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