left buttock pain radiating to mid back

hi all,

thr is this gentleman c/o left buttock pain, radiating to Lt. mid back.
it was found that his left gluts muscle, especially gluts medius is swollen,
tender to deep palpation.
injury occured 1/12 ago when this young footballer twisted his legs in the air attempted to kick the ball. [ Lt hip in flexion/internally rotated/adducted; kn. moving towards ext. from flx]
pain oftenly radiate upward 2 midback, currently started to radiate downward to mid thigh.

how does gluts pain radiating up to midback?
he attended 2 sessions of treatment, no improvement.

Please help.

jacinta

Hello - It seems that the primary injury is to the buttock, which means gluteal inhibition. This makes it difficult to cant (lift) the hemi-pelvis on the uninjured side in order to lift the good leg and so allow it to swing through. It is likely that your patient is therefore leaning his trunk towards the injured side to "passively" lift the pelvis. If this is done repetatively when walking mid-back pain could follow. Try using a walking stick on the uninjured side. Driver-Jowitt

hi
there is a need to do detailed reevaluation according to me .
these are my rationale for it
to detect the primary cause of pain-gluteal,sacroiliac joint,low back
to find out whether the buttock pain and mid back pain is interrelated ya seperate entites
if interrelated mechanism causing it
isolated strength testing of pelvic-hip musculature
to rule out regional interdependence
to plan out a treatment stratergy based on the finding

eager to see other views

hi jowitt & linbin,

thanks for the replies.

jowitt, his pain only came about in prolong sitting & if in standing,
the mentioned pain only came about on trunk side flx to the Lt, with Lt rotation in outer range. walking stick dont sound like a young-man friendly aid for him. :)

linbin,

he had multiple old injuries. here are some finding that u might wanna know
- Rt Hams injury 1 yr ago
- Rt Lower back pain 1 yr ago
- Lt calf spasm
- bilat. T8 - L5 muscle spasm with multiples trigger points.
- Lt piriformis tightness [ released]

eager to hear from you guys. :)
thanks.

jacinta

I agree absolutely. It is axiomatic that any diagnosis, particularly with vaguely defined symptoms, be illuminated by careful clinical assessment. However to aim to do an "all-encompassing assessment" on every patient is neither practical nor productive. On the principle that common things occur commonly the most likely diagnosis should be considerd as a hypothesis to be confirmmed by a limited but focussed assessment. This could include a "theraputic trial" of standard physiotherapy modalities, or something like trying a walking stick, as suggested. At the end of the day the search is for a benefit, not a diagnosis. If something works it doesn't matter how or why it works (at least for that patient - questioning the mechansm of how therapy works is most useful in appraising potential management of subsequent patients) JP Driver-Jowitt

Quote:

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Originally Posted by linbin

hi
there is a need to do detailed reevaluation according to me .
these are my rationale for it
to detect the primary cause of pain-gluteal,sacroiliac joint,low back
to find out whether the buttock pain and mid back pain is interrelated ya seperate entites
if interrelated mechanism causing it
isolated strength testing of pelvic-hip musculature
to rule out regional interdependence
to plan out a treatment stratergy based on the finding

eager to see other views

---

hi
is there any neurodynamic tests positive on left side
i feel the gluteal pain and radiation to mid thigh may be due to reduced mechanosensitivity of sciatic branches.development of ectopic impulse generation site
the back pain as is occuring with primary combination of left lateral flexion and left rotation.
i would like to know the effect on pain if flexion/extension is superadded to the above mentioned primary combination
how is the quality of movement while he is doing spinal flexion/extension

any pain reproduction with passive accessory movements
AP
TRANSVERSE/ROTATIONAL

hi linbin,

will keep u update once I find out more info
thanks.

jacinta

Thank you. I am afrad that many of the terms and concepts presented in you letter which are unfamiliar to me, and I cannot usefully comment.

Quote:

---

Originally Posted by linbin

hi
is there any neurodynamic tests positive on left side
i feel the gluteal pain and radiation to mid thigh may be due to reduced mechanosensitivity of sciatic branches.development of ectopic impulse generation site
the back pain as is occuring with primary combination of left lateral flexion and left rotation.
i would like to know the effect on pain if flexion/extension is superadded to the above mentioned primary combination
how is the quality of movement while he is doing spinal flexion/extension

any pain reproduction with passive accessory movements
AP
TRANSVERSE/ROTATIONAL

---

hi friend
i feel i used terms which are quite familiar
neurodynamics - based on shacklock
combined movement - edwards
passive accessory movements -maitland
if you need any clarification regarding any concepts feel free to ask
cheers

HI,

I'd also be curious to know what the SIJ is doing (simple test like the stork test might help), and a slump or SLR for neuro things, or PKB if it's front of thigh radiating as well.

I definitely agree with a more thorough assessment of the lower lumbar spine as well, and find a "quick test" that easily and reliably reproduces the pain (eg the action of kicking a football), then analyse that.

Msk101

Quote:

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Originally Posted by msk101

HI,

I'd also be curious to know what the SIJ is doing (simple test like the stork test might help), and a slump or SLR for neuro things, or PKB if it's front of thigh radiating as well.

I definitely agree with a more thorough assessment of the lower lumbar spine as well, and find a "quick test" that easily and reliably reproduces the pain (eg the action of kicking a football), then analyse that.

Msk101

---

SI pain is always a possibility, and as a precaution pain in the joint, perhaps caused by an incidental pathology which is made symptomatic by a relatively minor incident (such as ankylosing spondylitis) could be considered. Purely traumatic SI pain is rare, as this is an extaordinarily stable joint, certainly in a young male like this. Driver-Jowitt

hi all,

sorry for the late reply.
this gentleman came yesterday.

dear linbin & msk101,

-since his 1st treatment, neurodynamic tests [ SLR, PKB, Slump's] all -ve
-accesorry movement tested in all directions did not produce symptom.
only P-A on Lt. L3 - L5 facets produced pain. [ muscle spasm was thr]
-combine mvt do not elicit pain.

dear jowitt,

i have to agree with u as he has no symptom at all on both SIJ.
mobility is good.
but his blood test n x-ray ruled out A.S. and spond.

jacinta

currently, his left gluts tenderness reduced.
pain still comes back when imitating kicking ball [ Lt hip in flexion/internally rotated/adducted; kn. moving towards ext. from flx]
hwver, pain only localised on Lt. gluts.

bilat hams tightness unresolved; worse on Rt. ishcial tuberosity whr it arises & previously injured.

lots of MFR was done, with u/s and cold compression given.
stetching and cycling are keep at 20 mins & 30mins each.

is thr anythg that i miss out?

Have you considered an intra-articular hip pathology or possible iliopsoas strain? Labral tears have been known to refer superiorly into the lumbar spine - or associated with maladaptive gait patterns with subsequent NSLBP. Beyond that from the MOI I would be thinking Lx first (more likely facet) and SIJ second. If its purely an acute muscular injury (i.e. strain) I would have expected considerable improvement in 1/12.

hello dace,

thanks for the reply.
it was found that thr is NAD in his gait.
this gentleman was not sure had he injured his hip previously,
but claimed numerous falls on buttock.
No x-ray was done.

It's a good news to me that his left thigh adn mid back pain are resolved.
Rt. hamstrings tightness reduced.
Lt. hip pain reduces in VAS: 3-4 /10 (previously 7/10)

new finding: Lt. iliopsoas tighness (again, thanks for your suggestion)
stretches are taught.
will wait & see how next week.


jacinta

Perform some additional tests for piriformis syndrome which may mimick low back pain or sciatica. Also ckeck for tranchanteric birsitis. Have a look over the tests for piriformis syndrome.

Pace test: Reproduction of sciatica type pain with weakness is noted by resisted abduction/external rotation (Pace test).

Freiberg test: The Freiberg test is another diagnostic sign that elicits pain upon forced internal rotation of the extended thigh.

Beatty maneuver: The Beatty maneuver reproduces buttock pain by selectively contracting the piriformis muscle. The patient lies on the uninvolved side and abducts the involved thigh upward; this activates the ipsilateral piriformis muscle, which is both a hip external rotator and abductor with the hip flexed

hi sdkashif,

thks for the reply.
piriformis syndrome was tested +ve on his 1st visit.
resolved in 1/52+ after daily stretching.
the problem is, pain is still on left buttock, but not from the piriformis.

the 3 tests that u suggested are new to me,
I would like to re-ax it on his next visit,
thanks for the suggestion.

jacinta

Hi Jacinta
You said that it is iliopsoas tightness, did you assess the SI joint Function?

hello mohan,

his iliopsoas tighthness had been relieved since previous visit
SIJ mobility is good(tested in std -> trunk fwd flx & alt. hip/kn. flx); only produce localized pain on LT SIJ in the position prescribe previously, & on overpressure

hi sdkashif,

all 3 tests are -ve
we suggested a MRI.
result shown that he had a disc protrusion more to the left of L5/S1
pt is now seen for backpain rehab instead of sport rehab.

smthg that i do not understd,
why would all neurodynamics tested -ve?
eager to hear explaination from any guru out there.

thanks

Hi Jacinta. Sounds like you are on the right track with sorting this fellow out. Without "poking and prodding" it sounds reasonable that he could be getting over a very acute strain of gluts and underlying SIJ ligs / fascia (based on the pain with kicking position that you described).
Have you looked at his thoracic spine lately?? Now that the acuity of his symptoms have settled, you may be able to get a clearer picture. Considering pre-injury he c/o trigger points in his Tsp he may have some long-standing mobility issues there. If he is not rotating throughout his thorax with kicking (and any other functional activities for that matter), he is going to get more stress through the hip / pelvis. If you can address mobility issues in the thorax it may decrease the possibility of reinjury to the gluts with return-to-sport.

To jacinta

I have some guesses why the neurodynamic tests did not test +ve
1) because the protrusion was not large enough and the dural sheath rather than the nerve root was irritated. A crossed leg SLR may have helped to confirm a compression
2) because a significant amount of inflammation had reduced before any of the tests were undertaken

When there is a low back pain with multisegmental distribution of pain (as described by you, downward and upward referrals), the dural sheath irritation should be suspected.

it sounds like your treatment so far has focused on resolving the abnormal biomechanics that may have caused some stress in the low back hence the minimization of pain. It is not uncommon to have low back problems that never start with the low back but emanate somewhere else. Cyriax techniques mention this phenomenon.

Quote:

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Originally Posted by Driver-Jowitt

I agree absolutely. It is axiomatic that any diagnosis, particularly with vaguely defined symptoms, be illuminated by careful clinical assessment. However to aim to do an "all-encompassing assessment" on every patient is neither practical nor productive. On the principle that common things occur commonly the most likely diagnosis should be considerd as a hypothesis to be confirmmed by a limited but focussed assessment. This could include a "theraputic trial" of standard physiotherapy modalities, or something like trying a walking stick, as suggested. At the end of the day the search is for a benefit, not a diagnosis. If something works it doesn't matter how or why it works (at least for that patient - questioning the mechansm of how therapy works is most useful in appraising potential management of subsequent patients) JP Driver-Jowitt

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As a manipulative physiotherapist I do no personally find differentiating Lumbar derangment from gluteal dysfunction or injury much of a stretch and certainly it wouldn't require an "all-encompassing assessment"

I would be deeply dissapointed if i saw a physio who precribed a gait aid for my sporting injury! You would never see me again. I hope this wouldnt lead you to (incorrectly) assume that i was fixed and did not need further treatment.

Quote:

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Originally Posted by jacinta

hello mohan,

his iliopsoas tighthness had been relieved since previous visit
SIJ mobility is good(tested in std -> trunk fwd flx & alt. hip/kn. flx); only produce localized pain on LT SIJ in the position prescribe previously, & on overpressure

hi sdkashif,

all 3 tests are -ve
we suggested a MRI.
result shown that he had a disc protrusion more to the left of L5/S1
pt is now seen for backpain rehab instead of sport rehab.

smthg that i do not understd,
why would all neurodynamics tested -ve?
eager to hear explaination from any guru out there.

thanks

---

This is easy to say now that i'm tagging onto the end of the discussion, but a thorough testing for Lumbar Posterior Derangment would have been top of my list - along with the local gluteal assesment- even from the subjective history, distribution of pain (despite the direction the clients feels the pain radiates in) and mechanism of injury.

Referred pain above the knee does not require direct neural compression / irritation or involvment as the outer layers of the Lx disc's annulus are known to be a powerful source of somatic referred pain. Neurodynamics can be normal in this case (and often is!)

The only way to thoroughly definatively test for Lumbar disc involvement would be the use of repeated movements. Palpatory methods on the spine and examining movement in fx ex rotn lat flexion only once or twice in each directtion will not always reveal an effect on referred pain from the disc as a source- likely because of the biomechanics of the intevertebral disc. to exclude the Disc as a source of pain, we MUST use repeated movements (we're talking 5 to 10, someites 20 repetitions, looking for change in referred symptoms: patterns of peripheralisation, centralisation, worsening intensity, abolishing symptoms, changes in range etc.)

Can i suggest that you read up on the McKenzie method of Mechanical Diagnosis and Therapy? And really get into the detail of the concepts. It is used poorly by many physios but is an incredibly useful frame-work to build Lumbar spine assessment around. It's incredible how much of what we are trying to treat peripherally is really coming from a central / spinal source

McKenzie ("MDT") has changed the way i practice.

BTW, this diagnosis is not any more difficult to treat than all of the others - people often equate disc problems with something quite incurable. Again - Mckenzie works brilliantly in this case

Cheers

SIJ dysfunction can cause pain upon lying down (rolling around in bed), sitting to standing, sitting for prolonged periods, or standing for prolonged peroids. If the SIJ is not functioning properly, the altered biomechanics can cause compensatory patterns above and below the lesion? (muscle tightness being one of them). Why was an X ray not taken? If anything sinister were underlying would it not be wise take one?

SIJ pain can be ruled out through the following; motion palpation, static palpation, (difference in movement, oedema findings) history findings with the above clues.

Also does the patient have a short leg? Anatomical or Functional. Flat feet? Also check the functionn of the rest of joints in the spine.

Neurological testing can produce no postive signs even when a disc lesion is present.

hi treat, hi aussiePhysio

thank you so much for your information.
sorry for late reply .

treat,
his limbs are of equal length, his shoes were assess previously.
I found that his shoes had got sufficient arch support for his flat foot.

AussiePhysio,
I have to agree with the credit point that u had given to McKenzie.
this gentleman is now having very mild pain occasionally after practicing
McKenzie for 2/52.

he is eager to go back to soccer. I suggested mild & non-contact exercises for
another 1/12 as an observational period.
Planning to put him on low load high reps work-out after that.
Is there any standard time frame for this sportman to return to soccer?

Jacinta,

My personal thoughts are that with low back pain, return to sport is not as predictable as with a tendon injury or ligament injury. The way his symptoms progress are far more important than a time frame.

let's keep in the mckenzie model for a moment if that is helping:
If his problem as truly a posterior derangment and Extension in lying helped initially, but is no longer helping, or his improvement has hit a plateau, you might need to progress the force, (Extension in lying with overpressure - either therapist generated or patient generated, or add mobilisations (Mckenzie mobs work a treat).

the phases of treatment for a derangment in Mckenzie is 1. reduce derangement and abolish symptoms, 2. maintain reduction, 3. restore function (i.e. flexion in his case) 4. prophylaxsis (continue with the reductive exercise as part of his normal warmup / cool down and once a day otherwise)


If however his symptoms no longer fit a Mckenzie Posterior derangment, he may well have some other issues lingering on - possibly more motor control issues (core stability / movement control) rather than mechanical stiffness or disc issues. this wil often happen as a result of fear-avoidance behaviour or pain inhibition of key muscles groups

But i think that if mckenzie helped initially, it's worth pursuing the extension principle to it's fullest including exploration of lateral glides (frontal plane work) if extension stops proving useful. - this is basic mckenzie principles that often get ignored or not taught - mckenzie is a lot more than the "Extension in lying" exercise. Sounds like you're using mckenzie already - let me know if you don't follow any of the above mckenzie stuff.


Keeping active is really important and even with a 'disc' injury, and i would think that a strengthening program can be continued with attention to his direction preference - keep him doing activities in Lx extension or neutral. jogging might be ok provided he doesn't slump and flex / sit in his cool down like so many do. Pilates (with an extension bias in his case) is a great form of exercise that would probably work in well with his physio.

discs like any soft tissue injury take at least 6 weeks to fully heal once they are unloaded and repetitive stresses are taken out of the equation. even after he feels symptom free (well before full healing takes place) he is at risk of reinjurying - so he should continue his reductive exercise even after he starts to feel 'pain free' and then continue on to work with you in regaining flexion in a safe and controlled way.

hope my thoughts help.
keep up the good work matey!

And lastly - don't put too much stock into CT's and scans - go with his symptoms. Broadbased disc bulges are really common and often do not correlate with symptoms. go with what you see and assess!

Hi Aussie,

thank you for the advise.
his symptoms is now progressing, pain reducing slowly.

in fact, we started McKenzie's with trunk lat. slide in pr., as well as in frontal plane.
The latter, of course is for his convenience as he has a 9-5 office job.
But this gentleman prefer the earlier exercise as he found it more comfortable.
Flexion exercise is KIV until pain subside.

Very kind of you to remind me of pilates exercise.
I am planning to train his core stability with few ideas that i have:
1. crunches in crook ly with s/bags resistant.
2. 'Aeroplane' with gym-ball: (alternate )UL reaching forward & c/l LL backward.
3. Obliques muscle strengthening - sustain upper trunk twist in crook ly;hands behind head
4. upper trunk extension - hand behind back;

I am not train for pilates rehab. Got the ideas from researching book.
Hope to hear correction/suggestion from any expert out there.

This gentleman started swimming 1/52 as advised.
shall wait and see if his condition improve further.
:) cheers~

I only just read this but I would like to add to AussiePhysio's comments. I also use repeated movements with my low back assessments however sometimes I find repeated motions in standing can also increase a patients pain, and confound results. This is usually with the more acute cases. So I always add prone bilateral LE manual traction as an assessment, and prone on elbows. Also sometimes you may have to have them lay over a pillow or two as the extension from laying flat maybe too much.
Just my 2 cents for additional screens I use.

How is your patient feeling right now. Is he still having pains when he imitates kicking a ball. Is there any other pains or niggles

Hi Kiwi,

sorry for late reply as I had been away for some time.
Your opinion definately worth much more than 2 cents :)

I 'experimented' on few patients and had the same finding like you.
Certain patients pain scale increase when prac McKenzie in pr. position, but pain
goes off with pillow support;
while some display totally contradicting symptoms.

Pain elicited might be due to hyperext of lumbar spine,
causing sudden increase of discal pressure, & compression of surrounding structure possibly lead to increase neural tension.
I am yet to find out any evidence regarding this.
Could anyone tell me if thr's any journal or paper that I could refer to?
Please correct me if I am wrong.

once comfort approach is determined, result is more satisfactory with trunk lat. flx added into the component.

Anthony, I am yet to see him since i went off.
Do hope he improve.
thanks.


Jacinta