Sign of buttocks
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sign of buttock seven signs clinical findings interpretation
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Sign of the Buttock (Cyriax)
The sign of the buttock is a term coined by James Cyriax. It is not a single sign but a combination of 7 clinical findings that together indicate serious pathology within the buttock — posterior to the axis of hip flexion/extension. It is considered a red flag in musculoskeletal examination.
Purpose
To differentiate whether buttock pain and restricted hip motion arise from:
- Local serious pathology in the buttock (positive test — the sign)
- Referred pain from the lumbar spine, sciatic nerve, or hamstring muscles (negative test)
How to Perform
- With the patient supine, perform a passive Straight Leg Raise (SLR).
- Note the point of limitation (restricted, painful, with an empty end-feel — no resistance from tissue, just pain stopping movement).
- Return the leg to neutral, then passively flex the hip with the knee flexed (this relaxes the hamstrings and sciatic nerve, which cross the knee joint).
- Assess whether further hip flexion is now possible.
Interpretation
| Finding | Result | Implication |
|---|---|---|
| Hip flexion increases when knee is flexed | Negative | Limitation was from hamstring tightness or lumbar spine/sciatic nerve involvement |
| Hip flexion does NOT increase when knee is flexed | Positive | Serious pathology in the buttock or hip itself |
For the test to be fully positive, all three criteria must be present:
- Restricted SLR
- Restricted hip flexion (regardless of knee position)
- Non-capsular pattern of hip ROM restriction (not the pattern seen in, e.g., osteoarthritis)
The end-feel is typically empty — painful before tissue resistance is met — distinguishing it from capsular or muscular restriction.
The 7 Signs of the Buttock (Cyriax's combination)
The "sign" actually refers to a cluster of clinical findings found together:
- Restricted and painful SLR
- Restricted hip flexion (no improvement when knee is bent)
- Non-capsular pattern of hip restriction
- Restricted hip extension
- Restricted hip abduction
- Positive resisted hip movements may be present
- Swelling or tenderness over the buttock region (redness/swelling without trauma is highly suspicious)
Conditions Indicated (Causes of a Positive Sign)
These are serious, non-musculoskeletal or deep structural lesions:
- Ischiorectal abscess
- Septic gluteal bursitis / rheumatic bursitis
- Osteomyelitis of the upper femur
- Neoplasm of the upper femur or ilium
- Fractured sacrum
- Septic sacroiliitis
Clinical Significance
A positive sign of the buttock is a red flag requiring:
- Immediate imaging — MRI or CT scan
- Medical referral for further investigation
- Consideration of infectious, neoplastic, or fracture pathology
It should be routinely tested during lumbar spine examination, since the SLR is typically performed at that stage — making it the ideal moment to flex the knee and check for this sign. A positive finding should not be attributed to a disc lesion or hamstring pathology without excluding serious buttock disease first.
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