BUTTOCK PAIN IN ATHLETES - a patient's guide
Dr Ruth Highet - Sports Physician

What is buttock pain?

At least half a dozen times a week, an athlete will walk into the clinic complaining of a "pain in the butt". Usually they are a runner, a cyclist, or an athlete in a kicking or sprinting team sport.

Diagnosis of the specific cause of buttock pain can be difficult as pain can arise from local structures in the buttock or be referred from the lumbar spine or sacroiliac joints. These are the joints at the bottom end of the low back where the hipbones (ilia), connect to the sacrum (the low end of your low back).

What causes the condition?

The most common causes of buttock pain are referred pain from the lumbar spine and sacroiliac joints and problems involving the hamstring attachments on the ischial tuberosities (these are the hard bony parts of your bum that take your weight when you sit down!).

Injuries commonly seen in this area include a tendonitis at the origin of the hamstring muscle, a partial tear of the hamstring muscle, or a bursitis at the hamstring attachment (ischial bursitis). Tight and inflamed ligaments that pass from the ischial tuberosities back to the sacrum (sacrotuberous ligaments) can also cause very acute and localised pain in this area. The bursa inflammation (bursitis), may give rise to pain when sitting, and is a frequent complaint of cyclists who take most of their weight on their "bum bones" - ischial tuberosities is better "table-talk".

Buttock pain that refers down the back of the thigh will usually suggest that its origin is in the low back but this can also be caused by tight external hip rotator muscles. This is important to recognise to avoid sometimes unnecessary back surgery for presumed sciatica from a damaged disc. The reason why these can be confused is that the sciatic nerve sometimes passes through the pyriformis muscle (deep inside the buttock), which can get very tight in athletes. Compression of the nerve by the tight muscle may mimic the "true" sciatica caused by a swollen or damaged disc or narrowed joint compressing the nerve where it exits the spine. The pyriformis tightness problem is much more easily remedied with appropriate stretching of the muscle groups, work on muscle balance of the hip and low back muscles, and regular massage.

Buttock pain which is worse in the mornings, and improves with light exercise, is more suggestive of pain arising from inflamed sacroiliac joints. This cause of buttock pain will be usually be associated with pronounced low back stiffness in the mornings, which can take 30 minutes to several hours to ease. Inflammation in these joints is often associated with inflammation in other tendons, joints and tissues in the body (e.g. plantar fasciitis, Achilles tendonitis), and may be part of medical conditions such as ankylosing spondylitis. This cause of buttock pain will usually be significantly relieved with nonsteroidal anti-inflammatories since it is true "inflammation" causing the symptoms.

What can be done to help?

Treatment for the various causes of buttock pain will obviously be very dependent on the actual diagnosis. It may involve therapy to try and mobilise the low back and sacroiliac joints, stretch tight pelvic ligaments, strengthen back supporting muscles, exercises to improve the strength and flexibility of the hamstring muscles, and deep tissue massage to the muscles attaching around the pelvis and the connective tissues enveloping them - the "myofascia".

Inflammation of the bursa, overlying the "bum bone", will not usually get better with frictional massage, ultrasound or other mechanical physio modalities, and may require an anti-inflammatory injection to dampen it down. If the sciatic nerve is very tight due to scarring and adhesions around it, this may also cause sciatica symptoms. In this case, the physios will do a lot of "neural stretching" and give the athlete neural stretches to do as part of their home rehab programme. These need to be carried out cautiously to avoid aggravating symptoms.

Hamstring injuries often occur because of "relative overuse" of the hamstring muscles. We see many runners who have forgotten how to use their buttock muscles (gluteals), but have extremely strong hamstring muscles. They have often had years of hamstring pain thinking that the answer to their problems is further hamstring strengthening. Very specific exercises to make them start using their "glutes" again and so reduce the load on the hamstrings often results in a dramatic improvement in their symptoms.

Conclusion

As in all areas of sports medicine successful treatment requires a specific diagnosis being made and then an appropriate rehabilitation programme for that diagnosis. Anti-inflammatory pills and rest may well reduce symptoms but if the primary cause is not treated, the same symptoms will usually recur on return to activity, cessation of pills or after surgery is completed.

In many cases of buttock pain, an important lesson to give patients is to "work their glutes" and stop overusing their hamstrings! "Pretend you've got a $100 note in the buttock crease and keep it there all day - in the supermarket queue, going uphill or stairs, standing around talking to people or talking on the phone. The possibilities are "endless" or should I say "bottomless"?