Pain in the upper buttock region may be related to soft tissues. Soft tissues are non-bony structures that connect, support, or surround other structures and include muscles, tendons (which connect your muscles to the bone) and fascia (Figure 2.1).

Fascia is 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.

There are many muscles that support and move the hip and pelvis. In the upper buttock region, many muscles and their surrounding thin fibrous wrapping (fascia) converge, joining firmly onto the pelvis and sacrum. These back, abdominal and buttock muscles play a vital role in generating and transferring forces that pass across the pelvis, between the back and hips. The muscles are also covered in strong fascia that continues from the hips (gluteal fascia) into the back (thoracodorsal fascia). This strong, stretchy wrapping helps store and transfer energy through this region (Figure 2.1).

The upper part of the gluteus maximus muscle, and the gluteus medius muscle beneath, run from their anchor points on the pelvis and sacrum, around to the side of the hip (lateral hip region) (Figure 2.1). The piriformis muscle also sits under the gluteus maximus in the upper buttock, having strong connections into the bones and ligaments of the sacroiliac joint (SIJ) at the back of the pelvis (Figure 2.2).

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

The most likely bone-related issues associated with pain in the upper buttock region, are fracture or stress fracture of the sacrum. The sacrum is the wedge-shaped bone that sits between the two bony wings of the pelvis (Figure 3).

A fracture:

• is the medical term for a broken bone
• usually occurs from a traumatic event like a fall, car accident or more severe sporting injury. A hard fall backwards onto the pelvis may cause a sacral fracture.
• is more likely to occur in a weakened bone e.g. osteoporosis or genetic diseases like osteogenesis imperfecta.

A stress fracture:

• is the medical term used for a tiny crack in a bone
• starts as localised swelling in the area of bone exposed to highest stress (you won’t see this at skin level as it is just within the bone) – this may be called a stress reaction or bony stress response

Stress fractures can be divided into two main types:

1. Fatigue fracture: where a bone has been exposed to an abnormal accumulation of repeated small traumas e.g. long-distance running
2. Insufficiency fracture: where the bone strength is insufficient to resist normal daily forces

Sacral fatigue fractures are seen most commonly in long distance runners or triathletes.  Compared with bony injuries of the leg and foot, these are relatively much less common.  Sacral insufficiency fractures occur most commonly in elderly females with osteoporosis.  A diagnosis of sacral stress fracture may be missed or delayed, as the associated pain in the upper buttock region is often assumed to be related to the sacroiliac joint or lower back.

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 general or sporting activity
• address muscular or biomechanical issues that may be contributing to bone-related pain, for example, running style may have an impact

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, Oncologist, Vascular Specialist. 

Anterior Hip 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 similarto 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 Professionalwill 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.