Differential Diagnosis of Posterior Buttock Pain: A Conceptual Review Based on Topographic Localization of Pain, Is It Really the Sacroiliac Joint?

  • International Journal of Spine Surgery
  • November 2025,
  • 8821;
  • DOI: https://doi.org/10.14444/8821

Abstract

Diagnosis and management of musculoskeletal pain in the lower back, buttock, and hip can be complex due to the multilayered muscular anatomy in this region. Each structure or functional group (ie, hip abductors) may present as a local pain syndrome. Pain may arise from osseous, intra-articular, ligamentous, musculotendinous, myofascial, neural, or vascular sources. Diagnosis is challenging due to overlapping innervation and referred pain patterns, particularly sclerotomal referral from osseous and ligamentous structures. Effective treatment requires accurate diagnosis. A regionalized approach categorizing pain syndromes into 6 anatomic zones—above the iliac crest, the iliac crest, the lateral hip, the gluteal region, sciatic nerve related, and the ischial tuberosity—may improve diagnostic clarity and guide treatment. A regionalized, 6-zone framework for posterior buttock pain may enhance diagnostic accuracy and guide individualized management.

Introduction

Sacroiliac joint dysfunction (SIJD) is increasingly recognized as a significant contributor to low back and posterior pelvic pain. Estimates suggest that the sacroiliac joint (SIJ) is the primary pain generator in 15% to 30% of patients with chronic low back pain.1,2 With a prevalence of chronic low back pain exceeding 600 million people globally,3 SIJ-related pain represents a major clinical and socioeconomic burden, contributing to disability, work loss, and substantial health care expenditures. Historically underdiagnosed, SIJD has gained recognition in the past decade through improved diagnostic algorithms, randomized trials of surgical interventions demonstrating safety, effectiveness, and durability.4–7 Increased awareness of the condition has occurred across the health care provider landscape. Education on SIJ diagnosis and treatment is becoming a consistent element of physician training. This heightened awareness has coincided with an expansion of treatment options ranging from the traditional belts and physical therapy to include interventional injections, radiofrequency ablation, and, more recently, minimally invasive surgical fusion procedures.8 There has been a marked increase in the awareness of SIJD across medical specialties, with an associated increase in utilization of SIJ procedural and surgical treatments.9–11

The SIJ plays a unique role as the biomechanical link between the spine and lower extremities, enabling bidirectional load transfer. The stability of the SIJ is traditionally described as a balance of form closure—provided by the congruence of the sacral and iliac joint surfaces with their interlocking ridges and grooves coupled with the shape and orientation of the osseous elements and their respective joint surfaces that passively limit SIJ motion to a small arc—and force closure—generated by active tension from ligaments, fascia, and surrounding musculature.12 Passive ligamentous tension in the supporting ligaments, including the interosseous, sacrotuberous, and sacrospinous ligaments, contributes to static stability, while muscle groups such as the erector spinae, pelvic floor, and abdominal wall contribute to dynamic stabilization through indirect action on the SIJ. Paired muscle groups crossing the SIJ and the midline have been described as additional dynamic stabilizers.13,14

Spinopelvic biomechanics tightly couple the lumbar spine, SIJ, and hips. Alterations in 1 region, such as lumbar fusion, sagittal imbalance,15 or hip impingement and/or osteoarthritis,16–18 can result in abnormal load across the SIJ, leading to SIJD and pain. The SIJ accommodates multidirectional forces, with load transfer occurring from the spine through the SIJ to the pelvis and lower extremities. Maladaptations, including changes in orientation of the pelvis in any plane, such as increased/decreased pelvic tilt, or alterations in hip biomechanics, such as increased femoral anteversion (FAV), shift force vectors across the SIJ, altering joint reaction forces and predisposing to pathological accommodation of load.19

Sex-based differences in anatomy and physiology significantly influence SIJ biomechanics and may help explain the increased prevalence of SIJD in women. Women exhibit greater sacral slope, increased lumbar lordosis, wider pelvic dimensions, and decreased ligament stiffness compared with men.20 Hormonal influences, particularly relaxin, reduce ligament stiffness during pregnancy, further destabilizing the SIJ.21 Pregnancy induces increased anterior pelvic tilt and lordosis, weakening of the abdominal wall, and the pelvic floor. Parturition may result in injury to the SIJ ligaments and the pelvic floor. These factors may compromise SIJ stability and predispose to abnormal loading of the SIJ, loss of ability to accommodate SIJ loads, and ultimately to symptomatic SIJD.22 Notably, pelvic girdle pain occurs in 23% to 65% of pregnancies and may persist postpartum in up to 25% of women, highlighting the burden of sex-specific risk factors.20,23 Genetic polymorphisms and hormones contribute to pain perceptions, modulation, and responses. These differences underscore the importance of considering sex, sex-based anatomy, and hormonal influences in the evaluation of posterior pelvic pain.24–26

The clinical presentation of SIJD is heterogeneous, often mimicking lumbar discogenic pain, intra-articular hip pathology, or a wide number of musculoskeletal pain syndromes of the posterior pelvis.27–29 Pain may localize near the posterior superior iliac spine but frequently radiates into the buttock, posterior thigh, or groin. These referral patterns reflect the broad sclerotomal innervation of the spine, pelvis, and hips.30 Sclerotomal pain is deep, diffuse, poorly localized, and difficult to differentiate.31 This variability complicates diagnosis and underscores the need for a structured regional assessment.

Evaluation of suspected SIJD begins with exclusion of serious pathology such as infection, neoplasm, spondyloarthropathy, and neural compression. History should elicit pain location, pain onset, aggravating factors (stair climbing, sitting, and single-leg stance), pregnancy and surgical history, and gait or postural asymmetries. History should include questions focused on pelvic floor and abdominal wall function. The examination includes observation of sitting and standing posture and assessment of gait. Sit-to-stand and step-up functional assessments provide insight into spinopelvic load transfer. Palpation of the sacral sulcus, iliac crest, and posterior superior iliac spine (PSIS) areas localizes to the SIJ. A cluster of SIJ provocation tests improves diagnostic accuracy,32 while confirmatory image-guided intra-articular block remains the reference standard.33,34

While the SIJ is a common cause of posterior spine and buttock pain, it is important for the practitioner to understand that the SIJ is part of a complex system (bone, ligament, muscle, fascia, and neuro-control) linking the spine to the pelvis. There are many musculoskeletal structures in the anatomic region of the lumbar spine, pelvis, SIJ, hip, and proximal lower limb. These structures function to link the spine to the pelvis and the pelvis to the lower extremities as a single system. The SIJ is the central link in this system. Pathology of these regionally localized structures may result in regional symptoms that may be confused with SIJD, may be an underlying cause of SIJD, or, in many cases, may manifest as both a specific musculoskeletal syndrome and a contributor to SIJD.

In this article, we review these syndromes by grouping them into 6 anatomic zones: above the iliac crest, at the iliac crest, lateral hip, gluteal musculature, deep gluteal space, and ischial tuberosity (Figure). Given the diagnostic overlap among spinal, sacroiliac, and hip-related pathologies, a regionalized framework for differential diagnosis enhances clinical clarity. Organizing syndromes by anatomic region facilitates systematic evaluation, may help minimize misdiagnosis, and guides targeted multimodal treatment strategies. Pain originating from the SIJ is often misdiagnosed as another condition, which can lead to misdirected surgeries; careful, accurate diagnosis can therefore play a critical role in improving surgical outcomes, whether for SIJ fusion or other procedures.35

Topographic localization of pain syndromes of the posterior buttock. Topographic zones: (A) Above the crest; (B) at the crest; (C) lateral hip; (D) gluteal region; (E) sciatic nerve related; (F) ischial tuberosity.
Figure

Topographic localization of pain syndromes of the posterior buttock. Topographic zones: (A) Above the crest; (B) at the crest; (C) lateral hip; (D) gluteal region; (E) sciatic nerve related; (F) ischial tuberosity.

Pain Syndromes Localized Above the Iliac Crest

Pain syndromes above the iliac crest (Table 1) typically arise from lumbar facet joints, the quadratus lumborum (QL) muscle, and thoracolumbar fascia (TLF). These structures are critical to spinal stability and lumbopelvic load transfer. Pathology in this region commonly produces localized lumbosacral pain with radiation to the posterior pelvis, buttock, or lateral hip and may mimic sacroiliac or hip joint disease. Careful clinical assessment with selective diagnostic blocks is often required to differentiate among these sources.

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Table 1

Pain syndromes localized above the iliac crest.

Lumbar Facet Syndrome

Lumbar spinal facet joints are synovial articulations that stabilize and guide lumbar motion. Degeneration, trauma, or repetitive stress can produce pain typically presenting in the midline with referral into the buttock(s) or posterior thigh(s). Pain is typically exacerbated by lumbar extension and rotation and is relieved by flexion. Diagnostic medial branch blocks are the standard for confirming facetogenic pain. The management of lumbar facet pain includes PT, NSAIDs, intra-articular injections, and radiofrequency ablation.36–40

QL Syndrome

The QL muscle stabilizes the lumbar spine and pelvis during gait and respiration. Overuse, poor posture, repetitive strain, or lumbar surgery can lead to pain in the lateral lower back (with myofascial trigger points) as well as referred pain into the sacrum, posterior pelvis, and lateral hip. Diagnosis is made by physical examination, including pain on palpation (tenderness) and occasionally anesthetic block41,42 or steroid injections.43 Management includes stretching, manual therapy, and core stabilization exercises. Active and/or passive stretching of the QL muscle is difficult, especially in patients with a history of multilevel lumbar or thoracolumbar spine fusion.

TLF Dysfunction

The TLF is an osteofascial compartment that surrounds and separates the intrinsic back muscles (erector spinae and multifidus) from the posterior abdominal wall muscles (QL). The TLF is an anchor point for several muscle groups and aids in transmitting muscular force and helps coordinate the movement of the trunk and limbs. Injury, fibrosis, or postsurgical changes can impair lumbopelvic stability and proprioception, producing diffuse lower back pain that may radiate to the posterior pelvis. Magnetic resonance imaging (MRI) may demonstrate fascial thickening. Treatment emphasizes soft tissue mobilization and lumbopelvic stabilization exercises.44–46

Pain Syndromes Localized to the Iliac Crest

Pain in the iliac crest region often arises from the SIJ, gluteus maximus tendon origin, or entrapment/compression of the superior cluneal nerves (Table 2). These conditions may present with focal pain at the PSIS or along the crest, often radiating into the buttock. Because SIJD and cluneal nerve syndromes share overlapping referral patterns, careful clinical evaluation and diagnostic injections are frequently required to distinguish them. Imaging may help exclude alternative pathology arising from the spine or hips but is often nonspecific.

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Table 2

Pain syndromes localized at the iliac crest.

Sacroiliac Joint Dysfunction

The SIJ accounts for 15% to 30% of chronic low back pain cases1,2,47–50 and may produce pain localized to the PSIS with radiation into the buttock, groin, or posterior thigh. Diagnosis relies on a positive cluster of provocation tests (eg, FABER, pelvic gapping, posterior thigh thrust, pelvic compression, and Gaenslen)51,52 combined with confirmatory intra-articular injections. Conservative management includes belts, stabilization exercises, and PT.53 Interventional approaches include corticosteroid injections54 and radiofrequency ablation;55 minimally invasive fusion may be indicated for refractory cases.5,56,57

Gluteus Maximus Tendinopathy at the Iliac Crest

This enthesopathy arises at the tendinous origin of the gluteus maximus from the posterior iliac crest.58 Patients present with deep aching pain along the posterior iliac crest, aggravated by hip extension or prolonged standing. Imaging with ultrasound or MRI may reveal tendon thickening, enthesopathy, or adjacent bursitis.59 Management includes rest, gluteal and core strengthening, eccentric exercises, and occasionally corticosteroid or platelet-rich plasma (PRP) injection.60

Superior Cluneal Nerve Entrapment

The superior cluneal nerves cross the posterior iliac crest through osseofibrous tunnels in the TLF. Entrapment produces sharp, burning pain localized 7 to 8 cm lateral to midline, radiating into the buttock, often mimicking radiculopathy or SIJ pain.61 Diagnosis is supported by tenderness over the entrapment point, a positive Tinel’s sign, and a confirmatory nerve block. Treatment includes activity modification, PT, ultrasound-guided nerve block, radiofrequency ablation, or surgical neurolysis if nonsurgical management fails.61–63

Pain Syndromes Localized to the Lateral Hip

The lateral hip region (Table 3) is a common source of musculoskeletal pain, particularly among women and older adults. The term greater trochanteric pain syndrome (GTPS) encompasses a spectrum of more specific soft tissue pathologies with chronic or subacute pain symptoms localizing to the region of the greater trochanter. Historically described as trochanteric bursitis, the more comprehensive term GTPS is now used to describe an array of peritrochanteric pathologies, including (working from the inside out) short external rotator tendinopathies, gluteal tendon disorders, trochanteric bursitis, tensor fascia lata (TFL) inflammation/tear, and proximal iliotibial band (ITB) enthesopathy. Pathology in the lateral hip may present with pain when lying on the affected side, walking, or stair climbing. Pathology is typically related to altered biomechanics of the hip, pelvis, and/or lower extremity(ies) or overuse injury. Careful evaluation is required to distinguish pain syndromes in the lateral hip region64 from referred pain due to lumbar radiculopathy, SIJD, or intra-articular hip pathology.65

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Table 3

Pain syndromes localized at the lateral hip.

Tendinopathy of the Short External Rotators

The piriformis and the short external rotators insert on the posterior aspect of the greater trochanter. Tenderness to palpation on the posterior aspect of the greater trochanter is often indicative of an enthesopathy of the insertion of the piriformis/short external rotators of the hip.66 Treatment is stretching, diagnostic/therapeutic blocks, possibly botulinum toxin injection, and rarely surgical release.67

Gluteus Medius/Minimus Tendinopathy

The gluteal muscles provide pelvic stability and locomotion. The muscles insert on the proximal lateral femur. The Maximus, providing primarily for hip extension, inserts on the gluteal tuberosity caudal to the greater trochanter on the posterior femur. The medius, a hip abductor and external rotator, inserts on the lateral facet and the superoposterior facet of the greater trochanter. The minimus, a hip abductor and internal rotator, inserts on the medial facet. The tendinous insertion(s) of the gluteal muscles are subject to injury, typically overuse or chronic strain. Repetitive loading above the functional range but below failure results in inflammatory changes leading to a cascade of secondary cellular and ultimately structural changes. This process is frequently painful and may result in functional limitation and is a risk for tendon failure. This condition is often the primary driver of GTPS.68 It presents with lateral hip pain radiating down the thigh and weakness on resisted abduction, sometimes producing a Trendelenburg gait. MRI or ultrasound may demonstrate partial tears or tendinosis. Conservative care includes eccentric strengthening and load modification,69 while refractory cases may benefit from injections or surgical repair.70

Greater Trochanteric Bursitis

Trochanteric bursitis is an inflammatory process of the trochanteric bursa, most commonly related to repetitive mechanical overload and frictional compression by the overlying ITB and TFL. The trochanteric bursa (subgluteus bursa) is interposed between the greater trochanter and the overlying ITB/TFL complex. Its primary role is to reduce friction and distribute mechanical loads generated during hip motion and weight bearing. Histologically, the bursal lining demonstrates inflammatory changes leading to thickening and fibrotic change. The TFL originates anteriorly from the iliac crest and anterior superior iliac spine, inserting into the ITB. Dysfunction or tightness of the TFL can increase lateral hip tension, accentuating ITB compression over the underlying greater trochanter and trochanteric bursa. The ITB is a dense fibrous structure extending from the TFL and gluteus maximus down the lateral thigh to the proximal tibia. Repetitive movement can cause thickening or injury (tearing) of the ITB, typically starting at its deep surface. In some cases, the pathology results in painful palpable snapping (external coxa saltans) of the ITB as the greater trochanter moves beneath it.71 Clinical presentation includes lateral hip pain and focal tenderness over the greater trochanter, worsened by side lying, stair climbing, prolonged walking, or squatting.72 Swelling and warmth may occasionally accompany more severe forms. Management includes physical therapy to address the underlying biomechanical imbalances, NSAIDs, corticosteroid or PRP injection, and extracorporeal shockwave therapy.73,74 There has been a recent trend toward arthroscopic decompression of the bursa with surgical repair of partial and/or complete tears of the overlying TFL/ITB complex.75

Proximal ITB Syndrome

ITB pathology typically presents with pain in the lateral hip and thigh extending to the knee. ITB syndrome may also present as pain at its origin from the iliac crest and TFL76 or anterolateral hip.77 It is frequently underdiagnosed in athletes and individuals with pelvic instability. Clinical findings include focal tenderness along the proximal ITB and pain with hip flexion or abduction. Treatment emphasizes activity modification, ITB stretching, gait correction, and targeted gluteal strengthening.

Pain Syndromes Localized to the Region of the Gluteus Musculature

The region of the gluteal musculature includes pathologies deep to the muscle, such as intra-articular hip disorders that may present as buttock pain. Pain in this region can arise from posterior femoroacetabular impingement (FAI) or labral pathology, increased FAV, middle cluneal nerve compression, or vascular insufficiency (Table 4).78 Presentations often overlap with lumbar and sacroiliac sources, necessitating a careful history, targeted examination maneuvers, and, in some cases, advanced imaging such as MR arthrography.79

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Table 4

Pain syndromes in the region of the gluteus musculature.

Posterior FAI

Posterior FAI occurs when cam or pincer deformities of the femoral head-neck junction and acetabular rim cause abnormal contact during hip extension and external rotation. It may lead to posterior labral damage and cartilage injury. Conservative therapy includes activity modification and strengthening,80 with surgical arthroscopic correction considered for refractory cases.81–84

Posterior Labral Tears

Posterior acetabular labral tears typically result from repetitive hip extension, trauma, or posterior FAI.85 Symptoms include posterior hip pain with mechanical catching or locking. MR arthrography confirms the diagnosis.86 Management includes PT, injections, or arthroscopic labral repair or reconstruction.87,88

Increased FAV

Increased FAV syndrome is characterized by excessive inward twisting of the femoral neck relative to the femoral condyles.89 Persistence into adolescence/adulthood may produce in-toeing gait, hip instability, patellofemoral pain, or posterior buttock pain. FAV is associated with hip impingement, labral stress, and altered load transfer, particularly in athletes and dancers.90 Diagnosis relies on CT or MRI torsional assessment. Management includes PT and activity modification; derotational osteotomy is reserved for severe cases.91

Middle Cluneal Nerve

Middle cluneal nerve syndrome is an entrapment neuropathy of the S1 to S3 branches as they pass under or through the long posterior sacroiliac ligament.92 Patients present with medial buttock pain exacerbated by sitting or lumbar extension, often mimicking SIJD.93 Exam reveals localized tenderness and positive Tinel’s. Diagnosis is confirmed by an anesthetic block. Conservative management includes PT and postural correction; interventional options include injections, RFA, or surgical release.94,95

Gluteus Maximus Claudication

Gluteus maximus claudication syndrome results from vascular insufficiency of the gluteus maximus muscle, usually due to internal iliac artery disease,96 or more rarely due to gluteal artery stenosis.96 Patients report exertional buttock pain relieved by rest. Diagnosis requires vascular studies (Ankle Brachial Index, Doppler, and CTA). Management includes vascular risk factor control, supervised exercise,97 and revascularization in advanced cases.98

Pain Syndromes Related to Sciatic Nerve (Deep Gluteal Space)

The deep gluteal space is a common location for extraspinal causes of sciatic and pelvic nerve pain (Table 5).99,100 Entrapment syndromes in this region may mimic lumbar radiculopathy, often leading to misdiagnosis. Key structures include the piriformis, obturator internus, the gemelli-quadratus femoris complex, pudendal and obturator nerves, and the ischiofemoral space.101 Careful examination, advanced imaging, and selective nerve blocks are frequently necessary to establish the diagnosis.79

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Table 5

Pain syndromes related to the sciatic nerve (deep gluteal space).

Piriformis Syndrome

The compression of the sciatic nerve by the piriformis muscle produces buttock pain radiating into the leg, often worsened by sitting or hip flexion.102,103 The FAIR test (flexion, adduction, internal rotation) is commonly positive.104 Also utilized is the seated piriformis stretch test. This is performed with the patient seated upright with the affected leg crossed in figure 4 position with the ankle on the contralateral knee. Stretch is accentuated with trunk flexion, lifting up on the ankle and pressing down on the knee of the affected limb. MRI helps exclude other causes.105 Management includes PT, piriformis stretching, nerve blocks, botulinum toxin injection, and surgical decompression/release in refractory cases.106,107

Obturator Internus Syndrome

Overuse injury or pelvic floor dysfunction may cause pain related to the obturator internus muscle.108 Patients often report deep buttock or pelvic pain, occasionally with perineal symptoms. MRI may demonstrate muscle edema.109 Treatment involves pelvic floor PT, posture training, and targeted injections.110

Gemelli–Quadratus Complex Strain

Strain or hypertrophy of the gemelli111 or quadratus femoris muscles112 may cause sciatica-like pain. The sciatic nerve is closely related to the gemelli-quadratus femoris complex.113 Examination reveals pain with hip internal rotation and extension. MRI may show edema or strain. Therapy includes rest, PT, and pelvic stabilization, with ultrasound-guided injections considered if persistent.114

Pudendal Nerve Entrapment

Entrapment of the pudendal nerve, often in Alcock’s canal or between the sacrotuberous and sacrospinous ligaments, produces burning perineal pain worsened by sitting.115–117 Diagnosis is based on the Nantes criteria and confirmed with diagnostic blocks.118,119 Conservative therapy includes pelvic floor PT; interventional approaches include nerve blocks or botulinum toxin injection,120 with surgical decompression for refractory cases.121,122

Obturator Nerve Compression

Compression within the obturator canal results in medial thigh pain and weakness of hip adduction.123 It can mimic lumbar radiculopathy but is differentiated by EMG or imaging. Treatment includes PT, activity modification, and targeted nerve blocks; surgical neurolysis is reserved for refractory cases.124,125

Extraspinal Sciatic Nerve Compression

Extraspinal compression of the sciatic nerve may also result from fibrous bands, hypertrophic muscles, or vascular structures in the deep gluteal region. Symptoms mimic radiculopathy but with a negative straight leg raise. Diagnosis may require MR neurography.126 Management includes neural mobilization, injections, or decompression.127

Ischiofemoral Impingement

This syndrome involves narrowing between the ischium and lesser trochanter, compressing the quadratus femoris and increased ischial and femoral neck angles.128,129 Patients experience buttock or posterior thigh pain exacerbated by hip extension or long stride walking.130 MRI demonstrates narrowing of the ischiofemoral space and muscle edema. Conservative management includes activity modification and PT; injection into the ischiofemoral space or surgical decompression is considered if symptoms persist.131

Pain Syndromes Localized to the Ischial Tuberosity

The ischial tuberosity is the origin of the hamstring muscles and adductor magnus, as well as the attachment of the sacrotuberous ligament. Pathology in this region often presents with deep buttock pain exacerbated by sitting or hip flexion and may be misdiagnosed as lumbar radiculopathy, sciatic nerve compression, or SIJD (Table 6). Careful clinical examination, imaging, and in some cases, diagnostic injections are necessary to identify the pain generator.

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Table 6

Pain syndromes at the ischial tuberosity.

Sacrotuberous Ligament Strain/Pain

The sacrotuberous ligament stabilizes the SIJ and serves as an attachment site for several muscles. Injury or degeneration may produce localized buttock pain mimicking hamstring tendinopathy or SIJD.132,133 Tenderness is often elicited with palpation, and MRI can demonstrate ligamentous edema. Treatment includes stabilization exercises, prolotherapy, and, in rare cases, surgical management.134,135

Proximal Hamstrings Tendinopathy

Overuse injury, typically running, subacute strain, or prolonged sitting, can produce tendinopathy at the hamstrings origin.136 Symptoms include deep buttock pain worsened by hip flexion and tenderness at the ischial tuberosity. Symptoms may be confused with lumbar spine, SIJ, or posterior hip pathology. MRI findings often include tendon thickening and/or partial tearing. Management includes eccentric strengthening, shockwave therapy, or PRP injections, with surgical repair reserved for refractory cases.136–140

Hamstrings Tear

Sudden eccentric overload may cause partial or complete avulsion of the hamstring tendons or tearing of the substance of the proximal hamstrings tendons. Patients present with acute buttock pain, bruising, and weakness in knee flexion.141 MRI confirms tendon retraction.142 Partial tears may be treated conservatively, while complete avulsions or full-thickness tendon tears often require surgical reattachment.143–145

Adductor Magnus Tendinopathy/Avulsion

This syndrome may mimic hamstring injury, presenting with posteromedial thigh or deep buttock pain. It commonly arises from sports-related overuse or acute strain.146,147 MRI confirms the diagnosis. Management parallels hamstring tendinopathy, focusing on eccentric strengthening and therapeutic injections, with surgery reserved for refractory cases.147,148

Ischial Bursitis

Ischial bursitis, often caused by prolonged sitting or trauma, produces focal pain at the ischial tuberosity that worsens with sitting on hard surfaces. Ultrasonography or MRI results may show bursal fluid.149 Management includes cushions, NSAIDs, physical therapy, and corticosteroid injection; bursectomy is rarely required.150

Conclusion

This review emphasizes that posterior buttock pain represents a spectrum of regional musculoskeletal syndromes. While the SIJ is commonly suspected as a cause of posterior buttock and pelvic pain, the differential diagnosis includes a large number of musculoskeletal conditions. A regionalized diagnostic framework categorizing conditions by anatomic location supports more precise evaluation and may reduce misdiagnosis and misdirected treatment. Understanding the osseous, ligamentous, and muscular anatomy and the accompanying neural innervation is essential. The spine, SIJs, and hips are an anatomic, physiological, and functional system. Multimodal management strategies tailored to the focal pain generator may improve patient outcomes.

Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests Dr. Reckling discloses that he is an employee of SI-BONE, Inc. As an employee of SI-BONE, he receives salary and stock in SI-BONE, Inc. Dr. Polly is a consultant to SI Bone, Medtronic, and Globus. He receives royalties from SI Bone and Springer. He is an investor in See All AI. His institution has received research support from SI Bone, Medtronic, Mizuho OSI, and AO Spine.

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International Journal of Spine Surgery

Vol. 19, Issue 5

1 Oct 2025

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    Differential Diagnosis of Posterior Buttock Pain: A Conceptual Review Based on Topographic Localization of Pain, Is It Really the Sacroiliac Joint?
    • International Journal of Spine Surgery
    • Nov 2025,
    • 8821;
    • DOI: 10.14444/8821
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Keywords

sacroiliac joint, SI joint dysfunction, pain, pain management