buttock pain in athletes: c ase examples michael fredericson, md professor and director, pm&r...
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Buttock Pain In Athletes: Case Examples
Michael Fredericson, MDMichael Fredericson, MDProfessor and Director, PM&R Sports MedicineProfessor and Director, PM&R Sports Medicine
Team Physician, Stanford Athletics Team Physician, Stanford Athletics Stanford UniversityStanford University
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Disclosures Grants:
Ipsen, Inc. American Medical Society for Sports Medicine
Medical Advisor: Cool Systems, Inc.
Journals/Magazines: Founding Senior Editor, PM&R Scientific Advisor, Runner’s World
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Illustrative Case
21 y.o. previously healthy female collegiate XC runner
CC: R. low back & sacral pain that began after run 3 days ago
No prior hx of LBP or stress fractures History of old bilateral pars defect at L5
w/ minimal anterolisthesis of L5 on S1 History of amenorrhea & osteopenia
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Physical Exam
Tenderness to deep palpation sacrum Localized sacral pain w/ hopping on
affected leg
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Diagnostic studies
DEXA scan: L1-L4 Z score= -2.0 L. hip Z score = 0.6
MRI: negative for sacral stress response,
fracture, or pelvic injury
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Differential dx
Broad differential dx Lumbar disk disease Facet arthropathy Spondylolysis Musculotendinous strain SI joint dysfunction/Sacrolilitis Sacral stress fracture
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3-day f/u
Pain improved slightly w/ PT Felt less “ tight” in sacrum; no pain
walking around campus Pain after a few minutes when
attempted to run again Bone scan & SPECT ordered
All 3 phases bone scan negative SPECT: increased tracer uptake in L5- S1 pars-
intrarticularis ( compatible w/ old pars defect)
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Further w/u
Repeat MRI showed old L5 pars defect & broad central disk protrusion @ L4-5 without central canal or neuroforaminal stenosis
Pain thought to be referred from L-spine; prescribed diclofenac 75 mg bid x 1 week without relief
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Further w/u
Tried easy run again, but symptoms returned
Underwent fluoro guided injection to L. L5 facet & pars Symptoms mildy improved, but
still pain w/ runningGiven persistent pain, repeat MRI of sacrum ordered
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Repeat MRI
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Sacral stress fractures: MRI not always definitive for early stage injuries.
Fredericson M, et al. American Journal of Sports Medicine. 2007; 35:835-839.
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Concerns for Osteopenia
A cancellous stress fracture in a female may be a warning sign of early onset osteopenia.
Marx et al. Stress fracture sites related to underlying bone health in athletic females. CJSM, 2001.
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Pelvic stress fx and bone health
Fredericson, et al ( 2003): case study of 21 runners w/ sacral stress fx9/12 females had history of
amenorrhea7 females met criteria for osteopenia; 2 w/ osteoporosis
2 men w/ osteopenia
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Illustrative Case A 32-year-old female elite middle-distance
runner with right upper hamstring and buttock pain related to running. She had seen another physician for lumbar disk bulge, treated with lumbar epidural injections and physical therapy. Her low-back pain improved sufficiently to allow her to compete in the Olympic Finals. However, the upper-thigh and buttock pain persisted, preventing her from competing at maximal capacity.
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Illustrative Case Cont. After the Olympics, she continued to
experience a viselike squeezing of her proximal thigh that caused a throbbing pain at the end of a race. She discontinued racing for the next several months, and by midautumn her symptoms had resolved except for occasional left buttock pain with prolonged sitting. During this period, she became pregnant but continued to stay in shape with gentle running, aerobics, and light weight lifting.
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Illustrative Case Cont. The following autumn, she started running
again without significant pain; however, as her training intensified, she noted increasing pain in the right buttock and decided to seek a second opinion at our clinic. Her symptoms were present even at rest or sitting on a hard surface and most pronounced with track work and faster speeds. She did not have any current low-back pain, numbness, or tingling in the lower extremities.
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Differential Diagnosis
Sacroiliac dysfunction Piriformis syndrome Lumbar radiculopathy Obturator internus bursitis Ischiofemoral impingement Proximal hamstring tendinopathy
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Pelvic MRI
* Sciatic nerve inflammation/adhesions
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Proximal Hamstring Tendinopathy
Distance runners Lower gluteal pain Worse with faster speeds Focal ischial pain with
prolonged sitting
Fredericson et al. High Hamstring Tendinopathy in Runners. Phys Sportsmed, 2005.
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Supine Plank Test
Fredericson et al. 2005
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Bent Knee Stretch Test
Fredericson et al. 2005
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Cacchio et al. Reliability and Validity of Pain Provocation Tests Used for the Diagnosis of Chronic Proximal Hamstring Tendinopathy, BJSM 2012.
Modified Bent Knee Stretch Test
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Rehab: Progressive Eccentric and Core Strengthening
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Hamstring Injection Therapy
Recommended after failed physical therapy!