Upper buttock pain is pain that is experienced over the upper part of the buttock. There are many potential causes for upper buttock pain. Explore the information under each tab below to understand more about the anatomy of the area and things that may go wrong.
Common conditions associated with upper buttock pain:
Pelvic girdle pain or Sacroiliac joint pain/dysfunction – see Joint-Related Pain
Referred pain from the lower back – see Back-Related Hip Pain
Pain experienced in the upper buttock region may be related to:
joints of the hip & pelvis, where two bones meet
‘soft tissues’, non-bony structures, such as muscle
bones, such as the femur (thigh bone) or bones of the pelvis
the lower back
nerves that run through and around the hip & pelvis
pelvic organs or blood vessels, or other health issues masquerading as hip pain
What is pain?
Pain is an experience that the brain creates for the purposes of stimulating you to change your behaviour or seek help for a perceived problem with your body.
Irritating or potentially damaging stimuli in your body (like high levels of pressure, tension or extremes of temperature) activate sense receptors (danger sensors) in the area. Signals from danger sensors in the body travel through the nervous system to the brain. Here the information is processed and the brain sometimes (but not always) produces a pain experience.
A joint is formed where two bones are joined together, with varying amounts of movement occurring between them. Pain may be related to the structures involved in the function and support of a joint. The sacroiliac joint is the joint most likely to be related to pain in the upper buttock region (Figures 1.1 & 1.2).
Pain related to the Sacroiliac Joint
Pain and functional difficulties related to the sacroiliac joint:
most commonly develop during pregnancy or childbirth
may occur after a major trauma, such as a hard fall onto the bottom or a large force through one leg, for example being dragged by one leg after a fall from a horse or water-skis
may develop over time, related to certain types of repetitive forces
can develop when there is a problem with the lower back or hip joints, transferring extra load across the sacroiliac joint
Sacroiliac pain and dysfunction are however, greatly over-diagnosed. While true instability does occur, it is relatively rare and there are many people living unnecessarily in fear, related to a diagnosis of ‘pelvic instability’ or being told their pelvis keeps moving ‘out of place’.
Here are a few facts about the sacroiliac joint that may dispel some of this fear:
The structure of the sacroiliac joint makes it a very stable joint
Asymmetry in the human body is normal
Differences in tightness of the muscles that join on to either side of the pelvis occur naturally, related to leg or arm dominance, sport and occupation. This asymmetry may cause an appearance of asymmetry in the resting position and movement of the pelvis. This is normal and has not been linked to harm.
Differences in leg length of up to around 1cm are common and normal. Leg length difference may also produce an appearance of asymmetry in pelvic position in standing.
A click occurring in a joint does not mean it has moved ‘in or out of position’. All of us click and pop, some just a little more than others. These are usually normal joint or tendon sounds.
There are also causes for sacroiliac joint pain that are related to other general health conditions. Sacroiliitis refers to an inflammation of the SIJ’s associated with a systemic inflammatory disease such as Ankylosing Spondylitis. You can read more about non-musculoskeletal causes of hip and pelvic pain here.
Pain related to the sacroiliac joints is most commonly experienced in the upper buttock region, usually right over the joint, in the area of the dimples at the top of the buttocks. As the pelvis is a ring joined at the front by the pubic symphysis, problems with the sacroiliac joints are sometimes associated with pain in the groin region.There are many other causes for groin pain however, so visit our Pain Locator Map to read about different factors that may be related to pain in each of these regions.
Your Hip Pain Professional will be able to assess your sacroiliac joints to determine if they are likely to be the cause of your pain. If you have sacroiliac joint related pain, you may require:
advice on modifications to activities or positions – e.g. workplace set-up
an exercise program to provide optimal muscle support around the joints
advice regarding short term bracing or taping–only appropriate for short term use and usually only for severe pain and during late stage pregnancy or after trauma
an injection for short term relief of severe pain, while you work on your rehabilitation
Soft Tissue Related
Soft Tissue Related Pain
Pain in the upper buttock region may be related to soft tissues. Soft tissues are non-bony structures that connect, support, or surround other structures and include muscles, tendons (which connect your muscles to the bone) and fascia (Figure 2.1).
Fascia is stretchy, thin, white fibrous tissue. All our muscles are enveloped in fascia, like stretchy stockings that help transfer energy from muscle and movement. Fascia also forms sheaths or tunnels for safe passage of blood vessels and nerves and wraps and supports all our bodily organs.
There are many muscles that support and move the hip and pelvis. In the upper buttock region, many muscles and their surrounding thin fibrous wrapping (fascia) converge, joining firmly onto the pelvis and sacrum. These back, abdominal and buttock muscles play a vital role in generating and transferring forces that pass across the pelvis, between the back and hips. The muscles are also covered in strong fascia that continues from the hips (gluteal fascia) into the back (thoracodorsal fascia). This strong, stretchy wrapping helps store and transfer energy through this region (Figure 2.1).
The upper part of the gluteus maximus muscle, and the gluteus medius muscle beneath, run from their anchor points on the pelvis and sacrum, around to the side of the hip (lateral hip region) (Figure 2.1). The piriformis muscle also sits under the gluteus maximus in the upper buttock, having strong connections into the bones and ligaments of the sacroiliac joint (SIJ) at the back of the pelvis (Figure 2.2).
Bone Related Pain
Although relatively more rare than soft tissue or joint problems, bony problems such as a fracture, stress fracture or very rarely, infection or tumour within the bone may cause hip and pelvic pain.
The most likely bone-related issues associated with pain in the upper buttock region, are fracture or stress fracture of the sacrum. The sacrum is the wedge-shaped bone that sits between the two bony wings of the pelvis (Figure 3).
is the medical term for a broken bone
usually occurs from a traumatic event like a fall, car accident or more severe sporting injury. A hard fall backwards onto the pelvis may cause a sacral fracture.
is more likely to occur in a weakened bone e.g. osteoporosis or genetic diseases like osteogenesis imperfecta.
A stress fracture:
is the medical term used for a tiny crack in a bone
starts as localised swelling in the area of bone exposed to highest stress (you won’t see this at skin level as it is just within the bone) – this may be called a stress reaction or bony stress response
Stress fractures can be divided into two main types:
Fatigue fracture: where a bone has been exposed to an abnormal accumulation of repeated small traumas e.g. long-distance running
Insufficiency fracture: where the bone strength is insufficient to resist normal daily forces
Sacral fatigue fractures are seen most commonly in long distance runners or triathletes. Compared with bony injuries of the leg and foot, these are relatively much less common. Sacral insufficiency fractures occur most commonly in elderly females with osteoporosis. A diagnosis of sacral stress fracture may be missed or delayed, as the associated pain in the upper buttock region is often assumed to be related to the sacroiliac joint or lower back.
perform a thorough assessment and let you know if a bone issue may be suspected. In these cases, you may be advised to undertake further imaging or referral to a medical specialist for further advice
provide or refer you for rehabilitation at an appropriate time following bony injury
provide important information about managing general or sporting activity
address muscular or biomechanical issues that may be contributing to bone-related pain, for example, running style may have an impact
Back Related Hip Pain
Pain experienced in the upper buttock regions sometimes has nothing to do with a condition in this area.
Lower back issues are often associated with pain that extends from the back into the upper buttock or pain that occurs only in the upper buttock.There are two main ways this might occur:
Referred pain is pain felt in a part of the body other than its actual source. For example, if there is a problem in the lumbar (lower back) discs or joints, small nerve endings serving these structures generate ‘danger’ messages that are transmitted along small nerve fibres into the spinal cord.
However, this area of the spinal cord also receives information from structures in the hip and pelvis.The brain is unable to distinguish where the information came from, (the back, the hip or the pelvis) so you might feel pain in any one or a combination of these areas (Figure 4.1).
Pain in the buttock may be referred from joints or intervertebral discs of the mid-lower lumbar spine.
is usually a dull, aching or gnawing pain
can expand into a wide area that is difficult to localize
is not related to a problem of the nerve roots in the spine
is not associated with other nerve-related symptoms such as tingling or numbness
Peripheral Nerve Related Pain
The nervous system (Figure 5.1) is a complex network of nerves and cells that carry messages between the brain and spinal cord and your body. It is through this system that we feel, move and control our bodily functions.
Nerve roots leave the spinal cord via the intervertebral foramina (holes or spaces between the vertebrae) and join together from various levels of the spine to travel as cord-like structures, called nerves, to their destinations.
It is these nerves that travel outside the spinal cord that are referred to as “peripheral nerves”.
Some peripheral nerves travel only a short distance and others all the way from the lower back to the foot. Along their journey they run between and through muscles and fibrous tunnels.
While radicular pain arises from a problem as the nerve root exits the spine, nerve-related pain may develop due to a problem along the pathway of a peripheral nerve, outside the spine. Pain related to a nerve is called “Neuralgia”.
Neuralgia felt around the hip and pelvis may develop in many ways including excessive compression or stretch of the nerve. This may be caused by a sudden, acute mechanism, for example a fall or blow to the area resulting in compression, or the leg being caught and wrenched, resulting in stretch.
Alternatively, the onset may be subtle, with a gradual onset associated with sustained postures or repetitive movements that cause cumulative nerve irritation.
Nerves will also be influenced by the health of the tissues they run through or alongside. For example, high muscle tension or tendinopathy may over time result in irritation of neighbouring nerves. Nerve related symptoms are usually experienced differently from pain associated with muscle and joint problems.
Peripheral nerve irritability may result in:
symptoms in the area served by that peripheral nerve (which is different from dermatomal patterns associated with nerve root irritation -radicular pain)
odd zings or zaps of pain
tingly sensations or numbness
weakness – only for those nerves that supply muscles, like the femoral nerve
Nerves of the Upper & Lower Buttock Regions:
Nerves that pass through or supply the buttock region (Figure 5.2) include:
the sciatic nerve
the cluneal nerves – superior, middle and inferior
the gluteal nerves – these are motor nerves that serve muscles and not the skin
superior gluteal nerve – serves the gluteus medius, minimus and tensor fascia lata muscles
inferior gluteal nerve – serves the gluteus maximus muscle
posterior femoral cutaneous nerve – provides nerve supply to a large area of skin of the back of the thigh
Nerve Related Pain/Neuralgia in the Buttock Regions
The Sciatic Nerve and “Sciatica”
The term “sciatica” is often used incorrectly in reference to any pain felt in the area runningfrom the back, down into the leg.
See our section on “back-related hip pain” to read more about radicular pain associated with irritation of the nerve roots as they exit the spine.
The sciatic nerve does not exit the spine as a single nerve. Nerve roots from the lower levels of the lumbar spine (lower back) and sacrum (tailbone) join together in the pelvis.
Here they form a thick, cord-like structure, called “the sciatic nerve”. This large nerve exits the inner pelvis via the greater sciatic notch and runs through the buttock and down the back of the thigh (Figure 5.4).
The sciatic nerve can sometimes be compressed, irritated or entrapped as it runs through the soft tissues of the buttock.
Traditionally, sciatic pain (neuralgia) generated from issues within the buttock has been termed “Piriformis Syndrome” (see Figure5.4 to view the piriformis muscle and the sciatic nerve).
This was based on a finding that in about 20% of the population, all or part of the sciatic nerve runst hrough the piriformis muscle. Compression of the nerve within the piriformis muscle was thought to be the problem in all cases of nerve-related buttock and leg pain that could not be associated with a problem in the back.
It is now thought that this is the case in only a relatively small number of cases and that this condition has been over-diagnosed. So much so, that some believe it does not exist at all.
The term “Deep Gluteal Syndrome” has been suggested recently as an alternative term to piriformis syndrome. It refers to any irritation of the sciatic nerve in the deep gluteal space, beneath the gluteus maximus muscle.
In this space, the sciatic nerve may be compressed or irritated at the level of the piriformis, as it runs over the deep external rotator muscles or by fibrous bands anywhere along its path through the buttock.
The nerve can also be irritated as it leaves the pelvis to head down into the thigh. Here it runs through a tunnel (ischial tunnel), between the outer side of the sitting bone (ischial tuberosity) and the upper thighbone (femur) (Figure5.4).
In this tunnel it may be squeezed between the bones or irritated by unhealthy hamstring tendons (tendinopathy).
Of the cluneal nerves, the superior and inferior are more likely to be at risk of compression. Irritation of the superior cluneal nerve may result in upper buttock pain. The superior cluneal nerve branches run from the spine, over the top of the back of the pelvis and down into the buttock.
They usually run through fibrous tunnels as they cross the top edge of the pelvis. This is where the small nerves may become compressed or irritated. This is usually associated with a fairly localised area of pain in the upper buttock, in the region of its skin supply (Figure5.3).
Gluteal Nerve Neuralgia
The gluteal nerves do not have a sensory supply to the skin, but gluteal neuralgia may be felt as a deep buttock pain, sometimes like a cramping feeling.
These nerves provide important motor supply (the ability to make the muscles work/contract) to the gluteal muscles and the Tensor Fascia Lata (TFL) muscle at the side of the hip.
Damage to these nerves may alter your ability to stand on one leg, walk without a limp, climb stairs, and lift the leg out to the side or behind you. The nerves may be irritated or compressed as they pass out into the back of the pelvis and run through the soft tissues of the buttock.
Very occasionally, these nerves may also be damaged by surgery, such as a posterior approach Total Hip Replacement (where the scar is at the back of the hip).
For Pain Related to Nerves/Neuralgia throughout the Hip, Pelvis, Buttock and Groin:
perform specific tests in the clinic to see if nerve involvement is likely
provide treatments and give you exercises that may improve the health or movement of the nerve
help improve health of the muscles and tendons beside the nerve (this may be the source of nerve irritation)
review the positions you spend time in and activities you perform daily and provide strategies when performing these tasks that might help protect the nerve, thus reducing your symptoms. This may include changing your sitting or lying posture, or changing stretches or strength exercises that you have been performing that may be contributing to the irritation the nerve
provide nerve gliding or mobility exercises that can be useful in some situations
refer you for further tests or to a neurologist, orthopaedic specialist or other pain specialist if required
In some cases, your hip pain professional may refer you to a pelvic floor physio for further assessment should they consider the pelvic floor muscles are involved
*Please note: Nerve supply can overlap and be quite variable between individuals. The diagrams provided in this section only provide an approximate guide of nerve supply in each region.
Other causes of hip, pelvic & groin pain
There are other processes that may produce pain around the hip and pelvis.
These conditions are relatively rare compared to musculoskeletal pain, but when present you will need to see a medical practitioner and usually a specialist for that system or problem, for example, a Rheumatologist, Orthopaedic Specialist, Oncologist, Vascular Specialist.
Anterior Hip pain can also be associated with organ problems (ovaries, uterus, bowel, bladder, prostate). One of the most common causes of organ-related pain in females is endometriosis. This occurs when tissue that is similarto the lining of the uterus (womb) grows outside the uterus attaching to other structures such as the pelvic ligaments or the bladder and bowel. This can lead to debilitating pain that may be cyclic, relating to the menstrual cycle. Diagnosis and management of organ related problems will usually require the assistance of a specialist, for example a gynaecologist (female reproductive organs), urologist (bladder and prostate) or gastroenterologist (gut/bowel).
A skilled assessment by a Hip Pain Professionalwill help clarify if the problem requires further medical attention and whether it is likely to be related to a musculoskeletal problem or not.