Transcript Evaluation of the Athlete with Buttock Pain An

An Approach to Diagnosis and
Management
2015 AAPM&R Annual Assembly
• John Vasudevan, MD
• University of Pennsylvania
• None relevant
• Matthew Smuck, MD
• Stanford University
• None relevant
• Michael Fredericson, MD
• Stanford University
• None relevant
1. Develop an effective clinical approach to the patient
with buttock pain
2. Discuss the optimal diagnostic work-up and treatment
based on the diagnosis
3. Design a rehabilitation for effective return to sport
and injury prevention
1. The DDx of Buttock Pain
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Suggested Approach to Diagnosis
2. Clinical Review
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Pearls of common diagnoses
Rare diagnoses
3. Case-Based Discussion
• Buttock pain is a challenge
• Local?
• Referred?
• Most often with fitness activities featuring running,
sprinting, kicking, jumping
• So…pretty much any sport?
1. Is there concomitant low back pain?
2. Is there altered strength, sensation, or reflexes?
3. Is the pain predominantly posterior, lateral, anterior,
or medial in the hip/pelvic region?
• +Neurologic deficit: lumbosacral radiculopathy
• -Neurologic deficit, spinal: discogenic pain, facet
arthropathy, spondylolysis, spondylolisthesis, lumbar
spinal stenosis
• -Neurologic deficit, extraspinal: sacroiliac joint
dysfunction, sacral stress fracture, iliolumbar ligament
sprain, active trigger point
• Posterior: high hamstring tendinopathy, ischial bursitis,
piriformis myalgia, gluteal strain, posterior compartment
syndrome
• Lateral: gluteus medius tendinopathy, greater trochanteric
pain syndrome, tensor fascia lata/IT Band syndrome
• Anterior: labral tear, femoroacetabular impingement,
osteoarthritis, iliopsoas tendinitis, femoral neck stress
fracture
• Medial: adductor tendinitis, athletic pubalgia, osteitis pubis
Not just what, but why
Functional Assessment
MULTI-SEGMENTAL ROTATION
Thoracic
Lumbar
Hip
Foot/ankle
Where is the breakdown in biomechanics?
Functional Assessment
OVERHEAD SQUAT
Head position
Thoracolumbar
spine
mechanics
UE
position
UE position
Knee
position
Foot ankle
position
Functional
dorsiflexion
Buckle up!
• Buttock Pain with Back Pain and with Neuro Deficit
• Radiculopathy
• Buttock Pain with Back Pain and without Neuro Deficit
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Muscle strain
Ligamentous sprain
Facet arthropathy
Spondylolysis and Spondylolisthesis
Ankylosing spondylitis
Sacroiliac joint pain
Sacral stress fracture
• Muscle strain/Ligamentous sprain
• 90% of all injury; don’t forget the iliolumbar ligament
• Lumbosacral radiculopathy
• 10% of adolescent back pain (may present atypical); 85% return
to sport by 6 months
• Facet arthropathy
• >40 years old; joint effusion may cause radicular pain
• Spondylolysis
• Bracing makes no difference*; recovery ≠ bony healing
• Ankylosing Spondylitis
• 1.2% prevalence; young person acting like an old person; contact
sports discouraged
Lawrence 2006; Watkins 1996; Kraft 2002; Trainor 2004; Iwamoto 2010; Trainor 2004; Anderson 2001; Heck 2000;
Sairyo 2010; McTimoney 2003; Standaert 2001; Kraft 2002; Trainor 2004; Sassmannshausen 2002; Tallarico 2008;
Saraste 1987; Miller 2004; Harper 2009; Jennings 2008; Harper 2009; Lim 2005; Thumbikat 2007
• Joint allows flexion/extension, superior/inferior glide
• Average 2° rotation and 0.5mm AP translation
• Gold standard of diagnosis is by diagnostic injection
• If presentation supports and work-up for spinal Dx unrevealing
• Treatment:
• Abductor and short external rotator strength, manual
mobilization, SI belt (may limit motion up to 30%), foot orthoses
for LLD, steroid injection
Sturesson 2000; Atlihan 2000; Fortin 1999; Brolinson 2003; Chen 2002; Tibor 2008
• Most often observed in young female runners
• Also documented in young male soldiers
• Commonly missed in pregnancy/postpartum state
• Often increased intensity and/or nutritional deficiency
• Less often a primary hormonal disorder, but up to 75% have a
history of dysmenorrhea 2/3 osteopenia, 1/6 osteoporosis
• May present as SIJ dysfunction
• Imaging: Bone scan sensitive within 72h, MRI may
remain negative in early stage
Bottomley 1990; Fredericson 2003; Johnson 2001; Schils 1992; Volpin 1989;
Fredericson 2007; Celik 2013; Perdomo 15; Speziali 2014; Solmaz 2013
• Treatment: PWB until can ambulate without pain, core
strength and attention to proximal kinetic chain and
running biomechanics
• Start with swimming, water running, cycling, antigravity
treadmill
• Full return to sports takes ~12 weeks, perhaps sooner if no
identified components of female athlete triad
• Encourage Calcium and Vitamin D supplementation, review diet!
Fredericson 2003; Tenforde 2012
• Buttock Pain without Back Pain and with Neuro Deficit
• Lumbosacral plexopathy
• Sciatic neuropathy
• (Radiculopathy)
• Rare in athletes
• Case series of 216 peripheral nerve injuries in athletes
• 31 to lower limbs, only 2 sciatic neuropathies
• Trauma to pelvic ring may effect L4 and L5 roots which
pass anterior to sacral ala and SIJ
• Suspicion for neoplasm, endometriosis, visceral disease
• Work-up: EMG, MR pelvis, MR neurography
Wilbourn 1998
• Buttock Pain without Back Pain & without Neuro Deficit
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Greater Trochanteric Pain Syndrome
Tensor fascia lata/IT band syndrome
Piriformis syndrome
High hamstring tendinopathy
Ischial and greater trochanteric bursitis
• Secondary to tendinopathies
• Gluteus medius: hip abduction and hip internal (anterior
fibers) and external (posterior fibers) rotation
• Functional consequence of weakness is decreased running speed,
jumping distance, limb stability with lunging or landing
• Associated with tightness of tensor fascia lata/iliotibial band
• Exam: single-leg squat or step-down
• Lateral pelvic shift, pelvic drop, trunk sway indicate weakness
• Lateral hip pain, +FABER, and –pain with donning shoes
Ho 2012; Presswood 2008; Earl 2005; Hertel 2005; Bird 2001; Wilson 2005; Fearon 2012
Fredericson 2011
• Treatment:
• Strengthening (open-chain NWB > closed-chain WB)
• Stretching and myofascial release of TFL/ITB
• MRI if conservative measures fail
• Assess for tendon tears
• Consider injections (steroid, PRP), needle tenotomy
• Greater trochanteric bursa > sub-gluteus medius bursa injection
• Tendinopathy > bursitis under ultrasound
Fredericson 2000; Engebretson 2010; McEvoy 2012; Klauser 2013; Mallow 2014; Long 2012
• Definition (Robinson, 1947): buttock and posterior leg pain secondary to
compression of sciatic nerve by enlarged or inflamed piriformis
• Most common in sports with frequent hip flexion, adduction, IR
• ~5 million coded cases/year but only 5 documented cases with
electrodiagnostic and surgical confirmation!
• Better term: piriformis myalgia
• Secondary to weakness of larger gluteal muscles
• Diagnostic Criteria: Pain and tenderness as excepted,
negative imaging and EMG, positive response to guided
injection
Robinson 1947; Bravman 2009; Stewart 2000; Natsis 2014; Miller 2012
• Exam: concordant pain with active hip ER/extension or
passive hip IR/flexion
• Special tests: Freiberg, Pace, Beatty, FAIR (none validated!)
• Treatment (Fishman study: spray/stretch, massage,
ultrasound for deep heat, stretching of piriformis,
strengthening of gluteals
• Guided injections of anesthetic, steroid, botulinum toxin
• Limited evidence to support
• Surgical release not recommended without +EDX findings
• Sciatic neuropathy is a complication!
Beatty 1994; Fishman 2002; Freiberg 1934; Pace 1976; Finnoff 2008; Fishman 2004; Gonzalez 2008; Hanania 1998;
Huerto 2007; Lang 2004; Reus 2008; Smith 2006; Yoon 2007; Martin 2014; Kitagawa 2012; Tenforde 2015; Justice 2012
• Common in middle/long-distance runners, worse with acceleration
• Weakness/fatigue with eccentric contraction in late swing phase
• Exam: tender over ischial tuberosity, positive supine
plank and bent-knee stretch tests
• Pain in children/adolescents raises concern for apophysitis
• Imaging: x-ray (bony avulsion), MRI (may indicate
prognosis for recovery)
• MRI: Increased tendon size, peritendinous T2 signal with a distal
feathery appearance, and ischial tuberosity edema
Fredericson 2005; Koller 2006; Sutton 1984; Puranen 1988; Verrall 2001;
Verrall 2003; Askling 2007; De Smet 2011; Cacchio 2011
• Treatment:
• Pool running allows non-impact training during rehabilitation
• Strength: double to single limb, static to dynamic/plyometric,
eccentric exercise, core strength, muscle co-activation
• Recalcitrant cases
• US-guided peritendinous corticosteroid (50% relief at 1 months,
24% at 6 months), or intratendinous platelet-rich plasma
• Extracorporal shock wave therapy
• Surgical debridement
Robinson 1947; Bravman 2009; Stewart 2000; Ohberg 2004; Wilder 1994; Fredericson 2005, Kuszewski 2009; Sherry
2004; Zissen 2010; Clanton 1998; Lempainen 2007; Sarimo 2008; Servant 1998; Fader 2014
• Rare disorders
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Posterior compartment syndrome
Myositis ossificans
Tumors: lipoma, myxoma, rhabdomyosarcoma, osteochondroma
Entrapment of superior/inferior gluteal nerves
Gluteal claudication/thrombosis
External iliac endofibrosis
• Posterior Compartment Syndrome
• Tightness/claudication pain with exercise, predictable and
progressively worsening onset
• Usually with acute traumatic history (e.g., hamstring avulsion)
• Assess with compartment pressure testing
• MRI may reveal edema in muscles
• Chronic compartment syndrome has also been described
Brandser 1995; Franklyn-Miller 2009; Hynes 1994
• Tumors: Commonly myositis ossificans, lipoma, myxoma,
rhabdomyosarchoma, osteochondroma (children)
• Entrapment of superior/inferior gluteal nerves
• After local buttock trauma (fracture, surgery, injections)
• Thrombosis of gluteal vasculature
• Associated with claudication, peripheral vascular disease,
coronary artery disease, smoking
• Evaluate with ankle-brachial index, duplex ultrasound,
angiography
Blitman 2009; McCrory 1999; Rask 1980; Batt 2006; Berthelot 2007
• External iliac artery endofibrosis
• May be the cause of exercise-induced lower limb claudication in
as much as 10-20% of elite cyclists
• Luminal narrowing consequent to repetitive compression and
intimal damage from vascular kinking underneath psoas muscle
• Not exclusive to cycling: key is repetitive extreme hip flexion
Ford 2003; Lim 2009
• Available upon request
• Email John Vasudevan
• [email protected]
• Or see: Vasudevan JM, Smuck M, Fredericson M. Evaluation of the Athlete
with Buttock Pain. Curr Sports Med Reports. 2012;11(1): 35-42.
What does/should your physical therapy include?
1. Reduction of Pain
1. Modalities, manual therapies, NSAIDs
2. Remobilization
1. ROM, strength, restoring muscle balance
2. Isometric to concentric to eccentric
3. Static to dynamic and functional
3. Rehabilitation
1. Restore proper spine, pelvic, hip biomechanics
2. Core stability
3. Functional movement
Then on to the cases!
• 15-year-old female lacrosse athlete with distal leg pain
• Progressive, 1.5 years, worse at night, responsive to ibuprofen
• Initially posterolateral right knee and leg
• XR/MR knee: bony contusion at lateral femoral condyle
• Pain progressed proximally into thigh and buttock
toward low back
• Tender over right sacroiliac joint
• Intact reflexes and sensation BUT mild weakness of right ankle
plantarflexion; negative neural tension signs
• What is your leading diagnosis, and why?
• What would be your next clinical step for this diagnosis?
• What is your alternate diagnosis, and why?
• What would be your next clinical step for this diagnosis?
• Discuss with you neighbor to the left and right!
• MRI L-spine, then CT L-spine: sclerotic lesion with
central nidus contacting right S1 and S2 roots
• Diagnosis: osteoid osteoma
• The patient underwent surgical excision of the tumor,
with pathologic confirmation of osteoid osteoma.
• Her symptoms had resolved by 3 weeks post-op and was
cleared for gradual return to her athletics.
• A unique presentation and possibly the first report of a
sacral osteoid osteoma presenting initially as distal leg
pain and progressing proximally in an adolescent
athlete.
• Benign osteoblastic tumor with central nidus and
surrounding sclerotic bone
• Most often 1-2 cm diameter, 80-90% in long bones
• Classically worse pain a night, improves with NSAIDs
• Lag between symptoms and radiographic signs
• CT most specific for diagnosis and procedural planning
• Treatment: surgical excision, CT guided excision, laser
or radiofrequency ablation
• 12% recurrence rate
• Rob Wise, PT
• Matt Ryan, MD
With Drs. Smuck & Fredericson
[email protected]
[email protected]
[email protected]