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).

Soft Tissue-Related Pain in the Upper Buttock

Pain in the upper buttock can be associated with any of the local soft tissues – the muscles, their attachments onto the bone and the fibrous wrapping (fascia) that surrounds them.

Problems in these soft tissues may develop due to:

• an acute injury, usually related to heavy lifting or twisting or a sports injury
• weakness in the buttock or trunk muscles
• overuse of the buttock or trunk muscles. Increasing bulk in muscles that are working too hard also has the potential to worsen pain
• general overload–doing too much of a particular task or activity; increasing activity too quickly, without adequate recovery
• general underload – a sedentary lifestyle with too little stimulus to keep your muscles healthy. This may also happen after a period of relative rest, for example, after traveling, or after being ill.

Muscle pain in the buttock is often referred to as Piriformis Syndrome, which is in fact a nerve condition.
Hip Pain Help have developed a self help course for this condition. For more info click here.

Your Hip Pain Professional can:

• assess the buttock and trunk muscles that may contribute to pain in this region
• determine if a strengthening program is needed, which exercises are likely to be most effective and which are best to avoid
• assess if there is excessive activity or ‘gripping’ of the muscles in this area and provide strategies in how to combat this
• provide important advice about sporting and other activities
  • advice about ‘how much is too much’
  • allowing adequate recovery between sessions
  • temporary reduction in activity levels may be required
  • rest from particular actions or altering techniques that place high stress through the upper buttock region

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

Pain experienced in the upper buttock regions sometimes has nothing to do with a condition in this area.

Lower back issues are often associated with pain that extends from the back into the upper buttock or pain that occurs only in the upper buttock.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).

Pain in the buttock may be referred from joints or intervertebral discs of the mid-lower lumbar spine.

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. It’s 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 4.3).

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 lower lumbar vertebrae (L3-5) could, for some people, result in painful sensations across the upper buttock (Figure 4.3).

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 the Buttock Regions

The Sciatic Nerve and “Sciatica”

The term “sciatica” is often used incorrectly in reference to any pain felt in the area runningfrom 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 Figure5.4 to view the piriformis muscle and the sciatic nerve).

This was based on a finding that in about 20% of the population, all or part of the sciatic nerve runst hrough 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) (Figure5.4).

In this tunnel it may be squeezed between the bones or irritated by unhealthy hamstring tendons (tendinopathy).

Hip Pain Help have developed a self help course for the management and rehabilitation of deep gluteal (piriformis) syndrome. For more info click here.

Cluneal Nerve Neuralgia

Of the cluneal nerves, the superior and inferior are more likely to be at risk of compression. Irritation of the superior cluneal nerve may result in upper buttock pain. The superior cluneal nerve branches run from the spine, over the top of the back of the pelvis and down into the buttock.

They usually run through fibrous tunnels as they cross the top edge of the pelvis. This is where the small nerves may become compressed or irritated. This is usually associated with a fairly localised area of pain in the upper buttock, in the region of its skin supply (Figure5.3).

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 the Tensor 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, Oncologist or 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