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KajSundqvist
JariArokoski

Buttock and Hip Pain

See also article on low back pain Low Back Pain for the differential diagnostics of the sciatic syndrome.

Essentials

  • Nerve root syndromes, spinal stenosis, sacroiliitis, and malignant diseases should be identified.

Aetiology

  • Children and adolescents
    • Synovitides, arthritides, traumas, congenital dislocation of the hip, epiphysiolysis of various origins
  • Adults and the elderly
    • Disorders of intervertebral disks (referred pain), even those of the lower thoracic spine, osteoarthrosis of the hip, bursitides in the hip/buttock region, sacroiliitis, laxity of the pelvic ligaments in association with pregnancy, rheumatic diseases, aseptic bone necrosis of the femoral head, malignancies (lesser pelvis, prostate gland)

Diagnostic tips

  • Spine-related pain
    • Buttock pain is common in acute back pain Low Back Pain. The pain may increase with bending of the back.
  • Arthritis or arthrosis of the hip
    • Restricted movement is a typical finding: limitations are first seen in inward rotation, thereafter in extension and finally in outward rotation and abduction.
    • Pain is usually aggravated when walking or putting load on the joint.
    • Often pain and tenderness in the groin
    • Pain originating in the hip cannot be referred lower than the knee (LIII dermatome).
  • Referred pain due to nerve root compression
    • Nerve root compression (sciatic syndrome; Low Back Pain): Pain usually increases on forward flexion of the spine frequently radiating below the knee. Walking may alleviate the symptoms. The symptoms are often more troublesome in the morning (the intradiscal pressure is greater).
    • Spinal stenosis Lumbar Spinal Stenosis (LSS): Pain is aggravated when walking or standing and is alleviated when sitting down (note: claudication pain Lower Limb Ischaemia due to arterial disease is already alleviated when the patient makes a stop in walking). Claudication symptom due to spinal stenosis that presents as numbness in both legs has a more troublesome natural course than claudication pain that radiates only to one leg. In the latter case the cause usually is only a narrowing in the nerve root canal.
  • The so-called piriformis syndrome is no longer considered a significant aetiological factor in buttock pain.
  • Sacroiliitis
  • Pain in the pelvic region during pregnancy (laxity and instability of the pelvic ligaments)
    • Present in ca. 20% of pregnant women. Prevalence decreases to one third of the original in 3 months after delivery.
    • Symptoms may be aggravated when standing or sitting.
  • Pubic bone stress fracture Stress Fractures
    • In military conscripts
  • Sacral stress fracture
    • Typically in elderly women with osteoporosis
  • Strain induced pain in tendon insertions
  • Claudication pain (spinal or vascular) Lower Limb Ischaemia
    • When walking
  • Greater trochanter pain syndrome Trochanteric Pain
    • Tears of gluteus medius and minimus muscles, external coxa saltans (snapping hip)
      • Rotator cuff of the hip
      • Occurrence 10-20% at the population level, more common in women
      • More common than average in persons with overweight, low back pain, knee pain, or if there is difference in the length of lower limbs.
      • Often occurs in runners, football players and dancers.
  • Trochanteric bursitis
    • The most common type of bursitis in the hip region
    • Local tenderness to palpation at the greater trochanter
    • Pain may be felt in resisted abduction of the hip and in extreme passive abduction; compare the sides
  • Tears of gluteus medius and minimus muscles
    • Standing on one foot for more than 30 seconds is a sensitive and specific test of gluteus medius or minimus tear.
    • In differential diagnostics remember that irritation of the L5 nerve root in patients with sciatica typically causes pain in the hip region and may even cause tenderness at the trochanter.
  • Bursitis of the ischial tuberosity
    • Local buttock pain and pain while sitting
    • Besides tenderness to palpation there may be stretch pain at straight leg raising.
    • In differential diagnostics remember avulsion fractures of the ischial tuberosity and muscle tears.
  • Malignant diseases: lesser pelvis, prostate cancer (rectal touch!)

References

  • Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Med Arthrosc 2010;18(2):113-9. [PubMed]
  • Chowdhury R, Naaseri S, Lee J et al. Imaging and management of greater trochanteric pain syndrome. Postgrad Med J 2014;90(1068):576-81. [PubMed]
  • Lequesne M, Mathieu P, Vuillemin-Bodaghi V et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Rheum 2008;59(2):241-6. [PubMed]
  • Gonzalez-Lomas G. Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis. J Am Acad Orthop Surg 2021;29(24):e1282-e1290.[PubMed]
  • Hu YE, Ho GWK, Tortland PD. Deep Gluteal Syndrome: A Pain in the Buttock. Curr Sports Med Rep 2021;20(6):279-285.[PubMed]
  • Gollwitzer H, Banke IJ, Schauwecker J ym. How to address ischiofemoral impingement? Treatment algorithm and review of the literature. J Hip Preserv Surg 2017;4(4):289-298.[PubMed]