Tingling to Left Buttock: Causes and Treatment
The most likely cause of tingling in the left buttock is sciatic nerve compression from piriformis syndrome or other deep gluteal space pathology, which should be evaluated clinically and treated conservatively first, with imaging reserved for cases that fail to respond or have concerning features. 1, 2
Primary Diagnostic Considerations
Nerve Compression Syndromes
- Piriformis syndrome is the most common nondiscogenic cause of buttock tingling and sciatica, occurring when the piriformis muscle compresses the sciatic nerve 1, 3
- Deep gluteal syndrome encompasses sciatic nerve entrapment in the subgluteal space from anatomical variants, muscle spasm, or peri-neural fibrosis 2
- Patients typically present with buttock pain, paresthesias radiating down the posterior thigh, and worsening symptoms with sitting 3
- Neurological examination is usually normal with negative straight leg raise 3
Radiculopathy vs. Referred Pain
- Buttock pain in spinal stenosis patients is more commonly due to radiculopathy rather than facet joint pathology, as demonstrated by superior response to selective nerve root blocks compared to facet blocks 4
- Lumbar radiculopathy should be considered, particularly if symptoms extend beyond the buttock 2
Other Peripheral Nerve Causes
- Cluneal nerve entrapment at the iliac crest can cause "pseudo-sciatica" with buttock tingling 2
- Pudendal nerve or posterior cutaneous nerve of thigh involvement may occur in the subgluteal space 2
Clinical Evaluation Approach
Key Physical Examination Findings
- Flexion, adduction, and internal rotation (FAIR test) reproduces symptoms in piriformis syndrome 3
- Freiberg sign (pain with passive internal rotation) and Pace sign (pain with resisted abduction and external rotation) suggest piriformis involvement 3
- Direct palpation of the piriformis muscle should reproduce buttock pain and paresthesias 3
Red Flags Requiring Imaging
- Symptoms persisting >6 months despite conservative treatment 2
- Progressive neurological deficits 2
- Failure to respond to standard therapies 1
Imaging Strategy
When Imaging is Indicated
- MRI is the primary modality for evaluating pelvic neural causes of chronic buttock pain, showing sciatic neuritis, neural compression, and peri-neural adhesions 2
- Ultrasound can identify nerve pathology and guide interventional procedures 2, 3
- Imaging is primarily used to rule out other etiologies (disc herniation, spinal stenosis, tumors) rather than confirm piriformis syndrome, as studies are typically normal 3
Treatment Algorithm
First-Line Conservative Management
- Physical therapy focusing on piriformis stretching and strengthening is the mainstay of initial treatment 3
- Medications including NSAIDs and neuropathic pain agents (gabapentin, duloxetine) 3
- Activity modification and avoidance of prolonged sitting 3
- Conservative treatment is successful for the majority of patients 3
Second-Line Interventional Options
- Corticosteroid injections into the piriformis muscle for recalcitrant cases 3
- Botulinum toxin injections are effective when standard therapies fail, particularly for cases with excessive muscle tension 1, 3
- Ultrasound or imaging guidance improves injection accuracy 3
Surgical Consideration
- Piriformis tenotomy and sciatic nerve decompression reserved only for patients who fail all conservative and interventional treatments 3
Common Pitfalls to Avoid
- Do not assume all buttock pain is lumbar spine-related: Pelvic neural pathology is a significant but often overlooked cause, especially when symptoms are prolonged 2
- Do not order imaging prematurely: Most cases respond to conservative treatment, and imaging findings are often normal in piriformis syndrome 3
- Do not confuse with vascular causes: The evidence about tinnitus and vascular bruits is not relevant to buttock tingling 5, 6
- Consider radiculopathy first in spinal stenosis patients: Nerve root pathology is more likely than facet joint disease when buttock symptoms are present 4