“Pain in the BUTT!”: Part 1- Differential Diagnosis of Posterior Thigh & Buttock Pain 

Hamstring strains are notoriously prone to recurrence (Sherry, 2004) and it is not uncommon to work with patients in a physical therapy setting who have had multiple injuries to the same leg or experience chronic “tightness” or pain in their hamstrings. 

What if some of these more persisting hamstring symptoms are not coming from the muscle or tendon itself, but are due to an underlying nerve irritation or sensitivity?

“What if some of the persistent hamstring symptoms that we see in our patients is actually due to a nerve issue?”-Leda McDaniel, PT, DPT, OCS

Understanding the possible causes of posterior thigh pain (and related buttock pain) and the regional anatomy involved can help to optimize treatment success and aid in selection of best examination tests. The purpose of this post is to explore some of the possible “pain generators” at the back of the thigh and buttocks and to improve understanding for treatment techniques to reduce chronic or recurrent symptoms (including those from hamstring muscle/tendon and sciatic nerve issues). 


DIFFERENTIAL DIAGNOSIS of Posterior Thigh & Buttock Pain:


2-IDENTIFY “TISSUE OF ISSUE” (hamstring muscle, tendon, sciatic nerve)

Differential diagnosis of the cause of posterior thigh pain is not always that straightforward. Pain could be from musculoskeletal pathologies such as hamstring strain injury, high hamstring tendinopathy, sciatic nerve pathology, or pain referral from nearby joints (lumbar spine, SI joints, hip joints). Screening out “red flag” pathologies, or those that are not appropriate for physical therapy or conservative care, should be the first step in differential diagnosis. This is often done via a patient’s report of symptom behavior and onset and suspicion is increased if symptoms are not “reproducible” with physical exam testing.    

Once symptoms have been determined to be neuromuscular in origin, not emergency conditions, and likely mechanical in nature (i.e., increased or decreased by specific movements, positions, or tissue loading), the next step often is to screen nearby joints (screen joints “above and below”). See below for joint screening tests related to posterior thigh pain:  

IDENTIFY “TISSUE OF ISSUE” (hamstring muscles or tendons, sciatic nerve)

Once, screening tests have been performed (see chart above); the next step is to try to discover if symptoms at the back of the leg are coming from the hamstring muscle/tendon or from sciatic nerve components. The terminology definitions below will help to guide the next section’s discussion of these differential diagnoses. 

Decision Tree for Differential Diagnosis of Post Thigh Pain; SapiensMoves, 2021


“Sciatica”: non-specific sciatic nerve irritation­­

“Piriformis Syndrome”: first used by Robinson in 1947 to describe “non-discogenic” sciatica (Robinson, 1947)

“Deep Gluteal Syndrome”(Park, 2020) has been defined as “compression of sciatic or pudendal nerve due to non-discogenic pelvic lesions,” (Park, 2020) umbrella term that includes: “piriformis syndrome,” “gemelli-obturator internus syndrome,” “ischiofemoral impingement syndrome,” and “hamstring syndrome,” could cause post buttock pain or perineal/genital pain

“Hamstring Syndrome”(Current Concepts, Martin, 2018; Martin, 2016)

Sciatic nerve irritation as it passes lateral to the ischial tuberosity and under the fascia from the biceps femoris (hamstring muscle/tendon) attachment at the ischial tuberosity. This could be present in up to approximately 1/3 of patients with history of proximal hamstring avulsion injury (Park, 2020).  

“Ischiofemoral Impingement”: As the sciatic nerve runs distal to the piriformis, it passes behind (posterior to) the quadratus femoris muscle and between landmarks on the ischium (ischial tuberosity specifically) and femur (greater trochanter specifically). As the sciatic nerve passes lateral to the ischial tuberosity and medial to the lesser trochanter, if this space is reduced, impingement can occur causing symptoms/irritation at the sciatic nerve. Additionally, forces in this area could cause injury to the quadratus femoris muscle or hamstring tendons (Park, 2020)

Post Pelvis/Thigh Anatomy, Figure Above from Park, 2020

As part of the clinical exam to differentiate between causes of pathology at the posterior thigh, subjective questioning and objective testing can provide clues for which tissue may be most at fault. See table below for a breakdown of these sources of information and possible exam findings for hamstring vs. sciatic nerve related pathology. 

As with most neuromuscular diagnoses, the best “Special Test” for hamstring muscle/tendon pathology and sciatic nerve irritation will be to utilize a “Cluster” of signs and symptoms for justification based on information gleaned from a comprehensive Subjective and Objective Examination process as described above!

Good luck in your differential diagnosis process for posterior thigh and buttock pain and for treatment ideas please check out : Pain in the BUTT!: Part 2- Treatment Strategies for Posterior Thigh & Buttock Pain

References: Part 1

  • Cyriax J. Textbook of orthopaedic medicine, diagnosis of soft tissue lesions, vol 1, 8th edition. London: Baillière Tindall; 1982.
  • Current Concepts of Orthopaedic Physical Therapy 4th Ed.Orthopaedic Section, APTA, Inc.; 2016.
  • Maitland G; Hengeveld E, Banks K, eds. Maitland’s Vertebral Manipulation: Management of Neuromusculoskeletal Disorders—Volume 1. 8th ed. London, United Kingdom: Churchill Livingstone; 2013. 
  • Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy. 2005;10(3):207-218. 
  • Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy. 2003;49(2):89-97. 
  • Martin HD, Khoury A, Schröder R, Palmer IJ. Ischiofemoral Impingement and Hamstring Syndrome as Causes of Posterior Hip Pain. Clinics in Sports Medicine. 2016;35(3):469-486.
  • Martin RL, Schröder RG, Gomez-Hoyos J, et al. Accuracy of 3 Clinical Tests to Diagnose Proximal Hamstrings Tears With and Without Sciatic Nerve Involvement in Patients With Posterior Hip Pain. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2018;34(1):114-121.
  • Park JW, Lee YK, Lee YJ, Shin S, Kang Y, Koo KH. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. Bone Joint J. 2020 May;102-B(5):556-567.
  • Robinson DR. Pyriformis syndrome in relation to sciatic pain. The American Journal of Surgery. 1947;73(3):355-358
  • Sherry MA, Best TM. A Comparison of 2 Rehabilitation Programs in the Treatment of Acute Hamstring Strains. RESEARCH REPORT. 2004;34(3):10.
  • Telli H, Telli S, Topal M. The Validity and Reliability of Provocation Tests in the Diagnosis of Sacroiliac Joint Dysfunction. Pain Physician. 2018 Jul;21(4):E367-E376.
  • van der Wurff P, Buijs EJ, Groen GJ. A Multitest Regimen of Pain Provocation Tests as an Aid to Reduce Unnecessary Minimally Invasive Sacroiliac Joint Procedures. Archives of Physical Medicine and Rehabilitation. 2006;87(1):10-14.

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