Jaclyn H. Bonder, MD Assistant Professor Department of...
Transcript of Jaclyn H. Bonder, MD Assistant Professor Department of...
W E I L L . C O R N E L L . E D U
Non-Spinal
Causes of
Buttock Pain
J a c l y n H . B o n d e r, M D
A s s i s t a n t P r o f e s s o r
D e p a r t m e n t o f R e h a b i l i t a t i o n M e d i c i n e
W E I L L . C O R N E L L . E D U
Diagnoses to Review
• Sacroiliac Joint Pain
• Intra-articular Hip pathology
• Hamstring Tendinopathy
• Piriformis Syndrome
• Ischiofemoral impingement – Quadratus Femoris
syndrome
• Obturator internus/Gemelli syndrome
July 7, 2014Title for Slide Deck 2
W E I L L . C O R N E L L . E D U
Sacroi l iac Joint Anatomy
Anterior View Posterior View
http://www.drdooleynoted.com/wp-content/uploads/2015/04/IMG_3688.jpg
July 7, 2014Title for Slide Deck 3
http://www.edoctoronline.com/media/19/photos_0395a4bf-99ab-4a71-b987-351dc4d10a16.jpg
W E I L L . C O R N E L L . E D U
SIJ Pain – Clinical Symptoms
• Posterior buttock pain with:
– Rising from seated position
– Standing prolonged period of time
– Getting out of bed in the morning
– Going up stairs
July 7, 2014Title for Slide Deck 4
W E I L L . C O R N E L L . E D U
Sacroi l iac Joint : Exam Maneuvers
• Tenderness over:
– SIJ
– Sacrotuberous ligagment
– Piriformis muscle
– Pubic symphysis
• Positive Fortin Finger test
• Gillet’s for aberrant SI
motion
• Patrick’s/FABER
• Gaenslen’s
• Distraction and
Compression tests
July 7, 2014Title for Slide Deck 5
W E I L L . C O R N E L L . E D U
Hip Joint : Poster ior Anatomy
July 7, 2014Title for Slide Deck 6
http://www.smartdraw.com/muscular-system/examples/hip-muscles-posterior/https://www.studyblue.com/notes/note/n/chap-9-hip-joint-and-pelvic-girdle/deck/8430587
W E I L L . C O R N E L L . E D U
Hip Joint Intra-Art icular Pathology:
Clinical Symptoms
• Posterior/gluteal pain is least common presentation
• Often in conjunction with groin and thigh pain
• May radiate past the knee
• Limp is more characteristic of hip than spine or SIJ
• Groin pain with limp
• C-sign
• Click, catch, snapping, locking
July 7, 2014Title for Slide Deck 7
W E I L L . C O R N E L L . E D U
Hip IA Pathology: Physical Exam
• Gait – antalgic or
Trendelenburg
• Single leg squat
• FADDIR/SCOUR
• FABER
• Posterior impingement
test
• Rule out spine or pelvic girdle
pathology
• Often not definitive for
structural pathology
• Many exam maneuvers don’t
truly isolate the hip joint
– Overlap with SIJ
– Can provoke pain from
lumbar or pelvic structures
July 7, 2014Title for Slide Deck 8
W E I L L . C O R N E L L . E D U
Hamstr ing Pathology: Anatomy
July 7, 2014Title for Slide Deck 9
http://stretchcoach.com/articles/hamstring-injury-treatment/
W E I L L . C O R N E L L . E D U
Hamstr ing Pathology: Cl in ical Symptoms
• Acute or insidious onset
• Pain in the lower gluteal region with occasional radiation
into the posterior thigh
• Pain during running
• Pain with prolonged sitting
July 7, 2014Title for Slide Deck 10
W E I L L . C O R N E L L . E D U
Proximal Hamstr ing : Physical Exam
• Gait
• Posture
• Inspection – ecchymosis may be present
• Palpation – tenderness and/or muscle defect over IT
• Strength testing
– Pain with resisted knee flexion
– Concentric and Eccentric testing
• Passive knee extension
July 7, 2014Title for Slide Deck 11
W E I L L . C O R N E L L . E D U
Pir i formis Muscle: Anatomy
July 7, 2014Title for Slide Deck 12
http://link.springer.com/article/10.1007/s12630-013-0009-
5/fulltext.html
W E I L L . C O R N E L L . E D U
Pir i formis Syndrome: Cl in ical Symptoms
• Pain after sitting for longer than 15-20 min
– Improves with standing and walking
– Change in position doesn’t relieve it completely
• +/- paresthesias from buttock down posterior thigh to
knee
• Feeling of weakness in affected leg
• Pain with rising from seated or squatted position
• Abdominal, groin and/or pelvic pain
• Dyspareunia and pain with bowel movements
July 7, 2014Title for Slide Deck 13
W E I L L . C O R N E L L . E D U
Pir i formis Syndrome: Physical Exam
• Tenderness in region of the muscle and attachment sites
• Weakness on affected leg
• Pain with hip internal rotation of affected side
• Piriformis sign – ER of lower extremity in supine
• Lasegue’s sign – pain with pressure over muscle, hip
flexed and knee extended
• Freiberg sign– passive IR of the hip
• PACE sign - pain and weakness with resisted abduction
and external rotation of the flexed thigh
July 7, 2014Title for Slide Deck 14
W E I L L . C O R N E L L . E D U
Pir i formis syndrome
July 7, 2014Title for Slide Deck 15
W E I L L . C O R N E L L . E D U
Ischiofemoral Impingement: Def in i t ions
• Ischiofemoral Space -
smallest interval between
the cortex of the lesser
trochanter and cortex of
the ischium
• Quadratus Femoris
Space - smallest interval
between the hamstring
tendons and either the
iliopsoas tendon or
lesser trochanter.
July 7, 2014Title for Slide Deck 16
W E I L L . C O R N E L L . E D U
Ischiofemoral impingement Syndrome
• Occurs when IFS is
decreased and
associated findings of:
– QF edema
– rupture
– atrophy exist
• Severe edema
compression of sciatic
nerve
July 7, 2014Title for Slide Deck 17
W E I L L . C O R N E L L . E D U
IFI : Cl in ical Features + Symptoms
• Deep Posterior buttock pain with or without radiation
down posterior thigh
• Sciatica symptoms
• More common in women
• Usually associated with trauma history
• No specific physical exam findings have been identified
July 7, 2014Title for Slide Deck 18
W E I L L . C O R N E L L . E D U
Obturator Internus : Anatomy
July 7, 2014Title for Slide Deck 19
W E I L L . C O R N E L L . E D U
Obturator Internus-Gemel l i syndrome
• Acute strain, chronic overuse/myofascial pain/muscle spasms,
contusions, tendinopathy, calcific tendinitis, or bursitis
• Pain with sitting
• Mid buttock pain
• Symptoms of Pudendal or
Sciatic nerve irritation
• Unilateral pelvic floor pain
July 7, 2014Title for Slide Deck 20
W E I L L . C O R N E L L . E D U
Obturator Internus Syndrome: Physical
Exam
• Palpatory tenderness in the interval between the
piriformis muscle and the ischial tuberosity
• Maximal tenderness at the posterior ischium
• Pain with Flexion, Adduction and IR
• Freiberg sign
• PACE sign
July 7, 2014Title for Slide Deck 21
W E I L L . C O R N E L L . E D U
Obturator Internus - pelv ic f loor
component
• Prone
• Identify ST ligagment
• Move fingers medially to ischiorectal
fossa
• Angle fingers laterally toward obturator
foramen where muscle originates
• Ask for ER of hip
• Can be felt on internal pelvic floor exam
– PACE sign
July 7, 2014Title for Slide Deck 22
W E I L L . C O R N E L L . E D U
Thank you!
July 7, 2014Title for Slide Deck 23