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A Pain in the Butt

Bum, bottom, buttocks, derriere, booty, behind. Whatever you call it, it never leaves you and follows you around like a lovesick puppy. But when it is unhappy, it is no longer cute. It bites when you sit down, it annoys you as you get up, it bombards you at the most inconvenient point on a long walk, it even wakes you in the middle of the night begging you to roll over. Basically, you’ve got a pain in the butt.

Buttock pain usually sneaks up on you, gradually getting worse over time until the day that it is all you can think about. It is also one of the most inconvenient places to experience pain and to some a little bit embarrassing, so they leave it until it becomes unbearable before seeking help.

 

Who does it affect most?

Women complain about buttock pain more often than men. Literal buttock pain, not figuratively. These are both perimenopausal as well as younger more sports active women. We also see it amongst people that have hip surgery, especially hip replacements.

Often misdiagnosed as pain coming from the back, yet interestingly it is also more prevalent in people with back pain (a double whammy)1. So don’t make assumptions here.

The upper part of where the hamstring attaches forms part of buttock pain and this kind of pain is seen amongst fast walkers and runners. It’s called hamstring tendinopathy.

 

Where does the pain come from?

Lets start off by saying that this is a very complex area of the body and contains many moving parts in a small deep space within the pelvis. The biggest and most well-known of the muscles are the glutes muscles. There are 3, the Gluteus Maximus, the Gluteus Medius and the Gluteus Minimus (sounds a bit like Roman Gladiator names) . These are extremely important muscles which help us to walk, run, jump and climb stairs to name a few. They form part of the outer layer of the buttocks.

Within this complex space the sciatic nerve (which starts in the lower back) snakes a course down to the legs passing a few buttock muscles and bony prominences along the way. The back end of the hip joint, structures called bursas (cushioning devices found between bone and tendon) and ligaments connecting the parts of the pelvis together can all be found in this confined space.

Even deeper, we find smaller but equally important muscles for hip control. The Piriformis (there is a syndrome named after this one, it is small but self-important), the Obturator muscles, Gemelli muscles and Quadratus Femoris to name a few. These help you to do the twist.

And you thought the buttocks were only for comfortable sitting.

Due to the complex and intricate nature of these structures, it is often hard to differentiate which structure is and which isn’t the pain in the butt. For this purpose we use umbrella terms to describe buttock pain.

 

Two types of Butt pain

Greater Trochanteric Pain Syndrome (GTPS)

This is used to describe the pain coming from the outer (lateral) part of the buttocks over a jutting bone that you can feel when your hands hang down your sides. The anatomical term is the greater trochanter. A number of the muscles mentioned earlier attach to this structure. When these structures are very sensitized, pain can even transfer further down the leg to the outer thigh.

pain in the butt glutes

Typical complaints:

  • Pain experienced when standing on one leg or walking on uneven ground/camber
  • Pain/stiff sensation upon rising from a chair after sitting for a prolonged period. This typically settles after 10-30 minutes of moving
  • Pain with lying on the affected side (often takes some time before it registers and wakes you)
  • Friends tell you that you are swaying or limping when walking
  • Balance is often impaired due to pain
  • Your hip mobility is still good, it can flex past 90 degrees.

 

Deep Gluteal Pain Syndrome (DGPS)

This umbrella term is used for pain felt deeper and toward the lower part of the buttocks. It can also be felt on or around the “sit bones” on the bottom of the bum. The anatomical term for the “sit bones” is the ischial tuberosity. These structures can create a feeling very similar to back pain that refers down the leg when they become very sensitized. This is because the sciatic nerve can be irritated by the muscles, bursa and narrowing of space between bones.

pain in the butt ischial tuberosity

Typical complaints:

  • Pain whilst sitting on involved buttock
  • “Sit bone” feels like a boggy mass
  • Pain gets worse with driving
  • Symptoms may get worse with crossing legs (involved leg)
  • Taking large steps may be painful
  • A straight leg raise is usually painful

 

Stretching is a no-go

We all love the feeling of a good stretch and when a muscle hurts, it is almost instinctual to stretch that part. It may feel better during the stretch and even for a period of 20 minutes or so after. However, this inevitably leads to latent (delayed) pain increase because with the presence of the tuberosities (jutting bony parts), the tendon and bursa that are already angry get compressed against the bone during a stretch. It is similar to what happens when we lie on the affected side. The compression adds an unwanted load, the structure is already not coping and then you add more load with the stretch.

Some people experience relief with stretching but the ratio of ‘Do get relief’ vs ‘Do not get relief’ is very biased towards not getting relief. So you may want to experiment for yourself and see where you fall. Once you have the answer, stick with what works for you.

Self-release techniques may be of greater benefit here as they may reduce the sensitivity of the pain centres in the brain.

 

 

Tips and tricks for reducing pain in the butt

Greater Trochanteric Pain Syndrome (GTPS)

Reducing the load on the painful structures

  • When standing up from a chair, pretend like you are riding horse and gently push the knees outwards as you extend the hips.
  • Pain with standing – make sure that you always distribute your weight between both legs, avoid lazy stance on one leg. Orthotics may help to start off, a simple midfoot arch support or heel raise.
  • Pain with climbing stairs – gently direct the leading knee toward the rail or wall (whichever is closest so the knee moves outwards). You may also want to drive through the heel of the leading leg as you push to extend the hip
  • Pain with sitting – limit crossing your legs
  • Running pain – take shorter, faster steps (increase your cadence) at a pace that reduces the pain. This is often higher than you expect. We often plod along too slowly and this adds load to the muscles because we spend more time standing on them.
  • Pain at night – sleep on your back, or on your opposite side with a pillow between the legs to prevent stretching or loading the painful buttock. An eggshell topper to your mattress may be a game changer, creating some extra cushioning for when you do roll over onto the painful side.
  • Reduce the painful activity but do not rest completely. Continue to be active and participate in your sport but keep the pain at low/tolerable levels. It is suggested to find what your 4/10 pain level is and not to push beyond that.

Strengthening the painful structures

  • Learn how to tuck your tail in and become mindful of what it feels like to activate your glute muscles.
  • Slowly and progressively begin to strengthen the gluteal muscles. This means, easy simple movements with light loads and gradually make the load heavier and increase the complexity of the exercise.

 

Deep Gluteal Pain Syndrome (DGPS)

Reducing the load on the painful structures

  • As with DGPS, activating the glutes to unload the deeper structures and hamstring helps. So, pretend you are riding horse and gently push the knees outwards as you stand up and extend the hips.
  • Pain with standing – make sure that you always distribute your weight between both legs. If full hip extension causes pain, “soften” your knees by bending them slightly. Orthotics may help to start off, a simple midfoot arch support or heel raise.
  • Pain with climbing stairs – gently direct the leading knee toward the rail or wall (whichever is closest so the knee moves outwards). You may also want to drive through the heel of the leading leg as you push to extend the hip
  • Pain with sitting – use a cushion, wedge or doughnut pillow. Sitting on a higher chair or tilting the pelvis backwards (tuck tail in) may offload enough to reduce pain
  • Try to avoid daily tasks that require you to squat
  • Running pain – avoid long strides. As with DGPS take shorter, faster steps (increase your cadence) at a pace that reduces the pain. This is often higher than you expect. We often plod along too slowly and this adds load to the muscles because we spend more time standing on them.
  • Pain at night – sleep on your sides with a pillow between the legs. Contrary to regular sleep position advice, you may want to adopt a slightly more curled up position and definitely avoid lying on your tummy.
  • Reduce the painful activity but do not rest completely. Continue to be active and participate in your sport but keep the pain at low/tolerable levels. It is suggested to find what your 4/10 pain level is and not to push beyond that.

Strengthening the painful structures

  • Learn how to tuck your tail in and become mindful of what it feels like to activate your glute muscles instead of the hamstrings or deeper buttock muscles.
  • Slowly and progressively begin to strengthen the gluteals and hamstrings. This means, easy simple movements with light loads and gradually make the load heavier and increase the complexity of the exercise.

 

Back, bottoms and basics

Do you recall how I mentioned earlier in the article that there is a high incidence of concomitant buttock pain with lower back pain? Back pain transferring into the leg is a topic on its own but in the meantime, a great place to start are the Big 3 exercises as developed and researched by Dr Stuart McGill. These exercises are designed to provide the spine with stability and slowly improve muscle endurance and tolerance to load. Here is a small series of exercises I put together in early 2020 including the big 3 and some mobility exercises in between as breaks.

 

If you are having trouble even after following this advice, why not come in and see one of our wonderful physiotherapists? They will assess, properly diagnose and direct your exercises. And if it calls for, use adjunct treatment techniques such as myofascial release, dry needling and shockwave to help reduce pain and get you started on your exercise routine.

 

Reference

  1. Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists. P Justin Tortolani et al. Spine J. Jul-Aug 2002:2(4):251-254. https://pubmed.ncbi.nlm.nih.gov/14589475/

 

 

Medical Disclaimer:

This content is for education and information purposes only. It is not intended to replace professional medical advice, diagnosis or treatment. If you have any health concerns or pain, please contact your local healthcare provider directly.

1 thought on “A Pain in the Butt”

  1. Just loved this blog – thank you so much for such informative help with the added visuals. Now to putting the videos into practice.
    THANK YOu

    Reply

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