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

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

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

Physical Exam

Tenderness to deep palpation sacrum Localized sacral pain w/ hopping on

affected leg

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

Differential dx

Broad differential dx Lumbar disk disease Facet arthropathy Spondylolysis Musculotendinous strain SI joint dysfunction/Sacrolilitis Sacral stress fracture

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)

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

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

Repeat MRI

Sacral stress fractures: MRI not always definitive for early stage injuries.

Fredericson M, et al. American Journal of Sports Medicine. 2007; 35:835-839.

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.

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

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.

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.

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.

Differential Diagnosis

Sacroiliac dysfunction Piriformis syndrome Lumbar radiculopathy Obturator internus bursitis Ischiofemoral impingement Proximal hamstring tendinopathy

Pelvic MRI

* Sciatic nerve inflammation/adhesions

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.

Supine Plank Test

Fredericson et al. 2005

Bent Knee Stretch Test

Fredericson et al. 2005

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

Rehab: Progressive Eccentric and Core Strengthening

Hamstring Injection Therapy

Recommended after failed physical therapy!

Thank You! Thank You! mfred2@stanford.edumfred2@stanford.edu

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