gluteal and leg pain

A patient of mine complains of pain in the right gluteal region with referred pain centrally down her whole right leg for 2years. she saw a neuro sugeon 2yrs ago and started on back extension exercises which helped to reduce the pain at that time. she is not sure of the diagnosis!
she presented to me 15days ago after being referred by a orthopedic surgeon who thinks she has S2 problem and asked for back extension exercises. she presented with dull aching continuous pain at the ischeal tuberosity which was radiating to whole of her right leg. no obvious aggravating or relieving factors,no red flags,full painfree ROM at the lumber spine,no pain on compression and distraction of SI joint. Her SLR was negative. She felt that pressure applied over the gluteal region eased that pain slightly. Her right piriformis seems tight and she also appears to have tight abductors.
I have tried doing ultrasound at the tender gluteal area, hot/coldpacks, piriformis strecthing. The only thing which gave her some relief was the cold pack but the pain returned after a few hours. A few days ago, the surgeon requested that I try tractioning the lumbar spine. I have tried this daily for 25minutes for four days and she reports that her pain has eased during the day but is still present at night and first thing in the morning. She owns a shop and is still working as normal. However, today when she arrived she complained of right calf pain which she did not have before.
I am at a loss as to what is the source of her pain. It does not seem to fit neatly into a pattern and I am no longer sure of what to do!! Any ideas of alternative diagnosis or treatment ideas would be greatly appreciated!

hi
it seems like a inflammatory conditon, if it is stiff and sore in the morning, or possibly a disc bulge, which is unlikely if SLR is Ok. I would give heat packs and piriformis stretches. check if she is on any antiinflammatories. If you are tractioning make sure u keep upper lumbar spine in flexion to gap, lower spine. what are the aggravating factors???????????

I agree with naveeneden. ask what 3 things make it better and 3 that make it worse, ie activities, positions, times etc. I would look closely at the right piriformis with stretching and releasing techniques. I would give them a tennis ball to roll around on to self release at home. When in doubt treat the impairments that you found in your initial eval. Tight piriformis and abd. I suspect IR is going to be limited R>L. Keep us informed.

Inflammatory perhaps, and seems so,

but piriformis stretches away will hardly, rarely, solve the issue.

So many times I see Knee to chest stretch, knee crossover stretch given over and over over weeks. Never, or rarely actually solves the problem as this stretch (especially done without supervision) does not get to the root of the issue.

The more likely issue is that there is some form of related mis-alignment issue that is causing the piriformis to tighten, and perhaps the glutes (abductors) in a manner that causes the issue to return repetitively.

The ideal would be to look at alignment and strengthen the piriformis in a position that improves lower limb, hip alignment (in relation to other daily activities said individual performs). Gluteal work is a must in these situations.

Regards

Hi all, I am brain stroming and I suggested that the patient might probably is a "buttock gripper". Whatever it is but it only means someone is having an over-active gluteal muscles. If it is the case, the hip joint might probably in more external rotation and this would contribute a tight deep external rotator, like the piriformis. Look at the posture and gait and see how the client walks. By the way, it only assumes the deep extenral rotators are the source of problem. What about the hamstring and the low back?

I suffer from the same gluteal pain,but I already have a problem in my right leg 3 years before.My foot(nearly at the navicular),knee & hip joint hurts,I can't determine where the site of pain exactly.I've visited lots of orthopedic drs they just give me analgesics.I thought my gluteal pain was related to my old leg pain so I didn't ask drs.Plz help me what to do about me leg.