Differentiating Buttock Pain and Sacroiliac Joint Disorders

Original Editors - Jessie Tourwe

Top Contributors - Mariam Hashem and Kim Jackson 

What Is Causing the Pain?

The diagnosis of Gluteal or buttock pain is complicated due to the overlapping symptoms of many conditions such as [1]:

The differential diagnosis of pain and dysfunction a challenging task due to the complicated anatomy of the Sacroiliac joint, the Lumbar spine and the buttock area. The diagnosis is even challenged more by the inconsistency of MRI findings and imaging with the symptoms leading to misdiagnosing the conditions. Using subjective assessment measures and special tests can give an idea of the symptoms but without specifying the source of the pain[2]. Up to this day, there are no fixed guidelines for the diagnosis of buttock pain[3].

Chronicity of symptoms could be a result of biopsychological factors but shouldn't rule out structural pathology. The development of chronic pain might have been the result of catastrophisation and fear-avoidance as a result of a missed primary structural pain[4]. This can contribute to the difficulty in determining the cause of the dysfunction and pain.

Structural Anatomy

Piriformis, gemmeli, obturator, quadratus femoris.PNG

The Sacroiliac joint is the joint connection between the spine and the pelvis formed by the fusion of the three bones of the pelvis: the ilium, ischium, and pubic bone[5]. The sacroiliac joint has different functions:

  • Load transfer between the spine and the lower extremities
  • Shock absorption
  • Converts torque from the lower extremities into the rest of the body[6].

This region is surrounded by and covered with the dorsal sacral nerve, the iliolumbar ligament, the dorsal sacral ligaments, the erector spinae fascia, which is part of the thoracolumbar fascia and makes palpating specific structures difficult[4].

The subgluteal space is located between the middle and deep gluteal aponeurosis layers. It contains[1]:

  • the Superior/Inferior gluteal nerves
  • Blood vessels
  • Ischium
  • Sacrotuberous/sacrospinous ligaments
  • Sciatic nerve
  • Piriformis

The piriformis muscle is innervated by the branches of the L5, S1, and S2 spinal nerves.

The sciatic nerve has a complicated relationship with the piriformis muscle, passing above, below and through the muscle before and after dividing[1].

[7]

Differential Diagnosis

Ruling Out the Lumbar Spine

Buttock pain can be caused by a referred pain from the lumbar spine in the respective dermatome[3], A study [8] by Eubanks reported significant improvement in buttock pain following facet joint block.

Red Flags are serious pathologies and should be spotted on the first contact.

Spondyloarthropathies and other inflammatory conditions at the lumbar spine level could possibly refer pain to the buttock area. Patients with Ankylosing spondylitis or Reiter's syndrome may present with inflammatory bowel diseases, such as Diverticulitis or Chrohn's disease, prolonged severe morning stiffness, bilateral enthesopathies such as Achilles tendinopathy or Plantar fasciitis.[4].

Gynaecological problems, potential infectious diseases, possible malignancies and patients not responding to physiotherapy management can possibly reflect the presence of serious pathologies[4].

This table is adapted from a study by Zibis [9] on the characteristics and physical examination of Low Back Pain:

History Physical Examination
  • Low back pain
  • Pain may radiate down to the leg
  • Electric character of pain
  • Sitting, standing, changing posture, coughing or sneezing may exacerbate pain
  • Lasegue sign (or Straight Leg Raise test)[10]
  • Inverted lasegue sign (or Cross Straight Leg Raise test)
  • Femoral nerve stretch test
  • Slump test
  • Bowstring sign
  • Trendelenburg test (L5 radiculopathy)
  • Sensory deficits
  • Motor deficits Altered reflexes

Ruling Out the Sacroiliac Joint

Sacroiliac dysfunction.is defined as Any pain from the sacroiliac joints or the surrounding myofascial, nerve or neural structures, connective tissues and ligament structure. It is known to present individuals with lumbar pain of with an incidence rate of 13%-48%, more commonly in females[11].

The following structures can be responsible for provoking posterior hip pain[4]:

Sacroiliac Joint pain could start gradually or suddenly. Gradual pain can result from maladaptive postures, seronegative spondyloarthropathies, osteoarthritis, pregnancy-related pain. Sudden onset develops due to sudden movement, strain or trauma, for example, missing a step or unilateral loading with a twist which can be accompanied by a click.

The Sacroiliac Joint pain is characterised with difficulties with standing, walking, walking up the stairs, squatting getting out of the car, turning in bed which causes sleep disturbance. Psychosocial factors can influence the presentation and the symptoms. The Pain can refer to the pubic symphysis, the groin, the coccyx, and the posterior thigh[4].

Other associated symptoms: pelvic organ dysfunction, such as urinary incontinence, prolapse, or constipation and sexual dysfunction, It can also be associated with respiratory distress such as aberrant breathing patterns[12].

This table is adapted from a study by Zibis [9] on the characteristics and physical examination of Sacroiliac Joint Dysfunction:

History Physical Examination
  • Pain may worsen when walking down a hill
  • Pain may worsen when using a tight belt
  • Sacroiliac distraction test[13]
  • Sacroiliac compression test Gaenslen’s manoeuver
  • FABER test (buttock pain)
  • Thigh thrust test

Special Tests

Individual tests have low reliability in diagnosing Sacroiliac Joint Dysfunction[14]. Instead, it's advised to use a cluster or a group of tests. The use of special tests is a useful clinical tool but not so reliable. A study by Dreyfuss et al found positive findings on Sacroiliac Joint provocative tests in asymptomatic patients[15].

The March/Stork test is a load transfer test of the ability of the pelvic girdle to transfer a load when lifting the opposite leg, A positive test however doesn't show where the failure of load transfer happened (on which level)[4].

Active straight leg raise and Laslett's composite tests are validated but not specific and cannot be relied on in determining the cause of the pain.

The one-legged squat test, femoral glide test. passive accessory tests are unvalidated but you can help to compare the bilateral mobility of the joint

The Pelvic joint compression with the use of a sacroiliac belt can be very helpful to help control and increase force closure across that lumbar-pelvic area[4].

Imaging

Imaging cannot be used to diagnose Sacroiliac Dysfunction but in the differential diagnosis of infections, metabolic disorders, fractures and tumours[16].

Sacroiliac Joint Infiltration can ease the symptoms when injecting an anaesthetic but it doesn't differentiate the pathological structure[4].

Ruling Out Deep Gluteal pathology

Gluteal Tendinopathy is characterized by chronic, intermittent pain over the buttock and lateral aspect of the thigh[9].

Symptoms are mainly located in the inferior gluteal aspect '' retro-trochanteric'' between the ischial tuberosity and the surrounding structures radiating onto the back of the greater trochanter[4].

Pain originating at the lesser trochanter which could possibly reflect ischio-femoral impingement,

The definition of greater trochanteric pain syndrome has now been expanded upon to include the insertional region of the Gemelli's and the Obturators[4].

Patients with Gluteal tendinopathy present with sleep disturbance and difficulties with physical activity and quality of life[17]. Gluteal tendinopathy is highly present in menopausal or peri-menopausal females so it's important to rule out gynaecological pathologies[18].

Pain can refer to the groin, the coccyx, the anterior thigh, the lateral thigh around the sacroiliac joint, the buttock and down to the insertion of the iliotibial tract on the proximal tibia[9] which makes it more difficult to differentiate it from Sacroiliac Joint.

This table is adapted from a study by Zibis [9] on the characteristics and physical examination of Gluteal Tendinopathy:

History Physical Examination
  • Proximal thigh pain may radiate to the knee
  • Inability to sleep on the affected side
  • Thigh pain when rising from a seated position
  • Thigh pain when climbing stairs
  • Pain with flexion and resisted hip abduction
  • Jump sign

Ruling Out Piriformis Syndrome

Impingement of the sciatic nerve occurs mostly in the deep gluteal space and around the piriformis muscle than in the lumbar spine level[4].

This table is adapted from a study by Zibis [9] on the characteristics and physical examination of Piriformis Syndrome:

History Physical Examination
  • Diffuse pain in the buttock or posterior thigh
  • Occasionally radiating, sciatica-like pain
  • Pain on sitting
  • Active piriformis contraction test[19]
  • Seated piriformis stretch test
  • FAIR test
  • Beatty manoeuvre
  • Piriformis sign
  • Freiberg sign
  • Pace sign

Resources

A Case Report: Differential Diagnosis of Deep Gluteal Pain in a Female Runner with Pelvic Involvement.

Podcast: Lateral Hip Pain with Dr Alison Grimaldi

Infographic - Deep gluteal syndrome with Benoy Mathew

How to Assess and treat Posterior Hip and Gluteal Pain with Benoy Mathew 

References

  1. 1.0 1.1 1.2 Carro LP, Hernando MF, Cerezal L, Navarro IS, Fernandez AA, Castillo AO. Deep gluteal space problems: piriformis syndrome, ischiofemoral impingement and sciatic nerve release. Muscles, ligaments and tendons journal. 2016 Jul;6(3):384.
  2. Tonosu J, Oka H, Higashikawa A, Okazaki H, Tanaka S, Matsudaira K. The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS One. 2017 Nov 15;12(11):e0188057.
  3. 3.0 3.1 Shim DM, Kim TG, Koo JS, Kwon YH, Kim CS. Is it radiculopathy or referred pain? Buttock pain in spinal stenosis patients. Clinics in orthopedic surgery. 2019 Mar 1;11(1):89-94.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Bell-Jenje T. Differentiating Buttock Pain and Sacroiliac Joint Disorders. Physioplus Course 2020
  5. Dutton M. Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York: McGraw Hill, 2008.
  6. Sacroiliac Joint. Physiopedia Page (last accessed 20/09/2020) Available from: https://physio-pedia.com/Sacroiliac_Joint#cite_note-Dutton-2
  7. SI Joint Anatomy, Biomechanics & Prevalencet . Available from:https://www.youtube.com/watch?v=D6NTMgWCSaU[last accessed 21/09/2020]
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  11. Madania SP, Mohammad Dadian M, Firouzniac K, Alalawid S. Sacroiliac joint dysfunction in patients with herniated lumbar disc: A cross-sectional study. J Back Musculoskelet Rehabil 2013; 26 :273-279.
  12. O’Sullivan PB, Beales DJ. Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: a case series. Manual therapy. 2007 Aug 1;12(3):209-18.
  13. Simpson R, Gemmell H (2006) Accuracy of spinal orthopaedic tests: a systematic review. Chiropr Osteopat 14:26
  14. . Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 1994; 19:1243-1249.
  15. Dreyfusss P, Dreyer S, Griffin J, Hoffman J, Walsh N. Positive sacroiliac screening tests in the asymptomatic adults. Spine 1994; 19:1138-1114.
  16. Hilal Telli MD, Serkan Telli MD, Murat Topal MD. The validity and reliability of provocation tests in the diagnosis of sacroiliac joint dysfunction. Pain physician. 2018 Jul;21:E367-76.
  17. Grimaldi A, Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):910-22.
  18. Ganderton C, Semciw A, Cook J, Pizzari T. Does menopausal hormone therapy (MHT), exercise or a combination of both, improve pain and function in post-menopausal women with greater trochanteric pain syndrome (GTPS)? A randomised controlled trial. BMC women's health. 2016 Dec 1;16(1):32.
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