Deep gluteal pain syndrome

The gluteal region has a complex anatomy. Pain and dysfunction in this area can be a manifestation of various conditions, such as sacroiliac joint dysfunction, gluteus maximus tendinopathy, lumbar radiculopathy, and piriformis syndrome. The scientific literature has examined the involvement of various structures in the development of symptoms.

Deep gluteal pain syndrome (DGS) is defined as pain or numbness in the buttock, hip, or posterior thigh region with radiating or radicular pain along the sciatic nerve. This condition is characterized by:

It is not discogenic.
Associated with damage to the sciatic nerve.
Pinched nerve in the deep gluteal space. The most common sites of entrapment are: piriformis muscle (67.8%), greater sciatic foramen (6%), sciatic tunnel (4.7%).

OHSS is an umbrella term that represents a collection of different conditions with similar and overlapping symptoms.

Pinched pudendal nerve

The sacrotuberous ligament arises from the ischial tuberosity and attaches to the sacrum and coccyx, while the sacrospinous ligament lies at a 90-degree angle to it, deeper to the sacrotuberous ligament and attaches to the ischium. The thickness of these ligaments can lead to pinching of the pudendal nerve, called Alcock's canal syndrome or cyclist's syndrome.

In addition to pain in the gluteal region, symptoms of pudendal neuralgia include sexual dysfunction, rectal pain, fecal incontinence, and urinary incontinence. Thus, a pinched pudendal nerve can significantly impact quality of life.

This may be caused by prolonged sitting, especially when riding a bicycle, or a recent change of bicycle saddle. Symptoms are typically worsened by sitting, but sitting on the toilet has been reported to relieve pain by relieving pressure on the nerve.

Ischiofemoral impingement syndrome

After hip surgery, especially after total hip replacement, some patients complain of pain in the back of the leg and deep pain in the buttock, especially with hip extension and adduction. Ischiofemoral pain is a rare cause of hip pain, first described in three patients after total hip arthroplasty and proximal femoral osteotomy.

The ischiofemoral space is a very small space bordering the ischial tuberosity and the lesser trochanter. Tightness and inflammation of the quadratus femoris muscle (such as with bursitis) can cause this space to narrow and affect the nociceptive structures in this area. One study (Gollwitzer, 2017) found that symptoms were associated with a decrease in the distance between the bony edges of the ischium and femur, measured using axial magnetic resonance imaging (MRI) sequences.

Symptoms:

Deeply localized pain in the buttock, sometimes radiating to the knee.
When running, short steps are less painful than long steps. This is due to a narrowing of the ischiofemoral space during hip extension and adduction due to an increase in step length.
Facet-type pain at L3-4 or L4-5, which can be confused with a lower back problem. Low back pain may be associated with decreased hip extension.
Pain due to ischiofemoral impingement syndrome intensifies with terminal (at the end of the amplitude) hip extension and adduction.
Pain on palpation of the ischium during passive provocative movements.
A clicking, crunching, or locking sensation in the hip joint when walking at a fast pace, caused by the lesser trochanter being forced around the ischium.

Physical examination findings are not conclusive regarding the diagnosis of ischiofemoral impingement syndrome. A combination of passive hip extension, adduction, and external rotation is used to provoke symptoms.

The long stride test (walking with long strides) has a sensitivity of 92% and a specificity of 82%.

Types of pain

Back pain when walking can have different severity and character. It depends on what caused it, as well as on the pain defect of a particular person and on the neglect of the problem.

The pain may be severe or mild. They also distinguish between the aching, sharp, stabbing, dull and pulling nature of this sensation. When visiting a doctor, you should try to describe exactly what type of pain is inherent in a particular case.

Types of painful sensations:

Acute pain is very intense, but does not last long. Moreover, it is felt most strongly in the problem area; this sensation passes to the leg and buttock in a weaker form. The easiest way to deal with such discomfort is to deal with it.
With aching pain, the sensation quite evenly integrates into the limbs located near the site of the lesion. The pain may ache and drag. This makes diagnosing the problem difficult.
Chronic pain syndrome is the most painful. It may be present continuously for several months. Treatment of such discomfort is the most difficult.

Types of pain

Hamstring tendinopathy

Hamstrings start at the ischial tuberosity (very close to the sciatic nerve). Proximal hamstring tendinopathy is common among long-distance runners and athletes performing sagittal plane exercises (eg, sprinting, hurdles) or change-of-direction exercises such as soccer and hockey movements.

Symptoms:

History of repeated flexion loads. During flexion movements such as deadlifts and other flexion activities, the proximal hamstring tendon is subjected to tensile loading at its insertion on the ischial tuberosity.
Deep localized pain in the area of the ischial tuberosity.
The pain is worse when sitting, driving, lifting heavy objects, and running uphill. This occurs due to shear forces between the hamstring attachment and the ischial tuberosity as hip flexion increases. During running, force peaks in the late swing phase and has a second peak in the early stance phase.
Positive straight leg raise test.
A positive stoop test, which indicates sciatic nerve compression but does not rule out hamstring tendinopathy.
Thickening on palpation around the ischial tuberosity.

Pain assessment should be performed as stress assessment tests are performed:

Transition from a bridge with one leg bent at the knee to a bridge with a long lever.
Deadlift on one leg.
Three passive stretch tests (flexed-knee stretch, modified flexed-knee stretch, and Puranen-Orava test) have moderate to high validity and high sensitivity and specificity for diagnosing proximal hamstring tendinopathy.

Causes of pain

Damage to the sciatic nerve is a consequence of prolonged exposure to negative factors. These may include direct damage to the nerve due to injury or as a result of compression by certain anatomical structures. Thus, any injuries in which the integrity of the bones is disrupted and the soft tissues of the back of the thigh are damaged are a significant risk factor for the development of inflammation and pinching of the sciatic nerve. In addition, a serious threat to its damage is posed by neoplasms of various natures, including vascular ones, as well as diseases of the spine of various natures.

Thus, the causes of pain along the sciatic nerve can be:

fractures of the pelvic bones, hips (in this case, the nerve can be damaged not only directly at the time of injury, but also during immobilization);
local infectious processes of any origin, as a result of which pathogenic bacteria can penetrate deep into the soft tissues and cause inflammation of the sciatic nerve;
systemic infections that damage peripheral nerve fibers and weaken the immune system (HIV, tuberculosis, measles, herpetic infection, diabetes mellitus);
intoxication caused by the use of drugs, alcohol, toxins;
metabolic disorders, against the background of which harmful compounds accumulate in tissues and provoke damage to the vessels that supply the sciatic nerve;
inflammatory diseases of the pelvic organs, including the uterus, appendages, intestines and others, which, in the absence of timely treatment, can provoke the spread of the inflammatory process involving the sciatic nerve;
medical manipulations on the lower extremities and sacral region - non-compliance with the rules for performing injections, especially blockades often used for diseases of the spine, as well as surgical interventions can provoke inflammation and pain along the sciatic nerve.

In some cases, it is not possible to determine the cause of pain along the sciatic nerve and its inflammation. In such cases, idiopathic neuralgia is diagnosed.

Another common cause of pain along the sciatic nerve is sciatica. Most often, it is provoked by the presence of congenital and acquired pathologies of the spine, which may be accompanied by circulatory disorders in the affected area. As a result of nutritional deficiency and compression, soft tissues suffer, which can lead to the development of an inflammatory process, which may also involve the sciatic nerve.

Sciatica as a cause of pain along the sciatic nerve

Sciatica means pinching of a nerve by one or another anatomical structure, which provokes the appearance of characteristic pain. It is typical for pain to occur under certain conditions.

The appearance of pain can be provoked by getting out of bed, walking or standing for a long time, running, bending, etc. However, initially they can be barely noticeable and go away on their own over time. This condition can persist for several years and is often ignored by people. But over time, continued compression of the nerve leads to the development of neurological symptoms, and sooner or later careless movement or physical overexertion will lead to an acute attack of pain.

It is at this stage that people most often consult a doctor. During the examination, a neurologist using special neurological tests can almost accurately diagnose sciatica. After this, the patient is necessarily sent for a comprehensive examination, the purpose of which is to identify the causes that led to the pinching of the sciatic nerve.

These can include diseases of the spine, excessive physical activity, pregnancy, etc. The most common causes of sciatica are:

Osteochondrosis and intervertebral hernias are the main cause of radicular syndrome, i.e. pinched nerves. As a result of a sedentary lifestyle, prolonged sitting or excessive physical activity, the intervertebral discs wear out and become thinner. They cease to cope with natural functions, and their shells become thinner. This causes back pain, and subsequently protrusion of part of the nucleus pulposus of the disc beyond the anatomical boundaries, i.e. the formation of a hernia. Pain along the sciatic nerve can be caused by intervertebral hernias that form in the discs of the lumbosacral spine.
Spinal stenosis is a disease in which herniated discs or other formations compress the spinal canal. This is accompanied by severe pain, which intensifies while walking and doing physical work. Since the spinal cord suffers greatly due to such processes, this affects the quality of functioning of all other nerves and the functioning of internal organs.
Spondylolisthesis is a disease of the spine, accompanied by a displacement of the vertebra relative to the underlying one by a greater or lesser amount, which can provoke compression of the nerves passing in the immediate vicinity.
Facet syndrome is a disease in which nerve fibers are pinched in narrow openings between the vertebrae, causing their deformation by osteophytes and other disorders.
Scoliosis – curvature of the spine in the lateral plane leads to pinched nerves, severe pain and can be accompanied by a number of other complications, the severity of which is determined by the degree of deformation of the ridge.

Also, the development of sciatica and pain along the sciatic nerve can be caused by piriformis syndrome. It is located under the gluteal muscle and in some people the sciatic nerve runs through it. Therefore, with strong physical exertion on the buttocks, a spasm of the piriformis muscle may occur, which will lead to compression of the sciatic nerve and the appearance of corresponding symptoms.

With sciatica, it is extremely important to determine the causes of sciatic nerve compression. Otherwise, prescribing only symptomatic therapy will give only short-term results, while the underlying pathology will progress and not only cause even greater damage to the sciatic nerve, but also cause other complications.

Therefore, for sciatica, treatment is always comprehensive. It includes means to eliminate pain and neurological symptoms, as well as etiotropic therapy. The second is given special attention, since the prognosis of the entire treatment depends on the correctness of its development. In some cases, patients are prescribed conservative therapy, including medication, physiotherapy, exercise therapy and massage, while in others, surgical intervention is required to effectively eliminate the cause of sciatica.

Prerequisites for pain

A number of factors reflecting the lifestyle and individual characteristics of a particular person can lead to the development of the above diseases and inflammation of the sciatic nerve. These include:

age – middle-aged and elderly people are more at risk of developing neurological diseases due to natural age-related changes;
excessive physical activity - loaders, athletes and people in other professions whose work is directly related to the need to perform heavy physical work are most at risk of pain along the sciatic nerve;
pregnancy - increased load on the spine, compression of the internal organs by the pregnant uterus and hormonal changes do not have the most favorable effect on the body and can lead to pinching and inflammation of the sciatic nerve, but often the problem resolves on its own after childbirth.

Grade

First of all, pathology of the lumbar spine should be excluded. Physical examination includes palpation, assessment of the pelvic girdle and sacroiliac joints, and an active straight leg raise test.

Patients with sciatic nerve entrapment often have a history of previous trauma, pain with sitting, radicular leg pain, and paresthesias.

A positive March test or active straight leg raise test indicates poor control and inadequate load transfer, but neither differentiates the pathological structure.

Total range of motion and the FADIR test are used to rule out hip osteoarthritis. In addition, a negative FADIR allows the exclusion of intra-articular pathology, such as labrum damage.

A positive FABER test provokes sciatic nerve symptoms because in this position the nerve slides along the posterior border of the greater trochanter. If you experience pain in the greater trochanter during this test, it is most likely due to gluteus maximus tendinopathy.

If the patient feels pain deep in the buttock, then most likely this is compression or irritation of the piriformis muscle or one of the “deep six” muscles.

Patients with deep gluteal pain syndrome may present with altered nerve conduction tests, reflex changes, muscle weakness, and tenderness that make it difficult to differentiate the lumbar spine from the gluteal region.

The combination of a seated piriformis stretch test with an active piriformis test has a sensitivity of 91% and a specificity of 80% (Martin, 2014).

Palpation skills can be helpful in differentiating the location of pain and soft tissue texture. Use the ischial tuberosity as a reference point when attempting to reproduce the patient's pain by palpation to understand the likely source of the symptoms.

Diagnosis and treatment of pain in the butt

The treatment process for pain in the buttocks depends entirely on the nature of the pathology. The patient needs to see a proctologist and attend an initial consultation. The doctor will examine the affected organ and perform palpation. If purulent discharge, bleeding and infectious processes are detected, then we suggest performing an operation to remove anal fissures.

For pain in the butt resulting from an injury, the patient is prescribed painkillers and warming ointments that can relieve swelling. Non-steroidal medications relieve pain and promote rapid healing of soft tissues.

For boils, patients are prescribed Vishnevsky ointment and ichthyol ointment. In untreated cases, medical workers use massages, warm compresses, and physical therapy.

After consulting a doctor, the patient begins to engage in physical therapy. Improves muscle tone and strengthens. Doctors at the private clinic “KDS Clinic” have developed a special gymnastic system that will relax injured muscles and reduce pain.

Differential diagnosis

The following table presents conditions that may have symptoms similar to OHSS.

Reactive hamstring tendon, bursitis. Running uphill, deadlifting, lifting boxes/other bending load, feeling like one is sitting on a boggy mass.
Non-discogenic sciatic nerve entrapment. Radicular pain in the leg when flexing the hip.
Pudendal neuralgia. Increased cycling time or changing saddles is accompanied by pain. Sitting on the toilet relieves pain.
Ischiofemoral impingement syndrome, pain in the lumbar region, pain in the sacroiliac joint, pain when extending the hip or increasing step length. History of hip injury or surgery.
Tendinopathy of the gluteus maximus, obturator or gemellus muscles. Limping after sitting for a long time.

Treatment

Principles

It is recommended to differentiate the source of pain using knowledge and assessment skills.
Educate your patient about the anatomy and possible causes of symptoms.
Addressing chronic pain factors using a biopsychosocial approach.
Load management.

Hamstring tendinopathy

Avoid deadlifts and other bending exercises.
Avoid hamstring stretches, such as straightening your leg to 90 degrees of hip flexion.

Sciatic nerve damage

When driving, move your car seat closer to the steering wheel to relieve tension on the sciatic nerve.
For runners, reducing your stride length may be necessary to relieve symptoms.

Pudendal nerve damage

You may need to refer the patient to a physical therapist who specializes in women's or men's health to help manage symptoms such as rectal pain, fecal incontinence, or urinary incontinence.
Refer patients over 50 years of age to a gynecologist to understand their hormonal status. Lifestyle changes and weight loss are also recommended.

General recommendations

Weight control.
Lifestyle changes.
Sleep hygiene.
To give up smoking.

Myofascial release and manual therapy, combined with appropriate rehabilitation and specialist consultation, are useful clinical tools in the treatment of deep gluteal pain syndrome.

Image-guided anesthetic blocks or steroid injections may also be effective.

Using massagers to relax muscles

Massagers have shown excellent effectiveness in eliminating pain. The devices massage the skin, improving blood circulation. This reduces pain, improves intracellular metabolism, and eliminates discomfort in the body. Depending on the type of model, devices have different types of effects. For example, infrared devices generate infrared radiation, warming up the internal structures of the body, vibration devices affect the skin and muscles through vibrations, etc. More detailed information about the use of massagers will be provided to you by sales consultants of the Medtechnika Orthosalon network, as well as specially trained managers of our call center.

Using manual and electric massagers

The use of massage devices has a beneficial effect on the cells and tissues of our body. Manual and electric massagers at Medtekhnika Orthosalon provide the following effects:

Warming up the skin and muscle structures;
Stimulation of blood circulation and lymph flow;
Elimination of fatigue, soreness, muscle pain and pain syndromes of nervous etiology;
Prevention of nerve pinching;
Improving the metabolism of internal tissues.

We invite you to personally familiarize yourself with the range of manual and electric massagers and visit one of the medical equipment stores in your city.

Applicator Lyapko

The analgesic effect of Lyapko applicators is carried out due to the point (acupuncture) effect on the nerve endings located on the surface of the skin. Needles made of noble metals stimulate nerve endings, as a result of which the functioning of the nervous system is normalized, pain and fatigue are eliminated, and the reflex mechanism is improved. The advantages of Lyapko applicators include the following:

Effective massage effect;
Quick relief of pain;
Stimulation of nerve endings;
Improvement of blood and lymph flow;
Prevention of chronic diseases of the musculoskeletal and nervous system.

Lyapko applicators are one of the effective methods for eliminating pain syndromes. You can buy Lyapko applicators, massagers, orthopedic pillows for the lower back and many other useful products for your health in the Medtechnika Orthosalon chain of stores.

Exercises

Principles for selecting exercises:

Try limiting exercise to 15 or 20 minutes per day to improve patient compliance and adherence.
Avoid stretching at the beginning of treatment for tendinopathy to reduce the strain on the tendon and possibly return to it later when the pain has subsided.
When treating tendinopathy, aim to keep pain below 5 on a scale of 10 and not worsen for 24 hours afterwards, especially when performing functional exercises such as step-ups, single-leg squats, dynamic lunges and split squats. .
When performing the piriformis stretch with the hip flexed at 90 degrees, the hip should be externally rotated. The piriformis muscle is an abductor and external rotator of the hip below 45-60 degrees of hip flexion, but functions as an internal rotator above 60 degrees of hip flexion.
Combine exercises with neurodynamic techniques such as sciatic nerve glides.
Recommend glute strengthening in the form of bird-dog exercises, split squats, and functional loading exercises.
Progressive loading with emphasis on hip extensors, abductors and external rotators.