left buttock pain radiating to mid back

[Driver-Jowitt]

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

[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

[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

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

[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

[jacinta]

hi linbin,

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

jacinta

[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?

[Driver-Jowitt]

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.

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

[linbin]

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

[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

[Driver-Jowitt]

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

[jacinta]

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

[Physio Dace]

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.

[jacinta]

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

[AussiePhysio]

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

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.

[jacinta]

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