Back pain is one of the main reasons clients see massage therapists. Trigger points, hypertonicity, strains, sprains, and a host of other complaints are all common causes of low-back pain. We look to these causes first when examining the source of our client’s pain. Yet, sometimes their complaint doesn’t fit the pattern of these conditions, or they do not respond to treatment. In these cases, it’s helpful to think outside the box.

In this column, we’ll look at cluneal nerve entrapment in the gluteal region. The cluneal nerves are susceptible to compression and may be the source of pain complaints in the lumbopelvic region or lower extremity. Let’s explore where they are, how they are injured, and a few key treatment strategies.

Anatomy

The cluneal nerves are a group of cutaneous sensory nerves in the gluteal region. They are divided into three groups: superior, middle, and inferior. There are several branches within each of these three groups, but for the sake of simplicity, I’ll address the smaller branches as components of the three primary groups.

Superior Cluneal Nerves

The superior cluneal nerves are composed of three branches and originate from the dorsal rami of the lower thoracic and upper lumbar spinal nerve roots, usually from T11 to L3 (Image 1). The dorsal rami are small nerve branches that depart from the main nerve root and go immediately in a posterior direction. These small and sensitive nerves must pass through several soft-tissue channels and directly through several muscles. It is easy to see why they are susceptible to pathological compression.

After they exit the spinal region, the superior cluneal nerves pass lateral to the multifidus muscle and then pierce the erector spinae muscle group. They then pass directly through the latissimus dorsi muscle and over the top of the iliac crest before terminating in the upper gluteal region. The superior cluneal nerves provide sensory innervation to the upper iliac crest and the skin overlying the superior-medial portions of the gluteus maximus.

In about 39 percent of the population, the superior cluneal nerves pass through a fibro-osseous tunnel in the upper iliac crest.¹ This tunnel is created by the thoracolumbar fascia and a bony groove in the iliac crest. Compression and irritation of these nerves in the region of this tunnel are often mistaken for sciatica or other causes of low-back pain.²

Middle Cluneal Nerves

The next group is the middle cluneal nerves, which originate from the dorsal rami of the upper sacral nerves, including S1, S2, and S3. These nerves course through the sacral foramina and then pass adjacent to the long posterior sacroiliac ligament (Image 2). Anatomical studies have shown some variation between individuals regarding whether the middle cluneal nerves pass above or below the long sacroiliac ligament. When compression pathology affects the middle cluneal nerves, they are most likely passing under that ligament. The middle cluneal nerves innervate the skin overlying the middle portion of the gluteus maximus.

Inferior Cluneal Nerves

The final group are the inferior cluneal nerves, which are sensory fibers that branch off the posterior femoral cutaneous nerve near the ischial tuberosity. They course from inferior to superior and wrap around the lower margin of the gluteus maximus (Image 3). The inferior cluneal nerves provide sensory innervation to the skin overlying the lower portion of the gluteus maximus muscle, as well as the region lateral to the anus and some aspects of the pelvic floor.

Pathophysiology

The most common cause of pathology with the cluneal nerves is entrapment by adjacent anatomical structures. The superior cluneal nerves are most vulnerable to compression by the quadratus lumborum and the thoracolumbar fascia, or entrapment against the iliac crest as the nerves pass over the top of it. There is a strong fascial connection between the thoracolumbar fascia on one side of the body and the gluteus maximus on the opposite side (Image 4). Consequently, myofascial tension on one side may also play a role in cluneal nerve entrapment on the opposite side.

The middle cluneal nerves are most commonly entrapped by the long posterior sacroiliac ligament. As noted earlier, they sometimes go underneath this ligament and sometimes over the top of it. Entrapment is most common when the nerves are under the ligament.

The inferior cluneal nerves are not as vulnerable to compression as the middle and superior cluneal nerves. However, they may be somewhat susceptible to compression near the ischial tuberosities, depending on the individual’s anatomical structure. Inferior cluneal nerve entrapment is likely to produce groin pain and may often be mistaken for other problems such as pudendal nerve injury. External compression, such as pressure from sitting, can add to the problem in any of these locations.

Several other factors can also contribute to cluneal nerve compression, such as local trauma, intervertebral disc herniation, muscle spasms, lumbar stenosis, scoliosis, and vertebral fractures. Interestingly, Parkinson’s disease can play a role due to abnormal muscle tone as well as altered postures and gait mechanics.

Assessment

For all three cluneal nerve groups (superior, middle, and inferior), pain in the lower back or buttock region is the most common complaint. Reports of aching or prickly sensations in the gluteal region are most common, but the location may not be highly specific. There may be some muscle weakness in the area if other motor nerves are affected. However, cluneal nerves are purely sensory, so their compression would not cause muscle weakness or atrophy.

The symptoms of cluneal nerve entrapment often mimic those of sciatic nerve irritation. There are no specific physical examination tests that accurately pinpoint the entrapment, however. It is also hard to isolate these regions during basic active, passive, or resisted evaluation movements. Therefore, a thorough client history along with a detailed palpatory exam is essential.

During motion evaluations, superior cluneal nerve compression may cause increased discomfort or additional symptoms with lumbar extension, side bending, or rotation, either actively or passively. Prolonged standing, sitting, walking, and rolling are also likely to aggravate superior nerve irritation. Because of their location and lack of mobility, the middle and inferior cluneal nerve groups are not as affected as much during lumbar or hip movements.

Palpation can be a helpful tool for identifying cluneal nerve involvement because the nerves are close to the skin’s surface. Palpating the region of nerve entrapment will usually reproduce neurological sensations in the gluteal region, such as burning, tingling, or electrical-type symptoms, if the nerve is sensitized from compression. If symptoms increase when the area is palpated, do not continue to place pressure on that area. Additional pressure could further aggravate and sensitize those nerves.

Sometimes trigger points are evident in areas near cluneal nerve compression due to the involvement of myofascial tissues. Consequently, it may be challenging to distinguish trigger point pain from nerve compression, as the symptoms of both can be similar, if not identical.

Treatment

Cluneal nerve entrapment is likely underdiagnosed, and there is little published literature on appropriate treatment strategies for these problems. Traditional medical treatments may include gentle exercises that free up the nerve and encourage decreased irritation during movement. Clients should avoid positions of sitting or walking that aggravate symptoms.

With nerve compression pathologies, the more symptoms are aggravated, the greater the chance of developing sensitization in those nerves that can spread to other regions. Increased neural sensitization makes the nerves more sensitive, and therefore less irritation is needed to exacerbate symptoms. Nerve blocks or surgical release of the tissue surrounding the nerve may be recommended if conservative treatments are ineffective.

I have not found any mention of manual therapy used to address cluneal nerve entrapment in any published literature. However, this is one of those situations where clinical reasoning suggests a beneficial role for massage. Because the nerves are so close to the skin’s surface and often entrapped by other soft tissues, our soft-tissue treatments may be helpful. However, be selective in choosing techniques so as not to aggravate the nerve compression further.

Deep, specific pressure techniques, such as those performed with a thumb, finger, elbow, or other small contact surface, could further compress the nerve and worsen the condition. A more helpful approach would be broad-contact surface applications, such as those with the palm or forearm. These techniques are more beneficial when there is less lubricant and the pressure is applied across the surface of (tangential to) the skin, instead of pressing directly down into the tissue.

Treatment techniques commonly referred to as myofascial release, skin dragging, or dermoneuromodulating are very helpful for addressing cluneal nerve involvement. A key benefit of these approaches is they are relatively easy to perform with self-massage, so you can teach the client how to do this themselves.

Sometimes it appears that the nerves respond well to pressure in specific directions. However, knowing which direction is going to work best is discovered through trial and error. Good communication with the client during the treatment is imperative. Give a gentle pull to the superficial tissues and ask the client if there is any relief of discomfort or change in sensation (better or worse).

For example, you might begin by applying pressure over the upper iliac or gluteal region aimed inferiorly. Then apply that same type of skin drag medially, then laterally. You might then try doing the same thing in a superior direction. When you find the direction that gives the most relief, hold the position for a few seconds while the nerves adjust to the new sensation. Then gently and easily release the pressure. Often these sensory changes can begin to reduce neural sensitivity. Make sure you thoroughly treat the lumbar and gluteal regions and lower extremities to encourage relaxation and help relieve nerve irritability.

Cluneal nerve entrapments are not common, but if not recognized, they can lead to the condition worsening or to poor effects from improper treatment. If you assume someone’s low-back or gluteal pain is from muscle tightness or trigger points, there may be a temptation to treat those areas with deep, specific work. This approach could end up aggravating the existing complaint. Our knowledge of a wide variety of orthopedic disorders and their signs and symptoms is a valuable way to make sure we give our clients the very best care.

Notes

1. Toyohiko Isu et al., “Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain,” Neurospine 15, no. 1 (March 2018): 25–32, https://doi.org/10.14245/ns.1836024.012.

2. Jay Karri et al., “Pain Syndromes Secondary to Cluneal Nerve Entrapment,” Current Pain and Headache Reports 24, no. 10 (August 2020): 61, https://doi.org/10.1007/s11916-020-00891-7.