Differential Diagnosis of Buttock Pain: Vague to Specific
“ I was told by my physiotherapist that my glutes are sleepy.”
This is by far the most common answer I get from my patients when I ask them what they have been told about their buttock pain by the healthcare professionals they’ve been to.
Physios love blaming the glutes. Either they are overactive or underactive. Even the pelvis is not spared. It either slipped upwards, downwards, sideways, front and back. For many physios, the pelvis is a social beast, a party goer who goes out all the time!
Due to the various anatomical structures within the posterior hip and the fact that most of these structures can contribute to nociception, the diagnoses of buttock pain gets complicated. Adding to this confusion is, referred pain from the lumbar spine and the sacroiliac joint which can always confuse physios. In order to avoid getting caught up in this conundrum, many physios oversimplify the diagnosis of buttock pain and provide a general treatment. This can lead to buttock pain turning into a persistent pain problem for the patient and can most likely lead to impaired function and disability.
Dr Alison Grimaldi, an Adjunct Senior Research Fellow at the University of Queensland and world-renowned expert on everything hip pain, sat down with us on the Physio Explained podcast (where you can learn from the best in 20 minutes or less) to help us navigate the tricky business of differential diagnosis of buttock pain. This blog is based on the tips and advice she has provided on the podcast episode.
Check your sources
The very first step in the process of differential diagnosis is to become aware of the likely sources of local nociception and more remote sources of pain referral. Awareness of these sources helps to guide our clinical reasoning skills. The second step is to recognise the presentation of these sources. Identifying these structures can help us direct our treatment to the underlying problem. Being given a specific diagnosis and explanation can be of great help for the patient rather than using a vague term like “deep gluteal syndrome” in some cases.
Do not forget about the lumbar spine as a potential source while doing the differential of buttock pain. Pain due to neuro-compressive processes, such as radicular pain, stenosis, referred pain from the lumbar intervertebral discs or facet joints can present as posterior hip pain. Next step is to be aware of the presentation of referred lumbar pain which might include the area of pain being the lumbosacral region with radicular pain radiating from the lower back and into the buttock and below the knee.
Bilateral symptoms can indicate stenosis. Information about the aggravating and relieving factors can help further confirm the involvement of lumbar spine with history of exacerbation of back and buttock pain with activities like bending forwards and lifting or repetitive end-range lumbar movement. It is prudent to remember that buttock pain with leg pain does not exactly rule out the involvement of the lumbar spine!
Think of it as the hardware and software of your computer. The hard parts- your bones and the joints and the soft parts in the posterior hip region- the bursae, the muscles, tendons, ligaments, etc.
If the pain is localized in the mid-buttock region at the posterior aspect of the joint accompanied by loss of range of motion we must start thinking about a hip joint condition in our differential. Instead of oversimplifying buttock pain, we should pay close attention to the patient’s history which include identifying presentations and aggravating factors like difficulty manipulating shoes and socks, lack of stability or confidence when weight bearing in flexion, deep flexion, pain while loading tasks associated with rotation along with mechanism of injury and onset of symptoms.
Sacroiliac joint (SIJ) related buttock pain.
In the case of the SIJ, we are always looking to be convinced. Unfortunately, SIJ is overdiagnosed as being ‘out of place’ and something that needs to be adjusted. This has led to worse situations in which patients are misdiagnosed and are unethically treated following methods and techniques that are not evidence based.
Mid-buttock or lower buttock pain provoked by loading around the SIJ during activities such as sit to stand, rolling in bed, lifting into hip flexion, wide leg positions like the sumo squat or single leg function like the deep split lunge can be some of the features associated with sacroiliac joint related buttock pain. The primary area of pain is in the Fortin’s area, near the PSIS and the patient’s history will most likely include pregnancy or postpartum, particularly with a history of a traumatic natural delivery or history of pelvic trauma and heavy impact through one leg.
Clinical tests of the SIJ including the Posterior Shear test, compression distraction test and Gaenslen’s test, can help us be more specific about SIJ involvement. We should not forget about the ligaments around the SIJ as potential sources of nociception. True instability is rare but it can happen along with symptomatic overload. It is imperative for healthcare practitioners to be aware of these presentations of true SI joint related buttock pain rather than telling everyone that their SI joint is “out-of place”.
Blaming the glutes
Muscles are deemed the main culprit for buttock pain in most cases. It is either the glutes not firing properly or firing too much or it is the ever-encompassing, ever-tight piriformis which is always in a need of a release from elbows!
We tend to forget that the muscles are run by the nervous system. Muscles being ‘weak’ or ‘underactive’ could be because of the pain response and the muscles trying to guard and protect the area. Any peripheral entrapment or iatrogenic injury to the gluteal nerves (e.g. following a hip replacement surgery) can cause the glutes to become underactive. Lack of weight bearing stimulus can lead to under stimulation of the glutes. Glutes can change their normal antigravity behavior if they are not loaded sufficiently enough over a long time.
Similarly, not all supposedly overactive glutes or piriformis muscles need you digging into a patient’s bum with your elbows! Excessive use of the glutes could be due to muscle atrophy because it would need to employ more fibres than a healthy muscle to perform the same task. Sometimes, the glutes need to work hard due to the bony morphology, for instance the neck-shaft angle of the femur will influence the femoral offset and the lever arm of the gluteus medius and minimus muscles.
“Assumptions that any exercise that induces high levels of EMG will provide superior strength and size gains must be re-examined. High excitation or activation may simply be a reflection of mechanical inefficiency, and poorly correlated with force generation.”
-Dr. Alison Grimaldi
Different types of training stimulus can lead to glute hyperactivity. Being aware of the effects of volitional cues and exercise techniques can help with loading the muscles and associated structures effectively. During treatment, we need to decide the goals we need to focus on and the best ways to achieve those goals without causing undue fear of movement in our patients.
The consequences of misdiagnosis.
Why is the differential so important?
Unfortunately, the same general treatment methods are applied to almost every patient without understanding the underlying pathology leading to a large population of buttock pain patients being managed poorly with ‘deep gluteal massages’ and ‘hip activation drills’. Those who often need a graded exposure type of approach are stuck in this vicious cycle and often do poorly with these sorts of treatments.
Some have posterior joint instability and remain stuck in the web of piriformis release, steroid injections, and SIJ adjustments. Understanding the potential source is of paramount importance in order to guide our clinical reasoning and spread positive narratives during patient education.
Dr. Grimaldi, in this 20 minute podcast, guides us through the complex yet essential process of differential diagnosis of buttock pain. She drives home the importance of going back to our basics and being aware of the possible sources of nociception and their presentations in buttock pain. It is paramount to spend time with your patient listening to their history and understanding their behavior of pain. Keeping in mind the psychological aspect of pain, along with addressing unhelpful beliefs, will help reduce protective responses and improve patient outcomes.
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