Buttock Pain in the Athlete: the Role of Pelvic Floor Dysfunction

  • Xiaoning Yuan
  • Anna-Christina Bevelaqua
Sports Medicine Rehabilitation (B Liem and BJ Krabak, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Sports Medicine Rehabilitation


Purpose of Review

Pelvic floor dysfunction is an often overlooked cause of buttock pain in the athlete. Literature on pelvic floor dysfunction in athletes is limited, and therefore, it is frequently missed on evaluation and left untreated. This purpose of this article is to review the role that pelvic floor dysfunction plays in several musculoskeletal conditions experienced by athletes and to discuss pertinent history and physical examination findings that will help healthcare providers identify and treat athletes with pelvic floor dysfunction.

Recent Findings

Recent studies show the prevalence of pelvic floor dysfunction in athletes is higher than one might expect. Structural changes in pelvic floor muscles have been identified in athletes, although the effect of these changes on pelvic floor function is not clear. Muscles of the pelvic floor are involved in controlling motion at the hip, sacroiliac joint and lumbar spine. Dysfunction in these muscles may contribute to a number of conditions that present with buttock pain.


It is important to recognize pelvic floor dysfunction as a potential cause of buttock pain in athletes, particularly in cases that have remained refractory to other conservative therapies.


Buttock pain Myofascial pelvic pain Pelvic floor dysfunction Piriformis syndrome Pudendal neuralgia Sacroiliac joint dysfunction 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


  1. 1.
    Eickmeyer SM. Anatomy and physiology of the pelvic floor. Phys Med Rehabil Clin N Am. 2017;28:455–60. Scholar
  2. 2.
    Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, Coates KW. Innervation of the female levator ani muscles. Am J Obstet Gynecol. 2002;187:64–71.CrossRefPubMedGoogle Scholar
  3. 3.
    Prather H, Spitznagle TM, Dugan SA. Recognizing and treating pelvic pain and pelvic floor dysfunction. Phys Med Rehabil Clin N Am. 2007;18:477–96, ix. Scholar
  4. 4.
    Wallace K. Female pelvic floor functions, dysfunctions, and behavioral approaches to treatment. Clin Sports Med. 1994;13:459–81.PubMedGoogle Scholar
  5. 5.
    Prather H, Dugan S, Fitzgerald C, Hunt D. Review of anatomy, evaluation, and treatment of musculoskeletal pelvic floor pain in women. PM R. 2009;1:346–58. Scholar
  6. 6.
    Prather H. Pelvis and sacral dysfunction in sports and exercise. Phys Med Rehabil Clin N Am. 2000;11:805–36. viiiPubMedGoogle Scholar
  7. 7.
    Bennis S, Hwang S. Office evaluation of pelvic pain. Phys Med Rehabil Clin N Am. 2017;28:461–76. Scholar
  8. 8.
    Laycock J, Brown J, Cusack C, Green S, Jerwood D, Mann K, et al. Pelvic floor reeducation for stress incontinence: comparing three methods. Br J Commun Nurs. 2001;6:230–7. Scholar
  9. 9.
    Khatri G, Khan A, Raval G, Chhabra A. Diagnostic evaluation of chronic pelvic pain. Phys Med Rehabil Clin N Am. 2017;28:477–500. Scholar
  10. 10.
    Cho H-M, Park D-S, Kim DH, Nam H-S. Diagnosis of ilioinguinal nerve injury based on electromyography and ultrasonography: a case report. Ann Rehabil Med. 2017;41:705–8. Scholar
  11. 11.
    Roberts MM, Park TA. Pelvic floor function/dysfunction and electrodiagnostic evaluation. Phys Med Rehabil Clin N Am. 1998;9:831–51. viiPubMedGoogle Scholar
  12. 12.
    Casey EK, Temme K. Pelvic floor muscle function and urinary incontinence in the female athlete. Phys Sportsmed. 2017;45:399–407. Scholar
  13. 13.
    Nygaard IE, Thompson FL, Svengalis SL, Albright JP. Urinary incontinence in elite nulliparous athletes. Obstet Gynecol. 1994;84:183–7.PubMedGoogle Scholar
  14. 14.
    Eliasson K, Larsson T, Mattsson E. Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports. 2002;12:106–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Yi J, Tenfelde S, Tell D, Brincat C, Fitzgerald C. Triathlete risk of pelvic floor disorders, pelvic girdle pain, and female athlete triad. Female Pelvic Med Reconstr Surg. 2013;22:373–6. Scholar
  16. 16.
    Kruger JA, Heap SW, Murphy BA, Dietz HP. Pelvic floor function in nulliparous women using three-dimensional ultrasound and magnetic resonance imaging. Obstet Gynecol. 2008;111:631–8. Scholar
  17. 17.
    Roza TD, Brandão S, Oliveira D, Mascarenhas T, Parente M, Duarte JA, et al. Football practice and urinary incontinence: relation between morphology, function and biomechanics. J Biomech. 2015;48:1587–92. Scholar
  18. 18.
    Borin LCMS, Nunes FR, Guirro ECO. Assessment of pelvic floor muscle pressure in female athletes. PM R. 2013;5:189–93. Scholar
  19. 19.
    Middlekauff ML, Egger MJ, Nygaard IE, Shaw JM. The impact of acute and chronic strenuous exercise on pelvic floor muscle strength and support in nulliparous healthy women. Am J Obstet Gynecol. 2016;215:316.e1–7. Scholar
  20. 20.
    Leibovitch I, Mor Y. The vicious cycling: bicycling related urogenital disorders. Eur Urol. 2005;47:277–86; discussion 86-7. Scholar
  21. 21.
    Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin N Am. 2004;35:65–71. CrossRefGoogle Scholar
  22. 22.
    Menu P, Fouasson-Chaillou A, Dubois C, Dauty M. Piriformis syndrome diagnosis: on two professional cyclists. Ann Phys Rehabil Med. 2014;57:268–74. Scholar
  23. 23.
    Kay J, de Sa D, Morrison L, Fejtek E, Simunovic N, Martin HD, et al. Surgical Management of Deep Gluteal Syndrome Causing Sciatic Nerve Entrapment: a systematic review. Arthroscopy. 2017;33:2263–78e1. Scholar
  24. 24.
    Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J. 2010;19:2095–109. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Heiderscheit B, Evaluation MCS. Management of hip and pelvis injuries. Phys Med Rehabil Clin N Am. 2016;27:1–29. CrossRefPubMedGoogle Scholar
  26. 26.
    Foye PM. Coccydynia: tailbone pain. Phys Med Rehabil Clin N Am. 2017;28:539–49. CrossRefPubMedGoogle Scholar
  27. 27.
    Ryder I, Alexander J. Coccydynia: a woman's tail. Midwifery. 2000;16:155–60. Scholar
  28. 28.
    Dampc B, Słowiński K. Coccygodynia pathogenesis, diagnostics and therapy. Review of the writing. Polski przeglad chirurgiczny. 2017;89:33–40. PubMedGoogle Scholar
  29. 29.
    Demircay E, Kabatas S, Cansever T, Yilmaz C, Tuncay C, Altinors N. Radiofrequency thermocoagulation of ganglion impar in the management of coccydynia: preliminary results. Turk Neurosurg. 2010;20:328–33. Scholar
  30. 30.
    Finsen V. Corticosteroid injection for coccygodynia. Tidsskrift for den Norske laegeforening: tidsskrift for praktisk medicin, ny raekke. 2001;121:2832–3.Google Scholar
  31. 31.
    Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine. 2001;26:E479–83. discussion E84CrossRefPubMedGoogle Scholar
  32. 32.
    Scott KM, Fisher LW, Bernstein IH, Bradley MH. The treatment of chronic coccydynia and postcoccygectomy pain with pelvic floor physical therapy. PM R. 2017;9:367–76. Scholar
  33. 33.
    Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012;221:537–67. Scholar
  34. 34.
    Peebles R, Jonas CE. Sacroiliac joint dysfunction in the athlete: diagnosis and management. Curr Sports Med Rep. 2017;16(5):336–42. Scholar
  35. 35.
    Fortin JD, Washington WJ, Falco FJ. Three pathways between the sacroiliac joint and neural structures. AJNR Am J Neuroradiol. 1999;20(8):1429–34.PubMedGoogle Scholar
  36. 36.
    Bharucha AE, Lee TH. Anorectal and pelvic pain. Mayo Clin Proc. 2016;91:1471–86. Scholar
  37. 37.
    Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, et al. Functional anorectal disorders. Gastroenterology. 2016;150:1430–1442.e4. CrossRefGoogle Scholar
  38. 38.
    Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, Nogueira AA, Dos Reis FJ, Poli Neto OB. Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain Med (Malden, Mass). 2010;11:224–8. Scholar
  39. 39.
    Gyang A, Hartman M, Lamvu G. Musculoskeletal causes of chronic pelvic pain: what a gynecologist should know. Obstet Gynecol. 2013;121:645–50. Scholar
  40. 40.
    Kotarinos R. Myofascial pelvic pain. Curr Pain Headache Rep. 2012;16:433–8. Scholar
  41. 41.
    Spitznagle TM, Robinson CM. Myofascial pelvic pain. Obstet Gynecol Clin N Am. 2014;41:409–32. Scholar
  42. 42.
    Bonder JH, Chi M, Rispoli L. Myofascial pelvic pain and related disorders. Phys Med Rehabil Clin N Am. 2017;28:501–15. Scholar
  43. 43.
    Sikdar S, Shah JP, Gebreab T, Yen R-H, Gilliams E, Danoff J, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil. 2009;90:1829–38. Scholar
  44. 44.
    Turo D, Otto P, Shah JP, Heimur J, Gebreab T, Zaazhoa M, et al. Ultrasonic characterization of the upper trapezius muscle in patients with chronic neck pain. Ultrason Imaging. 2013;35:173–87. Scholar
  45. 45.
    Chen Q, Basford J, An K-N. Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon). 2008;23:623–9. CrossRefGoogle Scholar
  46. 46.
    Chen Q, Wang H-J, Gay RE, Thompson JM, Manduca A, An K-N, et al. Quantification of myofascial taut bands. Arch Phys Med Rehabil. 2016;97:67–73. CrossRefPubMedGoogle Scholar
  47. 47.
    Itza F, Zarza D, Salinas J, Teba F, Ximenez C. Turn-amplitude analysis as a diagnostic test for myofascial syndrome in patients with chronic pelvic pain. Pain Res Manag. 2015;20:96–100.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Moldwin RM, Fariello JY. Myofascial trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Curr Urol Rep. 2013;14:409–17. Scholar
  49. 49.
    FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:269–75; discussion 75. Scholar
  50. 50.
    Elkins N, Hunt J, Scott KM. Neurogenic Pelvic Pain. Phys Med Rehabil Clin N Am. 2017;28:551–69. Scholar
  51. 51.
    Labat J-J, Robert R, Delavierre D, Sibert L, Rigaud J. Symptomatic approach to chronic neuropathic somatic pelvic and perineal pain. Progres en urologie. 2010;20:973–81. Scholar
  52. 52.
    Antolak SJ, Hough DM, Pawlina W, Spinner RJ. Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment. Med Hypotheses. 2002;59:349–53.CrossRefPubMedGoogle Scholar
  53. 53.
    Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol. 2005;192:1663–8. Scholar
  54. 54.
    Stav K, Dwyer PL, Roberts L. Pudendal neuralgia. Fact or fiction? Obstet Gynecol Surv. 2009;64:190–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Filler AG. Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery. Neurosurg Focus. 2009;26:E9. Scholar
  56. 56.
    Labat JJ, Riant T, Lassaux A, Rioult B, Rabischong B, Khalfallah M, et al. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG. 2017;124:251–60. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Rehabilitation and Regenerative MedicineColumbia University Medical CenterNew York CityUSA

Personalised recommendations