A Pain in the “Butt”: Common Causes and How Physiotherapy Can Change It

Cannot sit still or walk properly because of a nagging discomfort in the buttocks? Buttock pain is a common complaint that can arise from a wide variety of causes, ranging from muscular strain and joint dysfunction to nerve-related conditions.

When it comes to the hip, many people think only of the gluteal muscles, which are often the cause. However, the anatomy of the posterior hip is much more complex, involving bones, joints, ligaments, nerves, and several muscle groups. Understanding the underlying cause is essential for effective treatment.

Below are some common conditions that can cause buttock pain. These conditions can broadly be explored under three categories: musculoskeletal, neurological, and other causes.

Musculoskeletal Causes of Buttock Pain

These involve the muscles, tendons, bones, or joints around the hip and pelvis.

Gluteal Muscle Strain 

Glute muscle strain is one of the most common causes of buttock pain. Of the three glute muscles, this most commonly affects the gluteus medius and minimus. This often occurs due to tearing of the muscles from overstretching, sudden forceful contraction, direct trauma, overuse, or overexertion during physical activity, leading to sharp or aching pain or tenderness. This is common in sports involving sprinting, jumping, or sudden changes in direction.

Symptoms may include:

• Localised pain in the back or side of the hip

• Swelling, bruising and/or tenderness 

• Pain aggravated by use of the affected muscles (walking, climbing stairs, running) 

• Pressure applied to the area i.e. lying on the affected side, or prolonged sitting

Gluteal Tendinopathy

Gluteal tendinopathy is a condition affecting the tendons of the gluteal muscles to the hip bone at the greater trochanter. This often involves degeneration and/or inflammation of the tendons, leading to pain and weakness in the outer hip. 

This often develops due to repetitive stress on the tendons, insufficient recovery, or accumulated microtrauma over time. It is most commonly seen in individuals over the age of 40, particularly women, and is often associated with repetitive movements such as running, long walks, or prolonged periods of standing. Its symptoms can closely mimic those of a gluteal muscle strain.

Proximal Hamstrings Strain and/or Tendinopathy

This involves injury or degeneration of the hamstring tendons at their origin on the ischial tuberosity (sitting bone). Common in runners and athletes. The cause is similar to those of the gluteal muscles. 

Symptoms may include:

• Deep pain at the base of the buttock (on the “sit bones”) 

• Discomfort with sitting, especially on hard surfaces

• Pain, and sometimes weakness, with sprinting, lunging, or bending forward

Piriformis Syndrome (also known as Deep Gluteal Syndrome)

This condition involves compression of the sciatic nerve by the piriformis muscle, which is located deep within the buttock. It often occurs when the piriformis becomes tight, hypertrophied, or inflamed. This is commonly associated with weakness or poor activation of the gluteus maximus and/or gluteus medius muscles.

Weakness in the gluteus maximus or medius can alter hip mechanics during movement, especially during weight-bearing tasks such as walking, climbing stairs, or squatting. As a result, the hip may excessively adduct and internally rotate, placing greater demand on the piriformis muscle. Over time, this increased eccentric load can strain the piriformis, raising the risk of developing piriformis syndrome.

Symptoms may include:

• Deep buttock pain

• Radiating pain or numbness down the back of the leg (sciatica-like symptoms)

• Pain worsens with prolonged sitting, hip rotation, or direct pressure on the muscle

• Discomfort aggravated by prolonged standing, walking, stair climbing, or squatting

Neurological Causes of Buttock Pain

These typically involve irritation or compression of nerves that refer pain to the buttock.

Lumbar Radiculopathy (commonly L4-S1)

A herniated disc, spinal stenosis, or degenerative changes in the lumbar spine can irritate nerve roots, leading to referred pain in the buttock and leg. 

Symptoms may include:

• Sharp, burning, or shooting pain from the lower back into the buttock

• Possible numbness, tingling, or weakness in the leg

• Pain worsened by prolonged sitting, bending, or lifting

Sciatic Nerve Entrapment

Besides piriformis syndrome, the sciatic nerve can be irritated by other structures, including soft tissue or post-surgical scarring.

Other Causes of Buttock Pain

Bursitis: Greater Trochanteric Pain Syndrome or Ischial Bursitis 

Bursae are small, fluid-filled sacs located throughout the body that act as cushions to reduce friction between moving tissues. In the posterior and lateral hip, there are two main bursae: the ischiogluteal bursa and the trochanteric bursa. Inflammation of either bursa can lead to pain in the buttock.

This often results from repetitive movements, overuse, or prolonged pressure on a joint. Direct trauma, such as a fall, can also trigger inflammation. In some cases, poor movement mechanics or muscle imbalances place extra stress on surrounding tissues, increasing the likelihood of bursitis. Additionally, underlying conditions like rheumatoid arthritis or gout, as well as infections, can cause bursae to become inflamed. Addressing the root cause, whether biomechanical, inflammatory, or activity related, is key to effective management.

Symptoms may include:

• Pain on the outside of the hip/buttock

• Worse when lying on the affected side

• Tenderness over the lateral hip (greater trochanter)

Sacroiliac Joint (SIJ) Dysfunction 

The sacroiliac joints, which connect the spine to the pelvis, can become inflamed or, less commonly, misaligned.

Symptoms may include:

• Pain near the dimples of the lower back, sometimes radiating to the buttock or thigh

• Worse with standing from sitting, walking uphill, or rolling in bed

In summary, while buttock pain can affect anyone, it is most commonly seen in middle-aged and older adults, women (particularly in certain conditions like gluteal tendinopathy or piriformis syndrome), individuals with sedentary lifestyles, those engaged in repetitive athletic activities, and people with existing back, hip, or nerve-related issues.

The posterior hip is a complex area with many possible causes of pain, getting the right diagnosis is important for effective treatment. If the source of the pain is not correctly identified, treatment may not work or could even make things worse.

A physiotherapist can help by assessing your movement, strength, and posture to find the root cause of the problem. With the right assessment, a personalised treatment plan can be created to reduce pain, improve movement, and prevent the issue from returning. If you are experiencing ongoing or worsening buttock pain, it is a good idea to consult a physiotherapist for proper care and guidance.