What is the appropriate management for a patient with right glute pain and a burning sensation in the right heel?

Management of Right Glute Pain with Burning Right Heel

This presentation strongly suggests sciatic nerve entrapment in the deep gluteal space (deep gluteal syndrome), and you should immediately pursue neurologic evaluation with subspecialist referral for electromyography, nerve conduction studies, and MRI. 1

Clinical Reasoning

The combination of gluteal pain with burning heel sensation is pathognomonic for neurologic involvement rather than isolated mechanical heel pathology. The burning quality specifically indicates nerve entrapment or radiculopathy, distinguishing this from purely mechanical causes. 2, 3

Key Diagnostic Features

Neurologic causes produce burning, tingling, or numbness—this is the critical distinguishing feature from mechanical heel pain. 2, 4

The anatomic distribution suggests:

• L5-S1 radiculopathy causing pain radiating from heel proximally through posterior leg and hip 1
• Deep gluteal syndrome (DGS) from sciatic nerve entrapment in the subgluteal space, presenting as buttock pain with radicular symptoms 5, 6

Physical Examination Priorities

Perform these specific maneuvers to differentiate the etiology:

• Palpate the middle-lower gluteal region for focal tenderness suggesting obturator internus tendinitis/bursitis or piriformis involvement 7, 5
• Straight leg raise test to assess for lumbar radiculopathy 1
• Neurologic examination of the lower extremity checking for motor weakness, sensory deficits, and reflex asymmetry 1
• Point tenderness mapping at the heel: palpate Achilles insertion, lateral calcaneal wall, and posterior superior calcaneus to rule out concurrent local pathology 2

Critical pitfall: Do not assume isolated plantar fasciitis when pain radiates proximally beyond the heel—this pattern mandates neurologic evaluation. 1

Diagnostic Algorithm

Immediate Steps

1. Lumbar spine MRI (preferred imaging for suspected radiculopathy) 1
2. Pelvic MRI if deep gluteal syndrome suspected based on gluteal tenderness 7, 5
3. Weight-bearing foot/ankle radiographs to exclude concurrent calcaneal stress fracture or other bony pathology 1

Advanced Testing

• Electromyography and nerve conduction studies are essential for confirmed neurologic involvement 2, 1
• MR neurography is the diagnostic procedure of choice for assessing deep gluteal syndrome and sciatic nerve entrapments 5

Management Based on Etiology

For Deep Gluteal Syndrome

• Ultrasound-guided corticosteroid injection into the obturator internus tendon sheath/bursa or around the sciatic nerve can provide immediate relief 7
• Physical therapy targeting hip external rotators and sciatic nerve mobility 5
• Endoscopic sciatic nerve decompression if conservative treatment fails after 6-8 weeks 5, 6

For L5-S1 Radiculopathy

• Immediate subspecialist referral to neurology or spine surgery 2, 1
• NSAIDs for pain and inflammation 2
• Activity modification avoiding provocative positions 2

If Concurrent Heel Pathology Identified

• For calcaneal stress fracture: Immobilization and protected weight-bearing 2
• For Haglund's deformity with bursitis: Open-backed shoes, heel lifts, NSAIDs, and corticosteroid injection (avoiding the Achilles tendon) 2

Corticosteroid injections are contraindicated near the Achilles tendon due to rupture risk. 2

Referral Indications

Refer immediately for subspecialist evaluation given the neurologic presentation. 2, 1

Additional referral triggers:

• No improvement after 6-8 weeks of conservative treatment 2
• Progressive neurologic deficits 1
• Need for advanced diagnostic testing or surgical intervention 2, 5

Common Pitfalls

• Never diagnose based on imaging alone—combine symptoms, clinical signs, and imaging findings 1
• Reexamine 3-5 days post-initial evaluation if symptoms are acute, as excessive swelling can limit initial examination 2
• Consider systemic causes (arthritides, infections, tumors, vascular compromise) when symptoms are bilateral or unexplained by mechanical causes 2, 1