Torn Glute?

[lrockwood]

Hello,

I have torn something which I think is my glute.

I'm a yoga student/teacher and I've torn hamstrings so badly they bled (interally) and intercostals so it hurt to laugh. I know muscle pulls, but this one is ridiculous. I'm doped up on pain killers and still can barely move.

I live on a island at the moment, so the medical advice here is not good. I don't know if a doctor can help, but I've heard that mabye I need surgury?

Pain is right at the top of my pelvis on the left side (very top of my butt). Any kid of movement hurts, but the worst is if I rotate my leg (any kind of hip movement). The longer I sit still, the worse it gets. Mornings are awful.

It's "take your breath away" bad.

Everyone keeps suggesting it's a spine or sacrum thing, but I'm super familiar with those injuries and what they feel like. This is some tissue (muscle, tendon?) way over on the left right at the pelvis. I can backbend perfectly, deeply, with no pain at all--but just crossing my legs on the floor is brutal.

It's been getting worse over the course of 4 months. I've lightened way up on my practice, but in general, I do heavy stretching all the time, every day for 5+ years.

If this is going to go away, I can deal with it. But if I need surgury, can someone suggest? That would be a last resort for me as I'm not big on the idea.

Any help would be VERY appreciated.

Thanks!
Lucas

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[karen.hankey]

I would doubt that you have torn your Glut. You would have had to do something severe to do this.

My initial thought would be a sacro-iliac joint problem. But I would suggest you get yourself check out by a physio

[lrockwood]

Thanks for the reply. I know. Seems impossible to tear a glute, but the doctor in the ER came to the same conclusion. The pain is way too far from my SI joint to be related unless it's a nerve thing.

How to explain... put your hands on your hips. Right where your thumb touches, that's where it is. It's swollen and everything. I'm guessing that's where the glute inserts onto the pelvis, no?

It's now 1/2 as bad (pain) as it used to be and I can even slowly touch my fingers on the floor. That said, I have to take tons of ibuprofin and muscle relaxers to get through the day.

For healing, is there anything I can do to speed it up? Foods or supplements?

Thanks again,
Lucas

[karen.hankey]

If I understand what you mean about putting my hands on my hips, then my thumb lies directly over my sacro-iliac joint. It is not you spine, it is where your spine joins your pelvis. Your glut max attaches to the inferior border of the iliac crest and has quite a big attachment.

Sacro-iliac joint problems are generally caused by stretching for an object whilst you are bent over. It goes stiff when you don't move it and doesn't like being slouched. So this fits in with first thing in the morning pain as you are stiff from not moving over night. This is either the same for sitting, or you are not sat with your bum in the back of the seat allowing posterior tilt of the pelvis that put stress on the sacro-iliac joint.

[lrockwood]

Hmmm... I see what you mean. Maybe it is my SI joint. That would explain why twists and hip rotation are so painful and why it was one my right side and then switched to the left.

Now the million dollar question... what can I do to heal it? I'm stretching, taking MSM, using heat, etc.

Thanks again!
Lucas

[physiobob]

I agree that this sounds like a referred pain issue. Could be the pelvis or could be the lumbar spine. Also could be the attachment of quadratus lumborum from the waist down onto the pelvis. Pain in this region is common on palpation with these types of issues but less so on simple leg rotation (I am thinking this was inwards?).

Lying down symmetrically on your back and get someone to check the apparent length of your legs and let is know if they are the same (check from the bumps or malleoli on the inside of the ankles for reference). Then also check on the anterior superior iliac spines on the front of the pelvis (again the bumps on the front of your pelvis) to see if they are also level or not. Also then stand on one leg vs. the other and tell us if either provokes symptoms.

Look fwd to your answers

[alophysio]

I agree with Physiobob [edit: and Karen!]. More info on standing on one leg.

Also, lie on your back and lift up one leg about 30cm then put it down. Then do the same on the other leg. Is there a difference between the sides in terms of effort, heaviness, ability, strength etc etc?

Thanks

[lrockwood]

Thanks all for your help!

I'm beginning to become convinced it's an SI joint issue.

Standing on one leg:
- pain on the left side (injured side), but no more intense than when standing on two

Lying on back leg lifts
- no problem either leg

Twists are excrutiating
So are forward bends
Backbends are fine (as long as i don't twist)

I have visible swelling/inflamation (way over to the left on top of pelvis). Pain sometimes radiates into my hip joint.

Any special treatment tips would be appreciated. I've read that scar tissue needs to form to stablize the joint. I've been practicing really heavy stretches for 5 years so it's quite possible that my SI joint is unstable.

Thanks again,
Lucas

[karen.hankey]

Hi Lucas,

The main way to treat the SI joint is to stabilise it through training of the deep abdominals.

Initially to reduce the pain, ice will help and you need to make sure that the joint doesn't become stiff.

[alophysio]

Hi Lucas,

If lying on your back and lifting up one leg felt the same on both sides in terms of effort and strength, then it is unlikely you have done an SIJ joint. Don't get me wrong, i absolutely love treating SIJ problems but yours sounds like a disc problem.

Some reasons why from what you have written (limited informatino clinical reasoning ):
1. Discs are the main restraint to twisting - this seems to be the worst movement for you. Facet joints can also be inplicated but they tend to be sore in backward bending...
2. Disc injuries are most commonly sore in forward bending - like you describe
3. SI pain from ligament injuries are usually sore from the PSIS down to the sacrotuberous ligament. This is most commonly referred to as Fortin's area of pain. He determined SIJ pain referred into this area by using injections into painful SIJs.
4. SIJ pains rarely refer into the hip joint. This more likely to be the L/S discs/nerves/joints doing this
5. A SIJ ruptured ligament will be difficult to stand on one leg - the main job of the SIJ is to transfer the load from your foot to your pelvis and up your spine and vice versa. An unstable SIJ will not let you stand on it.
6. Hip movement is likely to aggravate the sciatic nerve as it passes near the piriformis muscle.There are also other muscles nearby that can tension the sciatic and other nerves. SIJ pain is over the SIJ.
7. Crossing legs on the floor usually posteriorly rotates your pelvis which would strain the disc.

Quite simply, i do not believe (from the limted information we have) that you have an unstable SIJ. You would need SIGNIFICANT trauma to disrupt the ligaments there. You may an SIJ dysfunction but i do not believe it is causing your current pain. You sound like a classic disc patient to me. An MRI or CT scan can quickly solve this problem. From the sounds of it, the disc has probably herniated which is why you are in so much pain - the noxious chemicals of the disc are irritating and sensitising the nerves.

My money is on a disc problem - anyone else??

[alophysio]

BTW - i thought you said any hip movement was painful yet you say that lying on your back lifting up one leg straight was not painful...please explain...
or did they just feel the same...

[karen.hankey]

2. Disc injuries are most commonly sore in forward bending - like you describe But doesn't there have to be trauma for a disc injury to occur?

4. SIJ pains rarely refer into the hip joint. This more likely to be the L/S discs/nerves/joints doing this I see numerous patients with SI joint problems that are getting pain in the hip area. Whn assessing their hips no positive findings and all points to the SI joint.

6. Hip movement is likely to aggravate the sciatic nerve as it passes near the piriformis muscle.There are also other muscles nearby that can tension the sciatic and other nerves. SIJ pain is over the SIJ. SI joint problems can cause spasm especially in the gluts/piriformis which can cause sciatic type symptoms.

7. Crossing legs on the floor usually posteriorly rotates your pelvis which would strain the disc. Which also involves movement at the SI joint causing pain.

Quite simply, i do not believe (from the limted information we have) that you have an unstable SIJ. You may an SIJ dysfunction but i do not believe it is causing your current pain.

I don't believe the SI joint is unstable. It could just be inflammed due to the stresses but on it. I may be that the stretching technique needs to be altered as it is incorrect. It would be very hard to say without a physical examination.

[alophysio]

THanks for the reply Karen.

1. Overt trauma is not necessary for disc injury to occur. This is because of lots of microfractures to the annulus can add up to the disc reaching the outer 1/3 of the annulus which is innervated. Lucas is a yoga student/teacher - he will no doubt do LOTS of F + Rot enough to strain the discs - they take most of the segmental rotational loading in the L/S.

2. SIJ pain rarely refers into the hip joint. This has been confirmed by Fortin et al and widely accepted (1994 Spine 19(13): 1475-1489 - 2 part articles)

STUDY DESIGN. Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine. OBJECTIVES. To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals. SUMMARY OF BACKGROUND DATA. All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthesia running caudally from the posterior superior iliac spine. METHODS. Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns. RESULTS. Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection. CONCLUSION. A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.

Having said that, certainly a dysfunction of the SIJ can lead to hip joint problems but SIJ pain itself does not refer to the hip - the L/S does.

If you are seeing patients with hip pain, no positive hip signs but positive SIJ signs, then perhaps a L/S dysfunction is driving the SIJ dysfunction...Load transfer problems will also cause hip issues but you will find muscular or hip joint associations with this... to find NO hip signs and ONLY SIJ signs would be rare i would think...

3. I agree with the SIJ causing hip mm spasm also mimicking sciatica but it has to fit with the rest of the picture as described above... Your tight piriformis and gluts will show up on a hip screen (positive hip signs right?)

4. Posterior pelvic tilt may or may not stress the SIJ. If the SIJ is dysfunctional then they will counternutate and stress the Long Dorsal Lig which would then be sore on palpation (which incidently is over the Fortin area of pain...). If the SIJ is NOT dysfunctional, then it should merely stay in nutation (close packed position) and transfer the load as a good SIJ team should...

5. If the SIJ is truly stressed, then the pain should not centralise with a L/S McKenzie Evaluation yet be positive with Laslett's 5 tests of SIJ pain provocation (2003 AJP Vol 49: 89-97).

Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints

His tests were...
a. Distraction of the anterior SIJ (or compression of the posterior SIJ)
b. THigh Thrust in 90 hip F
c. Gaenslens Test - like Thomas test except over the edge of the bed to stabilise the Sacrum on the bed and then posteriorly rotate the innominate with hip F
d. Compression of the anterior SIJ in sidelying (on distraction of the posterior SIJ)
e. Sacral thrust (prone, PA pressure over sacrum).

His study in 2003 showed that if the L/S Mackenzie eval DID NOT centralise OR peripheralise the pain but the patients had 3/5 SIJ Pain provocation tests positive then they were 83% likely to have a painful SIJ (specificity = SPIN = specific positive test rules it IN, SNOUT = sensitive negative test rules it OUT which was 91% - that is if negative then 91% likely to be negative)

6. If the SIJ is painful then it would be painful on load transfer tests - Active Straight Leg Raise, Stork test in stance phase, etc. You would imagine that one leg standing would be more painful than 2 leg standing if the SIJ was painful.

It is for these reasons that i don't think the SIJ is the pain producing structure nor the primary dysfunction.

However, i am more than happy to be wrong and i appreciate any discussion about these things - it is the best way for me to learn!

THanks again Karen

[karen.hankey]

Thanks for that reply. I am only still fairly new to the physio world and your replies have outlined a few things that i hadn't thought of.

When I mentioned the pain refferal to the hip, I didn't mean speciafically the hip joint, just around that area. Thinking about it more it probably links with TFL tightness due to protective spasm.

It will be intersting to see what the reply to this is i thought you said any hip movement was painful yet you say that lying on your back lifting up one leg straight was not painful...please explain... as it could be a positive active SLR. Lucas, any answer on this yet?

[alophysio]

Thanks Karen,

The problem with communication is that forums are entirely based on words whereas normal communication also has verbal-non-verbal cues as well as non-verbal cues so i probably got a little bit literal on you.

I understand what you mean by "referral" and agree that SIJ dysfunction and pain can lead to pain developing around the hip region. I guess i took your "no positive [hip] findings" to mean also no overactive muscles, painful muscles, tight muscles etc etc as well. But you may have meant hip pathology since dysfunction is SO common without symptoms...

Lucas - Please don't forget our question about the leg raising and hip movement/pain...all this discussion is still about YOU !!

[jacquelinec]

Hello,

I have EXACTLY the same problem for the past 3 1/2 years, except my pain is on the right side of my iliac crest. As the swollen area all along the iliac crest gets irritated, by ways of sitting (THE WORST) standing in one spot to long, walking to long, twisting, bending, basically any form of movement through out the day that utilizes the glutes; causes pain that radiates up my spinal erectors and my then my T6, T7 subluxate and cause all kinds of other pain isses. I have had all sorts of CT scans, SI Joint injection, 2 x mri's, bone scans, xrays, ultrasounds, colonoscopy, gatroscopy. The doctors have found nothing medically wrong with me. I have even seen a physiatrist. SIJ dysfuction, bulging discs, nerve impingement, cancer, reumitoid disorders, tendonitis, bursitus have all been ruled out.

Findings:
1. Menguil cysts at the S1 S2: The neurosurgeon says this would not cause the pain I have and that they are very typical in people.
2. minor osteoarthritis L4 L5: Unlikely causing the pain becase my pain is 24/7 and unilateral

The only conculsion I can come to is a soft tissue injury that has never healed properly, which my doctor is starting to think is the problem. He says soft tissue damage does not show up on MRI, CT Scans, etc. I do recall one day being very stressed at work and I was sitting in my chair clenching my lower abs and upper gluste muscles. My back was not supported sitting at the edge of my chair. I remember feeling stress at the ride side iliac crest. As well, at that time I was running on my treadmill with weights in my hands crossing my hand over my body as I ran. Very shortly after this is when the excrusiating pain started. We focused on the middle back for a 1st year because the subluxation pain was so incredibly bad. My ribs would subluxate 5 minutes from walking out of my Chiro appt. When the ribs started staying in for longer is when I first noticed my lower back pain. By then I was seeing a physio and Massage Therapist for about 1 year. The pain is better, but still not near where I need it to be to work full time. I have had to quit my job do to the severe pain sitting causes me. I wear "Core Shorts" from my physio, everyday. It is the only thing that remotely helps me get through the day. Tylenol, Advil does nothing. T3's help a little. I generaly don't like to take loads of medication so I rely heavily on my core shorts and core physio exersices. I have recently joined yoga perscribed by my doctor. The problem I have is exercise seems to just aggrevate the injury. I'm an active person so the worst part about this is the limitations this mystery injury has caused me over the last 3.5 years.

ANY HELP to get better faster would be GREATLY APPRECIATED!!!!!!!! My physio, Chiro and doctors are all stumped!!!!! The pain is REAL. THE lump along the righ iliac crest is palpable. It's not in my head!!!!!! Pressing on the lump or swollen area doesn't hurt but if you play with it to much the pain will start about an hour later and it's excruciating. It's like palpation irritates the lump (whatever it is).

Thank you,
Jacqueline

[alophysio]

Hi Jacquelinec,

Being from BC Canada, in my opinion you live in a region where 2 of the best work...

LJ Lee and Diane Lee.

Honestly, if they can't figure out what is wrong with you, i don't know many who could.

Linda-Joy Lee Physiotherapist Corporation - Physiotherapy Education and Resource Company - Vancouver, BC and Diane Lee & Associates - Consultants in Physiotherapy

Good luck - bTW, i believe your pain is real!

[robin1]

This one seems to me different type of post...one who don't know about it before may get useful information from this post...well i wanna say that The way how u tried to explain some posts at here seems to me different.