left buttock pain radiating to mid back

[jacinta]

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

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[AussiePhysio]

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!

[jacinta]

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~

[KiwiDPT]

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.

[anthony32]

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

[jacinta]

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