Transcript Matthew Smuck, MD

The Evaluation of The Athlete With
Buttock Pain: An Approach To
Diagnosis And Management
AAPM&R Annual Assembly
October 2nd, 2015
Matthew Smuck, MD
Chief, Physical Medicine & Rehabilitation
Associate Professor, Department of Orthopaedics
Director, Wearable Health Lab
Stanford University
DISCLOSURES
Cytonics - Research support ($ - paid to institution)
Lumo BodyTech - Advisor (stock options)
BlueJay Mobile Health - Advisor (stock options)
Vivametrica - Founder (20% owner)
State Farm Auto Insurance - Expert Witness ($ - hourly)
SIS - Board of Directors ($ - travel/honoraria)
The Spine Journal - Executive Editorial Board ($ - travel)
Evaluation of The Athlete With Buttock Pain
 CASE 1 –
“A CHALLENGE FOR THE 4
DIAGNOSTIC SENSES”
 60 yo competitive cyclist with acute onset right buttock pain,
followed by right leg symptoms.
Day 1
Day 2-3
Day 4
Day 5
– acute pain onset while cycling uphill
– leg pain and numbness improved with rest
– buttock pain with thigh and calf cramping when walking
– visit with PCP, lumbar MRI and PM&R consult
Evaluation of The Athlete With Buttock Pain
 CASE 1 –
“A CHALLENGE FOR THE 4
DIAGNOSTIC SENSES”
 60 yo competitive cyclist with acute onset right buttock pain,
followed by right leg symptoms.
PM&R visit:
– Look - MRI shows no herniaiton, no stenosis
– Listen - Claudication with activity, not while standing
– Feel - localized gluteal tenderness, no other provocation
– Feel - normal neuro, diminished pedal pulses on the right
Evaluation of The Athlete With Buttock Pain
 CASE 1 –
“A CHALLENGE FOR THE 4
DIAGNOSTIC SENSES”
 60 yo competitive cyclist with acute onset right buttock pain,
followed by right leg symptoms.
WHAT DO YOU DO NEXT?
Evaluation of The Athlete With Buttock Pain
 CASE 1 –
“A CHALLENGE FOR THE 4
DIAGNOSTIC SENSES”
 60 yo competitive cyclist with acute onset right buttock pain,
followed by right leg symptoms.
Vascular Surgery visit:
– ABI = 0.6/1.0 (right/left)
– CT angiogram = dissection and partial occlusion of the
common iliac artery
SURGERY THE FOLLOWING DAY
Evaluation of The Athlete With Buttock Pain
 VASCULAR BUTTOCK PAIN
 Aneurysms and pseudoaneurysms
- Iliac arteries (common, internal, external)
- Sciatic artery
- Gluteal arteries (superior, inferior)
 Dissections and AV Fistulas
- Iliac arteries
 Endofibrosis and kinking
- Iliac arteries
Evaluation of The Athlete With Buttock Pain
VASCULAR
BUTTOCK PAIN
Evaluation of The Athlete With Buttock Pain
VASCULAR
BUTTOCK PAIN
Evaluation of The Athlete With Buttock Pain
 CASE 1 –
 Look
 Feel
“A CHALLENGE FOR THE 4
DIAGNOSTIC SENSES”
 Listen
Evaluation of The Athlete With Buttock Pain
 CASE 1 –
“A CHALLENGE FOR THE 4
DIAGNOSTIC SENSES”
 Look
 Listen
 Feel
 Smell
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 15 yo competitive baseball player with severe left upper
gluteal pain when batting.
July 13
Sept 13
Nov 13
Dec 13
Feb 14
– pain onset, continued play
– MRI shows pars stress reaction, restricted play
– pain free return to play
– MVC with return of pain
– first presents to our clinic with the following images
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 15 yo competitive baseball player with severe left
upper gluteal pain when batting.
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 15 yo competitive baseball player with severe left upper
gluteal pain when batting.
WHAT DO YOU DO NEXT?
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 15 yo competitive baseball player with severe left upper
gluteal pain when batting.
Feb 14
– first presents to our clinic
LET IT HEAL!
April 14 – pain free with progressive training, but left-sided
pain returned with recent attempt to resume batting
The following images were obtained:
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 15 yo competitive baseball player with severe left
upper gluteal pain when batting.
LET IT GO!
Thanks to D.J. Kennedy!
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 DX: Pars Stress Fractures
STANDARD EXAM
 Inspection, Palpation, ROM,
Neurovascular, Special tests
ONE
LEGGED HYPEREXTENSION
 “No association between test
and presence or absence of
active spondylolysis”
Masci 2006
Thanks to D.J. Kennedy!
Evaluation of The Athlete With Buttock Pain
 CASE 2 –
“LET IT HEAL OR LET IT GO”
 DX: Pars Stress Fractures
MRI
- BEST DEMONSTRATION OF OTHER PATHOLOGY
- LACKS SENSITIVITY?
 Case reports of missed lesions
 Spect vs MRI
› 40 pars fractures
› MRI positive in 39/40
› Correctly graded only 29/40
› Several false positives
Campbell 2006
Thanks to D.J. Kennedy!
Imaging Algorithm
History & Physical
Plain Films
• AP and Lateral (Spondylolisthesis)
Treat presumptively
Only Advance Imaging if: No response to treatment, red
flags ,etc
If no response
• MRI (eval for bone edema)
If still no response and negative MRI
• Bone Scan
Thanks to D.J. Kennedy!
CT Correlating with boney union
LIKELIHOOD TO HEAL
 L4
 L5
- (22/35) = 63%
 Listhesis > 5˚
 Listhesis < 5˚
- (3/65)
- (18/204) = 8.8%
Fujii 2004
= 4.6%
- (37/174) = 21%
Thanks to D.J. Kennedy!
Why CT scan?
VERY GOOD BONY ANATOMY
 Sensitivity less than bone scan
Early
CORRELATION WITH BONY UNION
 134 pts with 239 pars
- Early
(31/50) = 62%
- Progressive (9/103) = 8.7%
- Terminal
(0/86) = 0%
Terminal
Fujii 2004
Thank You!
Matthew Smuck, MD
Chief, Physical Medicine & Rehabilitation
Associate Professor, Orthopaedic Surgery
Director, Wearable Health Lab
Stanford University
[email protected]