You used to love going for long walks in the park, but now, just the thought of strolling down the block fills you with dread. Sitting at your desk for more than 20 minutes feels like torture, and you've started eating all your meals standing up because it's too painful to sit at the dinner table. Maybe it feels like you have a red-hot poker buried deep in the cheek of your derriere.
If this sounds familiar, you're not alone. Many people struggle with chronic buttock pain that interferes with work, hobbies, social activities, and overall quality of life. The constant aching, throbbing, burning, or searing pain can make you feel frustrated, exhausted, and hopeless—especially if you've already tried multiple conservative treatments like physical therapy, stretching, ice/heat, and NSAIDs without success.
As a peripheral nerve surgeon, Dr. Eric H. Williams wants you to know that medication may not be your only option. In many cases, chronic buttock pain that radiates down the leg or feels like a deep, relentless “charley horse” is actually being caused by compressed, pinched, or damaged nerves—and if physical therapy has not helped, then surgical intervention may provide significant, lasting relief by addressing the problem at its source.
Your Pain Isn't "All In Your Head"
Maybe you've been told by a doctor that your MRI looks fine, so there's nothing wrong with you. Or perhaps you've had friends or family members suggest that your pain is psychosomatic and you should just push through it. But we understand that just because we can’t also see the problem on X-ray or imaging studies, the pain may not be in your head, it may actually still be in your rear end! A true pain in the “rear end” that can be very debilitating.
When you're suffering from neuropathic pain caused by nerve compression or damage, it's not uncommon for diagnostic imaging to appear "normal." That's because nerves are small and imaging may not detect obvious signs of impingement, irritation, or injury on standard MRIs or X-rays. It is a frustration that, as physicians, we are more than aware of. It leads to a host of challenges, hence the reason for this article.
This is why getting a thorough evaluation from a peripheral nerve specialist like Dr. Williams is so important. He can evaluate through physical exam and history to try to determine if a compressed or damaged nerve is at the root of your buttock and leg pain.
Signs Your Buttock Pain Could Be Caused by Peripheral Nerve Damage or Compression
If you're wondering whether your chronic buttock pain might be nerve-related, Dr. Williams recommends looking out for the following signs and symptoms:
- Burning, searing, or electrical sensations. Nerve pain tends to have a distinct quality that's often described as hot, burning, or feeling like an electric shock. If your buttock or upper thigh pain has this fiery or zapping component, it's more likely to be neuropathic in nature.
- Pain that radiates. Irritated or pinched nerves often cause pain that spreads or shoots along the nerve pathway. For example, cluneal nerve pain may start in the upper buttock but radiate down into the hip or thigh. In comparison, sciatica-like pain from the piriformis muscle compressing the sciatic nerve can extend down the entire back of the leg and even into the foot.
- Numbness or tingling. While not always present, many people with nerve compression notice "pins and needles" sensations or sporadic numbness in the affected buttock, thigh, or leg. Patients may complain that the affected area feels “asleep.” These altered sensations are a common hallmark of nerve dysfunction.
- Hypersensitivity to touch. When a nerve is pinched or irritated, the skin it supplies may become extremely sensitive, hypersensitive, or painfully sensitive. Even light pressure or the brush of clothing against the buttock or thigh can feel tremendously painful.
- Positional pain. Nerve pain is often aggravated or relieved by certain positions or activities. For example, sciatica and posterior femoral cutaneous nerve pain tend to flare with prolonged sitting.
If several of these characteristics match what you're experiencing, it's worth getting evaluated by a peripheral nerve specialist—even if you've already seen other providers who told you they couldn't find anything wrong. Nerve-related pain often requires specific diagnostic tests that most orthopedic and spine surgeons simply don't perform.
A Pinched Nerve in the Lower Spine Isn’t Always to Blame
Admittedly one of the most common causes of buttock pain that radiates into the leg is a nerve root compression at the level of the lumbar spine. For example, a herniated disk that pinches the spinal cord. However, this pathology can be relatively straightforward to detect with current imaging techniques.
Our office does not treat these types of problems. Patients who have a clearly documented spine lesion, such as a herniated disk, need to see a board-certified spinal surgeon, such as a neurosurgeon or orthopedic surgeon, who is trained in treating spinal pathology.
The group of patients that we are looking to try to help are those patients who have been told that they have a normal spine. They may have been told, “It’s not coming from your back.” What do you do then? Or what if you already had your back operated on and you still have terrible pain in the buttock area and persistent “sciatica”? Where do you go now? What else could be causing your pain?
Part of the confusion comes from the old terminology used. Dr. Williams believes most medical providers think of this as a generic term that essentially means “pain running from your buttock down your leg,” but this pain can come from different sources.
As mentioned above, the most common source is actually not from your leg but from your lower back and spinal cord. This can also be called radicular pain or radiculopathy. This pain can look very much like your sciatic nerve because the sciatic nerve is made up of several nerve roots from different levels of the lumbar and sacral spine that coalesce together to form the entire sciatic nerve.
Since herniated disks are so common, and since the symptoms can at least partially appear very similar to a lesion affecting the sciatic nerve, patients who have a true sciatic nerve problem are often treated for presumed spinal pathology first. This is just a numbers game. It is actually not a bad thing, because ruling out a compression of the spine is one of the first things that needs to happen for patients with these symptoms. The only problem here is that, when the spine is cleared and the patient still has pain, frequently the patient’s workup seems to end, and the patient can be left without a satisfactory answer as to where their pain is coming from.
The next most common area that can masquerade as pain coming from sciatic nerve compression is sacroiliac (SI) joint pain. Because the SI joint is in the same region and very close to the sciatic nerve it also should be ruled out as a source of pain. However, this should have different characteristics. The joint pain should be a more orthopedic type of pain. It is typically duller, more achy, and should not radiate down the leg. It typically does not have the “electrical” qualities that nerve pain has, even though it can be quite intense.
If a patient’s spine and SI joint have been evaluated and have proven not to be the source of pain, then a workup needs to continue to look for other causes of these symptoms.
Typically, a direct injury to the sciatic nerve during a surgical procedure is not difficult to diagnose. If a patient has a hip replacement and then wakes up with a leg that does not work anymore, it should be pretty clear that an injury occurred. But when a sciatic nerve injury is slow to occur and the onset is without an obvious event, it can take some time to make the diagnosis.
Piriformis Syndrome
Piriformis syndrome is typically caused by the irritation or compression of the sciatic nerve as it passes through or beneath the piriformis muscle in the buttocks, piriformis syndrome’s most common symptom is severe refractory pain in the central buttock that can be described as sharp and stabbing. However, some patients will experience more of a dull, chronic gnawing, aching pain, which is why it can be hard to differentiate between SI joint and low back pain as described above. Many patients will have radiating pain down the leg. It is usually the subgroup of patients who have pain isolated to the buttock that is harder to diagnose.
Piriformis syndrome often develops due to repetitive trauma, prolonged sitting, or biomechanical abnormalities that cause the piriformis muscle to become tight or spasm. Athletes, particularly runners and cyclists, may be at higher risk due to repetitive motion and muscle overuse. The pain typically worsens with activity and prolonged sitting, and patients may notice increased discomfort when climbing stairs or performing squatting movements.
Patients who have blunt trauma to the buttock can also develop piriformis syndrome. A hard fall or direct blow to the buttock can cause bleeding, scarring, and inflammation can eventually entrap the nerve. This can be a slow process, making the diagnosis more challenging.
Many physicians also feel that piriformis syndrome is “so rare” that the patient sitting directly in front of them could not possibly have this problem. Dr. Williams believes this is simply not true.
Perhaps as mentioned above, this could just be a “numbers” problem. If you see 100 patients a week with spinal lesions and one patient a month with a sciatic nerve lesion that still looks kind of like a spine lesion, it will be very hard to pick this out. So we can not be too harsh on our colleagues who are on the front lines. It is easy to be a “armchair quarterback.”
However, it is our strong opinion that any patient with severe refractory “sciatica” symptoms or pain in the buttock into the lower extremity needs to be ruled out for piriformis syndrome if they are not responding to traditional care.
Superior Cluneal Nerve Entrapment
The superior cluneral nerve is a sensory nerve that supplies skin in the upper buttocks, lower back, and hip area. Entrapment of this nerve as it passes through tight fascial openings can lead to localized lower back and buttock pain that may radiate into the upper posterior thigh. Pain is often exacerbated by activities like bending over or lying flat.
Superior cluneal nerve entrapment frequently occurs where the nerve passes through a small tunnel in the thoracolumbar fascia, about 7-8 cm from the midline. Anatomical variations in this tunnel's size or location can predispose individuals to nerve entrapment. The resulting pain pattern can mimic other conditions such as facet joint syndrome or sacroiliac joint dysfunction, making it an important but often overlooked cause of lower back and buttock pain.
Posterior Femoral Cutaneous Nerve Entrapment
Running from the lower buttock down the back of the thigh towards the knee, the posterior femoral cutaneous nerve is a purely sensory nerve that transmits signals from the skin. If pinched or damaged, it can cause burning pain, electric shock sensations, tingling, and hypersensitivity in its distribution area. Symptoms of posterior femoral cutaneous nerve entrapment may flare with extended sitting or lying on the affected side.
The posterior femoral cutaneous nerve can become entrapped at various points along its course, particularly where it exits the pelvis through the greater sciatic foramen or where it passes through tight fascial bands in the posterior thigh. The condition is more common in individuals who spend long periods sitting, such as office workers or long-distance drivers, and can be exacerbated by direct pressure on the nerve from sitting on hard surfaces or a severe injury or fall directly to the buttock region, especially the ischium or “sit bone.”
Meralgia Paresthetica
Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve and is characterized by pain radiating along the outside of the thigh, from the anterior lateral hip area (the anterior superior iliac spine or hip bone) down to the outside of the knee. However, some cases present with pain radiating towards the buttocks.
The compression typically occurs where the nerve passes through the inguinal ligament, just below the hip bone. Risk factors include pregnancy, obesity, wearing tight clothing around the waist, and diabetes. The condition can also develop following trauma, surgery, or rapid weight gain, as these factors can alter the anatomical relationships around the nerve's pathway and increase pressure on the nerve at this vulnerable point.
What to Expect When You Visit Dr. Williams
When patients come to Dr. Williams with chronic buttock pain that hasn't responded to conservative care, he starts with an in-depth clinical assessment. This includes a thorough history, physical examination, and review of any prior treatment records and imaging studies.
Special in-office tests are used to check for signs of peripheral nerve compression or damage. For example, gently tapping over a compressed nerve may elicit a zinging or tingling sensation (positive Tinel's sign). Palpating a specific nerve can reproduce pain. Diagnostic nerve blocks, which use a local anesthetic to numb a precise area, are another powerful tool for confirming that a particular nerve is generating pain.
Advanced imaging, such as high-resolution MRI, MR neurography, or ultrasound, can visualize a compressed or entrapped nerve and guide treatment decisions. Electrodiagnostic studies (EMG/NCV) can assess nerve function and signal disruption.
If a peripheral nerve issue is diagnosed, Dr. Williams may recommend proceeding with surgical intervention if the patient has already failed extensive physical therapy and medications have been ineffective in treating the pain. While medications and injections can temporarily blunt symptoms, surgery may be the only way to release a pinched nerve or repair a damaged one for long-term pain relief. Peripheral nerve stimulators or spinal cord stimulation may be an option for some patients, but these procedures are typically performed by pain management teams—not peripheral nerve surgeons.
Dr. Williams performs these peripheral nerve procedures:
- Nerve decompression surgery. Using meticulous surgical techniques, Dr. Williams can free compressed nerves from surrounding tight fascial bands, muscles, scar tissue, or other structures. This restores space around the nerve, thus improving blood flow to the nerve, and may improve pain to allow for a return to normal function.
- Nerve repair. If a specific nerve has been severely damaged, Dr. Williams may need to trim away the injured portion and delicately suture the remaining healthy nerve ends back together with or without using a nerve graft. This is an intricate procedure that requires microsurgical expertise.
- Nerve excision/neurectomy. In some cases, a section of the nerve may be so badly damaged that it cannot be salvaged. Removing this painful, malfunctioning nerve segment can eliminate the spontaneous pain signals it generates. Dr. Williams often relocates the remaining nerve endings to a protected area to minimize the risk of recurrent pain or neuroma.
For optimal results, it's important to address chronic nerve pain proactively. If a compressed or damaged nerve goes untreated for too long, it can undergo irreversible changes. Early intervention gives you the best chance of full symptom relief.
Refer to the testimonials section of our website to learn more about the results Dr. Williams has been able to achieve for patients suffering from chronic buttock and leg pain caused by peripheral nerve dysfunction.