Inferior gluteal pain with sitting, unrelated to ischial bursitis

A 64-year-old woman presented to an academic medical centre with postoperative left ischial pain following a left total hip replacement. Her pain was exacerbated by sitting down and with forward flexion of the spine, and the pain radiated from the left ischial tuberosity to the left perineum, groin and medial thigh. An ischial bursa injection was performed, but only resulted in 1 day of excellent pain relief. A diagnosis of inferior cluneal neuralgia was then made. Subsequent inferior cluneal nerve radiofrequency ablation was performed, and provided sustained 50% relief in pain. The patient had a concomitant sensation of ‘ball like’ pressure at her rectum which was determined to be due to levator ani syndrome. She was prescribed pelvic floor physical therapy and botulinum toxin injection, which resulted in further notable improvement of her symptoms.