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Musculoskeletal mimickers of lumbosacral radiculopathyShawn Jorgensen, MDAANEM Annual Meeting October 2012
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Financial Disclosure• Nothing to disclose
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Mimics are common in nature
• Snake mimic caterpillar
• Thorn mimic leafhopper
• Stick insect
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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
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MSK mimickers of lumbosacral radiculopathies
• 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
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MSK mimickers of lumbosacral radiculopathies
• 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
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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
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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)
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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
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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
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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
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Hip pathology • Anatomyo Ball and socket jointo Anatomically, deep to the groin
(not greater trochanteric area)o Innervated by obturator and
femoral nerves
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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
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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)
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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)
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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)
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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)
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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)
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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
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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)
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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
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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
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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
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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
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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
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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
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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• Usually unilateral • 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
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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• Usually unilateral • 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
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Sacroiliac joint (SIJ) dysfunction
• Clinical presentation (Cohen 2013)o History
• Most likely source of pain when worst pain is within 10cm of PSIS
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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
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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)
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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)
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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)
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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
2016)
o Glutei tendons• Gluteus medius and minimus insertions are involved
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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)
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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
2009)
o MRI, USo Injection (diagnostic and therapeutic)
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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
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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
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Plantar fasciitis• What is it?
o Painful degeneration of the plantar fascia
• Why is it on this list?o Can mimic S1 radiculopathy
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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
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Thumb protocol when EDX negative for radiculopathy
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• Myofascial pain syndromeThumb protocol when EDX negative for radiculopathy
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• Myofascial pain syndromeThumb protocol when EDX negative for radiculopathy
• Piriformis syndrome
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• Myofascial pain syndrome
• Greater trochanteric pain syndrome
Thumb protocol when EDX negative for radiculopathy
• Piriformis syndrome
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• Myofascial pain syndrome
• Hamstring tendinopathy
• Greater trochanteric pain syndrome
Thumb protocol when EDX negative for radiculopathy
• Piriformis syndrome
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• Myofascial pain syndrome
• Hamstring tendinopathy
• Greater trochanteric pain syndrome
• ITB syndrome
Thumb protocol when EDX negative for radiculopathy
• Piriformis syndrome
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• Myofascial pain syndrome
• Hamstring tendinopathy
• Greater trochanteric pain syndrome
• ITB syndrome
• Plantar fasciitis
Thumb protocol when EDX negative for radiculopathy
• Piriformis syndrome
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MSK mimickers of lumbosacral radiculopathies
• 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
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Thank you!!Enjoy the meeting
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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
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Anesthesiology 2007;16:591-614.• Degan RM. Proximal Hamstring Injuries; Management of Tendinopathy and Avulsion Injuries. Curr
Rev Musculoskelet Med 2019;12:138-146.
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• 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
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