I had a patient last week who got a little testy with me because they thought I was not listening. And for once, I could plead not guilty.

At stakes was an acute episode of pain along the right upper buttock, just above the iliac crest. The patient was upset that I was working higher up in the lower midback, close to the last rib. She thought I did not correctly hear her out when she described her pain.

Pain along the iliac crest, just lateral to the lumbar spine, can be tricky to diagnose because a lot of structures reside in the area, and several neurological structures refer to the area as well. Most of the time, the pain is indeed coming from a local problem (upper sacroiliac, QL muscle, L5), but there is a pesky little sensory nerve bundle that travels all the way down from the lower midback and can cause mischief in the area. The distribution of the cluneal nerves is quite lateral, typically a vague achy sensation that patients have a hard time pinpointing, and sometimes associated with a tingling sensation. Cluneal neuritis will only respond to treatment in the area of origin, which is much higher than the area of pain. That is probably why I most often see it in its chronic stages, when patients have unsuccessfully tried various local therapies.