by Dr. Richard Beauchamp, M.D., FRCSC
Recently, we invited readers to send in topic suggestions for this column, and here is one of the replies we received:
“May I suggest an article about butt pain? In my case, it is probably a glute issue, which may or may not have been caused by years of running without adequate stretching. It is certainly inhibiting my running now. Is there anything I can do?”
No one likes a pain in the butt. The buttocks are at the back of the pelvis, which is covered by the gluteus maximus, gluteus medius and gluteus minimus muscles, commonly referred to as “the glutes.” There are also some other deeper muscles and tissues that can become inflamed or injured during activities such as running and other active sports. These include the short muscles responsible for the turning the hip and leg inwards or outwards. These “rotator muscles” include the superior and inferior glamelli, the obturators, the quadratus femoris and the pyriformis (also spelled piriformis) muscle. All these structures are in close proximity to the sacroiliac joint (Figure 1).
Buttock pain can be brought on by hamstring injuries, hip conditions, lower spinal problems or referred pain from either lower in the kinetic chain (the leg) or higher up in the spine. The cause can be muscular weakness, unbalanced conditions or more serious pathological diseases. Muscle tears or pulls are a common cause of acute injuries in this area.
Buttock pain can also be caused by a condition called pyriformis syndrome, where muscle spasms cause pain as well as numbness and tingling along the back of the leg. Not all physicians agree on the cause or existence of this syndrome, as sciatica mimics it so closely.1 Pyriformis syndrome is not usually an acute injury; rather, the symptoms develop slowly over time. The bursae (lubricating sacs) in the hip, pelvis and buttock regions may become inflamed for reasons related to overuse, injuries or anatomical variations.
The typical complaint from someone with pyriformis syndrome will be pain and tenderness in the area of the back of the hip deep in the buttock region.2 The pain and symptoms may begin with the first step of running and persist throughout the run. It usually does not get worse with activity but continues to nag the runner. Pain may not be severe enough to curtail the run completely but the runner may slow down her pace and cadence. The diagnosis is most obvious with acute painful tenderness on close palpation of the area in the buttocks. To confirm the location of the tenderness, place your fingers over the tender area and push hard while rotating your hip. You may be able to feel the tender area of the muscle deep in your buttock. As with any inflammatory condition, it is especially helpful to know what cause it so that effective treatment can be introduced. Repetitive movements to a susceptible tissue are probably the most common theory for most injuries. The tissue may have been rendered susceptible due to a recent injury, from a muscle tear or pull, from a loss or gain in body weight and associated weakening of essential (core) muscles. The true diagnosis my only be achieved after a period of excluding other conditions through careful physical examination or other investigations (such as x-rays, blood tests or electrical studies).
The pain from pyriformis syndrome will often be exacerbated by prolonged sitting, especially in soft chairs such as car seats and sofas. The pain usually eases when lying down or walking around. As the pyriformis muscle is intimately associated with the sciatic nerve, there may be some radiation of the pain down the leg as seen in sciatica conditions. The sciatic nerve usually lies adjacent to the pyriformis muscle, but in approximately 15% of individuals the sciatic nerve actually penetrates the muscle, as it exits the pelvis to provide the nerve supply to the rest of the leg.
The hamstring muscles originate from a part of the pelvis near the pyriformis muscle, so a pulled hamstring can have similar symptoms to pyriformis syndrome. Again, a good physical examination should be able to distinguish the two injuries.
Pyriformis syndrome is sometimes difficult to treat with the usual stretching exercises. As mentioned earlier, the pyriformis is a small external rotator muscle for the hip. To stretch this muscle, you must put your hip in maximum outward rotation in varying degrees of flexion. Also, resisted rotation is an important addition to the stretching in order to strengthen the muscle. This is accomplished by forcing the hip into an outward rotated position while inward resistance is applied. A popular and effective pyriformis stretch is as follows: lie on your back with knees bent and feet on the floor. Cross your right leg completely over the left. Gently pull the left knee towards your chest until you feel a stretch in the buttock area of the right hip. Hold stretch for 20 to 30 seconds. Switch to the opposite configuration to stretch the other side. Repeat three times on each leg (Figure 2).
Deep ice can be applied over the tender area of the buttocks following stretching or running. This is probably one of the few conditions that actually represent inflammation and therefore should be helped by a seven- to 10-day course of anti-inflammatory medication.
Your doctor may also recommend physiotherapy, which can include deep massage as well as range-of-motion hip exercises, strengthening or ultrasound. In severe recalcitrant cases, your doctor may recommend an injection with local anesthetic and/or steroids.3 In very rare cases, an abnormal anatomical relationship between the pyriformis muscle and the nerve may require surgery to relieve the symptoms.
The best strategy is to prevent this syndrome from happening. Some runners may develop reduced flexibility and weakness in their core muscles, associated with tightening of the hamstrings and buttock muscles. Good core strength should be maintained, along with a regular stretching program incorporating the pyriformis stretch shown above.
- Eur Spine J2010, Vol 19, 2095-2109.
- Eur J Orthop Surg 2018, Vol 18, 115-164.
- Turk Neurosurg 2014, Vol 24, No 4, 471-477.
Dr. Richard Beauchamp is an orthopedic surgeon based in Vancouver. He is the medical director of the Shriner’s Gait Lab at Sunny Hill Health Centre and a clinical professor in the Department of Orthopedics at the University of British Columbia. He is an avid runner and walker who has completed seven marathons.