Back and buttocks pain

[marticlar]

A 50 year old patient has been suffering from severe buttock pain whilst sitting for about 3 weeks. He doesn't kow what caused it but says that it is probably after lifting a heavy box. He feels pain in the left buttock, and walking and lyign supine eases the pain. The pain seemed to be aggravating until this morning, when the pain decreased slightly. He doesn't have and sensory abnormality.

During trunk flexion, his fingers reach till just below the knees and thinks that before, he used to reach lower. The movement is stopped by pain. ON trunk extension, the has slight pain at the end of ROM. Left side flexion is limited by pain, which on right side flexion no pain is felt.

Right straight leg rain was till about 70-80 degrees, and pain was felt in the left buttock. Left straight leg raise was also till about 80 degrees and the patient only felt very slight pain. However, the patient didnt seem sure about the pain after both SLR. And so I decided to redo them some minutes later. He didnt fell any pain limiting the SLR then! The slump test was immediatley positive even before carrying out the combined leg extension.

I thought of a minor disc prolapse, and gave him some McKenzie exercises to do. During the exercises the patient did not complain pof any pain. But immediately after the exercises he was in severe pain.

Do you have any ideas please?

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[wutti]

hi, sounds like a disc prolapse or protrusion. what about slight mobi and bedding the pat. in side lying (right side) with a chusion under right side and knees flexed 90°. is pain decreasing? i used that in acute pain and it worked pretty well. you can also start with some pelvic floor and core muscle exercises and active mobi of LS from this position.
also little massage/friction and stretching of lower back muscles might be usefull, sound that they are in spasm (limited flex).
good luck

[junior_physiotherapist]

Hi marticlar

i think u have to referr ur patient to a phyician specialied in orthopedic & or neurology in order to being have a clear diagnosis related to ur patient

It is the best to idenitfy underlying cause to help us to assess and give an effective plan of treatments...


Regards

[jwilso]

Hi Marticlar,
i would like you to answer a few questions please.

1/ any back pain?
2/ why do you think the right SLR was more restricted than the left when the pain is right sided?
3/ how did you come up with your diagnosis?
4/ you say that you gave Mckenzie exercises, which ones. by this i assume you mean extension in lying, but from your assessment there doesnt appear to be clinical reasoning for this. can you explain?
5/ is the patient off work? what is his/her job ?
6/ Posture?
7/ how many times have you seen them? if it is only once then he may have been worse after the exercises due to what you had done in the asessment rather than the exercises.

Hope to here more from you.

john

[sdkashif]

It seems to me that your patient is suffering from Acute Mechanical Backache (Back pain less than 6 week duration) with injury to both anterior and posterior elements as the history and pain pattern or provocation on testing the spinal movements suggest. Please perform additional examination of the Sacroiliac joints and hip joint to rule out any problems in these region. Perform a detailed neurological examination of lower limb for spine including sensory, motor and reflex testing examination. Let me know about your findings.

[jwilso]

how can you diagnose acute mechanical back pain from a derscription that doesnt even mention back pain. he only says that there is buttock pain!

[sdkashif]

how can you diagnose acute mechanical back pain from a derscription that doesnt even mention back pain. he only says that there is buttock pain!

Perhaps you are not well aware of the definition of Lower Back Pain and classification system of acute, subacute and chronic Low back pain. Kindly have a look over the information taken from EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARE


"Definitions
Low back pain is defined as pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain.
Acute low back pain is usually defined as the duration of an episode of low back pain persisting for less than 6 weeks; sub-acute low back pain as low back pain persisting between 6 and 12 weeks; chronic low back pain as low back pain persisting for 12 weeks or more."

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARE

[jwilso]

i take your point sdkashif. but without seeing the patient and with only limited info i am only saying that you cannot assume it is a back problem. could it be a hamstring problem? is the pain around the ischial tuberosity? has the patient simply been spending too much time sitting? i hope marticlar keeps us up to date.

[sdkashif]

I was just reviewing the patient case and discussing the possibilities as a result of current findings of the clinician. That is why I suggested him that he should perform additional examination for the rest of locomotor system to rule out other problems. Any how a clinician assessing a patient is in best position to tell us his assessment. But we are here just to comment upon the current patient subjective and objective examination and the possibilities of proposed & suggested diagnosis as a result of assessment. The proposed suggestions were the comments upon the current findings of the clinician.

[jwilso]

again i take your point but i do think that sometimes if people are really looking for useful help then they should give us a bit more infomation from their assessment. any spinal examination should routinely involve sensation, myotomes and reflexes. also more info regarding patients general health, posture,weight etc would help. surely you must agree

[sdkashif]

Yeah the case presentation is not complete as there no detail subjective and objective examination. And it is difficult to make any suitable diagnosis from these details. More detailed assessment is required.

[piyushphysio]

I'm also agree that there should be some examination of hip and SIJ and muscles associated with these joints. Neurological examination will give an idea that whether its a back problem or the nerve compressed somewhere at hip. To me it sounds like piriformis syndrome but not sure until the area and muscle are tested.

[arkesh_physio]

He is giving a H/o lifting heavy weight so we should focuss more on Discal Bulge.
I suggest u to check PAIVMS which will give a clear picture.
Regards
Ark

[tagreed-pt]

I agree with arkesh physio. it seems to be a back problem( disk prolabse) not just a local buttock problem.

[alophysio]

It seems that people love to blame the discs for the pain but there are so many innervated structures in the spine that could cause pain.

Matriclar, you describe a stretch pattern of pain - that is FF and LF L produce pain on the right buttocks. This could be from ligaments, joints, disc, muscles, nerves, dura etc

More information is needed to narrow down the source and cause of the pain. Bending over and lifting with a twist can be strain at the L/S, SIJ and Hip.

Fortin described SIJ pain as being from the PSIS/SIJ joint line and lower. So far, there is no L/S pain so SIJ would be ahead at the moment in the list of structures to test.

Thanks