A Pain In The Butt

Is sitting at work giving you a pain in the butt? Would you rather be out training? Or is training, not the misery of staring out your office window at the beautiful spring sunshine, the cause of your ailment?

Buttock pain can be a source of debilitation for the sportsperson, resulting in missed training, irritation and mood swings – like most injuries! It can sometimes be difficult to locate, and of gradual onset for usually no particular reason so sometimes a very frustrating condition to diagnose and treat. The best thing to do in a situation like this is to get a proper assessment by a physiotherapist with experience in sports injuries or a sports doctor or sports physician. Below I talk about buttock pain and its prevention.

Sources of Buttock Pain
Buttock pain can have a number of sources, including:
- Referral from the lower back
- Referral from the sacroiliac joint
- The hamstring attachment
- The gluteal muscles (myofascial pain)
- Piriformis tightness
- The attachment of gluteus medius
- Less common causes

 

Anatomy of the Gluteal Muscles
The muscles piriformis and gluteus medius are shown in figures one and two respectively.

The piriformis starts from the front surface of your sacrum (the bottom five fused vertebrae of your spine) and travels back and out to the greater trochanter (the top part of your femur bone).

The gluteus medius muscle attaches high up on your hip bone (ilium) and travels down to also insert on to the greater trochanter. Due to the line of its pull, this muscle is important in providing lateral stability of the pelvis.

There are several other deep buttock muscles that also contribute to hip rotational movements, but they are not often thought to be implicated in injury like the two described above.

Pain from the Gluteal Muscles (Myofascial Pain)
Trigger points, which are areas of increased sensitivity in a taut band of muscle, can be present in gluteus medius and piriformis especially. These usually occur as a result of poor pelvic stability and weakness in the gluteal muscles, or are sometimes secondary to back pain. Pain from these trigger points can travel down into the back of the leg.

Piriformis Syndrome
In 10% of people the sciatic nerve passes through the piriformis muscle. It is thought that the piriformis can sometimes put pressure on the sciatic nerve, a condition that may be seen more often in these people. Or tension may be put on the sciatic nerve as it wraps around a tight piriformis. This can result in buttock pain that can travel down to the calf muscle.

In other people, it may just be a case of the piriformis being tight and strained. This will present as pain sitting, climbing stairs and squatting.

Gluteus Medius Tendinopathy and Bursitis
If the pain is more on the outside of the hip, the trochanteric bursa, which sits between your hip bone and the gluteal muscles could be the source of your pain, along with injured gluteal tendons as they attach in to the trochanter.

Long distance runners are more likely to get this problem and poor core stability and muscle tightness often contribute. Assessment and appropriate management of these issues as well as rest will help fix this.

WAYS TO PREVENT BUTTOCK PAIN
The conditions described above are often overuse issues, where poor core stability, muscle weakness and tightness in the area all contribute. Correction of any muscle imbalances through stretching and strengthening will prevent injury.

Stretches
Cyclists and runners especially need to maintain flexibility in this region. Muscle groups to stretch that should be included as part of your training routine, especially if you feel tightness when stretching them, are the calves, hamstrings, hip flexors, quadriceps, iliotibial band (side of thigh) and gluteals.

Exercise 1 – Gluteal Stretch

Lying on your back, bring your left knee up to your chest and hold with your left arm.
Pull your foot around with your right hand.
Try pushing your left knee across your body and vary how much you pull your foot around.
Depending on what parts of the muscles are tight will determine the best position for you to hold the leg.
Hold for 30 seconds x2

Muscle Strength and Stability
Can you stand on one leg and bend your knee with good control? Do this in the mirror and see how you go. Your hips should stay level and knee should track over your second toeIf you can’t do this, lower abdominal and gluteus medius weakness may be an issue.

Exercise 2 – Single Knee Bends
Doing single knee bends like this can be an effective way to help strengthen the core and glutes.
Stand tall with your hands on your hip bones to monitor their height.
Contract your pelvic floor (like you are busting to go to the toilet, about 40% effort). This will help engage your lower abdominals. Don’t hold your breath though!
Bend and straighten your knee keeping good alignment (i.e. knee over 2nd toe)
3x10 each leg.
If you find it too difficult to maintain a level pelvis, place the toes of your other leg lightly on the ground behind you.

Exercise 3 – The Clam
Another simple exercise to help strengthen these muscle groups is the ‘clam shell’
Tie a theraband (stretchy piece of rubber used for exercises) around your knees.
Lie on your side with your knees bent and top hip slightly forward.
Contract your pelvic floor.
Lift top knee up without moving hip or back (clam shell opening).
3x10 each leg.

IT’S NOT JUST ABOUT INJURY PREVENTION!
Not only will you help avoid injury through these exercises, you will improve performance. Good core stability and buttock strength will mean when running you will eliminate unnecessary sideways movement and improve transference of force through your legs. During the support phase of running when your foot strikes the ground, there should be minimal sideways movement, or dropping of your pelvis. If there is, this will mean wasted energy that is not used to propel you forward. Take note next time you are out running what happens to your hips, especially when you are tired. Does your opposite hip drop when you strike the ground? If so, work on the above exercises to help with this.

When you are cycling, unnecessary rocking of the pelvis sideways also results in wasted energy. Get a friend to ride behind you, or watch your hips as you ride on a wind trainer and note any dropping of your hips. If this is the case working on core stability and the above exercises will help you. It may also pay to get your bike setup checked to make sure your saddle isn’t too high. By correcting any muscle weaknesses, you will improve the transference of force through your legs. Focus on good technique and a ‘stable pelvis’ to help with achieving this better transference of force.

There are also benefits with swimming as improved stability will mean a more effective kick with no wasted energy from a sloppy pelvis and with kayaking as you will have a more stable base to rotate on and better transference of force to your trunk from your leg drive.

 

By Alysha Blackwell

Physiotherapist based at Adidas Sports Medicine in Auckland, where she works to help  athletes of all levels overcome injury to achieve thier goals. For injury diagnosis and tretment and muscle balance assessment appointments you can contact her at physio@sportsmed.net.nz