Member Case Study: Pain in the Butt

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Differentiating between piriformis, sciatica and hamstring injury

Question from isis54

I need help differentiating between pinformis/sciatica/high hammy..and most importantly-REHABBING to get back out there running!!!!!

Answer
Pain in the posterior hip or buttocks is common in runners and can lead to significant pain and inability to continue running. This article addresses common causes and treatment of pain in this area.

Sciatica or shooting pain in the back of the leg refers to pain in the distribution of the sciatic nerve. Compression of, or trauma to the sciatic nerve is the cause of the pain, usually from a herniated disc. Sciatica occurs in 2-3% of all patients with low back pain, which is very common in the general population (5% annual occurrence).

The test that doctors use to elicit the pain is called the straight leg raise. In the seated or lying position the hip is flexed with the knee straight to see if this reproduces the pain. MRI is the test used to evaluate for herniated lumbar disc. Treatment includes physical therapy, avoidance of sitting, use of traction, anti-inflammatory medications, corticosteroid injections and sometimes surgery.

Piriformis Syndrome refers to sciatic nerve irritation as it passes through the piriformis muscle in spasm, causing buttock pain and radiation into the leg. The pirifromis muscle is one of a series of small muscles that go from the tailbone (sacrum) to the hip bone (femur) lying underneath all three layers of gluteal muscles. Their job is to rotate the hip out (external rotation). In about 1 out of 5 people, the sciatic nerve passes through the piriformis muscle. You may feel pain in the buttock with pain going down the leg that is worse with sitting and driving!

The pain can be brought about by deep pressure over the muscle or flexing, adducting and rotating the hip in. This can be distinguished from hamstring pain by the location of the tenderness and by reproducing pain with stretching or firing the hamstrings.

Imaging is usually not helpful to establish this diagnosis, but can be useful in ruling out other treatable problems. Treatment includes stretching and strengthening, rest, anti-inflammatory medicines, deep muscle massage (painful!), corticosteroid injection and, rarely, surgery.

Andrew Gregory, MD, FAAP
Vanderbilt University Sports Medicine
Member, AMSSM

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date: March 5, 2006