Buttocks pain

[Netty]

76 year old lady patient came today as since yesterday she had a very painful left buttocks. She did not know how it had happened and had not had it occur before. She was in lots of pain whilst standing or walking but the pain eased almost totally off when sitting or laying down. Because she was in so much discomfort it was very hard to carry out tests on her. When she was laying prone a very local area was tender to touch but not really painful. Any suggestions to what you think it could be would be appreciated. I thought that it could possibly be the piriformis muscle gone into spasm! During examination she began to feel unwell and therefore I sent her straight away to the GP's for some painkillers.

Any ideas?

Thanks


Netty

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[emad]

Netty ,

It is sensitive Sciatica ..may be piriformis as you mentioned and may be other forms , it is better to avoid performing complete examination ...She can NOT bear !

cheers
Emad

[jwilso]

I feel that with any acute, irritable condition the best thing to do is get things to settle with painkillers and NSAIds.Mother nature is quite good you know!!!!! she has only had the problem for one day and so she will probably be a lot better in 48 hours time. if it was me treating her i wouldnt be chasing a diagnosis st this point.you did the right thing in sending her to her GP.

[Netty]

Thank you both for your responses. I have only been qualified for a short time and it is reassuring to be able to ask questions - and think that perhaps I did the correct thing by sending her to the Gp. I will let you know what the outcome is.

Netty

[alophysio]

Hi - it could be a disc herniation irritating the nerves that innervate the disc or PLL. These structures are linked in innervation to the sympathetic trunk and so could have caused her ill feeling.

In the end, if you can't diagnose what it is, you can't treat it. If there was no back pain then perhaps it is SIJ (think Fortin's area of pain). At that age, she is a candidate for spinal stenosis - either canal or foraminal.

Let us know what goes on.. Thanks

[wutti]

hi i agree with the SI joint thing of alophysio. disc herniation should increase the pain in sitting i would say. but its also possible. Also the hip joint might be reason for the problem, the age is typical for degenerative problems, i.e. arthrosis. that she felt unwell might be caused by pain, or she was nervous and afraid that pain increases or something like that. GP should rule out and intestinal problems as well.
hope you will let us know more, soon.

cheers

[alophysio]

Indeed the hip might be involved - there are so many things that could be going on.

A more thorough S/E and O/E would be nice!

[wutti]

yeap, thats right!! I always start with sorting out the "easy" ´possibilities and then getting more and more detailed and specific.
sometimes it works :-))

cheers

[alophysio]

I am trying to think why i didn't think of the hip at first.

I guess it was because most hip pain people i see complain of anterior hip pain / groin pain, not posterior hip pain.

Couple that with the fact that i have just been revising the spinal innervation and i guess that is why i came up with the disc...

THanks !

[wutti]

...and your right with your thinking. I was just thinking of hip joint regarding to the pat. age. ant. hip pain is the most common, i agree. but I saw also pat. with radiating pain to post. hip even up to the LS and also down to the knee joint.
But anyhow, all ways of thinking should lead us to the cause!! sometimes you start easy and bang, thats it, the next time its complete false. thats the biggest problem with the EBP (remember discussion in paed forum).
cheers

[jwilso]

i dont agree that you always need a diagnosis to treat. and i would also question whether or not a 76 yr old is likely to get a herniated disc. in my 11 yrs as aphysio i have only ever seen one patient over 70 that has required a discectomy.Degenerative condition most likely but still i say give nature chance.see if it settles with simple adivice regarding posture, avoiding aggravating activites and simple mobilising execises perhaps. if she is still having problems in a couple of weeks then i would reassess.

[wutti]

you dont need a diagnosis to teat, but you need the cause or an idea what the problem is or might be. nobody was talking about discectomy as for as i remember. we just collecting thoughts to find out what that pat. problems might be. and i saw several older people with disc herniation most of them treated conservatively. and if a degenerative hip joint is the reason for pain, i would also treat her conservatively as long as possible. but here my experience is that surgery comes up one day to save pat. living standard and keep them mobile. that can also hapen with herniated discs.
cheers

[jwilso]

i wasnt suggesting that anybody thought that she needed surgery i was using the incidence of discecetomy in elderly patients to merely point out that elderly discs do not tend to prolapse as they become dehydrated with age. she has only had pai for one day!!!!!!!!!!. do we not all get some low back pain or nerve root irritaion that simply settles itself after a few days. if we look at soft tissue healing the lag phase lasts about 5 days. this is when the inflammation is at its most active and the nervous system at its most sensitive. i personnally feel that treatmnet in the lag phase should be kept to R.I.C.E. for peripheral problems and possibly heat in back problems.at the end of the day she is probably going to have either

1/ exacerbation of OA hip
2/ acute sciatica
3/ Degenerative disc
4/ Si joint problem
5/ hip bursitis

why did she seek physio before seeing her GP??

[alophysio]

Probably well trained :P

[wutti]

@alophysio: good call!!:-))

@jwilso: thats all possible. i agree.

cheers

[jwilso]

newly qualified

[alophysio]

She might also have a burst fracture of the vertebra, especially if her disc is patent. Disc innervation is also linked to the Sympathetic trunk

[Netty]

An up-date....................spoke by telephone today to the patients son. The Gp gave her some strong pain killers, but on Sunday the patient was still in so much pain they ended up at A&E. The doctor there said it was her S-I joint and she should see an osteopath. She went to an osteopath yesterday whom was able to examine her (which I had been unable to do because of her pain) and he also said S-I and told her to do hot/cold treatment and she is going back to see him Thursday..........unfortunately I do not know any more than that at the moment - but I will keep you informed when I do!

Thanks for all your input

Netty

[jwilso]

I would like to know how the A&E Dr diagnosed an SI joint problem. The A&E Drs that i know either diagnose a bony injury ie fracture or a soft tissue injury ie sprain. i wouldnt always agree with a Doctors diagnosis anyway. Sorry for being sceptical. Iwas once referred a patient from A&E with a knee sprain that turned out to be a ruptured patella tendon . Maybe he has a friend that is an osteopath? the other thing i would say is the fact that the ostepath could assess her and you couldnt last week may sugeest that actually she is improving.

[alophysio]

Hmm, For and A&E dr to say SIJ i think is fairly progressive to be honest - most A&E just write things off as muscular if they can't find a #!!!The Dr might have had this problem in the past...

Netty, you didn't mention what they did at A&E. If they came to SIJ because eveything else had been excluded, then ok. If no XR of hip etc, then how?

[arkesh_physio]

how can u guys discuss so many probabilities without a proper assessment of the patient

[jwilso]

how can u guys discuss so many probabilities without a proper assessment of the patient

Hi Arkesh,
if we didnt discuss the probabilities what else would we talk about? we dont have the patient in front of us for every discussion forum on here. so what is everyone talking about???

[arkesh_physio]

Hi Arkesh,
if we didnt discuss the probabilities what else would we talk about? we dont have the patient in front of us for every discussion forum on here. so what is everyone talking about???

I think with a proper assessment of the patient we could have focussed better on the topic inspite of discussing too vaguely...