Deep Gluteal Syndrome (DGS), often referred to as Piriformis Syndrome, is a condition where the sciatic nerve is compressed or irritated by structures within the deep gluteal space, most commonly the piriformis muscle. This condition leads to pain, numbness, or tingling that spreads from the buttocks down the leg, similar to sciatica.
Though it’s not as common as lumbar disc herniation, Deep Gluteal Syndrome is an underdiagnosed condition that can significantly impact daily activities, especially in people who sit for long periods or engage in repetitive lower body movements.
What Is Deep Gluteal Syndrome (Piriformis Syndrome)?
Deep Gluteal Syndrome is a non-discogenic condition caused by sciatic nerve entrapment in the gluteal region. The most well-known form of this condition is Piriformis Syndrome, where the sciatic nerve is compressed by the piriformis muscle, a small muscle located deep in the buttocks near the hip joint.
While Deep Gluteal Syndrome includes more than just piriformis involvement, the two terms are often used interchangeably due to the overlap in symptoms and management. The primary sites of nerve entrapment include the piriformis muscle (most frequent at 67.8%), the sciatic foramen (6%), and the ischial tunnel (4.7%). Rather than a single disorder, DGS encompasses a group of conditions with shared and often overlapping symptoms, making diagnosis and treatment dependent on identifying the specific source of nerve irritation.
Causes of Deep Gluteal Syndrome
Muscle Tightness or Hypertrophy
- The sciatic nerve can be compressed by overuse or tightness of the piriformis, obturator internus, or other deep hip rotators.
- Common in runners, cyclists, and individuals who sit for long periods.
Trauma or Injury
- A fall on the buttocks, pelvic fractures, or direct trauma can lead to scar tissue and inflammation that irritates the sciatic nerve.
Repetitive Movements
- Activities that involve repetitive hip rotation or flexion-extension, such as climbing stairs or prolonged walking, can irritate the deep gluteal muscles and nearby nerves.
Anatomical Variations
- In some people, the sciatic nerve may pass through the piriformis muscle rather than beneath it, increasing the risk of compression
Symptoms of Deep Gluteal Syndrome
The key indicator is discomfort or numbness felt in the buttock, hip, or back of the thigh, often extending along the sciatic nerve pathway.
- Deep, dull ache in the buttocks
- Tingling sensation or numbness down the back of the leg.
- Pain that worsens with prolonged sitting
- Pain when rising from a seated position
- Tenderness over the piriformis muscle
- Difficulty walking or running
Unlike true sciatica from a lumbar disc problem, Deep Gluteal Syndrome often does not cause lower back pain.
Diagnosis
Diagnosis is usually clinical, supported by:
- Patient history
- Physical examination (e.g., FAIR test – Flexion, Adduction, Internal Rotation)
- Imaging (MRI or ultrasound) may help rule out lumbar spine issues or show muscle hypertrophy.
- Nerve conduction studies can help differentiate DGS from spinal causes.
Physical Examination Tests for Deep Gluteal Syndrome
Several provocative tests are used to provoke symptoms and assess sciatic nerve entrapment in the deep gluteal space. These help differentiate Deep Gluteal Syndrome from other causes of posterior hip or leg pain.
FAIR Test (Flexion, Adduction, Internal Rotation)
How to Perform:
- The patient lies on the non-painful side.
- The affected hip is flexed to 60–90°, adducted, and internally rotated.
- The clinician stabilizes the pelvis while applying pressure at the knee.
Purpose:
Compresses the sciatic nerve between the piriformis and surrounding structures.
- Sensitivity: 88%
- Specificity: 83%
Positive Test: Pain or tingling in the buttocks or down the leg.
Pace Sign
How to Perform:
- Patient is seated with hips flexed at 90°.
- The examiner asks the patient to abduct and externally rotate both hips against resistance.
Purpose:
Activates the piriformis muscle, which potentially can irritate the sciatic nerve.
- Sensitivity: ~63%
- Specificity: Not well-documented
Positive Test: A positive test result occurs when pain or weakness is experienced during resisted abduction and external rotation.
Freiberg’s Test
How to Perform:
- • Patient lies supine.
- • Examiner passively internally rotates the extended hip.
Purpose:
Stretches and stresses the piriformis against the sciatic nerve.
- • Sensitivity: ~76%
- • Specificity: ~80%
Positive Test: Reproduction of pain or sciatica-like symptoms.
Beatty’s Test
How to Perform:
- The patient lies on the non-painful side.
- The affected leg is flexed at the hip and knee; the patient is asked to lift the knee off the table (abduct).
Purpose:
Contraction of the piriformis may compress the sciatic nerve.
Positive Test: The test is positive when there is Pain in the buttock during active hip abduction.
Seated Piriformis Stretch Test
How to Perform:
- The patient sits on a flat surface with feet flat.
- Examiner passively brings the affected leg into flexion, adduction, and internal rotation.
Positive Test: Reproduction of buttock or sciatic pain.
Palpation of the Sciatic Notch
How to Perform:
- The examiner applies pressure deep into the gluteal region at the sciatic notch.
- Positive Test: Localized tenderness over the piriformis or sciatic nerve path.
- Often combined with other tests for higher diagnostic value.
Rehabilitation and Treatment
Treatment includes:
1) conservative management: Rest and Activity Modification.
2) Stretching and Mobility Exercises.
3) Strengthening Exercises
Stretching and Mobility Exercises for Deep Gluteal Syndrome
Figure-4 Stretch
Single knee to opposite shoulder stretch
Strengthening Exercises for Deep Gluteal Syndrome
Strengthen gluteal and core muscles to reduce load on deep rotators.
1) Clamshells
Glute bridges
Single-leg Glute bridges
Side-lying hip abduction
splits squats
Prevention Tips
- Maintain good posture while sitting or standing.
- Incorporate regular stretching into your daily routine.
- Avoid prolonged sitting or static postures. Cross-train to avoid overuse injuries in athletes.
- Warm up before exercise and cool down afterward.
Final Thoughts
Deep Gluteal Syndrome, particularly Piriformis Syndrome, can be a painful and frustrating condition that mimics other forms of sciatic nerve pain. Fortunately, with proper diagnosis and a structured rehabilitation program focusing on stretching, strengthening, and soft tissue release, most people experience significant relief and can return to normal activities.
If you’re struggling with persistent buttock pain or sciatica that isn’t improving, consider visiting a physical therapist or healthcare provider to rule out Deep Gluteal Syndrome and begin a targeted recovery plan.
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