Case Report · The Fascia Institute
The “back pain” that was really the glute
A competitive golfer lost three months to “low back pain” that even radiated down his leg — and an MRI that seemed to point at his spine. But the imaging didn’t match his symptoms. The real culprit was a scarred gluteal muscle, and a single ultrasound-guided hydrodissection had him swinging pain-free within days.
Jacques Courseault, MD, CAQSM, FAAPMR · The Fascia Institute and Treatment Center®
· Golf Injury · Gluteal Pain · Pseudo-Sciatica · Hydrodissection
Patient
45-year-old male, 5-handicap golfer
Presentation
3 months of right low-back / buttock pain with leg radiation; can’t swing
Key Finding
Right gluteus maximus fibrosis on ultrasound; MRI didn’t explain it
Outcome
Pain-free swing; back to full golf in 3 days
01 · Presentation
Three months off the course
A 45-year-old man — a competitive 5-handicap golfer — hadn’t been able to play for three months. It started mid-swing: he felt a sharp pull in his right low back and buttock and hadn’t been the same since. His pain was mild at rest but flared with sitting, and he couldn’t take a full swing without significant pain. It also traveled down the right leg, though he had no weakness in the leg — an important detail.
He’d already had a lumbar MRI. It showed a mild disc bulge at the left L5/S1, without any nerve contact. On paper, that can sound like an explanation. Look closer, though, and it doesn’t hold up.
02 · The Imaging Didn’t Add Up
His MRI pointed the wrong way
Two things about that MRI should stop you. First, the disc bulge was on the left — but all of his pain was on the right. Second, the report explicitly noted no nerve contact. A finding that’s on the opposite side and isn’t touching a nerve simply can’t be the source of right-sided pain.
What the MRI showed
LEFT L5/S1 disc bulge · no nerve contact
An incidental finding — on the opposite side from his symptoms, and touching nothing.
Where the pain actually was
RIGHT gluteus maximus
A scarred, inflamed muscle — invisible on a lumbar-spine MRI, but obvious on ultrasound.
This is the rule, not the exception. In a large review, disc bulges appeared in 30% of pain-free 20-year-olds and 84% of pain-free 80-year-olds — findings so common they’re often just normal aging, “unassociated with pain” (Brinjikji et al., AJNR, 2015). Just as importantly, a lumbar MRI can’t even see the buttock: as one review of gluteal causes of sciatica put it, spine MRI “does not visualise the deep gluteal space and will not identify” a problem there (British Journal of General Practice, 2019).
03 · Evaluation
The exam and ultrasound told the real story
On physical exam, his pain localized cleanly to the right gluteus maximus — not the spine. We then scanned that muscle with diagnostic ultrasound, which revealed a focal area of chronic fibrosis with inflammation: scar tissue where the muscle and its fascia had failed to heal smoothly after the swing injury. For the first time, the picture matched the patient.
Diagnostic ultrasound showing focal fascial thickening and inflammation — the hallmark we target and release. Representative image · The Fascia Institute and Treatment Center.
Why ultrasound, not just the MRI
MRI is superb for the spine but blind to the gluteal soft tissue in this kind of case. Point-of-care ultrasound let us look exactly where it hurt, in real time, and see the fibrosis that was actually generating his pain — turning a three-month mystery into a specific, treatable target.
04 · Intervention
Ultrasound-guided hydrodissection — and a telling moment
Under ultrasound guidance, we performed a hydrodissection into the fibrotic area of the gluteus maximus, injecting fluid to separate and release the adhered, scarred tissue. As we reached the spot, the injection briefly reproduced his exact pain — a valuable confirmation that we’d found the true pain generator. Moments later, he stood up and took his golf swing without pain. The pain down his leg was gone, and he could sit comfortably.
The Injury
Swing overload
A forceful swing strained the right gluteal muscle and fascia — the power base of the golf swing.
The Problem
Fibrosis & referral
It healed as scar / adhesion, staying inflamed and referring pain down the leg — mimicking sciatica.
The Release
Hydrodissection
Ultrasound-guided fluid released the scarred tissue — reproducing, then resolving, his pain.
Educational illustration · The Fascia Institute and Treatment Center
05 · Outcome
Back to full golf in three days
After three months of failed rest and a misleading MRI, one correctly targeted procedure changed everything. He returned to full golf within three days, swinging and sitting without pain and with no leg symptoms. Because a hydrodissection also kick-starts healing in the released tissue — not just masks the pain — the goal is durable recovery, not a temporary quiet.
06 · Discussion
When “sciatica” is really the buttock
Gluteal pain is one of the great impostors in musculoskeletal medicine. Because the buttock can refer pain down the leg, it’s routinely mislabeled as “low back pain” or “sciatica” — and because a lumbar MRI so often turns up an incidental disc bulge, that false trail gets a stamp of approval. Patients can spend months (or years) treating a spine that was never the problem.
Why golfers, and why the glute? The gluteal muscles are the engine room of the golf swing — the power base for trunk rotation — and low back pain is the single most common complaint in golfers of every level. When strength, mobility, or technique fall short, that rotational load lands on the gluteal and lumbopelvic tissues, and glute activation is repeatedly tied to both causing and relieving golfers’ back pain (Low back pain and golf: biomechanical risk factors, 2022). A single overloaded swing can strain the muscle; if it heals as fibrosis, you get exactly this picture.
Why hydrodissection works here. Once ultrasound identifies an adhesion, the fix is mechanical: fluid injected under imaging separates the scarred planes and restores glide, and the technique is well-tolerated and safe (systematic review of ultrasound-guided hydrodissection, 2024). It’s the same approach Dr. Courseault first published for chronic hamstring injury and uses in our Hydrofascia Release™ program.
The clinical lesson
Match the findings to the patient. Right-sided pain with a left-sided, nerve-sparing MRI finding is a red flag that the imaging is incidental — and a cue to examine (and scan) the muscle that actually hurts. Read our companion case of a wasp sting resolved with hydrodissection for another example.
07 · Prevention & Recovery
Keeping the glute healthy and firing
Recovery doesn’t end at the injection. We pair it with a return-to-play plan built on gluteal strength and hip mobility — the foundation of a safe, powerful swing — plus smart load management around practice and rounds. For day-to-day maintenance, we like percussive massage after practice and rounds to keep the gluteal tissue supple, alongside the other evidence-based recovery strategies we’ve reviewed. If a strain doesn’t settle, that’s the signal to get evaluated before it becomes three lost months.
References & Further Reading
1. Brinjikji W, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015. — PMC
2. Deep gluteal syndrome: an overlooked cause of sciatica. Br J Gen Pract. 2019. — BJGP
3. Low back pain and golf: A review of biomechanical risk factors. 2022. — PMC
4. Safety and Efficacy of Ultrasound-Guided Perineural Hydrodissection: A Systematic Review. 2024. — PMC
5. Courseault J, et al. Fascial Hydrodissection for Chronic Hamstring Injury. Curr Sports Med Rep. 2019. — PubMed
6. The Fascia Institute — What is a Fascial Hydrodissection / Hydrorelease?
This is a single, de-identified patient case shared for education; individual results vary and this is not medical advice, nor does it create a physician–patient relationship. Imaging should always be interpreted alongside a clinical exam by a qualified physician. The Fascia Institute and Treatment Center® · 2520 Harvard Ave, Ste 2B, Metairie, LA 70001 · (504) 704-1254.
