Has your pain quite literally been a pain in the butt recently? Figuring out the cause of your symptoms is the most important first step to getting things managed and under control.
Pain in the buttock area is incredibly common. Whether it's something you experience after sitting for too long, after you've been standing or walking for a long period, or something in between, the symptom of buttock, gluteal, or hip-area pain is a pretty common issue we see. Quite frequently, people simply refer to these symptoms as "sciatica"... but as Drs. Ropper and Zafonte eloquently describe in the New England Journal of Medicine,
"The mundane malady sciatica has been known to physicians since antiquity. It is pain that radiates from the buttock downward along the course of the sciatic nerve, but the term has been used indiscriminately for a variety of back and leg symptoms."
The reality is that there are a number of anatomic structures and processes that can generate symptoms into the buttock/hip region (and beyond), and simply blaming one structure without thoroughly investigating can lead to a lengthy process to get on the right track to feeling better.
Identifying the Cause of Your Buttock and Hip Pain
Below, we will dive into some of the different structures and tissues that can be associated with buttock and hip pain. Our clinical approach is simple – be thorough and be targeted. It's easy to simply chalk up your buttock and hip pain to the sciatic nerve or to the hip joint... but what if it's not? Management, both medical and non-medical, for hip osteoarthritis should be quite different than what would be done for an upper lumbar spine issue. In the coming sections, we will discuss some of the joints and tissues that can be associated with symptoms in these areas, as well as some research associated with these.
Less common sources of buttock and hip pain
Buttock and hip pain from the spine and pelvis
Buttock and hip pain from the hip joint region
Nerve structures associated with buttock and hip pain
Less common sources of buttock and hip pain
Medical screening is still important, even with what might seem like a straightforward orthopaedic issue.. Most people don't think of non-musculoskeletal (in other words, pain of the buttock/hip coming from non-orthopaedic sources), but these do exist and need to be screened for. Some of these may include things like vascular issues, urogenital issues, and things like metastasis and/or space-occupying lesions.
Again, these are not statistically all that common. Nevertheless, seeing a provider that will at least ask the appropriate questions to try to screen for features suggestive of these is important. In the context of diagnosis, these are the kinds of things you don't want missed.
A few years ago, I saw a gentleman with intense low back and right-sided buttock pain. His symptoms really did not fluctuate much through the day and were much worse at night while lying down; the position in which he would lie down did not influence his nighttime symptoms. Prior to being referred to us, he had seen his primary care physician and an orthopedist, with a diagnosis of lumbar degenerative joint disease. After talking with him for about 30 minutes, it was revealed that he had some blood in his urine intermittently and a low-grade fever for a little over a week, as well as some fluctuation in pain intensity in the buttock after emptying his bladder. When he saw the providers, he said that no one had asked the non-orthopaedic, systemic questions. After requesting a urinalysis and urine culture, he was diagnosed with a urinary tract and kidney infection, and his symptoms improved with antibiotic treatment. Again – these types of things aren't common, but as the great Wayne Gretzky once said, "You miss 100% of the shots you don't take." Better safe than sorry when it comes to screening.
Buttock and hip pain from the spine and pelvis
The spine is a common source of pain in the area of the buttock and hip. However, there is some nuance to this. The spine is far from this singular entity. Even between two vertebrae, there are technically multiple joints to account for; likewise, structures like the intervertebral discs can generate symptoms. Ultimately, for a large percentage of people with symptoms generated from the spine, ruling out involvement of the hip is important, and a thorough physical exam will go a long way to helping determine what may be going on and how to manage symptoms.
So what does treatment look like with a physical therapist? The interview and exam are critical. Once we can rule down the potential that symptoms are coming from the hip or from neural structures or other medical causes, we can then utilize the physical exam to determine how your
symptoms respond and behave. Some types of pain coming from the spine respond really well to repeated mechanical movement or loading. Certain presentations respond well to things like spinal mobilization and manipulation. Others may do well with exercise training focused on movement patterns and control. To arbitrarily select an avenue for treatment may work out, but it may not. Ultimately, being as specific as is possible and constantly monitoring your symptoms and progress are very important to successful management.
Buttock and hip pain from the hip joint region
We often see people that have received a spine diagnosis from their physician. While the spine is a common source of buttock and hip pain, sometimes the structure(s) in the area of symptom can be the thing causing symptoms.
The hip joint (i.e., where the femur meets up with the pelvis) can generate symptoms in the buttock, as well as other areas into the leg. A study from Lesher et al found that among their
study cohort, over 70% of people with symptomatic hip joints had pain into the buttock. As we've discussed in other posts, it's irresponsible to simply assume that the local joint or tissues are always the cause – but sometimes, "the thing" in the area of your pain and symptoms is "the thing". Often times with pain arising from the hip joint, mobilization/manipulation and targeted mobility exercise can help with managing symptoms. Even in the event that a hip joint issue might be an issue that requires more medical attention (e.g., injection, surgery), it's important to recognize that a lumbar spine injection probably isn't going to do a whole lot if the hip joint is the primary driver of symptoms.
There are also other tissues to consider in the area of the buttock/hip, from pelvic floor muscles, gluteal musculature, the hip labrum, the proximal hamstring tendon and more. The big thing to take away from this is that symptoms here can be complex – there's a lot to account for, so be sure to seek out a provider that will do a deep-dive to identify what may be going on so that you can be best positioned to manage your symptoms and health. While some similarities often exist in terms of how your symptoms behave, certain activities/features are more distinctly associated with certain tissues, and your physical exam findings will often differ across these different diagnoses.
Nerve structures associated with buttock and hip pain
The sciatic nerve is the big one here, but it's important to recognize that the sciatic nerve is not
this uber-localized tissue or structure. Think of it more like a highway – the sciatic nerve is the peripheral accumulation of several nerve roots, and it ultimately will fork just above the knee into the tibial and peroneal (fibular) nerves, which continue down the lower leg.
While the sensitivity of the sciatic nerve can indeed generate buttock and hip pain, it's fairly common to also see some distal symptoms further down the leg (e.g., unusual tightness or aching, altered sensation like pins and needles or diminished feeling, etc.). Often, neural sensitivity can be influenced by structures like the soft tissue of the hip and thigh, spine, etc., so management with your physical therapist likely will involve some interventions to address those surrounding tissues and structures, as well as things to directly influence nerve sensitivity.
What to do for your buttock and hip pain
The big takeaway here is this – a thorough investigation is important. While things like X-rays and advanced imaging can sometimes have a role, these should rarely be the first step. As any good radiologist will indicate in their findings, the results need to be correlated to and compared against physical exam findings. Seeing a provider that will perform a thorough history and physical exam is important in order to start heading in the right direction to managing your buttock and hip pain.
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