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Buttock Pain in Athletes: Case Examples & Management Strategies

Explore case studies of athletes with buttock pain, differential diagnoses, imaging findings, and treatment approaches. Learn about sacral stress fractures, osteopenia concerns, and management of proximal hamstring tendinopathy.

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Buttock Pain in Athletes: Case Examples & Management Strategies

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  1. Buttock Pain In Athletes: Case Examples Michael Fredericson, MD Professor and Director, PM&R Sports Medicine Team Physician, Stanford Athletics Stanford University

  2. 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

  3. 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

  4. Physical Exam • Tenderness to deep palpation sacrum • Localized sacral pain w/ hopping on affected leg

  5. 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

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

  7. 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)

  8. 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

  9. 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/ running • Given persistent pain, repeat MRI of sacrum ordered

  10. Repeat MRI

  11. Sacral stress fractures: MRI not always definitive for early stage injuries.Fredericson M, et al. American Journal of Sports Medicine. 2007; 35:835-839.

  12. A cancellous stress fracture in a female may be a warning sign of early onset osteopenia. Concerns for Osteopenia Marx et al. Stress fracture sites related to underlying bone health in athletic females. CJSM, 2001.

  13. Pelvic stress fx and bone health • Fredericson, et al ( 2003): case study of 21 runners w/ sacral stress fx • 9/12 females had history of amenorrhea • 7 females met criteria for osteopenia; 2 w/ osteoporosis • 2 men w/ osteopenia

  14. 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.

  15. 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.

  16. 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.

  17. Differential Diagnosis • Sacroiliac dysfunction • Piriformis syndrome • Lumbar radiculopathy • Obturator internus bursitis • Ischiofemoral impingement • Proximal hamstring tendinopathy

  18. Pelvic MRI * Sciatic nerve inflammation/adhesions

  19. 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.

  20. Supine Plank Test Fredericson et al. 2005

  21. Bent Knee Stretch Test Fredericson et al. 2005

  22. Modified Bent Knee Stretch Test Cacchio et al. Reliability and Validity of Pain Provocation Tests Used for the Diagnosis of Chronic Proximal Hamstring Tendinopathy, BJSM 2012.

  23. Rehab: Progressive Eccentric and Core Strengthening

  24. Hamstring Injection Therapy Recommended after failed physical therapy!

  25. Thank You! mfred2@stanford.edu m

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