buttock pain

[Dr. Ice]

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46 year old female..seemingly "not crazy" with left buttock pain. Treated outside my practice initially with epidurals with no relief. MRI lumbar spine reveals minimal degenerative disc disease, mild lower lumbar facet disease. Tenderness over left PSIS, full range LS spine, normal strength, reflexes, sensation. Describes constant pain worse with prolonged sitting and transition.

I tried:

L SIJ, great contrast flow into joint (targeted medial head) - no relief
MSK US with one of the best guys in the country, US guided gluteus medius injection - no relief
PT, chiro, HEP, NSAIDS - no relief

I really dont think its facet mediated, but can try MBB for diagnostic purposes. It is so damn localized though. Getting CT scan of pelvis to look for sacral insufficiency fracture. Does anyone have any other thoughts??

Non work comp, non auto..doesnt seemingly have any secondary gain issues.

 

[mille125]

46 year old female..seemingly "not crazy" with left buttock pain. Treated outside my practice initially with epidurals with no relief. MRI lumbar spine reveals minimal degenerative disc disease, mild lower lumbar facet disease. Tenderness over left PSIS, full range LS spine, normal strength, reflexes, sensation. Describes constant pain worse with prolonged sitting and transition.

I tried:

L SIJ, great contrast flow into joint (targeted medial head) - no relief
MSK US with one of the best guys in the country, US guided gluteus medius injection - no relief
PT, chiro, HEP, NSAIDS - no relief

I really dont think its facet mediated, but can try MBB for diagnostic purposes. It is so damn localized though. Getting CT scan of pelvis to look for sacral insufficiency fracture. Does anyone have any other thoughts??

Non work comp, non auto..doesnt seemingly have any secondary gain issues.

it sounds facet mediated

 

[lobelsteve]

sacral insuff in 46 y/o is not likely. Inject MBB. If no better, no interventional care would appear appropriate beyond that. Try HEP and Cymbalta and if no better ask clinPsych why not.

Could ask Ob/Gyn to look retroperitoneal for stuff but still unlikely.

I he is the best Msk guy in the country, why did he US gluteus medius? It is not so much the ability to inject, but I've never met a medius strain that didn't have a clear history and readily provocative exam maneuvers.

 

[bedrock]

sacral insuff in 46 y/o is not likely. Inject MBB. If no better, no interventional care would appear appropriate beyond that. Try HEP and Cymbalta and if no better ask clinPsych why not.

Could ask Ob/Gyn to look retroperitoneal for stuff but still unlikely.

I he is the best Msk guy in the country, why did he US gluteus medius? It is not so much the ability to inject, but I've never met a medius strain that didn't have a clear history and readily provocative exam maneuvers.

Agree that usually obvious when glut med is involved. PSIS tenderness doesn't equal glut med involvement in my book. I'd target the piriformis before glut med with her story.

Recommend lumbar MBB as next step, and if you're convinced no psych issues, I would send to OB/GYN for work-up. 46 is a classic age for ovarian CA which can give this referral pattern.

 

[Sanchik]

maybe piriformis?

 

[Gauss]

if done posteriorly glute med could drift to piriformis; glute med tear, post hip labral tear, femoral head osteochondral lesion, avn, femoral neck stress fx, ischial bursitis, hamstrings origin tendinosis...
MRA hip, then move to pelvis...
$.02

 

[powermd]

Can you at least get temporary relief with an injection of local into the tender area? That would at least give you an idea of referred vs localized. If it's localized I'd shine the US beam right over the painful area and do selective injections of the muscles and fascia planes to figure out which is the problem, then blast it with local and steroids. Tends to work for these types of problems in my experience. One notable exception was a patient with a mild compression fracture at L5 and unilateral buttock pain. After multiple interventions (facets, SIJ, massive blind TP, esi) we finally did the kypho and it worked.

 

[lobelsteve]

Can you at least get temporary relief with an injection of local into the tender area? That would at least give you an idea of referred vs localized. If it's localized I'd shine the US beam right over the painful area and do selective injections of the muscles and fascia planes to figure out which is the problem, then blast it with local and steroids. Tends to work for these types of problems in my experience. One notable exception was a patient with a mild compression fracture at L5 and unilateral buttock pain. After multiple interventions (facets, SIJ, massive blind TP, esi) we finally did the kypho and it worked.

I find a physical exam more useful than US guided multiple trp to locate if it is a muscle or bursa. Muscles typically contract and have known patterns of shortening (actions). By isolating the muscle in certain positions and activating it, you can pretty reliably tell which muscle is causing the pain.

 

[SSdoc33]

It is not so much the ability to inject, but I've never met a medius strain that didn't have a clear history and readily provocative exam maneuvers.

disagree completely. chronic glut med tendonitis is ubiquitous, and equivalent to RTC tendonitis in the shoulder. we are not talking about an acute strain, rather a chronic tendonosis. i see this ALL THE TIME in my 40-50 something women who are a little bit chunky. glut med is a stabilizer that gets overworked b/c of weak core muscles.

it IS reproducible with physical exam maneuvers, but i think that this diagnosis is way underdiagnosed, and often misdiagnosed as SIJ pain

 

[SSdoc33]

if her butt hurts, and it is tender over glut med, dont do a MBB. she will be tender over her facets if there is true facetogenic pain. you could inject ANYTHING, but dont waste everyone's time and money with an MBB tht you know isnt going to work. yeah, you can get fooled, but honestly, how often is that?

 

[specepic]

interesting to see all the different opinions here. In my experience ( worlds worst disclaimer) pain in the sacroiliac and PSIS area is usually not primary and almost always referred. i.e., how many patient's actually have true blue 'sacroiliitis'. now certainly myofascial pain in that area can be primary but those folks should response to PT, OMT, Chiro, etc., may be some trigger points

I disagree that they have to have tenderness over the lumbar facets to have facetogenic pain, and I doubt that statement is supported vigorously in the literature. I do put more stock in tenderness over the cervical facets, there is just too much soft tissue over the lumbar facets to really know one way or the other.

with the patient like this I would have started, not finished, with medial branch blocks ( assuming no disc herniation/nerve root impingement in the low back).

with regard to gluteus medius tendinopathy, i.e. rotator cuff of the hip, I typically see this as a mid/lower gluteal pain or over the posterior trochanteric area, not at the PSIS area. I do not believe the gluteus medius should produce PSIS pain ( is more lateral than that in the upper gluteal area-- to do GM EMG would usually enter at half the distance between the ASIS and PSIS (or at least far away from PSIS)

0.02

 

[facetguy]

A little out of the box, but any foot/ankle or even knee weirdness in her case?

 

[jesspt]

46 year old female..seemingly "not crazy" with left buttock pain. Treated outside my practice initially with epidurals with no relief. MRI lumbar spine reveals minimal degenerative disc disease, mild lower lumbar facet disease. Tenderness over left PSIS, full range LS spine, normal strength, reflexes, sensation. Describes constant pain worse with prolonged sitting and transition.

I tried:

L SIJ, great contrast flow into joint (targeted medial head) - no relief
MSK US with one of the best guys in the country, US guided gluteus medius injection - no relief
PT, chiro, HEP, NSAIDS - no relief

I really dont think its facet mediated, but can try MBB for diagnostic purposes. It is so damn localized though. Getting CT scan of pelvis to look for sacral insufficiency fracture. Does anyone have any other thoughts??

Non work comp, non auto..doesnt seemingly have any secondary gain issues.

I would be curious about any hip pain provocation tests that were performed. As mentioned by Gauus, the hip could be a player here.

 

[mille125]

sacral insuff in 46 y/o is not likely. Inject MBB. If no better, no interventional care would appear appropriate beyond that. Try HEP and Cymbalta and if no better ask clinPsych why not.

Could ask Ob/Gyn to look retroperitoneal for stuff but still unlikely.

I he is the best Msk guy in the country, why did he US gluteus medius? It is not so much the ability to inject, but I've never met a medius strain that didn't have a clear history and readily provocative exam maneuvers.[/QUOTE]



i agree

 

[Yo GabbaPentin]

Zero relief with SI joint injection or just a couple of hours?

Any tenderness with a good hard push on the ischial bursa?

 

[sweetalkr]

have you considered cluneal nerves?

do a diagnostic cluneal nerve block, very simple, low low risk, and takes minutes.

i have seen a few cases of buttock pain relieve with this.

 

[Dr. Ice]

thanks all for your suggestions. No relief from SI joint injection. Will probably try diagnostic MBB. Cluneal nerves might be my next thought.

 

[PinchandBurn]

Can you at least get temporary relief with an injection of local into the tender area? That would at least give you an idea of referred vs localized. If it's localized I'd shine the US beam right over the painful area and do selective injections of the muscles and fascia planes to figure out which is the problem, then blast it with local and steroids. Tends to work for these types of problems in my experience. One notable exception was a patient with a mild compression fracture at L5 and unilateral buttock pain. After multiple interventions (facets, SIJ, massive blind TP, esi) we finally did the kypho and it worked.

Agree with this plan. Inject peri-psis. I dont know what the ICD/CPT would be though. It'll be diagnostic.

 

[PMR 4 MSK]

Since tender over PSIS, did you inject there? I inject these bursitis-like pains every now and then.