Deep gluteal syndrome: buttock pain and sciatica without a spinal cause

myBackPain Assessment

Deep buttock pain and leg symptoms but a normal spine MRI?

The myBackPain assessment identifies the deep gluteal syndrome pattern — buttock-dominant pain without true spinal nerve root features — and distinguishes it from disc-related sciatica. Results in minutes.

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Often

missed — spine MRI is normal or shows only minor changes inconsistent with the clinical picture

Clinical

diagnosis — identified from buttock tenderness, provocation tests, and absence of neurological signs

Responds

well to manual therapy and specific stretching once correctly identified

What is deep gluteal syndrome?

Deep gluteal syndrome describes pain and nerve irritation arising from the deep gluteal space — the area beneath the gluteal muscles where the sciatic nerve passes through or below the piriformis muscle. When the piriformis muscle becomes tight, inflamed, or develops trigger points, it can compress or irritate the sciatic nerve, producing symptoms that closely mimic disc-related sciatica.

It is one of the most common causes of “sciatica” that is not actually coming from the spine, and it requires different management. Treating the spine when the cause is in the deep gluteal space produces poor results.

Why it gets missed

MRI of the lumbar spine is often normal or shows only minor changes that are not consistent with the clinical picture. The diagnosis is a clinical one, made by identifying characteristic buttock tenderness, reproduction of symptoms with provocation tests (the FAIR test — hip flexion, adduction, internal rotation), and the absence of true dermatomal neurological findings on examination.

What does it feel like?

Deep, aching buttock pain — often unilateral
Pain radiating down the posterior thigh — usually not below the knee
Worse with prolonged sitting, particularly on hard surfaces
Worse with hip internal rotation and adduction — crossing legs, sitting with feet turned in
Tenderness on deep palpation of the piriformis muscle in the buttock
Often no neurological changes on examination — no reflex change, no dermatomal sensory loss

What helps?

Soft tissue therapy

Deep tissue massage and trigger point release to the piriformis and surrounding deep gluteal muscles is the primary treatment. Often produces immediate and significant relief. Best delivered by an osteopath, physiotherapist, or sports therapist.

Stretching

Specific piriformis stretches — the figure-4 stretch in sitting or lying positions — are highly effective. Should be performed daily as part of ongoing self-management. Maintain throughout recovery.

Hip strengthening

Gluteal strengthening addresses the underlying hip dysfunction that typically contributes to piriformis overload. Weak glutes cause the piriformis to work harder as a compensator, maintaining the cycle of irritation.

Activity modification

Avoiding prolonged sitting, adjusting driving position, using a coccyx cutout cushion on hard surfaces, and avoiding positions that internally rotate and adduct the hip.

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Download the Piriformis Syndrome Fact SheetPDF — printable summary to share with your GP or practitioner