dr_saiz_blogpost_butt_painDuring my training (residency and fellowships), learning how to tell apart low back pain (LBP) from butt pain, hip pain, or sacroiliac (SI) pain is difficult. The spine/ pelvis junction is a complicated piece of anatomy that is responsible for transferring weight from the legs to back and vice versa. The stresses across this area can easily be 2-3 times greater than your body weight. However, with medicine becoming a specialty profession, hip specialists are different than back experts; the SI joint often gets ignored (very few Doc’s have a good understanding of the SI joint). Most healthcare providers will focus on the back or the hip depending on which part they are most familiar with, leaving some potential causes of butt pain overlooked!

The SI Joint

Historically, the SI joint was thought to be the major source of leg, back, and butt pain. Orthopedic textbooks in the 1950’s devoted more discussion to sacroiliac issues than to lumbar spine pain. As studies (X-rays, CT scans, MRI) has become more popular, the lumbar spine has become more of a culprit for low back and leg pain. Interestingly, during this period of better tests, spine surgery has become more common. As we become more familiar with areas that can cause low back or leg pain (lumbar discs, pinched nerves, hip joints, spine joints); the SI joint has become more popular as a source of pain. It has been estimated that 20-25% of chronic low back pain may be related to the SI joint and nearly 50% of failed back surgeries may be related to the SI joint as a pain generator.

“So how do I know if my butt pain is related to the back, hip, or SI joint?”

That’s where the hard part comes in. The buttock is a popular place for referred pain from the back, hips, or pelvis. Doctors need to really listen to the patient and try to figure out what activities make pain worse and which activities help decrease the pain.

“Does getting out of the of a car cause butt pain? Which side hurts more, passenger or driver?”

“Is getting in and out of a chair painful? When you walk does the pain start right away or take time to develop?”

“Does your butt pain get worse when using stairs? Do you prefer to sleep on one side versus the other because of pain?”

Identifying the Cause

The problem for Doc’s is many of these so called painful activities can irritate all 3 areas(back, hip or SI joint). The doctor has to spend extra time trying to figure out which of these areas is the most painful. Can a patient have more than 1 area irritated…yes!!!! This is where the physical exam comes in handy; it helps to identify which body part is most painful. In addition, studies (X-ray, MRI, CT scans) can be helpful in finding the painful body part.

Conservative treatment for these problems includes physical therapy, stabilization belts, anti-inflammatories, and injections. Usually, these treatments help control the pain. The big problem is when pain and limitations persist despite using all conservative measures. Surgery is typically described after all non-operative treatments have failed and the surgeon feels comfortable that a surgery will help. Remember not all problems can be fixed with surgery!!!

If surgery is agreed upon, thankfully surgeons have more options than ever before. New technology has arrived which allows a minimally invasive technique to fuse (immobilize) the SI joint, smaller incision for Hip surgery as well as back surgeries to un-pinch nerves or stabilize moving parts. Many of these surgeries allow for a quicker recovery (same day or overnight).

As a surgeon evaluating low back and leg pain, trying to figure out which area can be difficult. As a patient, paying attention to your body and which activities bother you and what positions help the pain can be very helpful for your doctor. Thankfully, most patients get better with time, physical therapy, and occasionally injections.

Paul Saiz, MD

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