Deep gluteal syndrome

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida

Deep gluteal syndrome

Now that you are researching Deep gluteal syndrome you are likely suffering from not only the symptoms of this problem but the confusion of your diagnosis. Typically doctors do not diagnose Deep gluteal syndrome initially. They may call it other things like piriformis syndrome or sciatica, which may contribute to significant hip area pain. You may ultimately get the diagnosis of Deep gluteal syndrome if you display pain and numbness in your buttocks that radiate into your leg if initially this was not confused with problems of lumbar stenosis, or Sacroiliac Joint Dysfunction, ischiofemoral impingement, hamstrings, and pudendal nerve entrapment among the list of other possible causes. Another problem that may be difficult to identify is that you have multiple issues, Deep gluteal syndrome may in fact be only one of the problems causing your pain.

Despite all this confusion, one thing for sure and constant is that you have pain, it is not going away, and you have “tried everything,” without anything providing you with long-term relief.

Initially, you may have tried to self-manage your pain and the limitations it brought you including sitting difficulties and the need to find a well-padded chair to sit in. You found stretching and other exercises online, you applied heat, you applied ice, lidocaine patches, and various ointments and balms. Then you simply tried to rest to see if that helped. Eventually, you may have moved onto over-the-counter anti-inflammatory medications (NSAIDs) but the pain got worse. A trip to the pharmacy may have lead to purchases of a heating pad, a TENS unit for elctro-stimulation of the muscles, and a padded toilet seat. After all this, and continued pain, it is at this point that you seek medical attention.

At your initial doctor’s visit, your doctor may have isolated your problem to that of sciatic nerve compression. As this can be caused by the Piriformis muscle in your buttocks entrapping or irritating the sciatic nerve or it can be caused by the muscles of the deep gluteal space in the buttocks, including and obviously, the glutes that make up the buttocks you may have received a prescription for muscle relaxants. When this does not work, now what?

The new research on Deep gluteal syndrome

The problems we described above are the problems that have been described to us by patients and confused people looking for information on hip-spine-buttock pain. Recently and currently doctors too are coming to terms with the confusion surrounding the symptoms along the buttock and radiating pain down the leg. To help you understand your doctor’s point of view, let’s look at some of the new research doctors are talking to each other about.

Let’s start with a May 2020 study in The Bone & Joint Journal.(1) Here are the summary leaning points:

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. (The problem is not a lumbar disc problem but rather soft tissue damage and instability in the pelvis).
Deep gluteal syndrome can be an umbrella term to include:
- Piriformis syndrome,
- Gemelli-obturator internus syndrome (this is where the sciatic nerve is being trapped by the deep pelvic obturator internus muscle which is a hip muscle.
- The ischiofemoral impingement syndrome, and
- The proximal hamstring syndrome.
However, this umbrella term may cause confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions.

Recommendations for diagnosis may include:

Careful history-taking,
Physical examination including provocation tests,
An electrodiagnostic study, and
Imaging

Treatment recommendations:

Deep gluteal syndrome can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.
Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

For many people, these conservative recommendations may work very well. If you are reading this article, and you more fit the description of what we described above in our patients, these treatments did not work well for you.

Deep gluteal syndrome is not a problem in isolation

The reason that you may have had confusing, conflicting, or misdiagnosis of your problem is likely because you have many things working against you. You may have multiple diagnoses and the diagnosis of Deep gluteal syndrome is being used as an umbrella term to describe your pain.

Part of the workup of when you come to Caring Medical with complaints of butt pain or a diagnosis of Ischial tuberosity pain syndrome or impingement is an examination of all these areas, the hip, the sacroiliac joint, the low back, the groin area.

Is it Femoroacetabular impingement causing your issues or is it pelvic or lower back issues?

Doctors from Cambridge University Hospitals wrote in the journal International Orthopaedics (2) that extra-articular hip impingement syndromes encompass a group of conditions that have previously been an unrecognized source of pain. Extra-articular hip impingement syndromes mean problems caused from outside of the hip joint itself as opposed to intra-articular hip impingement syndromes which come from within the hip itself.

The Cambridge doctors categorized these syndromes as:

Ischiofemoral impingement: quadratus femoris muscle becomes compressed between the lesser trochanter portion of the thigh bone and the ischial tuberosity (the sit bones of the lower pelvis).
Subspine impingement: anatomical problems of the anterior inferior iliac spine (the wing of the upper iliac/pelvic bones) and the distal anterior femoral neck (the neck of the thigh bone) causing soft tissue entrapment of muscle and tendon.
Iliopsoas impingement: friction between the iliopsoas muscle and the hip labrum, resulting in hip labrum breakdown. We cover issues in this article of the iliopsoas or psoas muscle as a cause of difficult to treat groin pain. Also, see our article on surgery for a hip labral tear.
Deep gluteal syndrome: (the subject of this article) pain occurs in the buttock due to the entrapment of the sciatic nerve in the deep gluteal space. In our articles, we cover a lot of information on the buttock pain and the pelvis, lower spine connection.
Pectineofoveal impingement: pain occurs when the medial synovial fold impinges against overlying soft tissue, primarily the zona orbicularis (the hip annular ligament).

The researchers concluded with a message to doctors that extra-articular hip impingement syndromes should be taken into consideration and should form a part of the differential diagnoses alongside intra-articular pathology including femoroacetabular impingement particularly in the younger patient with a non-arthritic hip.

The piriformis muscle does not just tighten up on its own

The piriformis muscle does not just tighten up on its own. We have found that in many patients with this condition a sacroiliac ligament injury or a hip ligament injury is the cause. Basically, the sacroiliac or hip ligaments are stretched out and loose. Consequently, when the piriformis muscle tries to contract, it can’t, so it starts to spasm. When the piriformis spasms, it pinches the sciatic nerve, which causes the pain, tingling, and numbness that the person experiences.

Trying to loosen the piriformis muscle is not going to work to alleviate the patient’s symptoms. For these patients, in our opinion, the symptoms of piriformis syndrome can only be alleviated by treating the underlying cause of the problem which is loose sacroiliac and/or hip ligaments.

Ischial tuberosity?

Danielle R. Steilen-Matias, MMS, PA-C, describes the pelvic anatomy and how these various structures in the pelvis can cause Ischial tuberosity pain.
The Ischial tuberosity, the bony prominences at the base of the pelvis, or commonly, the “sit bones” or the “seat bones,” are just that. The bones you sit on. This is a suspected pain origin when a patient complains of “pain in the butt.”
A patient will often complain of problems with tight hamstrings as well. They report that they do a lot of stretching, they “foam roll,” they have had cortisone shots, the pain returns.
There are varying reasons for pain in this area.
- The patient’s pain is in fact related to the hamstring attachment at the Ischial tuberosity.
- (Image of Ischial tuberosity) If this hamstring tendon attachment is damaged, the patient will suffer pain when they put their whole body weight on it to sit.
- Sometimes a patient will come in with a chronic ischial tuberosity pain that doesn’t get better with anything they’ve tried because the pain is coming from elsewhere. It could be from the sacroiliac joints. When there is sacroiliac joint instability, this can tug on the hamstrings.
Part of the patient workup at Caring Medical who have complaints of butt pain or a diagnosis of ischial tuberosity pain syndrome or impingement is an examination of all these areas, the hip, the sacroiliac joint, the low back, the groin area.
Treatment: Ischial tuberosity pain syndrome is a degenerative condition. We have to first stop the causes of the damage and then we can begin to repair the area and get these tissues to regenerate and be strong. We use Prolotherapy injections, this is an injection of simple dextrose or sugar. Sometimes we may use the platelets in your own blood, this is better known as Platelet Rich Plasma Therapy or PRP. It usually takes 4 to 6 treatments. These treatments are described in more detail below.

Platelet Rich Plasma Therapy and Prolotherapy treatments

In the above video, Prolotherapy and PRP treatments are briefly discussed. These are the treatments that we utilize at Caring Medical for the treatment of the problems we have described in this article.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments.

Many people reading this article may have been told about Platelet Rich Plasma therapy. They may have heard very good things, they may have heard some not good things. The not good things usually are confined to the “it will not work for you,” suggestion they are given.

We are going to challenge that statement with some independent research and the 27+ years of experience we have in offering patients treatments for their hamstring and sports-related injury problems.

Platelet Rich Plasma Therapy draws out your own blood into a vial. Your blood is then “spun,” in a centrifuge to isolate out the components that heal injuries. These would be the anti-inflammatory and growth factors found in the blood platelets. This “Platelet Rich,” solution is then reintroduced, via injection, into the areas causing pain and weakness.

Platelet Rich Plasma injections and Prolotherapy injections for Gluteus Medius Tendinopathy

This video was created nine years ago. The basic concepts of healing remain the same. We have been treating sports-related injuries with regenerative medicine injections for 26+ years.

In this video, you will see the application of Platelet Rich Plasma injections and the use of Prolotherapy injections. Prolotherapy is the injection of dextrose, or a simple sugar, to irritate damaged hip ligaments. Hip ligaments provide stability, damaged hip ligaments provide INSTABILITY.

The dextrose in the Prolotherapy solution, when injected around the injury, causes a mild inflammatory response, mimicking what the body does naturally in response to soft-tissue injuries. The immune system is drawn to the area of injury and immune cells and platelets release growth factors to build new healthy tissue. The ligaments and tendons become thicker and stronger from this inflammatory response. Again, this is explained in the video above, and further below.

Demonstration of the Prolotherapy treatment addressing Ischial tuberosity

The Prolotherapy treatment begins at 1:37

In this video Ross Hauser, MD. demonstrates an Ischial tuberosity Prolotherapy treatment.

The patient in this video has been given a Topical analgesic and is comfortable during the treatment. The treatment is done quickly.
It is a long needle because the injections has to reach the Ischial tuberosity bone.
This treats the attachments of the semitendinosus, semimembranosus, biceps femoris muscles of the hamstring and the sacrotuberous ligaments.
In a typical treatment all these attachments are treated.

If you have questions about Deep gluteal syndrome, Get help and information from our Caring Medical staff

1 Park JW, Lee YK, Lee YJ, Shin S, Kang Y, Koo KH. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. The Bone & Joint Journal. 2020 May;102(5):556-67. [Google Scholar].
2 Nakano N, Yip G, Khanduja V. Current concepts in the diagnosis and management of extra-articular hip impingement syndromes. Int Orthop. 2017;41(7):1321‐1328. doi:10.1007/s00264-017-3431-4. [Google Scholar]