an approach to diagnosis and management 2015 aapm&r annual assembly

Evaluation of the Athlete with Buttock PainAn Approach to Diagnosis and Management2015 AAPM&R Annual Assembly

Disclosures• John Vasudevan, MD• University of Pennsylvania• None relevant

• Matthew Smuck, MD• Stanford University• None relevant

• Michael Fredericson, MD• Stanford University• None relevant

Objectives

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

Session Format

1. The DDx of Buttock Pain• Suggested Approach to Diagnosis

2. Clinical Review• Pearls of common diagnoses• Rare diagnoses

3. Case-Based Discussion

Basics• Buttock pain is a challenge• Local?• Referred?

• Most often with fitness activities featuring running, sprinting, kicking, jumping• So…pretty much any sport?

Key Questions

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?

DDx: +Back Pain• +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

DDx: -Back Pain, -Neuro Deficit• 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

Functional Assessment

MULTI-SEGMENTAL ROTATION

Thoracic

Lumbar

Hip

Foot/ankle

Where is the breakdown in biomechanics?

Functional Assessment

OVERHEAD SQUAT

Foot ankle

position

Knee position

Head position

UE position

UE positio

n

Thoracolumbar spine

mechanics

Functional dorsiflexion

Buckle up!

Diagnosis Review

Specific Disorders• Buttock Pain with Back Pain and with Neuro Deficit• Radiculopathy

• Buttock Pain with Back Pain and without Neuro Deficit• Muscle strain• Ligamentous sprain• Facet arthropathy• Spondylolysis and Spondylolisthesis• Ankylosing spondylitis• Sacroiliac joint pain• Sacral stress fracture

Back and Buttock Pain• 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 discouragedLawrence 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

Sacroiliac Joint Pain• 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

Sacral stress fracture• 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

Sacral stress fracture• 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

Specific Disorders• Buttock Pain without Back Pain and with Neuro

Deficit• Lumbosacral plexopathy• Sciatic neuropathy• (Radiculopathy)

Lumbosacral plexopathy and sciatic neuropathy• 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

Specific Disorders• Buttock Pain without Back Pain & without Neuro

Deficit• Greater Trochanteric Pain Syndrome• Tensor fascia lata/IT band syndrome• Piriformis syndrome• High hamstring tendinopathy• Ischial and greater trochanteric bursitis• Secondary to tendinopathies

Greater Trochanteric Pain Syndrome• 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

Step-down exercise

Fredericson 2011

Greater Trochanteric Pain Syndrome• 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

Piriformis Syndrome• 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

Piriformis Syndrome• 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

High hamstring tendinopathy• 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

Supine Plank

High hamstring tendinopathy• 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

Specific Disorders• Rare disorders• Posterior compartment syndrome• Myositis ossificans• Tumors: lipoma, myxoma, rhabdomyosarcoma,

osteochondroma• Entrapment of superior/inferior gluteal nerves• Gluteal claudication/thrombosis• External iliac endofibrosis

Rare Disorders• 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

Rare Disorders• 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

Rare Disorders• 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

References• Available upon request• Email John Vasudevan• john.vasudevan@uphs.upenn.edu• 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?

Therapeutic Considerations

General Treatment Principles

1. Reduction of Pain1. Modalities, manual therapies, NSAIDs

2. Remobilization1. ROM, strength, restoring muscle balance2. Isometric to concentric to eccentric3. Static to dynamic and functional

3. Rehabilitation1. Restore proper spine, pelvic, hip biomechanics2. Core stability3. Functional movement

Then on to the cases!

Questions?

Case #1• 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

Case #1• 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!

Case #1• MRI L-spine, then CT L-spine: sclerotic lesion with

central nidus contacting right S1 and S2 roots• Diagnosis: osteoid osteoma

MRI

CT

CT

CT

Assessment/Results• 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.

Discussion• 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.

Osteoid Osteoma• 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

Acknowledgements• Rob Wise, PT• Matt Ryan, MD

With Drs. Smuck & Fredericson

On to the other cases…

Thank you!john.vasudevan@uphs.upenn.edumsmuck@stanford.edumfred2@stanford.edu