Case Discussion: Buttock Pain and Repeated Motions

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

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.

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