Evaluation Buttock Pain

Differential Diagnosis

Most Common

1. Referred pain from the Lumbar Spine or Sacroiliac Joint

2. Hamstring Origin Tendinopathy

3. Ischiogluteal Tendinopathy

4. Myofascial Pain

Less Common

1. Piriformis Impingement or Muscle Strain

2. Fibrous Adhesions around Sciatic Nerve

3. Prolapsed Intervertebral Disc

4. Chronic Compartement Syndrome of the Posterior Thigh

5. Stress Fracture of the Ischium, Pubic Ramus, or Sacrum

6. Apophysitis or Avulsion Fracture of the Ischial Tuberosity

Not to be Missed

1. Ankylosing Spondylitis

2. Reiter's Syndrome of Reactive Arthritis

3. Psoriatic Arthritis

4. Arthritis Associated with Inflammatory Bowel Disease

5. Malignancy

6. Bone and Joint Infection

History

• Indications of referred pain

• Associated back pain

• Location of pain

• Aggravation by running, sitting, etc

• Morning Stiffness

• Associated problems such as Achilles Tendinopathy or Plantar Fasciitis

Examination

Always remember to examine the joint above (Lumbar Spine) and below (hip)

Inspection

1. From Behind

2. From Each Side

Palpation

1. Sacroiliac Joint

2. Gluteal Muscles

3. Ischial Tuberosity

4. Sacrotuberous Ligaments

5. Iliolumbar Ligament

6. Anterior Superior Iliac Spine

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Check active and passive ROM of the Lumbar Spine and Hip Joint

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Hip Extension

2. Hip Internal Rotation

3. Hip External Rotation

4. Knee Flexion

NeuroVascular

1. Check and Grade reflexes, sensation, and strength of lower limb nerve roots

2. Check Pulse

3. Rectal tone in suspected Cauda Equina Syndrome

Special Tests for Sciatic Nerve Irritation

1. Straight Leg Raise

2. The Prone Knee Bend Test for Femoral Nerve Stretch

3. Slump Test

Special Tests for Sacroiliac Joint Irritation

1. FABER Test

2. Sacroiliac Compression Test

Special Tests for Spondylolisthesis

1. Jackson Hyperextension Test

Investigations

1. Plain Films: Indicated for acute trauma, stress fractures, suspected spondylolisthesis, or suspected lumbar instability. Consider Xray in non-responsive back pain.

2. Bone Scan: May be helpful to diagnose spondylolysis or stress fractures.

3. CT may be performed for suspected nerve root symptoms, however it has low specificity. Also helpful for suspected spinal stenosis or facet joint arthropathy. It may also confirm a part interarticularis defect.

4. MRI: Very sensitive but poorly specific. Capable of confirming annular tear or disc disease. The investigator must confirm clinically: an abnormality on MRI is not necessarily responsible for the back pain.

5. Myelography: May be helpful for operative planning for disc herniation.

6. Discography: Dye is injected into the nucleus pulposis of the disc. Pain on exam confirms the diagnosis. The test may confirm the structure of the disk. This is the best true diagnostic test for discogenic back pain.

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