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Get to the Bottom of "Dead Butt Syndrome"

Hip Rotation Range of Motion

A few months ago, I evaluated a patient who was referred to our clinic for "Dead Butt Syndrome". She felt pretty hopeless at ever gaining back what was left of her butt and being able to do every day activities without pain. I explained how it is a result of muscle compensations and is very typical in many individuals treated at our clinic. What exactly is it and how is it treated?

Dead Butt Syndrome is another way to describe weakness in the glutes, particularly the gluteus medius on the outside of the hip. When the gluteus medius goes "on strike", the pelvic girdle is not stable and droops to one side. This creates a problem for many individuals. It is often caused by a disruption in the deep core musculature that leads to muscle compensations and tightness. It is often asymmetrical (one side more than the other) and alongside an asymmetry in the pelvic girdle, such as a rotated sacrum or leg length discrepancy. It is very common in runners and individuals with overuse syndromes, however many sedentary individuals develop it over time also. Pelvic floor dysfunction, tight pelvic floor muscles that disrupt function and negatively affect bowel, bladder and/or sexual function can underlying this common problem.

Vladimir Janda, a 20th century Czech physician described this "cross-patterning" concept, where one side is tight or weak and the symptoms manifest on the opposite side. For example, weakness in the left shoulder can cause pain on the right side of the neck. This is what I experience with "snapping scapula" on my left side from weakness in my shoulder stabilizers and further confirmed when I am dry needled. My left side is what experiences the "twitch", or involuntary muscle spasm, even though the symptoms are on my right side. In the pelvic girdle, the typical pattern is left sided gluteus maximus weakness, right sided gluteus medius weakness and a twist in the sacrum, where the left lumbosacral motion is restricted and jammed. This results in pain and swelling in the left sacroiliac joint region. Most often this is accompanied by tight hip flexors and hip rotators. After evaluating a patient, I often find the opposite side requires attention in the right psoas, right adductors/groin and right piriformis.

Dead Butt Syndrome is predictable and applies to Janda's Principles in most of my patients who present with a similar pattern of muscle weakness in the:

  • belly (transversus abdominus)

  • butt (glute medius and maximus)

  • back (multifidus)

  • bottom (pelvic floor)

  • front (quads)

Dead Butt Syndrome is the result of compensations that we are not even aware of until the symptoms begin. As a physical therapist, it is not enough to prescribe general exercises as each individual has a unique presentation. My approach is to evaluate spinal range of motion, leg length, hip range of motion, hip muscle strength, core motor control and pelvic alignment that are contributors to disrupting gluteal muscle firing patterns. Goals of treatment follow this order:

  1. Restore biomechanical alignment of the pelvic girdle and lower spine/ sacrum using manual therapy techniques including muscle energy, visceral mobilization, dry needling and intravaginal trigger point release, if needed for pelvic floor dysfunction.

  2. Restore hip rotation range of motion, including hip flexor flexibility that often restricts hip extension and obturator internus tightness that contributes to loss of hip external rotation (see photo above).

  3. Retrain the timing and sequencing of the deep core muscle system. This includes the diaphragm, pelvic floor, transverse abdominus (deepest abdominal muscle) and the multifidus (deep spinal stabiliers).

  4. Retrain the gluteus maximus with bridging variations. Retrain the gluteus medius with a variety of mat exercises such as clamshells and closed chain (weight bearing) exercises.

  5. Maintain hip range of motion and flexibility with stretches that target the psoas (hip flexor), piriformis (butt muscle) and groin.

Pilates Posture of Power is one of my favorite exercises to address most of the above issues. Hold the position for one minute with special attention to keeping the heels together, tightening the glutes (squeeze a pencil between your cheeks) and drawing the shoulder blades into your back pockets. This provides a fascial lift for the pelvic floor and helps to retrain the right muscles to hold your pelvic girdle together. You can also progress this exercise by pumping the arms quickly (palms facing backwards), as a modification of Pilates 100s.

To learn more about some of the treatment techniques mentioned here, including dry needling therapy, visit our website at It's time to wake up your butt muscles and get them back to work, where they belong!

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