Pain around the lower buttock may also be related to soft tissues. Soft tissues are non-bony structures that connect, support, or surround other structures and include:

• the muscles, which allow you to move (Figures 2.1 & 2.2).
• the tendons, which connect your muscles to the bone (Figure 2.2).
• the bursae – small, flat pockets of fluid that help all these things slide and glide against one another, reducing friction. There are bursae are all around the body in places where different structures may rub against one another, for example where a tendon runs around a bone (Figure 2.2).
• the fascia – stretchy, thin, white fibrous tissue. All our muscles are enveloped in fascia, like stretchy stockings that help transfer energy from muscle and movement. Fascia also forms sheaths or tunnels for safe passage of blood vessels and nerves and wraps and supports all our bodily organs (Figure 2.1).

The muscles of the lower buttock region are involved in providing support for the back of the hip joint and moving the hip into extension and external rotation–taking your leg backwards and turning your knee outwards.

If you put your hands on the lower half of your bottom you will be touching the lower portion of the gluteus maximus muscle, an important muscle for pushing up from a squat or lunge position or for extending the leg behind especially when walking up a hill or stairs (Figure 2.1).

The hamstring muscles (semimembranosis, semitendinosis and biceps femoris muscles) in the back of the thigh help to extend the hip (take the thigh backwards), but also bend the knee. This combined function makes the hamstring muscles very important muscles for transferring forces between the hip and lower leg in actions such as running, kicking, lifting and lunging (Figure 2.1).

Beneath the lower part of the gluteus maximus muscle, sit a group of small muscles, referred to as thedeep hip rotators (Figure 2.2). They work to rotate the thigh and turn the knee outwards.

They also have important connections into:

• the back of the hip joint, allowing them to provide extra stability for the hip joint
• the pelvic floor muscles.

The hamstring muscles in the back of the thigh also attach deep in the buttock, onto the sitting bones (ischial tuberosities). They attach onto the bone via elastic, fibrous tendons, together referred to as the proximal hamstring tendons (Figure2.2). Proximal simply refers to the end of a structure closer to the head-end of your body.

Directly on top of the hamstring tendon attachments is a small flat, fluid-filled cushion (the ischial or ischiogluteal bursa) (Figure 2.2). This helps reduce friction and allows smooth gliding of the largest buttock muscle (gluteus maximus) over the hamstring tendons.

Soft Tissue-Related Pain in the Lower Buttock Region:

Soft tissue related pain can occur in the Lower Buttock Region for many reasons:

• Muscle soreness, tears or strains may occur in this region related to large or unusual forces across the largest buttock muscle (gluteus Maximus) or the deep rotator muscles.  Tears of the deep rotator muscles may occur with rapid change or direction or a twisting injury.
• The deep rotators may also become overactive and painful associated with weakness or excessive activation of other muscles in this area (including the pelvic floor, gluteal or hamstring muscles).
• Ischiofemoral impingement is a diagnosis referring to a situation where one of the deep external rotator muscles (quadrates femoris) is repetitively compressed in a smaller than normal gap between the sitting bone (ischial tuberosity) and the thigh bone (femur).
• Hamstring tendon pain (Proximal Hamstring Tendinopathy) may come on quickly, in response to a large strain, often a slip or fall, or a rapid change of activity.  However, changes in tendon health often evolve more slowly, related to postural, movement or athletes training habits, particularly long distance and hill running.
• Ischial or ischiogluteal bursitis is a diagnosis referring to inflammation of the small flat, fluid filled cushion called the ishiogluteal bursa (figure 2.2) that sits over the hamstring tendons at the sitting bone.  The bursa becomes inflamed and painful when it is struggling to cope with high levels of compression or friction over the sitting bone, possibly associated with sitting on hard surfaces or athletic active such as running uphill.

Your Hip Pain Professional can:

• assess the gluteus maximus and deep hip rotator muscles
• assess the hamstring muscles and their tendons
• provide guidance as to what exercises will be most beneficial, for example hamstring stretching is usually not helpful for those with hamstring tendinopathy or tendon tears
• assess if weakness is an issue and if so, exactly which of the muscles are weak or activating too much, thus providing you with exercises specific to your individual needs
• assess if ‘neuromuscular’ control is an issue, that is, do you move in a way which may irritate or overload the painful structures
• provide important advice about sporting activities, such as
  • ‘how much is too much’
  • allowing adequate recovery between sessions
  • altering activity levels to match soft tissue tolerance o
  • resting from, or altering particular actions that place highest load across the lower buttock region
• provide advice on seating if pain on sitting is an issue
• advise if injections or surgery may be warranted

Although relatively more rare than soft tissue or joint problems, bony problems such as a fracture, stress fracture or very rarely, infection or tumor within the bone may cause hip and pelvic pain.

In growing children or adolescents, pain may be related to disorders of the growth plates of the femurs or pelvis.

Bone Related Pain

Bone related pain may be due to:

• Fracture–the medical term for a broken bone
• Stress fracture – a tiny crack in a bone, usually related to repetitive overload
• Apophysitis
• Avulsion fracture

The most common bone related issues associated with lower buttock pain are related to apophysitis or avulsion fracture of the ischial tuberosity (sitting bone) (Figure 3).

Apophysitis:

• usually referred to as ‘growing pains’
• occurs in adolescents
• is due to long bones such as the femur growing more quickly than the muscles, which then tug on the growth zones in the immature pelvis

In the lower buttock the hamstring muscles may pull harder than normal on their attachment to the ischial tuberosity (sitting bone) (Figure 3). This occurs when the femur grows rapidly, and the hamstring muscles become relatively short. It can take a little while for muscle length to catch up to bone length.

The pain of apophysitisis related to an inflammation of the bony growth centres where the muscles attach. Pain is generally experienced locally at the area of muscle attachment but can radiate around the area as well.

An avulsion fracture:

• is where a small piece of bone is pulled away from the main part of the bone
• may occur in adults where a large force across a ligament (joins bone–bone) or tendon (joins muscle to bone), causes a small piece of bone to come away with the ligament or tendon
• may occur in children at the bony growth plates. Occasionally a large pull from the hamstring muscles on the ischial tuberosity can cause displacement of the growth plate. In the case, the lower end of the sitting bone may shift a small distance away from the main bony pelvis.

Other growth-related bony issues:

• Perthes disease or Legg-Calvé-Perthes Disease – is misshaping of the femoral head related to issues with blood flow to the bone. Most common during ages 4-10 years.
• Slipped Capital Femoral Epiphysis or Slipped Upper Femoral Epiphysis – usually a small shift in the growth plate in the neck of the femur that can change the shape of the head and neck of the femur. Most common during ages 8-15 years.

Pain related to the bones could be felt anywhere around the hip or pelvis region depending on the bone affected and the cause of the bone pain. Click on our Pain Locator Map to review the areas you feel pain and learn more about the bones that may be related to pain in each area.

Your Hip Pain Professional can:

• perform a thorough assessment and let you know if a bone issue may be suspected. In these cases, you may be advised to undertake further imaging or referral to a medical specialist for further advice
• provide or refer you for rehabilitation at an appropriate time following bony injury
• provide important information about managing sporting activity and recovery in those with bony stress injuries or adolescents with bony ‘growing pains’
• address muscular or bio mechanical issues that may be contributing to bone-related pain, for example, running style may have an impact.

Pain experienced around the hip and pelvis sometimes has nothing to do with problems in this area.

Problems in the lower back can result in back pain and/or pain through the hips and down into the legs. There are two main ways this might occur:

Referred pain

Referred pain is pain felt in a part of the body other than its actual source. For example, if there is a problem in the lumbar (lower back) discs or joints, small nerve endings serving these structures generate ‘danger’ messages that are transmitted along small nerve fibres into the spinal cord.

However, this area of the spinal cord also receives information from structures in the hip and pelvis.The brain is unable to distinguish where the information came from, (the back, the hip or the pelvis) so you might feel pain in any one or a combination of these areas(Figure 4.1).

Referred pain:

• is usually a dull, aching or gnawing pain
• can expand into a wide area that is difficult to localize
• is not related to a problem of the nerve roots in the spine
• is not associated with other nerve-related symptoms such as tingling or numbness

Radicular Pain

Radicular pain is pain associated with irritation of the nerve roots as they exit the spine. Most commonly this is associated with inflammation or compression from the nearby disc. The nerve roots that exit at each level of the spine give rise to sensation indifferent areas of the skin, called dermatomes (Figure 4.2).

When a nerve root is irritated at the spine, pain may be felt in the area of skin that the nerve root supplies. For example, compression of the nerve roots that exit between the 4th and 5th lumbar vertebrae (L4-5) or the 5th lumbar vertebra and the sacrum (L5-S1),could, for some people, result in painful sensations across the buttock, down the back of the thigh and right down into the foot (see picture).

The nerve root compression of the lower levels (L4, L5 and S1 and their resulting referred pain is often called “sciatica”.

This term is not correct. The Sciatic Nerve is formed where the L4-S1 nerve roots blend together outside of the spine: the term “sciatica” refers to irritation of this nerve, NOT the nerve root.

So where the irritation is at the nerve root, before the nerve roots actually blend together to form the sciatic nerve, it is incorrect to use the term “sciatica.”

The term “radicular pain”is now used instead.

Radicular pain:

• is related to a problem of the nerve roots in the spine
• is usually accompanied by stabbing or shooting pains
• is usually easier to localise than referred pain
• may also be associated with an additional or background, deep, dull ache
• may be accompanied by other nerve related symptoms such as tingling, itching, burning or numbness

If the pain in your hip is due to a problem in the back, you can spend valuable time and money getting unnecessary treatment on the wrong area and this might delay an important diagnosis and your recovery.

It is also important to be aware that pain in some regions, particularly lateral hip and buttock pain, is often assumed to be back-related pain when the pain may be all or partly due to a problem of the hip.

Again, you may spend valuable time and money getting unnecessary or incomplete treatment.

Your Hip Pain Professional can:

• provide a skilled assessment
• help figure out the actual source of the problem and if you have more than one area contributing to the problem
• develop a comprehensive plan to help the problem – If your pain is lumbar-referred or radicular, you may need treatment on your back and not your hip or if you have two problem areas, both will need to be addressed within a comprehensive management plan
• recommend further tests or refer you to another specialist if the problem does not appear to be in the musculoskeletal system.

The nervous system(Figure 5.1) is a complex network of nerves and cells that carry messages between the brain and spinal cord and your body. It is through this system that we feel, move and control our bodily functions.

Nerve roots leave the spinal cord via the intervertebral foramina (holes or spaces between the vertebrae) and join together from various levels of the spine to travel as cord-like structures, called nerves, to their destinations.

It is these nerves that travel outside the spinal cord that are referred to as “peripheral nerves”.

Some peripheral nerves travel only a short distance and others all the way from the lower back to the foot. Along their journey they run between and through muscles and fibrous tunnels.

While radicular pain arises from a problem as the nerve root exits the spine, nerve-related pain may develop due to a problem along the pathway of a peripheral nerve, outside the spine. Pain related to a nerve is called “Neuralgia”.

Neuralgia felt around the hip and pelvis may develop in many ways including excessive compression or stretch of the nerve. This may be caused by a sudden, acute mechanism, for example a fall or blow to the area resulting in compression, or the leg being caught and wrenched, resulting in stretch.

Alternatively, the onset may be subtle, with a gradual onset associated with sustained postures or repetitive movements that cause cumulative nerve irritation.

Nerves will also be influenced by the health of the tissues they run through or alongside. For example, high muscle tension or tendinopathy may over time result in irritation of neighbouring nerves.  Nerve related symptoms are usually experienced differently from pain associated with muscle and joint problems.

Peripheral nerve irritability may result in:

• symptoms in the area served by that peripheral nerve (which is different from dermatomal patterns associated with nerve root irritation -radicular pain)
• burning pain
• odd zings or zaps of pain
• tingly sensations or numbness
• weakness – only for those nerves that supply muscles, like the femoral nerve

Nerves of the Upper & Lower Buttock Regions

Nerves that pass through or supply the buttock region (Figure 5.2) include:

• the sciatic nerve
• the cluneal nerves – superior, middle and inferior
• the gluteal nerves – these are motor nerves that serve muscles and not the skin.
  • superior gluteal nerve – serves the gluteus medius, minimus and tensor fascia lata muscles
  • inferior gluteal nerve – serves the gluteus maximus muscle
• posterior femoral cutaneous nerve – provides nerve supply to a large area of skin of the back of the thigh.

Nerve Related Pain/Neuralgia in theButtock Regions

The Sciatic Nerve and “Sciatica”

The term “sciatica” is often used incorrectly in reference to any pain felt in the area running from the back, down into the leg. See our section on “back-related hip pain” to read more about radicular pain associated with irritation of the nerve roots as they exit the spine. The sciatic nerve does not exit the spine as a single nerve. Nerve roots from the lower levels of the lumbar spine (lower back) and sacrum (tailbone) join together in the pelvis. Here they form a thick, cord-like structure, called “the sciatic nerve”. This large nerve exits the inner pelvis via the greater sciatic notch and runs through the buttock and down the back of the thigh (Figure 5.4).

The sciatic nerve can sometimes be compressed, irritated or entrapped as it runs through the soft tissues of the buttock. Traditionally, sciatic pain (neuralgia) generated from issues within the buttock has been termed “Piriformis Syndrome” (see Figure 5.4 to view the piriformis and the sciatic nerve). This was based on a finding that in about 20% of the population, all or part of the sciatic nerve runs through the piriformis muscle. Compression of the nerve within the piriformis muscle was thought to be the problem in all cases of nerve related buttock and leg pain that could not be associated with a problem in the back. It is now thought that this is the case in only a relatively small number of cases and that this condition has been over-diagnosed. So much so, that some believe it does not exist at all.

The term “Deep Gluteal Syndrome” has been suggested recently as an alternative term to piriformis syndrome. It refers to any irritation of the sciatic nerve in the deep gluteal space, beneath the gluteus maximus muscle. In this space, the sciatic nerve may be compressed or irritated at the level of the piriformis, as it runs over the deep external rotator muscles or by fibrous bands anywhere along its path through the buttock. The nerve can also be irritated as it leaves the pelvis to head down into the thigh. Here it runs through a tunnel (ischial tunnel), between the outer side of the sitting bone (ischial tuberosity) and the upper thighbone (femur) (Figure 5.4). In this tunnel it may be squeezed between the bones or irritated by unhealthy hamstring tendons (tendinopathy).

Cluneal Nerve Neuralgia

Of the cluneal nerves, the superior and inferior are more likely to be at risk of compression. Irritation of the inferior cluneal nerve may result in lower buttock pain. The inferior cluneal nerve branches run across the lower buttock, right over the sitting bone (ischial tuberosity). They can be compressed and irritated by a hard fall onto the bottom or sitting for prolonged periods on a hard surface, particularly if you don’t have much gluteal muscle bulk to cushion the bone. Again, associated symptoms are usually fairly localised to the area of skin supply (Figure 5.3). Sometimes the nearby posterior femoral cutaneous nerve can also be affected. Symptoms may then extend into the back of the thigh (see picture for region of nerve supply (Figure 5.3).

Gluteal Nerve Neuralgia

The gluteal nerves do not have a sensory supply to the skin, but gluteal neuralgia may be felt as a deep buttock pain, sometimes like a cramping feeling. These nerves provide important motor supply (the ability to make the muscles work/contract) to the gluteal muscles and theTensor Fascia Lata (TFL) muscle at the side of the hip. Damage to these nerves may alter your ability to stand on one leg, walk without a limp, climb stairs, and lift the leg out to the side or behind you. The nerves may be irritated or compressed as they pass out into the back of the pelvis and run through the soft tissues of the buttock. Very occasionally, these nerves may also be damaged by surgery, such as a posterior approach Total Hip Replacement (where the scar is at the back of the hip).

For Pain Related to Nerves/Neuralgia throughout the Hip, Pelvis, Buttock and Groin:

Your Hip Pain Professional can:

• perform specific tests in the clinic to see if nerve involvement is likely
• provide treatments and give you exercises that may improve the health or movement of the nerve
• help improve health of the muscles and tendons beside the nerve (this may be the source of nerve irritation)
• review the positions you spend time in and activities you perform daily and provide strategies when performing these tasks that might help protect the nerve, thus reducing your symptoms. This may include changing your sitting or lying posture, or changing stretches or strength exercises that you have been performing that may be contributing to the irritation the nerve
• provide nerve gliding or mobility exercises that can be useful in some situations
• refer you for further tests or to a neurologist, orthopaedic specialist or other pain specialist if required.
• In some cases, your hip pain professional may refer you to a pelvic floor physio for further assessment should they consider the pelvic floor muscles are involved.

* Please note: Nerve supply can overlap and be quite variable between individuals. The diagrams provided in this section only provide an approximate guide of nerve supply in each region.

There are other processes that may produce pain around the hip and pelvis.

These include:

• Systemic/Rheumatological conditions: eg Rheumatoid Arthritis, Polymyalgia, Polyarthralgia
• Infective processes: Septic arthritis, Osteomyelitis, Viral Arthritis
• Neoplastic processes (cancer)
• Vascular issues: Avascular Necrosis, External Iliac Artery Entrapment, varicotic gluteal vessels compressing the sciatic nerve

These conditions are relatively rare compared to musculoskeletal pain, but when present you will need to see a medical practitioner and usually a specialist for that system or problem, for example, a Rheumatologist, Orthopaedic Specialist, Oncologistor Vascular Specialist.

Lower abdominal and pelvic pain can also be associated with organ problems (ovaries, uterus, bowel, bladder, prostate). One of the most common causes of organ-related pain in females is endometriosis.

This occurs when tissue that is similar to the lining of the uterus (womb) grows outside the uterus attaching to other structures such as the pelvic ligaments or the bladder and bowel.

This can lead to debilitating pain that may be cyclic, relating to the menstrual cycle.

Diagnosis and management of organ related problems will usually require the assistance of a specialist, for example a gynaecologist (female reproductive organs), urologist (bladder and prostate) or gastroenterologist (gut/bowel).

A skilled assessment by a Hip Pain Professional will help clarify if the problem requires further medical attention and whether it is likely to be related to a musculoskeletal problem or not.

Your Hip Pain Professional can:

• provide a detailed assessment
• assist in determining if the problem is musculoskeletal or not
• develop a plan to help if the problem is musculoskeletal
• recommend further tests or send you to another specialist if the problem does not appear to be in the musculoskeletal system.