12/30/2025
๐๐ฒBetween Christmas and the beginning of the new year, we traditionally publish our โBest ofโ series featuring the most influential posts of the year that is coming to an end.
๐ฃ Today ๐ฅ # rank 9 in 2025
๐๐ฒ๐๐ผ๐ป๐ฑ ๐ก๐ฒ๐ฟ๐๐ฒ ๐๐ป๐๐ฟ๐ฎ๐ฝ๐บ๐ฒ๐ป๐: ๐ ๐ก๐ฎ๐ฟ๐ฟ๐ฎ๐๐ถ๐๐ฒ ๐ฅ๐ฒ๐๐ถ๐ฒ๐ ๐ผ๐ณ ๐ ๐๐๐ฐ๐น๐ฒโ๐ง๐ฒ๐ป๐ฑ๐ผ๐ป ๐ฃ๐ฎ๐๐ต๐ผ๐น๐ผ๐ด๐ถ๐ฒ๐ ๐ถ๐ป ๐๐ฒ๐ฒ๐ฝ ๐๐น๐๐๐ฒ๐ฎ๐น ๐ฆ๐๐ป๐ฑ๐ฟ๐ผ๐บ๐ฒ
โถ๏ธ Sciatica-like pain is frequently attributed to lumbar disc herniation or spinal stenosis, but in many patients, symptoms persist despite treatment of spinal causes, suggesting extraspinal etiologies (Guedes et al., 2020). Deep Gluteal Syndrome (DGS), first described by McCrory and Bell (1999) as sciatic nerve entrapment, has emerged as a significant source of nondiscogenic buttock and leg pain.
โถ๏ธ Prevalence estimates suggest that up to 17% of patients presenting with sciatica may have DGS (Kizaki et al., 2020). Traditionally viewed as a nerve entrapment disorder, more recent evidence highlights the contribution of muscular and tendinous pathologiesโparticularly enthesopathies of the deep external rotators and hamstring originโas primary pain generators (Martin et al., 2015; De Lorenzis et al., 2023).
โถ๏ธ This evolving perspective necessitates a redefinition of DGS that integrates muscleโtendon pathology with neural mechanisms.
๐ In a brand-new narrative review Yoon et al. (2025, https://www.mdpi.com/2075-4418/15/19/2531 -diagnostics-15-02531) expand the conceptual framework of Deep Gluteal Syndrome beyond sciatic nerve entrapment, emphasizing muscle- and tendon-related pathologies as central contributors.
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Pathogenesis: In addition to sciatic nerve compression, pathologies such as ischiofemoral impingement, proximal hamstring tendinopathy, and enthesopathy of the deep external rotators can directly generate pain or secondarily irritate neural structures.
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Diagnosis: Clinical differentiation from lumbar radiculopathy is critical. Provocative maneuvers (FAIR, piriformis stretch, Paceโs test) and imaging (high-resolution MRI, MR neurography, dynamic ultrasonography) aid in distinguishing nerve-dominant from tendon-dominant subtypes. This differentiation might be a crucial factor in clinical reasoning.
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Treatment: A stepwise strategy is recommendedโbeginning with conservative care (load management, progressive tendon loading exercises , neural mobilization/desensitization), depending on tendon involvement or neural mechano-hypersensitive with refractory cases reserved for surgery. But, current evidence largely comprises case series and expert opinion underscoring the need for randomized controlled trials.
๐ก Conclusion:
DGS should be reframed as a heterogeneous syndrome involving both neural entrapment and muscleโtendon pathology. Recognition of tendon-dominant and mixed subtypes allows for more precise diagnosis and tailored treatment strategies. Future work must focus on validating classification systems and establishing high-level evidence for emerging therapies.
๐ท Illustration: Anatomy of the subgluteal space according to Koh (2021) https://pubmed.ncbi.nlm.nih.gov/33827758/
Diagram of the deep muscles of the subgluteal space, with the gluteus maximus muscle removed.
The sciatic nerve (1) typically emerges from beneath piriformis muscle (P), passing over the obturator internusegemellus tendon and muscle complex, quadratus femoris (QF) muscle and lateral to the hamstring origin (H).
Note that the gemellus muscles lie superior (SG) and inferior (IG) to the obturator internus tendon within the subgluteal space; the obturator internus muscle belly lies deep to the subgluteal space within the pelvis (not drawn).
Medial to the sciatic nerve lies the PCNT (2). The inferior gluteal nerve (3) and pudendal nerve (4) emerge from below piriformis further medially within the subgluteal space.
The superior gluteal nerve (5) is seen superiorly within the subgluteal space, passing superior to the piriformis muscle and adjacent to the SI joint.
๐ References
Battaglia, P.J., Mattox, R., Haun, D.W., Welk, A.B., & Kettner, N.W. (2016). Dynamic ultrasonography of the deep external rotator musculature of the hip: A descriptive study. PM&R, 8(7), 640โ650. https://doi.org/10.1016/j.pmrj.2015.11.001
De Lorenzis, E., Natalello, G., Simon, D., Schett, G., & DโAgostino, M.A. (2023). Concepts of entheseal pain. Arthritis & Rheumatology, 75(3), 493โ498. https://doi.org/10.1002/art.42299
Guedes, F., Brown, R.S., Lourenรงo Torrรฃo-Jรบnior, F.J., Siquara-de-Sousa, A.C., & Pires Amorim, R.M. (2020). Nondiscogenic sciatica: What clinical examination and imaging can tell us? World Neurosurgery, 134, e1053โe1061. https://doi.org/10.1016/j.wneu.2019.11.083
Hauser, R.A., Lackner, J.B., Steilen-Matias, D., & Harris, D.K. (2016). A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, 9, 139โ159. https://doi.org/10.4137/CMAMD.S39160
Hernando, M.F., Cerezal, L., Pรฉrez-Carro, L., Abascal, F., & Canga, A. (2015). Deep gluteal syndrome: Anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal Radiology, 44(7), 919โ934. https://doi.org/10.1007/s00256-015-2112-6
Kizaki, K., Uchida, S., Shanmugaraj, A., Aquino, C.C., Duong, A., Simunovic, N., Martin, H.D., & Ayeni, O.R. (2020). Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: A systematic review. Knee Surgery, Sports Traumatology, Arthroscopy, 28(10), 3354โ3364. https://doi.org/10.1007/s00167-020-05966-x
Martin, H.D., Reddy, M., & Gรณmez-Hoyos, J. (2015). Deep gluteal syndrome. Journal of Hip Preservation Surgery, 2(2), 99โ107. https://doi.org/10.1093/jhps/hnv029
McCrory, P., & Bell, S. (1999). Nerve entrapment syndromes as a cause of pain in the hip, groin and buttock. Sports Medicine, 27(4), 261โ274. https://doi.org/10.2165/00007256-199927040-00005
Yen, Y.S., Lin, C.H., Chiang, C.H., & Wu, C.Y. (2024). Ultrasound-guided sciatic nerve hydrodissection can improve the clinical outcomes of patients with deep gluteal syndrome: A case-series study. Diagnostics, 14(4), 757. https://doi.org/10.3390/diagnostics14040757
Yoon, Y.H., Hwang, J.H., Lee, H.W., Lee, M., Park, C., Lee, J., Kim, S., Lee, J., de Castro, J.C., Lam, K.H.S., et al. (2025). Beyond nerve entrapment: A narrative review of muscleโtendon pathologies in deep gluteal syndrome. Diagnostics, 15(19), 2531. https://doi.org/10.3390/diagnostics15192531
