AAPM&R Annual AssemblyOctober 2nd, 2015

Matthew Smuck, MDChief, Physical Medicine & Rehabilitation

Associate Professor, Department of OrthopaedicsDirector, Wearable Health Lab

Stanford University

The Evaluation of The Athlete With Buttock Pain: An Approach To Diagnosis

And Management

DISCLOSURES

Cytonics - Research support ($ - paid to institution)

Lumo BodyTech - Advisor (stock options)

BlueJay Mobile Health - Advisor (stock options)

Vivametrica - Founder (20% owner)

State Farm Auto Insurance - Expert Witness ($ - hourly)

SIS - Board of Directors ($ - travel/honoraria)

The Spine Journal - Executive Editorial Board ($ - travel)

CASE 1 – “A CHALLENGE FOR THE 4 DIAGNOSTIC SENSES”

60 yo competitive cyclist with acute onset right buttock pain, followed by right leg symptoms.

Day 1 – acute pain onset while cycling uphill Day 2-3 – leg pain and numbness improved with rest

Day 4 – buttock pain with thigh and calf cramping when walking

Day 5 – visit with PCP, lumbar MRI and PM&R consult

Evaluation of The Athlete With Buttock Pain

CASE 1 – “A CHALLENGE FOR THE 4 DIAGNOSTIC SENSES”

60 yo competitive cyclist with acute onset right buttock pain, followed by right leg symptoms.

PM&R visit:– Look - MRI shows no herniaiton, no stenosis

– Listen - Claudication with activity, not while standing

– Feel - localized gluteal tenderness, no other provocation – Feel - normal neuro, diminished pedal pulses on the

right

Evaluation of The Athlete With Buttock Pain

CASE 1 – “A CHALLENGE FOR THE 4 DIAGNOSTIC SENSES”

60 yo competitive cyclist with acute onset right buttock pain, followed by right leg symptoms.

WHAT DO YOU DO NEXT?

Evaluation of The Athlete With Buttock Pain

CASE 1 – “A CHALLENGE FOR THE 4 DIAGNOSTIC SENSES”

60 yo competitive cyclist with acute onset right buttock pain, followed by right leg symptoms.

Vascular Surgery visit:– ABI = 0.6/1.0 (right/left)

– CT angiogram = dissection and partial occlusion of the

common iliac artery

Evaluation of The Athlete With Buttock Pain

SURGERY THE FOLLOWING DAY

VASCULAR BUTTOCK PAINAneurysms and pseudoaneurysms

- Iliac arteries (common, internal, external)- Sciatic artery

- Gluteal arteries (superior, inferior) Dissections and AV Fistulas

- Iliac arteriesEndofibrosis and kinking - Iliac arteries

Evaluation of The Athlete With Buttock Pain

VASCULAR BUTTOCK

PAIN

Evaluation of The Athlete With Buttock Pain

VASCULAR BUTTOCK

PAIN

Evaluation of The Athlete With Buttock Pain

CASE 1 – “A CHALLENGE FOR THE 4

DIAGNOSTIC SENSES”

Look

Feel

Evaluation of The Athlete With Buttock Pain

Listen

CASE 1 – “A CHALLENGE FOR THE 4

DIAGNOSTIC SENSES”

Look

Feel

Evaluation of The Athlete With Buttock Pain

Listen

Smell

CASE 2 – “LET IT HEAL OR LET IT GO”15 yo competitive baseball player with severe left

upper gluteal pain when batting.

July 13 – pain onset, continued play Sept 13 – MRI shows pars stress reaction, restricted

play Nov 13 – pain free return to play Dec 13 – MVC with return of pain Feb 14 – first presents to our clinic with the following

images

Evaluation of The Athlete With Buttock Pain

CASE 2 – “LET IT HEAL OR LET IT GO”15 yo competitive baseball player with

severe left upper gluteal pain when batting.

Evaluation of The Athlete With Buttock Pain

CASE 2 – “LET IT HEAL OR LET IT GO”15 yo competitive baseball player with severe

left upper gluteal pain when batting.

WHAT DO YOU DO NEXT?

Evaluation of The Athlete With Buttock Pain

CASE 2 – “LET IT HEAL OR LET IT GO”15 yo competitive baseball player with severe left

upper gluteal pain when batting.

Feb 14 – first presents to our clinic

April 14 – pain free with progressive training, but left-sided pain returned with recent attempt to

resume batting

The following images were obtained:

Evaluation of The Athlete With Buttock Pain

LET IT HEAL!

CASE 2 – “LET IT HEAL OR LET IT GO”15 yo competitive baseball player with

severe left upper gluteal pain when batting.

Evaluation of The Athlete With Buttock Pain

LET IT GO!

CASE 2 – “LET IT HEAL OR LET IT GO”DX: Pars Stress Fractures

Evaluation of The Athlete With Buttock Pain

STANDARD EXAM Inspection, Palpation, ROM,

Neurovascular, Special tests

ONE LEGGED HYPEREXTENSION

“No association between test and presence or absence of active spondylolysis”

Thanks to D.J. Kennedy!

Masci 2006

CASE 2 – “LET IT HEAL OR LET IT GO”DX: Pars Stress Fractures

Evaluation of The Athlete With Buttock Pain

MRI- BEST DEMONSTRATION OF OTHER PATHOLOGY- LACKS SENSITIVITY? Case reports of missed lesions Spect vs MRI

› 40 pars fractures› MRI positive in 39/40› Correctly graded only 29/40› Several false positives

Campbell 2006

Thanks to D.J. Kennedy!

Imaging Algorithm

History & Physical

Plain Films• AP and Lateral (Spondylolisthesis)

Treat presumptively Only Advance Imaging if: No response to treatment, red flags ,etc

If no response• MRI (eval for bone edema)

If still no response and negative MRI• Bone Scan

Thanks to D.J. Kennedy!

CT Correlating with boney union

L4 - (22/35) = 63%

L5 - (18/204) = 8.8%

Listhesis > 5˚ - (3/65) = 4.6%

Listhesis < 5˚ - (37/174) = 21%

Fujii 2004

LIKELIHOOD TO HEAL

Thanks to D.J. Kennedy!

Why CT scan?

VERY GOOD BONY ANATOMY Sensitivity less than bone scan

CORRELATION WITH BONY UNION 134 pts with 239 pars

- Early (31/50) = 62% - Progressive (9/103) = 8.7% - Terminal (0/86) = 0%

Fujii 2004

Early

Terminal

Thanks to D.J. Kennedy!

Thank You!

Matthew Smuck, MDChief, Physical Medicine & RehabilitationAssociate Professor, Orthopaedic Surgery

Director, Wearable Health LabStanford University

msmuck@stanford.edu