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Case Discussion: Buttock Pain and Repeated Motions

10/7/2014

4 Comments

 
A little more than a month ago, I was treating a young child for groin pain that responded fairly well to manual therapy within a few sessions. One day his mom came into clinic and started telling me about some buttock pain she had had for over a decade. There were some other odd subjective complaints, so I advised her to schedule an appointment with me to thoroughly address it.

Subjective
The patient reported
11 years go she developed buttock pain near her piriformis after giving birth via C-section. Patient reported sometimes her pain goes all the way down her R leg as well. Patient believed that her pain was increased by prolonged sitting on firm surfaces but was not certain. Patient could not identify any alleviating factors. Patient also reported an occasional "cold" sensation down her leg, but is uncertain of what causes it (upon retrospect, the patient's perception of "cold" may have been actually numbness). Patient states she has seen multiple doctors for years about it but no one could treat it. The patient denied any N&T, B&B problems, significant changes in weight in last 6 months, N&V, fever, or night pain.

Objective
(I will only post the relevant findings)
Observation:
    -patient overweight
    -excessive lumbar lordosis
Mobility Testing:
    Multi-Segmental Flexion: DN
    Multi-Segmental Extension: DP
    Multi-Segmental Rotation: DN bilat
    Lumbar Sideglides: Decreased and Painful to the R (repeated motion had patient report improved mobility)
    Deep Squat: DN
    Seated Passive Hip ER: DN on R and FN on L
Flexibility Testing:
    Hamstrings: Abnormal bilat
    Hip Flexors (Thomas Test): Abnormal bilat
    ITB (Ober Test): Abnormal bilat
Strength Testing:
    Glut Med: 4+/5 bilat
    Glut Max: 4/5 bilat
Special Tests
    (+) Slump Test
    (+) Fortin's Sign
    (-) Sacral Compression/Distraction, Sacral Thrust, POSH Tests

Picture
Clinical Reasoning and Day 1 Treatment
It seemed pretty clear to me she had a loading problem on her R side, suggesting repeated lumbar sideglides would be an effective treatment. Due to the positive Fortin's sign, I thought she would respond well to a SIJ manipulation as well. I performed a SIJ distraction manipulation which eliminated her pain and changed her Multi-Segmental Extension to Functional and Non-Painful. I followed that up with some general core stabilization exercises and a HEP of repeated R lumbar sideglides 10x/hour. I should note that I don't often just rely on a positive Fortin's sign to direct my decision on whether or not to use a SIJ distraction manipulation, but with the patient being overweight, palpation of anatomical landmarks was difficult.

Day 2
A week later the patient returned and reported she had no pain for a few days, but then it returned. The patient stated she was not consistent with the HEP and was uncertain if it was helping. The patient again presented with Multi-Segmental Extension Dysfunctional Painful and a (+) Fortin's Sign. I repeated the SIJ distraction manipulation and did some IASTM to her lumbar paraspinals. Again, her Multi-Segmental Extension became Functional and Non-Painful. I followed that up with some core exercises, again, and changed her HEP to Quad Rock Back, Supine BKFO, and repeated lumbar sideglides, emphasizing the importance of compliance on the frequency of the sideglides.

Day 3
The patient returned a week later again and denied any of the pain near her PSIS, but reported severe buttock pain after sitting for 2 hours. The patient also reports she had one night with significant swelling in her R leg but both the pain and swelling had improved since. At this point, I realized that the manipulation was inappropriate for the patient as she had difficulty complying with her HEP when she wasn't in pain. It appeared the repeated sideglides were not as effective as I had hoped either. I reassessed lumbar extension and noted that it recreated the patient's buttock pain. I also noticed during extension, that her L shoulder would go further posterior than her R shoulder. I had the patient do 20 repetitions of lumbar extension in standing but cued her to push her R shoulder further back. While the motion initially recreated her pain, after 20 repetitions, she had full lumbar extension and no pain. The patient's new HEP was standing lumbar extension (to end range!) 10x/hour.

Days 4 and 5
A week later the patient returned and stated that her back pain was better than it had in years and she noticed significantly less "cold sensations." I instructed the patient to continue with repeated standing lumbar extension in standing, emphasizing end-range and hourly performance. At the final visit a week later, the patient reported no pain or cold sensations her her leg, buttock, or back.
The patient was discharged with a progressed HEP emphasizing core stabilization and movement retraining exercises.
Picture
Picture
Discussion
I wanted to present this case for several reasons. One is to never rule out a person with a long history of pain as a potential fast responder. Often when we assess a patient that has had pain for several years, we assume that degenerative processes or central sensitization will make them a slow responder requiring significant education and lengthy treatment. That is not always the case, as most patients are fast responders. We should be looking for significant changes in pain in the first several visits. Secondly, I want to address the comparison of treating this type of patient with a Sahrmann approach versus repeated loading. With the Sahrmann approach, we are taught to stay away from the painful motion and educate the patient on proper movement patterns using core stabilization. This is contradictory to the repeated loading approach, as often we must repeatedly perform the painful motion (not always the case). It often also takes much more education and time for the Sahrmann method to succeed. Previously, when a patient would present with extensive lumbar lordosis, I would disregard extension as a useful treatment method, but think about all the time we spend in sitting! The final aspect I want to discuss revolves around the importance of end-range for repeated motions. I have treated multiple patients recently where I first assessed repeated motions and the patient reported no change in pain, ROM, or any other symptoms, thus making me hesitant to proceed. I have learned that I have to consistently tell the patient they need to get to end-range, as that is what is required to make a difference. We can't be scared away from pain so easily as that can contribute to central sensitization.

-Chris
4 Comments
Chris Staples
10/13/2014 01:40:15 am

Chris,
Could you please clarify what you mean by DN, DP, and FN in your objective findings? Also thanks for this review, we are currently covering buttock pain in one of my courses this quarter and my peers and I found this article very useful.

Thanks,

Chris Staples SPT, Midwestern University Glendale

Reply
Chris link
10/13/2014 02:04:58 pm

Hi Chris,

Thanks for your comments. I'm glad you are finding this useful! The descriptions FN, DN, DP, and FP are the ways motions are graded in the SFMA (Selective Functional Movement Assessment). FN=Functional Non-Painful. FP=Functional Painful. DN=Dysfunctional Non-Painful. DP=Dysfunctional Painful. Functional versus Dysfunctional refers to full versus lacking movement with a specific movement pattern in the SFMA. Painful versus non-painful is self-explanatory. If you have other questions let me know or if you need further clarification on this!

Chris

Reply
AJ Sobrilsky
10/28/2014 10:14:18 pm

Chris, another good discussion and self reflection/critique. As I do more and more self reflection I see my practice patterns changing in a positive fashion.

Why no repeated loading/ex assessment from the get go? I know you found the R side glide to improve mobility, but what about moving into the side glide and then ext while glided... I've found this extremely useful in the majority of patients that present with back and leg pain and paint a subjective preference for ext based activities (i.e. sitting and bending is aggravating). If the patient is pretty irritable, but still thinking there is a specific ex direction this patient will benefit them from, I'll unload the spine by putting them in prone and showing them how to shift their hips indep to perform POE and Prone push up with that glide bias...or utilizing a push up with a single UE to encourage the closing on a specific side like you did with your patient above.

Good food for thought... don't rush to respond back, I know you're busy... Curious to what Dr. E thinks about this as well.

Reply
Chris link
11/6/2014 07:22:12 am

Hi AJ,

When symptoms tend to be unilateral, I like to start my repeated motions with sideglides. Since she was responding during the evaluation, I administered it as her HEP and did not assess pure extension. My guess is that since she was pain-free she did not feel the need to do her HEP. I typically like to do a manipulation if I can to lower the patient's pain threshold and then lock in the gained motion with the repeated motions. However, patients like this one don't feel like the HEP is important anymore if they are pain-free and we lose compliance. Cases like this are a perfect example of why some people need to just do the repeated motions without a manipulation, because compliance will likely increase if pain-reduction is the incentive.

I love those examples of variations for repeated motions you listed. I don't typically use that big a variety, but I am sure there are cases where they could be implemented!

-Chris

Reply



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      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
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      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
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      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
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      • Speed's Test
      • Posterior Apprehension
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        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
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      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
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      • Push-up Sign
      • Ulnar Nerve Compression Test
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      • Posterior Drawer Test
      • Posterior Sag Sign
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      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
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      • Anterior Drawer
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      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test
    • HEP >
      • Neck and Shoulder >
        • Supine Chin Tuck
        • Supine DNF with Towel Assist
        • Supine DNF
        • Standing Chin Tuck Against Wall
        • Standing Chin Tuck Against Wall with Scaption
        • Seated Cervical Retraction Repeated
        • Seated Cervical Retraction with Extension Repeated
        • Seated Cervical Retraction with Sidebend Repeated
        • Seated Cervical Retraction with Rotation Repeated
        • Standing Wall Shrugs at 90 Degrees Flex
        • Seated Thoracic Whips
        • Standing Ballistic Shoulder Extensions
        • Standing Repeated Shoulder Extension with Squat
        • Standing Repetead Shoulder Horiz. Abd. with Ext. CKC
        • Seated with Arms on Pillows Cervical AROM (Flex/Ext/Rot/SB)
        • Seated with Arms on Pillows Shrugs
        • Seated with Arms on Pillows Shrug with Scapular Retraction
        • Supine Shoulder IR with GH Centralization
        • Supine Shoulder ER with GH Centralization
        • Holding Dumbbell at 180 Degrees Flexion for Time
        • Cat Camel
        • Prone T's
        • Prone Y's
        • Quad Chin Tuck w/ Shoulder Flexion
      • Low Back >
        • Supine TA Isometric
        • Standing TA Isometric Agains Wall with Squat
        • Supine BKFO
        • Quad Rock Back
        • Standing Hip Hinge
        • Sit to Stand with Hip Hinge
        • Repeated Lumbar Sideglides
        • Repeated Standing Lumbar Extension
        • Repeated Standing Lumbar Flexion
        • Repeated Prone Press-Ups
        • Repeated Supine DKC
        • Slump Sciatic Nerve Glides
        • Birddog Progression
      • Hip and Knee >
        • Clamshells with Progressions
        • Fire Hydrants with Progressions
        • Donkey Kicks
        • Bridge Variations
        • Repeated Hip Flexion
        • Squats
        • Seated Repeated Knee Extensions
        • CKC Seated Repeated Knee Extensions
        • Heel Slides
        • CKC DF with Tibial IR
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        • Calf Raises with Soccer Ball Between Medial Malleoli
        • Towel Scrunches with Foot in PF
        • Toe Flexion Using T-Band with Foot in PF
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        • DF with Toes Flexed Using T-Band
        • Forefoot Adduction
        • Gastroc Stretch
        • Repeated PF
      • Examination Templates