W E I L L . C O R N E L L . E D U

Non-Spinal

Causes of

Buttock Pain

J a c l y n H . B o n d e r, M D

A s s i s t a n t P r o f e s s o r

D e p a r t m e n t o f R e h a b i l i t a t i o n M e d i c i n e

W E I L L . C O R N E L L . E D U

Diagnoses to Review

• Sacroiliac Joint Pain

• Intra-articular Hip pathology

• Hamstring Tendinopathy

• Piriformis Syndrome

• Ischiofemoral impingement – Quadratus Femoris

syndrome

• Obturator internus/Gemelli syndrome

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W E I L L . C O R N E L L . E D U

Sacroi l iac Joint Anatomy

Anterior View Posterior View

http://www.drdooleynoted.com/wp-content/uploads/2015/04/IMG_3688.jpg

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W E I L L . C O R N E L L . E D U

SIJ Pain – Clinical Symptoms

• Posterior buttock pain with:

– Rising from seated position

– Standing prolonged period of time

– Getting out of bed in the morning

– Going up stairs

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W E I L L . C O R N E L L . E D U

Sacroi l iac Joint : Exam Maneuvers

• Tenderness over:

– SIJ

– Sacrotuberous ligagment

– Piriformis muscle

– Pubic symphysis

• Positive Fortin Finger test

• Gillet’s for aberrant SI

motion

• Patrick’s/FABER

• Gaenslen’s

• Distraction and

Compression tests

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W E I L L . C O R N E L L . E D U

Hip Joint : Poster ior Anatomy

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http://www.smartdraw.com/muscular-system/examples/hip-muscles-posterior/https://www.studyblue.com/notes/note/n/chap-9-hip-joint-and-pelvic-girdle/deck/8430587

W E I L L . C O R N E L L . E D U

Hip Joint Intra-Art icular Pathology:

Clinical Symptoms

• Posterior/gluteal pain is least common presentation

• Often in conjunction with groin and thigh pain

• May radiate past the knee

• Limp is more characteristic of hip than spine or SIJ

• Groin pain with limp

• C-sign

• Click, catch, snapping, locking

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W E I L L . C O R N E L L . E D U

Hip IA Pathology: Physical Exam

• Gait – antalgic or

Trendelenburg

• Single leg squat

• FADDIR/SCOUR

• FABER

• Posterior impingement

test

• Rule out spine or pelvic girdle

pathology

• Often not definitive for

structural pathology

• Many exam maneuvers don’t

truly isolate the hip joint

– Overlap with SIJ

– Can provoke pain from

lumbar or pelvic structures

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W E I L L . C O R N E L L . E D U

Hamstr ing Pathology: Anatomy

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http://stretchcoach.com/articles/hamstring-injury-treatment/

W E I L L . C O R N E L L . E D U

Hamstr ing Pathology: Cl in ical Symptoms

• Acute or insidious onset

• Pain in the lower gluteal region with occasional radiation

into the posterior thigh

• Pain during running

• Pain with prolonged sitting

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W E I L L . C O R N E L L . E D U

Proximal Hamstr ing : Physical Exam

• Gait

• Posture

• Inspection – ecchymosis may be present

• Palpation – tenderness and/or muscle defect over IT

• Strength testing

– Pain with resisted knee flexion

– Concentric and Eccentric testing

• Passive knee extension

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W E I L L . C O R N E L L . E D U

Pir i formis Muscle: Anatomy

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http://link.springer.com/article/10.1007/s12630-013-0009-

5/fulltext.html

W E I L L . C O R N E L L . E D U

Pir i formis Syndrome: Cl in ical Symptoms

• Pain after sitting for longer than 15-20 min

– Improves with standing and walking

– Change in position doesn’t relieve it completely

• +/- paresthesias from buttock down posterior thigh to

knee

• Feeling of weakness in affected leg

• Pain with rising from seated or squatted position

• Abdominal, groin and/or pelvic pain

• Dyspareunia and pain with bowel movements

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W E I L L . C O R N E L L . E D U

Pir i formis Syndrome: Physical Exam

• Tenderness in region of the muscle and attachment sites

• Weakness on affected leg

• Pain with hip internal rotation of affected side

• Piriformis sign – ER of lower extremity in supine

• Lasegue’s sign – pain with pressure over muscle, hip

flexed and knee extended

• Freiberg sign– passive IR of the hip

• PACE sign - pain and weakness with resisted abduction

and external rotation of the flexed thigh

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W E I L L . C O R N E L L . E D U

Pir i formis syndrome

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Ischiofemoral Impingement: Def in i t ions

• Ischiofemoral Space -

smallest interval between

the cortex of the lesser

trochanter and cortex of

the ischium

• Quadratus Femoris

Space - smallest interval

between the hamstring

tendons and either the

iliopsoas tendon or

lesser trochanter.

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W E I L L . C O R N E L L . E D U

Ischiofemoral impingement Syndrome

• Occurs when IFS is

decreased and

associated findings of:

– QF edema

– rupture

– atrophy exist

• Severe edema

compression of sciatic

nerve

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W E I L L . C O R N E L L . E D U

IFI : Cl in ical Features + Symptoms

• Deep Posterior buttock pain with or without radiation

down posterior thigh

• Sciatica symptoms

• More common in women

• Usually associated with trauma history

• No specific physical exam findings have been identified

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W E I L L . C O R N E L L . E D U

Obturator Internus : Anatomy

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W E I L L . C O R N E L L . E D U

Obturator Internus-Gemel l i syndrome

• Acute strain, chronic overuse/myofascial pain/muscle spasms,

contusions, tendinopathy, calcific tendinitis, or bursitis

• Pain with sitting

• Mid buttock pain

• Symptoms of Pudendal or

Sciatic nerve irritation

• Unilateral pelvic floor pain

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W E I L L . C O R N E L L . E D U

Obturator Internus Syndrome: Physical

Exam

• Palpatory tenderness in the interval between the

piriformis muscle and the ischial tuberosity

• Maximal tenderness at the posterior ischium

• Pain with Flexion, Adduction and IR

• Freiberg sign

• PACE sign

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W E I L L . C O R N E L L . E D U

Obturator Internus - pelv ic f loor

component

• Prone

• Identify ST ligagment

• Move fingers medially to ischiorectal

fossa

• Angle fingers laterally toward obturator

foramen where muscle originates

• Ask for ER of hip

• Can be felt on internal pelvic floor exam

– PACE sign

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W E I L L . C O R N E L L . E D U

Thank you!

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