Brukner 3rd Edition PDF - Chapter 22: Buttock Pain

Buttock Pain CHAPTER 22 B...

Buttock Pain CHAPTER 22 B uttock pain is most commonly seen in athletes involved in kicking or sprinting sports. It can occur in isolation or it may be associated with low History A deep, aching, diffuse pain, which is variable in site, is an indication of referred pain. Buttock pain back or posterior thigh pain. Diagnosis of but- associated with low back pain suggests lumbar spine tock pain can be difficult as pain may arise from abnormality. Buttock pain associated with groin pain a number of local structures in the buttock or can may suggest SIJ involvement. be referred from the lumbar spine or sacroiliac When the patient is easily able to localize pain of joint (SIJ). The causes of buttock pain are shown a fairly constant nature, the source is more likely to in Table 22.1. The anatomy of the buttock region be in the buttock region itself. Pain constantly local- is shown in Figure 22.1. ized to the ischial tuberosity is usually due to either tendinopathy at the origin of the hamstring muscles or ischiogluteal bursitis. Pain and tenderness more Clinical approach proximally situated and medial to the greater tro- When assessing a patient with buttock pain, the clini- chanter may be from the piriformis muscle. cian should attempt to determine whether the pain Pain aggravated by running, especially sprinting, is local or referred. Clues can be obtained from the is not diagnostic, as most conditions causing buttock nature and location of the athlete’s pain. Examination pain may be aggravated by sprinting. Increased local may then identify which of the local or the potential pain on prolonged sitting may be an indication that pain-referring structures are causing the buttock pain. ischiogluteal bursitis is the cause of the problem, Investigation is of limited usefulness in the assessment although lumbar spine problems can be aggravated of the patient with buttock pain. by sitting. Table 22.1 Causes of buttock pain Common Less common Not to be missed Referred pain Piriformis conditions Spondyloarthropathies Lumbar spine Impingement Ankylosing spondylitis Sacroiliac joint Muscle strain Reiter’s syndrome (reactive arthritis) Hamstring origin Fibrous adhesions around sciatic nerve Psoriatic arthritis tendinopathy Prolapsed intervertebral disk Arthritis associated with inflammatory Ischiogluteal bursitis Chronic compartment syndrome of the bowel disease Myofascial pain posterior thigh Malignancy Stress fracture of the sacrum Bone and joint infection Apophysitis/avulsion fracture Ischial tuberosity (children) B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L 381 Brukner-B-13_24.indt 381 5/6/06 11:53:03 AM  B PART B REGIONAL PROBLEMS The timing of the buttock pain is of importance in establishing the nature of the diagnosis. Inflam- matory pains such as that experienced in sacroiliitis as part of a spondyloarthropathy are typically worst L4–5 in the morning and improve with light exercise. invertebral joint Such ‘morning stiffness’ lasts at least 30 minutes. Other features that strongly suggest the presence of spondyloarthropathy include associated enthesopathy iliac crest such as Achilles tendinopathy or plantar fasciitis and multiple joint problems. gluteus sacroiliac medius Examination joint The slump test is an important part of the examina- tion in attempting to differentiate between local and gluteus referred pain. However, not all cases of referred pain maximus will have a positive slump test result. The lumbar spine should always be carefully examined, particularly for evidence of hypomobility of one or more interverte- bral segments. 1. Observation ischial (a) from behind (Fig. 22.2a) tuberosity (b) from the side 2. Active movements—lumbar spine (Chapter 21) (a) flexion Figure 22.1 Anatomy of the buttocks (b) extension (c) lateral flexion (a) Surface anatomy iliac crest iliac crest gluteus medius (cut) gluteus gluteus minimus medius superior gemellus piriformis gluteus & obturator maximus internus gluteus inferior gemellus maximus (cut) quadratus iliotibial femoris adductor band minimus gracilis semitendinosus biceps femoris (cut) long head (cut) adductor semimembranosus (cut) magnus iliotibial band biceps adductor semitendinosus femoris magnus biceps femoris (long head) short head semimembranosus (b) Muscles of the buttock: superficial (left) and deep (right) 382 B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L Brukner-B-13_24.indt 382 5/6/06 11:53:04 AM  CHAPTER 22 BUTTOCK PAIN 22 (d) combined movements 3. Active movements—hip joint (a) flexion/extension (Fig. 22.2b) (b) abduction/adduction (c) internal/external rotation 4. Passive movements (a) hip movements (b) hip quadrant (Fig. 22.2c) (c) external rotator stretch (Fig. 22.2d) 5. Resisted movements (a) hip extension (Fig. 22.2e) (b) hip internal rotation (Fig. 22.2f) (c) hip external rotation (Fig. 22.2g) (d) knee flexion (Fig. 22.2h) 6. Palpation (a) sacroiliac joint (Fig. 22.2i) (b) gluteal muscles (Fig. 22.2j) (b) Active movement—hip flexion/extension (c) ischial tuberosity (d) sacrotuberous ligament (e) iliolumbar ligament (f) anterior superior iliac spines 7. Special tests (a) slump test (Fig. 22.2k) (b) lumbar spine examination (Chapter 21) (c) sacroiliac tests (c) Passive movement—hip quadrant. The hip joint is placed into the quadrant position, which consists of flexion, adduction and internal rotation Figure 22.2 Examination of the patient with buttock pain (a) Observation from behind may detect asymmetrical muscle wasting. Observation from the side may detect the presence of a lumbar lordosis or anterior pelvic tilt (d) Muscle stretch—external rotators B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L 383 Brukner-B-13_24.indt 383 5/6/06 11:53:08 AM  B PART B REGIONAL PROBLEMS (g) Resisted movement—external rotation. Resisted external rotation from a position of internal rotation is used to isolate the piriformis muscle (e) Resisted movement—hip extension. With the knee flexed, this may reproduce pain arising from the gluteal muscles (h) Resisted movement—knee flexion. This should be performed both concentrically and eccentrically to reproduce hamstring origin pain (f) Resisted movement—internal rotation Investigations A plain X-ray may demonstrate a stress fracture of (i) Palpation—sacroiliac joint. The patient should the pars interarticularis, which may refer pain to be palpated in a posteroanterior direction over the the buttock. Spondylolisthesis may be evident. The region of the SIJ. This area also includes the iliolumbar presence of spondylolisthesis does not necessarily ligament 384 B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L Brukner-B-13_24.indt 384 5/6/06 11:53:12 AM  CHAPTER 22 BUTTOCK PAIN 22 mean, however, that the slip is causing the patient’s pain (Chapter 21). X-ray may also show degenerative changes in the SIJ in the older athlete. Inflammatory sacroiliitis with loss of definition of the SIJ strongly suggests a spondyloarthopathy. X-rays of the ischial tuberosity in cases of chronic hamstring origin tendinopathy are usually normal; however, occasionally erosions can be demonstrated. In the adolescent, apophys- itis or avulsion of the ischial tuberosity may be demonstrated. Isotopic bone scan may show increased uptake in the region of the SIJ or identify a stress fracture of the ischium or pubic ramus. Soft tissue ultrasound examination or MRI may image an ischiogluteal bursa or show evidence of chronic scarring at the (j) Palpation—buttock. The patient should be lying hamstring origin. prone with a pillow under the knee to place the hip Blood tests may indicate the presence of systemic into slight passive extension and relax the hip extensor disease. Useful screening tests are a full blood exami- muscles. Palpate from the hamstring origin across nation looking for a raised white cell count, suggesting to the greater trochanter. Palpation of the gluteus possible infection, and erythrocyte sedimentation medius, piriformis and the external rotators should rate, which may be elevated in the presence of an be performed in varying degrees of hip rotation inflammatory condition (Chapter 50). Referred pain from the lumbar spine Buttock pain may be referred from the lumbar spine in the presence or absence of low back pain. Any of the somatic, innervated structures of the lumbar spine may refer pain to the buttock. Abnormalities are found most often in the intervertebral disks and the apophyseal joints. Spondylolysis and spondylolisthesis may also cause buttock pain. The patient usually gives a history of a diffuse ache in the buttock that may vary in severity. The slump test (Fig. 22.2k) may reproduce the buttock pain with relief of pain on cervical spine extension. A positive slump test result indicates increased neural tension. This may be due to damage to the nerve itself or may be secondary to lumbar spine abnormalities. Failure of the slump test to reproduce the patient’s buttock pain does not necessarily rule out the possibility of referred pain as the cause of pain. Palpation of the lumbar spine may reveal areas of tenderness and hypomobility of intervertebral seg- ments. The best means of assessing whether a lumbar spine abnormality is the cause of buttock pain is to (k) Neural tension test—slump test. The slump test improve mobility of the stiff segments by mobilization should be performed. Reproduction of the patient’s or manipulation and to reassess the symptoms and buttock pain and alteration of the pain by alteration signs, both immediately after treatment and prior to of neural tension is regarded as a positive slump test the next treatment. B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L 385 Brukner-B-13_24.indt 385 5/6/06 11:53:15 AM  B PART B REGIONAL PROBLEMS Local areas of buttock tenderness may occur the reciprocal surface. Age changes begin to occur on with referred pain. In cases of longstanding referred the iliac side of the joint as early as the third decade. pain, soft tissue abnormalities are usually found, The joint surface irregularities increase with age especially in the gluteal muscles, external rotators and seem to be weight-bearing related. The capsule and lumbar multifidus. These include taut fibrous becomes more thickened and fibrous with age. bands within muscles and general muscle tightness. SIJ motion is best described as a combination of Active trigger points may refer pain in a characteristic flexion and extension, superior and inferior glide, distribution. and anterior and posterior translation. SIJ motion The treatment of lumbar disorders has been is minimal, with approximately 2.5° of rotation and described in Chapter 21 and requires an integrated 0.7 mm (0.3 in.) of translation,2 and it is best regarded approach. Local electrotherapy can reduce pain as a stress-relieving joint in conjunction with its and inflammation. Mobilization or manipulation is counterpart and the pubic symphysis. required to restore full mobility to stiff intervertebral In the normal gait cycle, there are combined segments. Soft tissue therapy and dry needling may be activities that occur conversely in the right and left used to treat chronic muscle thickening both around innominate bones, and function in connection with the lumbar vertebrae and in the gluteal region. Specific the sacrum and spine. Throughout this cycle there is stretching of the gluteal muscles and hip external rota- also rotatory motion at the pubic symphysis, which tors should be commenced if there is any evidence of is essential to all normal motion through the joint. In tightness. Neural stretches such as the slump stretch static stance, when one bends forward and the lumbar should be included if there is evidence of restriction. spine regionally extends, the sacrum regionally flexes, The patient should be shown an exercise program with the base moving forward and the apex moving involving stretching and strengthening of the muscles posterior. During this motion, both innominates go supporting the lumbar spine (Chapter 21). into a motion of external rotation and out-flaring. This combination of motion during forward flexion is referred to as nutation of the pelvis. The opposite Sacroiliac joint disorders occurs in extension and is called counternutation. SIJ dysfunction refers to an abnormal function (e.g. The concept of the sacroiliac joint (SIJ) as a pain hypo- or hypermobility) at the joint, which places generator is now well established.1 However, the stresses on structures in or around it. Therefore, evaluation and treatment of SIJ dysfunction remains SIJ dysfunction may contribute to lumbar, buttock, controversial. One issue is the broad categorization hamstring or groin pain. and terminology utilized for the anatomical etiologies The precise etiology of sacroiliac dysfunction is of the pain by various health professionals. Contro- uncertain. Osteopaths describe a number of dysfunc- versy also exists because of the complex anatomy and tions associated with hypomobility: biomechanics of the SIJ. There is no specific symptom or cluster of symptoms, 1. innominate shears, superior and inferior nor any specific examination technique that is both 2. innominate rotations, anterior and posterior sensitive and specific for the diagnosis of SIJ abnormali- 3. innominate in-flare and out-flare ties. There are no imaging studies that distinguish the 4. sacral torsions, flexion and extension asymptomatic from the symptomatic patient.1 It can 5. unilateral sacral lesions, flexion and extension. only be diagnosed using local anesthetic blocks.2 There Vleeming and colleagues6 have described their is currently no gold standard for treatment.1 integrated model of joint dysfunction. It integrates In patients with low back pain, the prevalence of structure (form and anatomy), function (forces and sacroiliac pain, diagnosed by local anesthetic blocks, motor control) and the mind (emotions and aware- is 15%.3, 4 The incidence may be even higher in high ness). Integral to the biomechanics of SIJ stability is level sportspeople. One study showed an incidence the concept of a self-locking mechanism. The ability of over 50% in elite rowers.5 of the SIJ to self-lock occurs through two types of closure: form and force. Functional anatomy Form closure describes how specifically shaped, The SIJ is diarthrodial (synovial anterior and fibrous closely fitting contacts provide inherent stability posterior). Its joint surfaces are reciprocally shaped independent of external load. Force closure describes but not congruent, have a high friction coefficient and how external compression forces add additional have two large elevations allowing interdigitation with stability. The fascia and muscles within the region 386 B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L Brukner-B-13_24.indt 386 5/6/06 11:53:17 AM  CHAPTER 22 BUTTOCK PAIN 22 provide significant self-bracing and self-locking to to one side but may occasionally be bilateral. SIJ the SIJ and its ligaments through their cross-like disorders commonly refer to the buttock, groin and anatomical configuration. posterolateral thigh. Occasionally, SIJ pain refers to As shown in Figure 22.3, this is formed ventrally the scrotum or labia. by the external abdominal obliques, linea alba, inter- Broadhurst7 describes a clinically useful descrip- nal abdominal obliques, and transverse abdominals; tion of pelvic/SIJ dysfunction. Clinically, the patient dorsally the latissimus dorsi, thoracolumbar fascia, has deep-seated buttock pain, difficulty in negotiat- gluteus maximus and iliotibial tract contribute sig- ing stairs and problems rolling over in bed, with a nificantly. Vleeming et al. further proposed that the triad of signs—pain over the SIJ, tenderness over the posterior layer of the thoracolumbar fascia acted to sacrospinous and sacrotuberous ligaments, and pain transfer load from the ipsilateral latissimus dorsi to reproduction over the pubic symphysis. the contralateral gluteus maximus.6 This load transfer The physical examination1 should begin by obser- is thought to be critical during rotation of the trunk, vation of the athlete both statically and dynamically. helping to stabilize the lower lumbar spine and pelvis. The patient should be evaluated in standing, supine A connection has also been shown between the biceps and prone positions, and symmetry assessed in the femoris muscle and the sacrotuberous ligament heights of the iliac spines, anterior superior iliac allowing the hamstring to play an integral role in spines, posterior superior iliac spines, ischial tuber- the intrinsic stability of the SIJ. The biceps femoris, osities, gluteal folds, and greater trochanters, as well which is frequently found to be shortened on the side as symmetry of the sacral sulci, inferior lateral angles of the SIJ dysfunction, may act to compensate to help and pubic tubercles. stabilize the joint. Leg length discrepancy should be assessed. True leg length discrepancies will generally cause asym- Clinical features metry and pain, whereas a functional leg length discrepancy is usually the result of SIJ and/or pelvic The patient with SIJ pain classically describes low dysfunction. Dynamic observation may reveal a back pain below L5. The pain is usually restricted decrease in stride length with walking, leading to a limp, or a Trendelenburg gait due to reflex inhibition linea of the gluteus medius. alba external Muscle strength and flexibility should be assessed. oblique transversus Full assessment of the hips and lumbar spine should (cut) abdominus internal also be performed. The presence of trigger points in oblique surrounding muscles, particularly gluteus medius, inguinal should be noted. Palpation over the SIJ may reveal ligament piriformis local tenderness. Numerous clinical tests have been described to assess SIJ function, but none have proven reliable. Some of the more popular tests include standing and seated flexion tests, the stork test and Patrick latissimus (Faber) test. dorsi There is no specific gold standard imaging test to thoraco- diagnose SIJ dysfunction due to the location of the lumbar joint and overlying structures that make visualiza- fascia tion difficult.1 gluteus maximus sacro- Treatment tuberous ligament Due to the complex nature of the SIJ and its sur- iliotibial rounding structures, treatment must focus on the tract entire abdomino–lumbo–sacro–pelvic–hip complex, biceps femoris addressing articular, muscular, neural and fascial restrictions, inhibitions and deficiencies.1 Figure 22.3 The cross-like configuration Core stability training (Chapter 11) should be demonstrating the force closure of the sacroiliac joint included. A recent study has suggested that the B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L 387 Brukner-B-13_24.indt 387 5/6/06 11:53:17 AM  B PART B REGIONAL PROBLEMS clinical benefits incurred with training the transversus A combination of local anesthetic and corticosteroid abdominis muscle may be due to significantly reduced agents may be injected into the region of the SIJ, as laxity in the SIJ.8 Exercise rehabilitation is an integral shown in Figure 22.5, either with or without fluoro- part of recovery from SIJ dysfunction. Pelvic or SIJ scopic guidance. Sclerosants are occasionally used dysfunction should be considered with the lumbar when hypermobility is present, sometimes referred spine in any program designed to improve the overall to as prolotherapy. control of the lumbopelvic area. Precipitating factors for the development of SIJ Stretching and soft tissue therapy are useful in disorders may include muscle imbalance between correcting pelvic/SIJ imbalance. The most common the hip flexors and extensors or between the external soft tissue abnormalities found with unilateral anter- and internal rotators of the hip, leg length imbalance ior tilt are tight psoas and rectus femoris muscles. and biomechanical abnormalities, such as excessive A technique to reduce psoas tightness is shown in subtalar pronation. Figure 22.4. Muscle energy techniques (Chapter 10) may also be helpful, as may osteopathic manipula- Iliolumbar ligament sprain tion. Sacroiliac belts have not been shown to be The iliolumbar ligament extends from the transverse particularly helpful. process of the fifth lumbar vertebrae to the posterior If these manual techniques fail to control the part of the iliac crest. Sprain of this ligament may cause sacroiliac pain, injection therapy may prove useful. sacroiliac pain, particularly at its iliac attachment. It is almost impossible, however, to differentiate clinically between pain from this ligament and pain from the SIJ and its associated ligaments. Useful techniques to mobilize the soft tissues and joints of the region are shown in Figures 22.6 and 22.7. This should be combined with passive hip extension (Fig. 22.6). Injection of a mixture of local anesthetic and corticosteroid agents to the insertion of the iliolumbar ligament at the iliac crest may also be effective. Hamstring origin tendinopathy Tendinopathy of the hamstring origin may occur near the ischial tuberosity after an acute tear that is Figure 22.4 Soft tissue therapy—psoas. Sustained longitudinal pressure is applied to the psoas muscle fibers superior to the inguinal ligament with the hip initially flexed and slowly moved into increased Figure 22.5 Corticosteroid injection to the region of extension the SIJ. Injection is directed inferolaterally 388 B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L Brukner-B-13_24.indt 388 5/6/06 11:53:21 AM  CHAPTER 22 BUTTOCK PAIN 22 Figure 22.7 Ischemic pressure with the elbow to the hip abductors in the position of increased neural tension Figure 22.6 Ischemic pressure with the elbow to the origin of the hip external rotators and associated passive internal and external rotation of the hip inadequately treated or, more commonly, as a result of overuse.9 It is frequently seen in sprinters. There may be a sudden onset of sharp pain but, more often, there is an insidious onset after a session of sprinting. On examination, there is local tenderness with pain on hamstring stretch and resisted contrac- tion. The lesion may be found at the attachment site, within the tendon or at the musculotendinous junction. The slump test may reproduce the pain but cervical extension makes little or no difference to the degree of pain. Initial treatment of this condition should include manual therapy (Fig. 22.8), specifically deep trans- verse friction to the area of palpable abnormality after reduction of inflammation with ice and NSAIDs. Initial friction treatment should be relatively light. As the inflammation settles, treatment can be more vigorous. Abnormalities within the musculotendinous unit can be treated with stretching, sustained myofascial tension, Figure 22.8 Ischemic pressure with the knuckles to the and dry needling if trigger points are present. hamstring origin in the position of increased length B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L 389 Brukner-B-13_24.indt 389 5/6/06 11:53:25 AM  B PART B REGIONAL PROBLEMS In longstanding cases of hamstring origin tendin- opathy, there will be marked muscle tightness and weakness of the hamstring muscles, which can be corrected by stretching and progressive strengthening (Chapter 26). Successful rehabilitation also requires stretching of the shortened antagonist muscles such as psoas and rectus femoris. Recalcitrant cases may ben- efit from a course of shock wave treatment to the region (Chapter 10) or injection of autologous blood. quadratus lumborum Fibrous adhesions Occasionally, in cases of chronic tendinopathy of hamstring origin, fibrous adhesions develop and irritate the sciatic nerve as it descends from medial to gluteus lateral just above the ischial tuberosity and then passes medius under the biceps femoris muscle. These adhesions may fail to respond to manual therapy, particularly piriformis if they have been present for some time. On these occasions, exploration of the sciatic nerve may be required with division of the adhesions and bands of fibrous tissue. This condition has been termed the ‘hamstring syndrome’.10 Ischiogluteal bursitis Figure 22.9 Site of trigger points which commonly The ischiogluteal bursa lies between the hamstring refer pain to the buttock tendon and its bony origin at the ischial tuberosity. This bursa occasionally becomes inflamed. It may exist in isolation or in conjunction with hamstring Careful palpation of these muscles should be origin tendinopathy. performed, palpating for taut bands and exquisitely Clinically, it is almost impossible to differentiate tender points that may be just tender locally or may between ischiogluteal bursitis and hamstring origin refer pain distally into the posterior thigh. Recom- tendinopathy as both may present as pain aggravated mended treatment is dry needling, which will result in by sitting or sprinting, and both are associated with immediate lengthening of the muscles with increased local tenderness with pain on muscle contraction. hip rotation and hamstring stretch on assessment. One indication that ischiogluteal bursitis may be It is important to remember that trigger points the diagnosis is that deep friction therapy fails to are a secondary phenomenon. The clinician needs relieve the pain. to be aware of the possible underlying causes, which Ultrasound examination may reveal a fluid-filled include lumbar spine disorders and reduced lumbo- bursa. In this case, an injection of corticosteroid and pelvic stability. local anesthetic agents into the bursa may be appro- priate. As a result of pain-induced muscle inhibition, Less common causes there is usually associated hamstring muscle weakness that requires comprehensive rehabilitation. Stress fracture of the sacrum Sacral stress fractures occur most frequently in female Myofascial pain distance runners. They may be associated with osteo- penia secondary to menstrual and/or eating disorders. The gluteus medius and piriformis muscles are two of Athletes describe unilateral, non-specific, low back, the most common sites at which trigger points develop. buttock or hip pain exacerbated by weight-bearing Active trigger points in these muscles may present as activity. The diagnosis of stress fracture may be con- buttock and/or posterior thigh pain (Fig. 22.9). These firmed with bone scan or MRI. Treatment consists muscles will be shortened (Fig. 22.2d). of non-weight-bearing until free of pain (one to two 390 B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L Brukner-B-13_24.indt 390 5/6/06 11:53:38 AM  CHAPTER 22 BUTTOCK PAIN 22 weeks), then a gradual increase in activity, initially gluteus non-weight-bearing (e.g. swimming, cycling, water medius (cut) running), and then graduated weight-bearing. Average return to sport is eight to 12 weeks. Attention should gluteus minimus be paid to possible causative factors.11, 12 sciatic nerve piriformis emerging below Piriformis conditions piriformis obturator The piriformis muscle arises from the anterior surface internus of the sacrum and passes posterolaterally through the superior gemellus sciatic notch to insert into the upper border of the quadratus greater trochanter. The sciatic nerve exits the pelvis inferior femoris gemellus through the sciatic notch and descends immediately in front of the piriformis muscle. In 10% of the popula- tion, anatomical variations result in the sciatic nerve passing through the piriformis muscle (Fig. 22.10).13 In addition to the myofascial condition described Figure 22.10 Course of the sciatic nerve in the above, there are two other piriformis conditions seen buttock in athletes. One results from pressure on the sciatic nerve, usually as a result of its aberrant course through (a) Normal the piriformis muscle. This presents with local and referred pain and abnormal neurological symptoms in the posterior thigh and calf. Although known as the ‘piriformis syndrome’, this would be better referred to as ‘piriformis impingement’.14 Treatment consists of stretching and massage therapy. Surgery may be required. The second condition is piriformis muscle strain. This may be acute or chronic and may be associated with chronic muscle shortening. It may present as deep buttock pain aggravated by sitting, climbing stairs and squats. aberrant nerves On examination, there is tenderness either in emerging the belly of the piriformis or more distally near its mid-piriformis insertion into the greater trochanter. Passive internal hip rotation is reduced and resisted abduction with the hip adducted and flexed may reproduce the pain over the piriformis. Pain may also be reproduced by (b) Aberrant resisted external rotation with the hip and knee flexed, beginning from a position of internal rotation so that end range is tested (Fig. 22.2d). is, pain increasing with exercise and a feeling of tight- Treatment involves stretching of the external rota- ness. Pain is typically in the buttock and posterior tors (Figs 22.11a, b), electrotherapeutic modalities (e.g. thigh and treatment involves massage therapy and, ultrasound, laser, high voltage galvanic stimulation), occasionally, surgery. Limited fasciectomy involving and soft tissue therapy to the tender area in the piri- the ischial tuberosity and upper 5 cm (2 in.) of the formis muscle. Longitudinal gliding combined with posterior fascia is performed. passive internal hip rotation (Fig. 22.11c) is an effec- tive technique, as is transverse gliding and sustained Apophysitis/avulsion fracture of the longitudinal release with the patient side-lying. ischial tuberosity In adolescents, apophysitis may occur at the attach- Posterior thigh compartment syndrome ment of the hamstring muscles to the ischial tuberosity This is an unusual condition that presents with the apophysis. This is frequently associated with overuse. typical symptoms of a compartment syndrome, that Treatment consists of ice, restriction of activity, gentle B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L 391 Brukner-B-13_24.indt 391 5/6/06 11:53:39 AM  B PART B REGIONAL PROBLEMS Figure 22.11 Treatment of tight piriformis muscle (a) Muscle stretch—hip external rotators. The hip is placed into flexion, adduction and then alternated into external and internal rotation (c) Soft tissue therapy—piriformis. Sustained longitudinal pressure to the belly of the piriformis muscle, initially in passive external rotation and then moving into internal rotation (illustrated) stretching and soft tissue therapy to overcome muscle tightness. This is a self-limiting condition. Avulsion fracture of the ischial tuberosity is seen in adolescents where, instead of the hamstring muscle tearing, muscle traction separates a fragment of bone from its origin at the ischial tuberosity. This fragment of bone is clearly demonstrated on plain X-ray (Fig. 22.12). Management of this condition is generally conservative. The patient should be treated as for a severe (grade III) tear of the hamstring muscle (Chapter 26). However, if there is marked separation (greater than 2.5 cm [1 in.]) of the fragment, then surgery is indicated. There have been a number of reports of this injury in adults. The results of late (b) Muscle stretch—external rotators surgical repair have been good.15, 16 392 B R U K N E R A N D K H A N , C L I N I C A L S P O R TS M E D I C I N E 3 E , M c G R AW- H I L L P R O F E S S I O N A L Brukner-B-13_24.indt 392 5/6/06 11:53:42 AM  CHAPTER 22 BUTTOCK PAIN 22 References 1. Brolinson PG, Kozar AJ. Sacroiliac joint dysfunction in athletes. Curr Sports Med Rep 2003; 2(1): 47–56. 2. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum. 4th edn. Edinburgh: Churchill Livingstone, 2004. 3. Maigne JY, Aivaliklis A, Pfeffer F. Results of sacroiliac joint double block and value of sacroiliac joint pain provocation tests in 54 patients with low back pain. Spine 1996; 21: 1889–92. 4. Schwartzer AC, April CD, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1992; 20(1): 31–7. 5. Timm KE. Sacroiliac joint dysfunction in elite rowers. J Orthop Sports Phys Ther 1999; 29: 288–93. 6. Vleeming A, Mooney V, Dorman T, et al. Movement, Stability and Low Back Pain: the Essential Role of the Pelvis. Edinburgh: Churchill Livingstone, 1997. 7. Broadhurst NA. Sacroiliac dysfunction as a cause of low back pain. Aust Fam Physician 1989; 18(6): 623–8. 8. Richardson CA, Snijders CJ, Hides JA, et al. The relation between the transversus abdominis muscles, sacroiliac Figure 22.12 Avulsion of the ischial tuberosity joint mechanics, and low back pain. Spine 2002; 27: 399–405. 9. Fredericson M, Moore W, Guillet M, et al. High hamstring tendinopathy in runners. Physician Sportsmed 2005; 33(5): 32–43. 10. Puranen J, Orava S. The hamstring syndrome. A new diagnosis of gluteal sciatic pain. Am J Sports Med 1988; 16(5): 517–21. Conditions not to be missed 11. Brukner PD, Bennell KL, Matheson GO. Stress Fractures. It should also be remembered that buttock pain may Melbourne: Blackwell Scientific, 1999. be the presenting symptom of systemic disorders, 12. 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