Pain In The Butt

By Rachel Levy PT, DPT, CIMT

“What a pain in the butt” has become synonymous with life’s little annoyances. But for anyone actually experiencing physical pain in the derriere, the symptom can be much more significant and disruptive. There are many conditions that can lead to pain in this area including sciatica, piriformis syndrome, coccyx injury, pudendal neuralgia, levator ani syndrome, and hemorrhoids. But you guessed it – all of these conditions can be helped with physical therapy.

Sciatica

Sciatica is probably the most talked about condition on this list. A review of Medicare recipients from 2007 – 2013 found 25% reported a history of sciatica (1) while other studies of the wider population estimate 5 out of every 1,000 people in Western countries experience sciatica (2). Sciatica is an irritation of the sciatic nerve, typically caused by degeneration or herniation of intervertebral discs in the lumbar spine. Typical symptoms of sciatica include pain in the back of the hip and leg running from the buttocks as far down as the foot, changes in sensation such as burning, numbness, or tingling in this same area, and weakness in the muscles of the leg. Physical therapists treat sciatica symptoms with manual therapy including dry needling, myofascial release, and joint mobilization and specific exercise instruction including stretching, nerve mobilization, postural retraining, and core stabilization exercises.

Piriformis Syndrome

The sciatic nerve can also be irritated further away from the spine as it travels down the leg. The piriformis muscle is part of a group of muscles known as the deep hip rotators and works to externally rotate and abduct the leg. The sciatic nerve typically lies under the piriformis muscle but cadaver studies show anywhere from 10-20% of the time the nerve actually pierces the muscle (3). This intimate arrangement means the piriformis muscle can also be a culprit in sciatic nerve irritation. Piriformis syndrome is characterized by buttock pain, pain aggravated by sitting, and pain aggravated by any position that puts stress on the piriformis muscle. (4) Physical therapists employ a variety of manual therapy and specific exercise techniques to reduce the myofascial restrictions of the piriformis muscle on the sciatic nerve and improve movement patterns to decrease the likelihood of symptom recurrence.

Coccyx Pain

The coccyx is more commonly known as the tailbone and pain in this area may be called coccydynia, coccygodynia, or simply tailbone pain. Coccydynia can be caused by trauma such as falling or after vaginal delivery and can cause significant difficulty sitting. Physical therapists can treat this condition by working on the muscles of the pelvic floor which attach to the coccyx, providing instruction in position and activity modifications, and targeted exercise to return you to a full level of activity.

Pudendal Neuralgia

Although not as well known as the sciatic nerve the pudendal nerve is also a big player in the pelvis and inflammation or entrapment of this nerve can lead to debilitating pain. The pudendal nerve carries sensory information to the genitals in both sexes and is involved in both penile and clitoral erection. Cycling is a known risk factor for pudendal neuralgia and other common mechanisms of injury to the pudendal nerve include chronic straining during bowel movements and vaginal labor/delivery. The pudendal nerve can also become entrapped as it travels through a narrow space between two ligaments in the pelvis. People with pudendal neuralgia can have significant difficulty tolerating sitting, wearing tight clothing, participating in a variety of activities, and may have decreased bowel and bladder control.  Some people with this condition will benefit from injections and some may require surgical decompression of the nerve. Physical therapists can identify and treat associated muscular pain and dysfunction in the pelvic floor, provide education in positional and activity modifications, and safely reintroduce increased exercise and activity.

Levator Ani Syndrome

The levator ani is a group of three muscles which collectively are considered the main component of the pelvic floor. A spasm in this muscle group causes pain in the rectum and perineum. A subtype of this condition called proctalgia fugax provokes sudden, brief pain likened to a heart attack in the rectum. Treatment to relax the muscles of the pelvic floor including manual therapy, stretching, and breathing exercises can be effective in relieving this pain.

Hemorrhoids

Hemorrhoids lead to roughly 4 million medical visits each year (5) and hemorrhoids can develop due to constipation and chronic straining during bowel movements. Pelvic floor physical therapists can assist in the management of constipation with education on toileting posture and other body mechanics for an optimal bowel movement as well as training the coordination of pelvic floor and abdominal muscles to reduce straining.

So what’s the bottom line? While we can’t clear up traffic or make your boss less annoying, highly trained physical therapists can address many of the causes of butt pain. Contact a pelvic floor PT near you to start identifying and treating the causes of your pain.

1. Maslak JP, Jenkins TJ, Weiner JA, Kannan AS, Patoli DM, McCarthy MH, Hsu WK, Patel AA. Burden of Sciatica on US Medicare Recipients. J Am Acad Orthop Surg. 2020 May 15;28(10):e433-e439. doi: 10.5435/JAAOS-D-19-00174. PMID: 31517882.
2. D.C. Cherkin, R.A. Deyo, J.D. Loeser, T. Bush, G. Waddell. An international comparison of back surgery rates. Spine, 19 (1994), pp. 1201-1206
3. Shacklock, Michael. Clinical Neurodynamics: A New System of Musculoskeletal Treatment. Elsevier Butterworth Heinemann, 2015.
4. Hopayian K, Danielyan A. Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. Eur J Orthop Surg Traumatol. 2018 Feb;28(2):155-164. doi: 10.1007/s00590-017-2031-8. Epub 2017 Aug 23. PMID: 28836092.
5. Sandler RS, Peery AF. Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol. 2019 Jan;17(1):8-15. doi: 10.1016/j.cgh.2018.03.020. Epub 2018 Mar 27. PMID: 29601902; PMCID: PMC7075634.