Gluteal pain is a frequent symptom in athletes. Its etiological definition can be a challenge for the pain specialist[1]Gonzalez-Lomas G. Deep gluteal pain in orthopaedics: a challenging diagnosis. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2021 Dec 15;29(24):e1282-90..
The gluteus medius is a highly functional muscle that helps with hip movement.
The gluteus medius is the muscle with a pattern of pain in the back of the seat and lower back – it can occasionally cause symptoms in the back of the thigh. This can occur if it becomes overactive, tense, and dysfunctional[2]Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British journal of sports medicine. 2013 Mar 1;47(4):207-14..
Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading
Self massage, stretching, exercise and any examination / treatment by a musculoskeletal specialist (chiropractor, physical therapist, manual therapist) are examples of measures that can help you get rid of myalgia[3]Yap EC. Myofascial pain-an overview. Annals-Academy of Medicine Singapore. 2007 Jan 1;36(1):43..
Main glutes muscles
The glutes are divided into three muscles:
- Gluteus maximus: is the largest, most superficial and has primary function in hip extension and is also an important lateral rotator.
- Gluteus medius: important abductor with 60% of the total transverse cutting area of the abductors, its anterior fibers perform medial rotation and the posterior fibers lateral rotation.
- Gluteus minimus: it is the deepest, all fibers perform abduction and the anterior fibers medial rotation and flexion.
These muscles have great importance in stabilizing the hip, knee and lumbar.
Gluteus Minimus Trigger Points
The gluteus minimus muscle can cause sciatica-like symptoms either down the back or the side of the leg. Clients with active gluteus minimus trigger points typically complain of:
- Pain in the buttock, hip, posterior, and/or lateral thigh and calf
- Hip pain while walking, leading to a limp
- Pain while rising from a chair
- Constant and excruciating pain, unaffected by positioning, similar to that of a disc herniation
Activating factors for gluteus minimus trigger points include limping due to lower leg or foot injury, walking or running on uneven ground, intramuscular injections, prolonged immobility such as driving long distances, true SI joint dysfunction, and sitting on a wallet.
Gluteus Medius Trigger Points
The gluteus medius muscle, positioned in the hip region, can cause pain across the iliac crest and gluteal fold. Common complaints associated with gluteus medius trigger points include:
- Low back pain in the sacral, gluteal, and SI joint areas
- Pain associated with walking
- Difficulty sleeping on the affected side
Activating factors for these trigger points include running, sudden falls or sports injuries, standing on one foot for extended periods, walking or running in sand, true SI joint dysfunction, intramuscular injection, and sitting on a wallet.
Gluteus Maximus Trigger Points
The gluteus maximus muscle, the largest muscle in the buttocks, primarily causes pain in the gluteal region, sacrum, and sometimes during swimming. Common complaints related to gluteus maximus trigger points include:
- Pain and tenderness in the gluteal region, especially while sitting
- Aching pain while walking uphill and/or in a bent forward position
- Cramping during swimming
Activating factors for these trigger points include swimming, falls or near falls, impact trauma, prolonged uphill walking while leaning forward, intramuscular injections, sitting on a thick wallet, and true SI joint dysfunction.
Piriformis Trigger Points
The piriformis muscle can cause pain in two ways: first, by the referred pain to the sacroiliac joint and/or hip, and second, by a condition known as piriformis syndrome.
This syndrome occurs when a tense piriformis muscle compresses the sciatic nerve as it exits the pelvis, causing sciatica symptoms such as radiating pain, numbness, and tingling traveling down the leg to the foot.
Factors that may activate or perpetuate piriformis trigger points include true sacroiliac dysfunction, sudden foot slip, twisting sideways while bending and lifting, running, sexual positioning, impact trauma, car accidents, chronic pelvic inflammatory disease, and hip replacement surgery.
Muscle Overuse or Strains
Engaging in repetitive or prolonged activities that involve the gluteal muscles, such as running, cycling, or sitting for extended periods, can lead to muscle overuse and strain. This can result in the development of trigger points in the gluteal muscles.
Imbalances between the gluteal muscles and other muscles in the surrounding area can contribute to the formation of trigger points. Weakness or tightness in certain muscles, such as the gluteus maximus or piriformis, can cause compensatory tightening or weakness in other muscles, leading to trigger point development.
Weakness of the gluteal region
The weakness of the gluteal region is one of the main reasons for poor posture. The set of abdominal and gluteal muscles together are responsible for stabilizing and supporting the hip.
The retroverted hip (buttocks inwards) can cause compression of the vertebral discs (herniated discs), overload the lumbar region, cause kyphosis in the thoracic region and project the head in front of the body (displacement of the cervical discs).
Maintaining poor posture, such as slouching or sitting with uneven weight distribution, can place excessive stress on the gluteal muscles. Over time, this can lead to the development of trigger points.
What are trigger points?
Trigger points are hypersensitive pain points located in the muscles and connective tissue. They are palpable nodules, where pain occurs by digital pressure, or spontaneously.
Trigger points can be produced by trauma, the result of chronic stretching, tension caused by daily activities, bad postural habits, incorrect movement pattern, ischemia, inflammation, functional overload, emotional stress, endocrine dysfunction, nutritional deficiencies and chronic infections[4]Jafri MS. Mechanisms of myofascial pain. International scholarly research notices. 2014;2014..
These points accumulate toxins and impair the proper functioning of the musculoskeletal system, altering coordination, flexibility and muscle strength, facilitating the appearance of injuries, thus hindering the performance of physical training and well-being in general.
What are active or latent trigger points?
Trigger points can be active or latent. When active, they cause exaggerated pain to the movement, limitation in its realization, since they hinder the muscle to stretch and contract and may also cause pain in another region of the body (referred pain).
The latent points can be discovered only through palpation, originating a localized pain.
Trigger points in specific gluteal muscles, like the gluteus maximus and medius, refer pain locally to the gluteal and sacral regions. Conversely, those in the gluteus minimus can refer pain down the lower extremity as far as the ankle (Simons & Travell, 1983).
What is referred pain?
The referred pain follows a pattern of localization. For example, a trigger point found in the trapezius muscle may be the cause of tension headache (headache related to muscle tension and the presence of trigger points).
This phenomenon can confuse diagnosis and treatment because the painful region is distant from the site that is causing the pain.
What happens if gluteus maximus and medius are weak?
When gluteus muscles are weak, overcompensation of the back muscles can happen, adding stress, tension and pressure in the lower back.
It’s easy to know when certain muscles, like those in your arms, aren’t strong: you can’t pick up a heavy box in the attic or lift your suitcase in the overhead compartment of an airplane, for example. But, it’s a little less clear how to tell when your glutes are weak. However, the signs are there. You just need to know what to look for.
And, although your glutes (technically three muscles: gluteus maximus, gluteus medius, and gluteus minimus) make up your buttocks, the signs of weakness don’t have much to do with a back. Instead, you may actually feel pain in certain other areas.
Causes of weakness in the gluteus muscles
Too much time sitting
Anyone who sits for more than four hours a day and doesn’t include glute-focused exercises in their workouts every week is likely to weaken their glutes.
Also, as you’ve probably heard before, this means you should get up and take a break every 30 minutes – even if it’s just to go to the bathroom or fill your water bottle.
Injury or Trauma
Direct trauma or injury to the gluteal muscles, such as a fall or impact, can result in the formation of trigger points. Injured muscle fibers may become shortened or contracted, leading to the development of trigger points.
Myofascial Pain
Myofascial pain syndrome is a condition characterized by the presence of trigger points in muscles and the surrounding connective tissue. Gluteal trigger points can be a part of this syndrome and may develop due to various factors mentioned above.
Gluteal syndrome, characterized by trigger points in the gluteal muscles, can arise from central sensitization, where the nervous system becomes overactive. This condition is often regulated by dysregulated immune and autonomic nervous systems (Skorupska & Dybek, 2021).
Possible treatments
Stretches
In this section, we’ll explore three simple glute stretches you can perform at home, in the office, or even seated in a chair. These stretches target the hip and glute muscles to release tightness and reduce tension in your lower back.
1. Figure Four Stretch:
The Figure Four stretch is a classic stretch for the glutes that can be done lying on your back. To perform this stretch:
- Lie on your back with knees bent and feet flat on the floor.
- Cross one ankle over the opposite knee.
- Reach through the opening created by your legs and grab your thigh.
- Gently pull your thigh towards your chest, feeling a deep stretch in the glute muscles.
- Hold for 20 seconds, then switch sides.
If you find it difficult to reach your thigh, you can use a strap, belt, or rope to assist in pulling your leg closer to your chest. Ensure that your head remains on the ground throughout the stretch to avoid straining your neck.
2. Pigeon Pose Stretch:
The Pigeon Pose is a more advanced stretch borrowed from yoga that targets the glutes and hip rotators. To perform this stretch:
- Start on your hands and knees.
- Bring one leg forward, bending the knee and placing it on the ground in front of you.
- Extend your other leg behind you, with your toes pointing backward.
- Sit down into your hips, feeling a deep stretch in the glute muscles of the bent leg.
- Maintain an upright posture and hold the stretch for 20 seconds.
- Switch sides and repeat.
Be cautious when performing this stretch if you experience knee discomfort. If you feel any pain or strain in your knee, try one of the other stretches instead.
3. Seated Chair Stretch:
The Seated Chair Stretch can be performed while sitting at your desk or in any chair. To perform this stretch:
- Sit in a chair with a tall posture and a natural curve in your lower back.
- Cross one ankle over the opposite knee.
- Hinge forward at your hips, keeping your back straight.
- Apply gentle downward pressure to the raised knee to enhance the stretch.
- Hold for 20 seconds, then switch sides.
Performing these three glute stretches regularly can help to release tightness in your hips and alleviate tension in your lower back. Remember to maintain proper form and breathe deeply throughout each stretch. By incorporating these stretches into your routine, you can experience relief from hip and back discomfort and improve your overall flexibility and mobility.
Hot pack
Hot compresses to increase blood circulation and promote a sense of relaxation. Temporarily reduces pain, but does not deactivate the trigger point.
Ultrasound
As a heating modality, ultrasound transmits vibrating energy up to about 2 inches, generating heat in the tissues. The exact mechanism on how ultrasound can be beneficial in treating myofascial trigger points.
Myofascial Release
One of the oldest soft tissue treatment methods in history. It seeks muscle relaxation consequently pain relief.
It consists of a pumping maneuver, a successive pulling-relaxing of a body segment, capable of reaching all the fascial structures contained therein, even the deepest.
The treatment is performed in three times: tension, maintenance of tension and return to the initial position. Such sequence enables muscle relaxation, improved circulation and joint regeneration.
Needle stimulation (Dry needling)
The technique of stimulation of trigger points with needles. It consists of the insertion and repeated manipulation of a thin, flexible needle (usually an acupuncture needle) in a trigger point to produce a local spasm response, in order to inactivate it.
Needle stimulation requires maximum precision and a greater number of repetitions.
The mechanism of producing muscle relaxation and pain relief in needle stimulation causes disruption of tissue nodularity.
The advantage of needle stimulation over other techniques is that we achieve a painless full range of motion at the time of treatment (immediate response).
Conclusion
Understanding the various trigger points and their associated clinical findings is vital in accurately diagnosing and treating gluteal pain. By recognizing the specific muscle involvement, healthcare providers can tailor treatment plans to address the root cause of pain effectively.
Awareness of the activating factors for these trigger points can also help patients make lifestyle adjustments to minimize the risk of gluteal pain recurrence. With the right approach, patients can experience relief from pain and improved quality of life.
MD, PhD. Physical Medicine & Rehabilitation Physician from São Paulo - Brazil. Pain Fellowship in University of São Paulo.
References
| ↑1 | Gonzalez-Lomas G. Deep gluteal pain in orthopaedics: a challenging diagnosis. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2021 Dec 15;29(24):e1282-90. |
|---|---|
| ↑2 | Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British journal of sports medicine. 2013 Mar 1;47(4):207-14. |
| ↑3 | Yap EC. Myofascial pain-an overview. Annals-Academy of Medicine Singapore. 2007 Jan 1;36(1):43. |
| ↑4 | Jafri MS. Mechanisms of myofascial pain. International scholarly research notices. 2014;2014. |