Trevine Albert, D.O. PGY-2 David Joyce, D.O. PGY-3 Steven .

Trevine Albert, D.O. PGY-2David Joyce, D.O. PGY-3Steven Licata, D.O. Program Director, FM/NMM2017 Annual FOMA ConventionDepartment of Family Medicine,Neuromusculoskeletal Medicine

Build a differential diagnosis for gluteal pain Briefly discuss sciatica as a leading diagnosis Describe four other commonly seen etiologies Review relevant anatomy Describe relevant orthopedic tests Review applications for ultrasound-guidedmusculoskeletal injections Discuss Osteopathic diagnosis and treatment of thepelvis and sacrum

A common complaint to the primary care office One of the top 3 workman’s compensation expenses US healthcare costs: 33 billion annually Disability and costs are related to pain, not to the diseaseprocess

Thoracolumbar fasciaTensor fascia lataeGluteus maximusIliotibial tract

Gluteus mediusPiriformis

Gluteus minimusObturator internusSuperior GemelusInferior GemelusQuadratus femoris

Gluteus maximusPosterior femoralcutaneous nerveInferior cluneal(bbr of PFCN)Sciatic nervePerineal(bbr of PFCN)

A 68 y/o woman presents for constant left sided lowerback pain, varying in intensity from 3-7/10, occasionallyradiating down the back of the left side of her thigh toabove her knee.She states this happened when she bent down to pick upsome boxes. The pain is minimally improved withchiropractic treatments and Advil OTC PRN and worse withwalking. She denies acute onset, muscle weakness,numbness/tingling down either lower extremity, or loss ofbowel or bladder function.

SciaticaPiriformis syndromeHip joint arthritisLumbosacral radiculopathySpinal stenosisGluteus medius / minimus tendinosusGreater trochanteric bursitisProximal hamstring strainSomatic dysfunction (Innominate, Sacral, Lumbar)Myofascial pain syndromeMononeuritisIschial bursitisSacroiliac joint painSacroilitis (eg Ankylosing spondylitis)Infected Pilonidal cystGluteal abscessCoccygodynia

M54.30PathophysiologyPain in the lower extremity resulting from irritation of thesciatic nerve, which is typically felt from the low back to thebuttock and radiating down and below the knee

G57.00PathophysiologySciatica-like pain caused by compressionof the sciatic nerve by the piriformismuscle

G58.9Pathophysiology Disease or trauma involving a single peripheral nerve Posterior gluteal irritation or pain

Superior gluetal N

Gluteus medius

Gluteus minimus

M76.0M70.6Pathophysiology Lateral hip pain Insidious onset Exacerbated with activity Pain may be exacerbated in lateral recumbent position Pain may radiate down the lateral thigh

M53.3 Posterior hip pain Most commonly mechanical Reproducible on palpation

M53.3IdentifyLocating via anatomic landmarks Palpate medial and deep to PSIS Pain on palpation along lateral margin of sacrum

Sacral canalIliac crestIliac wingPSISGreater sciatic notchSacral hiatusIschial spineObturator foramenLesser sciatic notchIschial tuberosityCoccyx

Diagnosis of somatic dysfunction relies on physical examfindings (TART):1)2)3)4)Tissue texture changesAsymmetryRestrictionTenderness Treatment (OMT) relies on a diagnosis of somaticdysfunction Eg M99.01 Segmental and somatic dysfunction of cervicalregion. Billable procedure OMT

PELVIS& SACRUMRELATED REGIONS Lumbar spine Lower extremities

So how do we diagnosesomatic dysfunctionsof the pelvis or sacrum?

TWO DIFFERENT PATHWAYS PELVISSACRUM Iliosacral motion Sacroiliac motion How the pelvis moves How the sacrum movesrelative to the sacrumrelative to the pelvis

PERFORM TWO SIMPLE TESTS STANDING FLEXIONTESTSEATED FLEXION TEST

POSITIVE STANDINGFLEXION TESTPOSITIVE SEATEDFLEXION TESTPELVIS(ILIOSACRAL)SACRUM(SACROILIAC)How the pelvis moves relativeto the sacrumHow the sacrum movesrelative to the pelvi

Pace JB, Nagle D. Piriformis syndrome. West J Med. 1976;124:435-439. Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004;35:65-71. Savarese, RG. OMT Review: A comp