The diagnosis of deep gluteal syndrome: a systematic review of the current literature
Background: Deep gluteal syndrome (DGS) is an increasingly recognized cause of posterior hip pain, particularly in athletes and physically act give individuals. It results from entrapment of neural structures within the deep gluteal space, frequently associated with musculotendinous imbalance, repetitive hip movements, and sport-specific biomechanical stress. Purpose: To systematically describe the musculotendinous and neural entrapment mechanisms underlying DGS, with particular focus on clinical presentation, imaging findings, and management strategies in athletes. Furthermore, a secondary aim was to evaluate the frequency and clinical relevance of DGS-related conditions reported in athletes. Methods: A systematic descriptive review was conducted in accordance with PRISMA guidelines. PubMed, Scopus, PEDro, and the Cochrane Library were searched. Studies addressing anatomical predispositions, clinical features, imaging characteristics, and conservative or surgical treatment were included. Results: Eighty-four studies met the inclusion criteria. DGS encompasses multiple entrapment patterns involving the sciatic, pudendal, posterior femoral cutaneous and superior gluteal nerves. In athletes, repetitive hip flexion–adduction–internal rotation movements, overuse microtrauma and hypertrophic musculature appear to contribute to neural compression. Clinical diagnosis remains challenging due to symptom overlap with lumbar disorders. MRI represents the primary imaging modality, although findings may be subtle or nonspecific. Initial management is conservative, while endoscopic decompression may be indicated in refractory cases. Conclusion: There are seven clinical conditions that may cause DGS: ischiofemoral impingement, piriformis syndrome, gemelli-internal obturator syndrome, posterior femoral cutaneous nerve entrapment, superior gluteal nerve entrapment, pudendal neuropathy, and proximal hamstring syndrome. Therefore, DGS is an “umbrella term” that encompasses different pathologies resulting in very similar clinical presentations. In the athletic population, the two most frequent conditions are pudendal neuropathy and proximal hamstring syndrome.