Navigating the Complex Path of Deep Gluteal Syndrome: A Case Study

Deep gluteal syndrome – over-diagnosed & a diagnosis of exclusion really…
the neurogenic thoracic outlet syndrome of the pelvis? 🧐
It does exist though..

The case

• Female ex-international handball player
• Now marathon training, High Intensity Interval Training (HIIT), CrossFit
• Worsening inferior gluteal pain – diagnosed as proximal hamstring tendinopathy, but no improvement with physio input & load management

The assessment

• 6 months later, symptoms evolving – pain radiating down posterior leg, calf, foot
• Intermittent paresthesia, subjective loss power & gait coordination
• Constantly stretching & massaging piriformis
• Sitting😡
• Lumbar spine & hip joint clear; seated stretch & active piriformis tests provocative
• MRI lumbar spine – no discogenic or radicular source
• MRI hip – peri-trochanteric inflammation (common in sporty people), but no response to guided injection

The differential diagnosis

Is it this hip joint?

• IT can refer pain in myriad ways – but no change with diagnostic hip joint injection
• 3D CT & motion analysis normal – no hip dysplasia
• Nothing to find on EUA with hip ortho surgeon

Could it be rheumatological?

• MRI SI joints show mild bone oedema.
• But bloods all normal, negative HLA-B27, no family history. SCREENDEM clear.
• Bone oedema around SI joints can be normal is exercising population – see paper

• Electrophysiology studies normal – rarely helpful in DGS or piriformis syndrome
• If abnormal, typically affects peroneal fascicle, as this is the one that takes an aberrant course around / through piriformis
• US guided hydrodissection inj around sciatic nerve – temporary response

The decision

• In meantime, increasingly disabled, walking tolerance reduced, can’t play with kids, tearful
• Distressing for all involved
• So agreed to proceed to open exploration & decompression of sub gluteal space
• Images show how challenging this is – ‘deep’ is accurate! SN = yellow band

Early days post op, but will update about outcome. Thank you Prof Tom Quick for your expertise here.

Wrapping up

Some useful review papers here that describe DGS subsets, anatomy, concepts to digest until the next installment.