Deep Gluteal Syndrome: When Trauma to Your Buttock Mimics Spine Problems

In my last post, I shared a case where “piriformis syndrome” turned out to be a massive disc herniation. Just weeks later, I encountered the opposite scenario—this time, the problem really was in the gluteal region, not the spine.

The medical community is moving away from the term “piriformis syndrome” toward “deep gluteal syndrome”—a more descriptive term for pain emanating from the muscles and structures outside the spine in the gluteal region. The piriformis is just one potential culprit; the gluteal muscles themselves and surrounding structures can all contribute to sciatic nerve irritation.

The Patient I Knew Well

This patient wasn’t new to me, though her journey had been long before we met. In mid-2024, she’d undergone a left-sided L4-L5 decompression for severe leg pain radiating down her L5 distribution. The initial surgery went well, but at the six-week mark, disaster struck: all her pain returned.

Her surgeon ordered an MRI, which revealed what nobody wanted to see—a re-herniation. It can happen in up to 10% of decompression cases, and she’d unfortunately drawn the short straw.

That’s when she first came to see me for rehabilitation. Rather than rushing into revision surgery, she wanted to try conservative management first. For twelve months, we worked together on a structured rehabilitation program—building strength, improving function, expanding range of motion.

By early 2025, she had transformed her situation. She was essentially pain-free, with only occasional twinges when she held certain positions too long. Despite the re-herniation still visible on imaging, she had built enough strength and control that her body could compensate. She’d avoided revision surgery through sheer determination and dedication to her program.

Then came the phone call from her holiday.

Ten Marble Steps and a Familiar Fear

“Joel, I’ve had an accident.”

She’d slipped at the top of a marble staircase—ten steps—and bumped down every single one on her buttocks. The familiar radiating pain down her left leg had returned. With her surgical history, her fear was understandable: had she damaged the surgical site? Re-herniated again? Injured the level above or below?

When she came to see me immediately upon returning, the worry in her eyes was palpable. After fighting so hard for her recovery, was she back at square one?

The Clinical Detective Work

My first priority was determining whether this was a spine issue or something else. I ran through a comprehensive series of biomechanical and neurodynamic tests—specialized assessments that put the spine in different positions while tensioning specific nerves.

Every single test came back negative.

This was puzzling but encouraging. If her spine was the problem, at least one of these tests should have been positive. But then I looked at her gluteal region, and the picture became clearer: massive bruising covered two-thirds of her left buttock, with swelling visible even through clothing.

The Scan That Revealed a Different Story

Given her surgical history, we couldn’t take chances. I called her surgeon to discuss the case. I shared my clinical findings—the negative neurodynamic tests and the extensive bruising. We agreed that imaging both the lumbar spine and the pelvic and gluteal soft tissues would give us the complete picture.

The MRI results were fascinating:

The excellent news: Her lumbar spine was absolutely clear. No disc re-herniations, no significant trauma, nothing sinister. The year of hard rehabilitation had protected her spine beautifully.

The diagnosis: A Morel-Lavallée lesion—a degloving injury to the deep gluteal fascia.

Understanding Morel-Lavallée Lesions and Deep Gluteal Syndrome

Let me explain what was happening in her buttock. When she fell down those stairs, the direct trauma created a shearing force that essentially pulled the skin and subcutaneous fat away from the fascia (the connective tissue surrounding muscles). This created a space that filled with fluid and fat, forming what we call a Morel-Lavallée lesion.

This lesion created inflammation and swelling that affected the surrounding structures, including the gluteal muscles and potentially the piriformis muscle. Here’s where anatomy becomes crucial: the sciatic nerve runs alongside the piriformis muscle, but its exact path varies between individuals. Sometimes it runs in front of the muscle, sometimes behind, and in certain cases, it can even run directly through the piriformis.

The swelling and inflammation from the degloving injury created compression on these muscles, which in turn irritated the sciatic nerve—not at the nerve roots in the lumbar spine, but where the fully-formed nerve passes through the gluteal region. This is true deep gluteal syndrome: trauma-induced nerve irritation occurring outside the spine.

The Recovery Difference

Several weeks post-fall, she’s improving steadily. The bruising has faded, swelling will hopefully reduce, and pain is diminishing. We hope for a full recovery without any invasive interventions—a completely different trajectory from what a spinal re-herniation would have required.

This case beautifully illustrates why accurate diagnosis matters. Her symptoms were nearly identical to her previous disc problems, but the cause was entirely different. The fall provided crucial context, the clinical tests pointed away from the spine, and appropriate imaging confirmed deep gluteal syndrome.

Key Lessons for Patients

Not all radicular pain comes from the spine. Direct trauma to the deep gluteal muscles can perfectly mimic disc-related sciatica.

Modern imaging can reveal subtle injuries. Morel-Lavallée lesions and other soft tissue problems need specific imaging protocols to detect.

The term matters less than understanding. Whether we call it piriformis syndrome or deep gluteal syndrome, what matters is recognizing when nerve irritation occurs outside the spine.

Previous spine problems don’t mean all future pain is spine-related. This patient’s history made her fear understandable, but her new problem had a completely different source.

When to Seek Medical Attention After a Fall

If you’ve had a fall and experience leg pain:

• Always get evaluated by your medical practitioner if you have a history of spine surgery
• Seek immediate care for numbness, weakness, or loss of bladder/bowel control
• Explain the mechanism of injury clearly to your healthcare provider
• Ask about imaging that includes both spine and soft tissues if appropriate
• Don’t assume the pain source—let proper examination guide diagnosis

The Evolution of Understanding

The shift from “piriformis syndrome” to “deep gluteal syndrome” reflects our evolving understanding of pain in this region. It’s not always the piriformis muscle at fault—multiple structures in the deep gluteal space can cause similar symptoms. This broader, more accurate terminology helps us better diagnose and treat these conditions.

These two cases—one a missed disc herniation (previous blog post), the other true deep gluteal syndrome—perfectly illustrate why we can’t make assumptions about pain. Similar symptoms can have vastly different causes, requiring completely different treatments.

For more information about understanding and managing spine-related pain, visit Vertera Health or download the app for comprehensive, expert-guided recovery protocols.