse, pain post
prolapse surgery and with pelvic floor and related obturator internus dysfunction. Buttock pain may also arise due to
either intrapelvic or extrapelvic vascular conditions. Pain associated with vascular structures is usually described as
throbbing, pounding or pulsating.

Malignancy, Infection, Nociplastic Pain States and Systemic Causes of Buttock Pain
Systemic causes, nociplastic pain states and psychosocial contributors to any pain presentation should always be
considered. There are also other processes that cause nociception within musculoskeletal structures, such as malignancy
or infection, so questioning around general health is mandatory.
We have focused on nociceptive and neuropathic mechanisms for buttock pain, but I did want to highlight the need for
early identification of spondyloarthropathies such as axial spondyloarthopathy and ankylosing spondylitis (AS). There is
often substantial delay between onset of symptoms, diagnosis and management of AS, particularly in those who are
HLAB27 -ve8. Awareness and screening is key to early diagnosis. Pain onset is usually in the 20's or 30's and patients
report back and buttock pain with morning stiffness that lasts more than 30minutes, isn’t eased with rest but improves
with activity and anti-inflammatory medication. While this diagnosis might come to mind more readily when assessing a
male patient with these symptoms, sometimes it is overlooked in females due to other more common sources of pelvic
pain. Make sure you consider this differential diagnosis in any such presentation, regardless of sex.

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Use Paul Kirwan’s great SCREEND'EM tool to screen for spondyloarthropathy:

S kin - rash or psoriasis?
C olitis or Crohns?
R elatives – family history of inflammatory arthritis?
E arly morning stiffness?
E yes – has the patient had Uveitis (painful red eye with photophobia and blurred vision)?
N ail involvement? Nail pitting, thickening or detachment
D actylitis? Sausage-like swelling of the fingers
E nthesopathy? Pain at entheses - Achilles, plantar fascia and patellar most common
M edication and movement response? Pain reduced with movement and anti-inflammatories but not rest

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