Musculoskeletal mimickers of lumbosacral radiculopathy

Musculoskeletal mimickers of lumbosacral radiculopathyShawn Jorgensen, MDAANEM Annual Meeting October 2012

Financial Disclosure• Nothing to disclose

Mimics are common in nature

• Snake mimic caterpillar

• Thorn mimic leafhopper

• Stick insect

MSK mimickers of lumbosacral radiculopathies

• Recurring themeso Diagnosis

• Symptoms, physical examination findings, and diagnostic imaging are usually non-specific, with key exceptions

• Often no gold standard• Often diagnosis by successful injection

o Treatment – unless otherwise stated, the following applies:• Conservative measures

o Rarely have solid evidence to guide themo Usually benign and favorable cost-benefit analyseso Include NSAIDs, muscle relaxers, physical therapy

• Surgery - usually no solid indications or evidence of efficacy

• Individual conditionso LS facet syndromeo Hip pathologyo Piriformis syndromeo Hamstring tendinopathy / tearso Sacroiliac joint (SIJ) dysfunctiono Gluteal myofascial pain syndromeo Greater trochanteric pains syndrome (GTPS)o Iliotibial band (ITB) syndromeo Plantar fasciitis

Lumbosacral facet syndrome• What is it?

o Pain stemming from the zygapophyseal joint (z joint)

• Why is it on this list?o Common – up to 15% of cases of LBP (Cohen 2007)o Can mimic radiculopathy

Lumbosacral facet syndrome• Anatomy

o Synovial joints with a synovial capsule, synovial fluid, and hyaline cartilage

o One on each sideo Occur between two adjacent

vertebrae (e.g. a right L4-5 facet)

• Pathophysiologyo Intimately tied to degenerative

disc disease (DDD) – rarely see facet DJD without DDD on MRI (Cohen 2007)

Lumbosacral facet syndrome• Clinical presentation (Cohen 2007)

o No clinical finding can reliably predict the response to a facet joint injection and therefore diagnose facet syndrome

o Pain referral patterns • Inconsistent, overlap• Upper facets to flank, hip, upper lateral thigh• Lower facets to distal lateral and posterior thigh• L5/S1 facets can radiate to lateral leg and foot

Lumbosacral facet syndrome• Diagnostic imaging studies (Cohen 2007)

o Not routinely recommended

• Diagnosis – by needle? (Cohen 2007)o Generally accepted that successful blocks are the most reliable

means of diagnosing facet syndrome

Hip pathology• What is it?

o DJD of the hip

• Why is it here?o Common – 11% of population in western countries

(Aresti 2016)o Frequently mimics upper lumbar radiculopathy

Hip pathology • Anatomyo Ball and socket jointo Anatomically, deep to the groin

(not greater trochanteric area)o Innervated by obturator and

femoral nerves

Hip pathology• Clinical presentation (Khan 2004)

o Most commonly refers to the groin, buttock, anterior knee and thigh

o Radiates below the knee in almost 50%o Physical exam – painful limited ROM

(especially internal rotation)

• Diagnosiso Plain filmso Intra-articular injection can confirm the hip joint as

the source of pain

Piriformis syndrome• What is it?

o Sciatica related to pathology of the piriformis and related muscles or their impact on the sciatic nerve

• Why is it on this list?o Clinically very similar to radiculopathyo 6-8% of sciatica cases yearly (Kirschner 2009)

Piriformis syndrome• What is it?

o Sciatica related to pathology of the piriformis and related muscles or their impact on the sciatic nerve

• Why is it on this list?o Clinically very similar to radiculopathyo 6-8% of sciatica cases yearly (Kirschner 2009)

Piriformis syndrome• Anatomy

o Piriformis muscle• One of several short external

rotators in the gluteal region• Arises on anterior sacrum, inserts

on greater trochanter• Runs through greater sciatic

foramen• Frequent anatomic variations –

shares muscle belly or tendon with other muscles (Probst 2019)

Piriformis syndrome• Anatomy

o Sciatic nerve• Exits pelvis around piriformis

(Probst 2019)o 90% inferior to piriformiso Some exit through piriformis, others

superioro Some are divided into tibial and fibular

divisions prior to exiting• Not clear if they matter!

o No significant difference in incidence of piriformis syndrome with normal or variant anatomy (Probst 2019)

Piriformis syndrome• Pathophysiology

o Is it a problem of the muscle alone or does it involve the sciatic nerve?o Probably nerve

• In a series of patients with sciatica with no definite lumbar cause, 86-94% had ipsilateral edema or hyperintensity of the sciatic nerve compared to the contralateral side on MRI neurography (Probst 2019, Lewis 2006)

o Variations or enlargement of piriformis on MRI have no definite association with piriformis syndrome (Kirschner 2009)

Piriformis syndrome• Clinical presentation

o History• 100% of patients have buttock pain and sciatica (Probst 2019)• Can radiate to posterior thigh (Kirschner 2009)• 92% post-traumatic (Probst 2019)• Usually unilateral

o Physical examination (Probst 2019)• No finding diagnostic of piriformis syndrome• 92% have pain to palpation in the sciatic notch

Piriformis syndrome• Diagnostic tests

o MRI is the test of choice (Probst 2019)o MRI neurography if availableo EDX

• NEE is often normal (Probst 2019)• Tibial H-reflex latency difference between FAIR and supine position

o 2 SD above normal in FAIR position – 85% sensitive 81% specific by clinical criteria (Fishman 1992)

Hamstring tendinopathy• What is it?

o Tendinosis of proximal hamstring, that can cause chronic pain or a sudden tear

• Why is it on this list?o Can mimic an S1 radiculopathy with buttock and posterior thigh pain

Hamstring tendinopathy

• Anatomyo 4 muscles, all arising from ischial tuberosity (SHBF from

femoral shaft)o All insert distal to the kneeo All are hip extensors, knee flexors

Hamstring tendinopathy• Clinical presentation

o Chronic, persistent posterior hip/thigh pain, worse with sitting or activity (Starzman 2017)

o Physical exam tests reproduce pain with passive hip flexion, knee extension or resisted knee flexion

• Diagnosis – MRI

Sacroiliac joint (SIJ) dysfunction• What is it?

o Pain stemming from the intra- or extra-articular structures of the SIJ

• Why is it on this list?o Common – 10-30% of chronic axial LBP/pelvic (Cohen 2013)o Frequently mimics radiculopathy

Sacroiliac joint (SIJ) dysfunction

• Anatomyo True synovial joint at junction of

sacrum and iliumo Ligaments may be source of paino Motion is limitedo Separates under the influence of the

hormone relaxin during pregnancy

Sacroiliac joint (SIJ) dysfunction• Clinical presentation (Cohen 2013)

o History• Will often have a reason, unlike facet or discogenic pain

o Usually axial loading and rotation or pregnancy• Referral patterns

o Highly variableo Most common is buttock radiating to the lateral thigho Below the knee – 28%o Groin pain - not common (14%), but much more likely than in

discogenic or facet pain• Usually unilateral • Often no lumbar pain

o Usually axial loading and rotation or pregnancy• Usually unilateral • Referral patterns

discogenic or facet pain

o Usually axial loading and rotation or pregnancy• Usually unilateral • Referral patterns

discogenic or facet pain

Sacroiliac joint (SIJ) dysfunction

• Clinical presentation (Cohen 2013)o History

• Most likely source of pain when worst pain is within 10cm of PSIS

Sacroiliac joint (SIJ) dysfunction• Clinical presentation

o Physical examination• Disagreement about the value of exam (Cohen 2013)• 3 positive provocative tests predicts response to injections well (Cohen 2013)

• Diagnostic studieso None are definitive (Cohen 2013)

• Diagnosis (Cohen 2013)o Confirmatory blocks gold standard

Myofascial pain syndrome• What is it?

o Clinical syndrome of muscle tension, characterized by trigger points and referred pain patterns

• Why is it on this list?o Common – up to 85% will experience in their lifetime (Weller 2018)o Common with radiculopathy

• Gluteal trigger points seen in 76% of patients with radiculopathy, 2% with controls (Adelmanesh 2015)

Myofascial pain syndrome• Pathophysiology

o Unknown; gluteal may be secondary to radiculopathy

• Clinical presentationo Persistent, regional paino Trigger points in a taut band refer pain to patterns dependent on the muscle involved – can range

from trunk to foot

• Diagnosiso Studies – none, but US elastography promising (Malanga 2010)

Greater trochanteric pain syndrome• What is it?

o Common syndrome of pain in the region of the greater trochanter of the femur, due to tendinopathy and/or bursopathy

• Why is it on this list?o “The great mimicker” because it is so commonly mistaken for other

conditions (Williams 2009), including radiculopathyo 63% of patients dx in one series had been evaluated by a spine surgeon

for radiculopathy (Williams 2009)o Very common – estimated to affect 10-25% of populations in

industrialized societies (Williams 2009)

Greater trochanteric pain syndrome• Anatomy

o Greater trochanter• Bony protuberance on most lateral aspect of femur, where femoral shaft and neck meet• Easy to palpate in the lateral hip

o Iliotibial band (ITB)• Coalescence of fascia of gluteus medius and minimus, TFL (Strauss 2011)• Runs down lateral thigh to insert on tibia

o Bursae• Subgluteus maximus (or greater trochanteric) bursa most commonly involved in GTPS (Reid

o Glutei tendons• Gluteus medius and minimus insertions are involved

Greater trochanteric pain syndrome• Pathophysiology

o Thought to be increased friction between the greater trochanter and the ITB, compressing the structures in between (gluteus medius, minimus, and greater trochanteric bursa) (Reid 2016)

o More frequently a tendinopathy than a bursitis by MRI (Barrett 2017)

Greater trochanteric pain syndrome• Diagnosis

o History• Pain on lateral hip• Radiates down lateral leg

o Past knee in 50%!! (Williams 2009)• Worse with lying on affected side (Williams 2009)

o Physical examination• Pain to palpation over greater trochanter “invariably” present (Williams

o MRI, USo Injection (diagnostic and therapeutic)

Iliotibial band (ITB) syndrome• What is it?

o Syndrome of lateral knee pain due to ITB friction against lateral femoral epicondyle during flexion and extension

• Why is it on this list?o Can mimic S1 radiculopathy

Iliotibial band (ITB) syndrome• Anatomy

o Surface anatomy - forms line between quadriceps anteriorly and hamstrings posteriorly

o Attaches at tibia (Gerdy tubercule)o Runs over lateral femoral epicondyle

• Clinical presentation (Strauss 2011)• Pain on lateral aspect of knee, worse with running or downhill • Noble test

• palpate ITB over lateral femoral epicondyle, passively flex/extend, pain at 30 degrees of flexion

• Diagnostic imaging – MRI or US

Plantar fasciitis• What is it?

o Painful degeneration of the plantar fascia

• Why is it on this list?o Can mimic S1 radiculopathy

Plantar fasciitis• Anatomy

o Fibrous connective tissue running along plantar aspect of foot, beginning at inferior calcaneus

• Clinical presentationo Pain restricted to plantar aspect of footo Worse first steps, better with more activityo Pain to palpation of inferior calcaneus

• Diagnosis – MRI, US, Bone scan

Thumb protocol when EDX negative for radiculopathy

• Myofascial pain syndromeThumb protocol when EDX negative for radiculopathy

• Piriformis syndrome

• Myofascial pain syndrome

• Greater trochanteric pain syndrome

• Hamstring tendinopathy

• ITB syndrome

• Plantar fasciitis

• Conclusionso MSK conditions frequently present with low back/pelvic/hip pain

radiating to the lower limbo Many of these conditions commonly radiate below the kneeo A few questions and physical exam maneuvers can rapidly and reliably

identify some of these mimickers

Thank you!!Enjoy the meeting

Sources• Adelmanesh F, Jalali A, Shirvani A, Pakmanesh K, et al. The Diagnostic Accuracy of Gluteal Trigger

Paints to Differentiate Radicular From Nonradicular Low Back Pain. Clin J Pain 2016;32:666-672.• Adelmanesh F, Jalali A, Jazayeri S, Raissi GR, et al. Is There an Association Between Lumbosacral

Radiculopathy and Painful Gluteal Trigger Points? A Cross-Sectional Study. Am J Phys Med Rehabil2015;94:784-791

• Aresti N. Hip osteoarthritis. BMJ 2016;354:i3405 doi: 10.1136/bmj.i3405• Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: a

systematic review. Br J Sports Med 2017;51:97-104.• Chang JS, Kayani B, Plastow R, Singh S, et al. Management of hamstring injuries: current concepts

review. Bone Joint J 2020;102;1281-1288.• Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology,

diagnosis and treatment. Expert Rev Neurother 2013;13:99-116. • Cohen SP, Srinivasa NR. Pathogenesis, Diagnosis, and Treatment of Zygapophysial (Facet) Joint Pain.

Anesthesiology 2007;16:591-614.• Degan RM. Proximal Hamstring Injuries; Management of Tendinopathy and Avulsion Injuries. Curr

Rev Musculoskelet Med 2019;12:138-146.

• Filler AG, Haynes J, Jordan SE, et al. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine. 2005;2(2):99-115.

• Fishman LM, Zybert PA. Electrophysiologic Evidence of Piriformis Syndrome. Arch Phys Med Rehabil1992;73:359-364.

• Weller JL, Corneau D, Otis JAD. Myofascial Pain. Semin Neurol 2018;640-643.• Khan AM, McLoughlin E, Giannakas K, Hutchinson C, et al. Hip osteoarthritis: where is the pain? Ann

R Coll Surg Engl 2004;86:119-121.• Kirschner JS, Foye PM, Cole JL. Piriformis Syndrome, Diagnosis and Treatment. Muscle Nerve

2009;40:10-18.• Lewis AM, Layzer R, Engstrom JW, Barbaro NM, Chin CT. Magnetic resonance neurography in

extraspinal sciatica. Arch Neurol. 2006;63(10):1469-1472.• Malanga GA, Cruz Colon EJ. Myofascial Low Back Pain: A Review. Phys Med Rehabil Clin N Am

2010;21:711-724.• Neufeld SK, Cerrato R. Plantar Fasciitis: Evaluation and Treatment. J Am Acad Orthop Surg

2008;16:338-346.

Sources

• Probst D, Stout A, Hunt D. Piriformis Syndrome: A Narrative Review of the Anatomy, Diagnosis, and Treatment. PM R 2019;11:554-563.

• Reid D. The management of greater trochanteric pain syndrome: A systematic literature review. J Orthop 2016;22:15-28.

• Starzman AN, Fowler O, Carreira D. Proximal Hamstring Tendinosis and Partial Ruptures. Orthopedics 2017;40:e574-e582.

• Strauss EJ, Kim S, Calcei JG, Park D. Iliotibial Band Syndrome: Evaluation and Management. J Am AcadOrthop Surg 2011;19:728-736.

• Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg 2009;108;1662-1670.

Sources

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