Test: Sign of the Buttock Test

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Background/Purpose

The Sign of the Buttock is a clinical examination finding that indicates the presence of serious pathology in the buttock region rather than a simple musculoskeletal problem originating from the lumbar spine or hip joint. First described by Cyriax, this test is used to differentiate between benign mechanical hip or lumbar spine dysfunction and significant pathology located within the buttock itself. Serious conditions that may produce a positive Sign of the Buttock include osteomyelitis of the proximal femur or pelvis, septic arthritis of the hip, gluteal abscess, neoplasm (primary or metastatic bone tumors), fractured sacrum or pelvis, severe bursitis (particularly ischial or trochanteric), or infectious processes. The test is essentially a combination of findings rather than a single maneuver, and it serves as a red flag indicating the need for further investigation with imaging studies and laboratory tests. Early recognition of the Sign of the Buttock is clinically important, as it may indicate conditions requiring urgent medical or surgical intervention.

Procedure

Patient Position:

The patient lies supine (on their back) on an examination table
The patient should be relaxed and comfortable
Both legs are initially in a neutral, extended position

Procedure:
Phase 1 - Passive Straight Leg Raise:
Stand on the side of the leg being tested
Place one hand under the patient's heel and the other hand over the anterior knee to maintain extension
Slowly raise the entire leg while keeping the knee fully extended (passive straight leg raise)
Elevate the leg until limited by pain, resistance, or hip flexion restriction
Note the range of motion achieved and the location/quality of any pain
Record the angle at which limitation occurs

Phase 2 - Hip Flexion with Knee Flexion:
7. From the limited position, allow the knee to bend (flex) while continuing to flex the hip
8. Observe whether additional hip flexion range of motion is gained when the knee is flexed
9. In normal circumstances or with lumbar/hamstring restrictions, flexing the knee should allow significantly more hip flexion
10. Note whether hip flexion remains limited despite knee flexion
Additional Assessments:
11. Assess for other associated findings including:
- Non-capsular pattern of hip restriction (limitation not in the typical capsular pattern)
- Empty end-feel on passive movement (patient stops movement due to severe pain before examiner feels tissue resistance)
- Painful and limited hip flexion in all positions
- Severe pain with resisted hip extension or other movements
Important Notes:
This is a collection of findings, not just a single test maneuver
The key finding is limited hip flexion that does NOT improve with knee flexion
Document all associated findings as they collectively indicate serious pathology
Performed: Unilaterally

Dialog

The examiner performs a passive straight leg raise followed by hip flexion with knee bent; limited hip flexion that fails to improve when the knee is flexed, along with other pain and restriction findings, indicates buttock pathology.

Criteria

• Hip flexion improves with knee flexion
• Non-capsular hip restriction
• No pain or tissue resistance

Measurement

LOINC Code

Scale/Grading

selection range; grade - LOINC ID
Option - Value option selection range; grade - LOINC IDPass ; Pass - Fail ; Fail -