Other Reasons for Buttock Pain

: On today's episode, other reasons for buttock pain. course, bust the widespread misconceptions. My name is Brody Sharp. I'm an online physiotherapist, recreational athlete, creator of the Run Smarter series, and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Let's start off with a bit of an apology. I do sound sick and that's because I am sick. The last couple of days have been quite congested nasally and I think this is just the sort of initiation with being a new dad. At the moment, my newborn daughter and my partner have been unwell and they've been so for the last week and eventually I ended up catching it and then... It's a bit hard to shake off with not as much sleep as I usually get and, you know, just being rocked a little bit, but the show must go on. We still need to record this podcast and this is a really valuable one. So first of all, thanks to Syed who released or sent me emailed me this paper. He's been sending me a couple of PhD papers and it's been really good keeping, um, keeping me informed and coming out. what with what is recent evidence on PHT and other similar topics. And so, um, so he'd sent me this email being like, Hey, thought you might want to check this out. And it's a great paper. It's a 2023 paper. So very well, you know, as recent as it can be for the time of recording. Um, the title of the paper is called Bionic Pain in Athletes, a narrative review. And so. This. narrative review is from the authors of this paper going through and explaining potential reasons for buttock pain and they talk through like different regions of the hip and buttock areas and I didn't cover the whole paper but thought I would cover some things that are quite relevant and particularly around PhD and then sort of expand upon or include most of the information when it came to the upper hamstring lower glutes sort of region. Um, but think you might find it really interesting. Um, I was initially hesitant to release this sort of topic because it does cover a whole bunch of different pathologies that it could be. And I do very well know that, um, some people can be, um, like, like a Technically, it's like an anxiety disorder. Um, if you, you sort of hear about a condition, you instantly think, oh yeah, that's me. I have this. Um, and I remember when I was at uni, this used to happen all the time. We used to go through, go to a lecture, go through some slides, go to some medical conditions, be like, oh, I think I have that. And turns out you never do, but we're just compelled to read something and link dots and, you know, Find links that aren't there. And so I want you to keep in mind that it is a natural tendency to hear about all these different conditions and all these different symptoms and things that it could be, and your mind is instantly gonna go to, oh my God, I have this, but just have a clean slate, have an open mind, be very rational with your thinking process, and we'll cover off these Who knows, like maybe this episode helps uncover a potential other diagnoses or a co diagnoses when it comes to your clinical presentation. So that's why I decided to be like, you know what, let's just talk about this paper anyway, because it's very informative, but just don't get too worried. When we start listing some things off. So I thought I would talk about the purpose of this paper to start with. So they say that the goal of this review is to provide a guide to systematically evaluate and diagnose sport-related buttock pain. Since buttock pain is a common yet challenging complaint for sports medicine clinicians, we have developed an overview of the common diagnoses in athletes presenting with buttock pain using an anatomical framework to illustrate the complex anatomy and multiple region, multiple pain generators. that may refer to this area. They start off with the lower back, the lumbar spine, which is just the lower section of your back. And this could potentially radiate or what we call refer the pain to these other areas. And so it starts off with lumbar spine pathology frequently refers pain to the buttocks with or without associated low back pain. So You can have low back pain and buttock pain, but you can also have just buttock pain that is referring from the back. They continue, differentiating lumbar spine pathologies involves assessment of the lumbar range of motion and directional preference. So trying to see if you are, they call it directional preference if you are more flexion-based or like bending forward, or if you are more extension-based arching backwards. So, trying to assess the lumbar region, then trying to find which camp you fall into. And they also say a detailed neurological exam, including sensory and motor testing and neurodynamic testing can further help identify the cause of pain. So not only would you do some range of movement stuff, but you would also look at the sensation is someone's skin altered, the sensitivity on their skin altered, or is their motor patterns or reflexes or anything like that altered, but then also doing neurodynamic tests, which is just like stretching a nerve in a particular way and seeing if that produces or reproduces your symptoms. Usually when it comes to the odd thing is, is like a lot of people have low back pain, it is super, super common. So a lot of people that have PHT will also have low back pain. I'm an example of this. I had PHT. I also have a long history of episodes of low back pain all the way back from my basketball days. And so that, you know, you can potentially link the two and say, Oh my God, it's connected if, but you know, in reality I've had low back pain for, I don't know, 20 odd years and the PHT only came on. during triathlon training. And so, wasn't really connected, but sometimes when I used to be in clinics and try and find out, okay, is this leg pain that someone has referred from the back? If they do have lower back pain, I usually ask questions like, okay, when your back is worse, is your foot symptoms worse? Or is your hamstring symptoms worse? Do they radiate and come on together? And if the answer is yes, it's sort of doesn't confirm anything, but it just increases our suspicion that the two might be linked. And if not, if it's like, oh no, I only get hamstring pain when I do a long run, but my lower back is just if I've been lifting and picking up the kids too much, something like that. If they're too independent, then it's less likely that the two are going to be connected. If someone is looking like it is referring, we can do like a slump test. You might need to YouTube that or something. I can, if one of my clients is listening to this and I have suspected that it might be something to do with the nerves, I would get them to do a slump test, something you can easily do online or just do yourself. Just to see if you put the sciatic nerve under stretch. does it radiate or reproduce your symptoms, your upper hamstring or sit bone problems, and then we do some sort of releasing at the head or releasing at the foot to see if it makes it better or worse, and we can sort of increase our theory, our hypothesis that it can be referring from the lower back. So these are some things to mention or keep in mind. I did mention earlier that the separating between flexion based pathology and extension based pathology can be a critical one so I thought I'd just expand upon that. So the paper says that when it comes to flexion based pathology in the lower back, so bending forward, they say that the L5S1 which is just the one of the lower levels of your spine it frequently refers pain to the buttocks. And they say that sitting, coughing, sneezing, and other flexion-based activities can produce this, refer this. So if you're coughing, or every time you sneeze, if that causes pain and that pain radiates into the hamstring, it's probably not PHT. It's probably something to do with the lower back. They say that lumbar disc herniations can also irritate or compress the nerve roots coming out of the lower back and that can cause pain to refer into the buttocks and or further down the leg. A radiculopathy includes sensory loss, so loss of sensation in the skin or muscle weakness. A positive seated slump or straight leg neural tension slash irritation and a diagnosis of lumbar radiculopathy. This is getting quite complex, but essentially saying that there are some tests we can do. If you do suspect that there may be some symptoms radiating from the lower back, get it assessed. Don't just assume these things because some of these tests, the reflexes, the motor control, the sensory stuff, the neurodynamic stuff requires some assessment. requires professional intervention. So just keep that in mind. So they're the flexion based stuff. Take, take away, um, that coughing, sneezing and flexion based activities might be, um, associated with this, but then it also says flexion based activities, like sitting and like bending forward, which is also, that can also produce. Um, symptoms if you do have PhD, I know a lot of people with PhD that have pain with sitting and also have pain. bending forward to pick something up off the floor. So these things do overlap. Okay, an extension-based pathology, I thought I'd just quickly mention this. So arching backwards, this is pain on spinal extension and suggests pathology of the posterior elements or posterior parts of the lower back, including the facet joints, which may refer into the buttocks. I rarely see this facet joint pain. that radiates into the hamstring. But if you do have low back pain and you do arch backwards, and they do say in the paper, it's frequent, these movement patterns are frequently seen in gymnasts, swimming, particularly butterfly and breaststroke strokes, dances, and any other athletes that sort of do that sort of movement. If you are arching back, especially arching back and rotating, if that causes pain in your hamstring, it's less likely it's going to be the, the PhD. We're not doing too much to the, to the tendon itself when we do those sort of back movements. So yeah, just keep that in mind. They talk about treatment. So treatment for the lower back. They say in the absence of red flag symptoms. So red flag just means, okay, there might be something quite serious going on. So we're talking about anesthesia in the saddle region or like around your groin and genitals, if there are losses sensation there, if you have bowel or bladder incontinence, that is progressive or progressive weakness, they are red flags and we need to do something else, we need to send you for like emergency sort of assessments. So in the absence of red flag symptoms, conservative treatment for the lower back disorders. Start with activity modification, physical therapy, heat, ice, and anti-inflammatories or analgesics. Conservative treatment, just meaning like non-surgical treatment, particularly exercise-based therapies is the first line of treatment in reducing pain and improving function in athletes. Athletes commonly benefit from a course of physical therapy direct. directing to mobility, strengthening and stability of the lumbar spine and its surrounding structures. So once again, they're promoting, like in the initial days, they're promoting just removing or when they say activity modification, that is just okay, finding out what aggravates symptoms and then trying to modify that so it doesn't aggravate symptoms. That might be changing how you sleep or how you bend forward or your posture when you sit in. your couch overnight or, you know, while you're watching TV, yeah, activity modification, and then just trying to restore some range of movement and strength. Depending if it's a flexion based pathology or an extension based pathology, we would assign different stretches. For strength, you can just do your generic sort of like planks, side planks. If you're ready for it, I like to give people a hyperextension type of strength. So you might see in the gym a machine or contraption where you just like, you're kind of leaning over. So you're standing, but then you lean over and you lean over a pad that's sort of at your hip crease and you just fold yourself forward and then you have to arch yourself up using your back muscles to extend you up. I think it's called a hyperextension. You can Google that. uh, and then just getting really strong from there. Like I say, I've had lower back pain in the past and there, I did go through a period of like being quite uncomfortable with sitting when I very first moved to this house and got a new computer chair and wasn't really agreeing with me. So I started doing these hyper extensions and being progressive with it, starting with body weight, three sets of 12, then increasing the weights more and more, just holding more weight at my chest and my back never felt better. And so. um, that, um, I've assigned to some people, some who I think might be appropriate and they've had the same reaction. Okay. The next category area of the body would be the sacral bone stress injury that this paper talks about. So your sacrum is just your, um, the, the bone that comprises of your tailbone. Most people know where the tailbone is, but, um, sort of connects the pelvis. and is sort of central, um, kind of higher up if it's a bit more of a sacral bone stress injury. Um, it says that it is seen in endurance runners, um, particularly those endurance runners that have what we call this red S which is relative energy deficiency in sports, um, pretty much those who under-fuel themselves and really over train and lose weight and sort of just, um, a chronic overloaded state where you're not feeding yourself enough to get the energy that's required for that training can run into a few disruptions there. They also talk about the sacroiliac joint. So if we just talked about the sacrum, which is that center part of your pelvis behind you, the ilium is that big round hip bone that just like spreads onto each side of the hip. So that crest, that bony crest that people are familiar with looks like big elephant ears, they are your ilium. And so your sacroiliac joint is the joint that connects those two together. You have one on the right hand side, one on the left hand side. And they say that, you know, this can be diagnosed with palpation, you know, you just press on the sacroiliac joint. And if that radiates and produces pain into your proximal hamstring, then Odds are that's probably where the pain is being referred from. So, um, I thought I'd just quickly just glance over those two, just so, you know, the paper does mention them, but I wanted to spend a little bit more time on some other topics. Um, so that's pretty much looking at the lumbar spine and areas associated with the lumbar spine. Now we're looking at the hip joint. And so the paper says that intraarticular hip pain refers to the pain originating from the hip joint itself. So we're looking at that ball and socket joint, which includes the femoral head and neck, the acetabulum, the cartilage, the articular cartilage, the labrum and the ligament and teres. Don't expect you to know all these, but we're just talking about the ball and socket joint and all the cartilage and the things that surround that joint. They say that common causes of intraarticular hip pain in athletes includes labral tears, a FAI, the femoral acetabular impingement, which just means that when it comes to the ball and socket, sometimes the ball is a little bit big or has some bony growth, or sometimes the socket is too deep and the bones can kind of pinch on one another, or it's more the cartilage that pinches, but just so you know, the shape of it is a bit too much in some areas and can start to... run into issues, or they say, ephemeral neck stress fracture. They say that the hallmark of these intraarticular pains can be provoked with hip flexion, with internal external rotation, so movements of the hip just trying to provoke some of those symptoms. Although it is traditionally accepted that symptomatic hips may refer into the anterior groin. They say that intraarticular hip pathology commonly refers into the buttock as well. So if you have FAI or some sort of impingement or some sort of labral tear, um, it can be at the front of the hip, it can be in the groin, but can also refer into the buttock as well. Prior studies have demonstrated that up to 70% of patients with symptomatic hips report having associated buttock pain. So 77% is quite high. So let's dive into these individually. The paper talks about the labial tears and the FAI, that impingement that I was just talking about. They say that FAI is a condition in which there is abnormal contact between the femoral head and neck with the acetabulum or hip socket. So just talking about that bullet socket I was mentioning before. With repetitive contact and loading, it may result in labial tears or cartilaginous injuries. Anterior meaning like the front, labial tears, which are more common than posterior labial tears, meaning the back, are common in sports involving repetitive lower extremity twisting movements such as ballet, soccer or basketball. I talked to a professional, I cannot remember her name, Lizzie. Lindsay Plass was her name. Um, we talked about FAI and label tears on the Run Smarter podcast. If you wanted to look more into that, the title, if you wanted to search for it is understanding FAI and label tears with Lindsay Plass, P-L-A-S-S. And, um, she talked about like your hockey goalie, like ice hockey when they're having to be in this crouched position the whole time and do a lot of rotations with their knees and their hips just to save a lot of shots. That's classic, like you'd become very symptomatic if you did have FAI and did those movements because there are a lot of people who do have an FAI that goes by asymptomatic. I am, speaking about being which most of the times asymptomatic. And if I had to do like a lot of sort of unboxing, if I had to put together like a flat pack box and all like some of my gym equipment, they all arrived in boxes and I had to like do a lot of squatting, a lot of like moving things around. I remember my hip being a bit irritated after that and my range of movement on that side when it comes to internal rotation is it just locks up. It is so, so poor. I have about 35 degrees internal rotation on my asymptomatic side and it's like five degrees on my symptomatic side. So a lot of signs pointing to FAI but for the most part pain-free because I just don't do anything to irritate it. Which I think is very large percent of the population do have an FAI, just it just goes by unnoticed. They say treatment for these sorts of things. So treatment for label tears and the this impingement. includes activity modification, again, trying to avoid what might cause pain, to avoiding repetitive impingement or end of range hip motion, they say physical therapy to improve your hip abductor strength and pelvic control. And they also said that corticosteroid injections may reduce pain in the hip joint. Talking about femoral neck. stress fractures, so like a bone stress reaction high up in the femur, close to that ball and socket joint. They say that stress fractures of the femoral neck are relatively uncommon, but have two distinct populations. So the first population they see this in is young, healthy, active individuals such as runners, endurance athletes or military recruits, and The other population would be your older athletes with osteoporosis and a risk of insufficiency fractures. So like, I guess the bone density isn't quite there and increases that risk. They say the femoral stress fractures may present with anterior groin pain with or without radiation, a radiation of pain into the back of the hip and it's worsened with weight bearing activities. So we're talking like standing still or standing on one leg or those sorts of things might produce those symptoms. They say an MRI can be utilized for a diagnosis if the clinician has a high suspicion that it might be a stress fracture because that can be quite serious, especially in the neck of the femur that's considered as like a high risk area. So we wanna be very careful with that. If we do suspect it, we would send you for scans. Okay, so. Let's go back. So we've looked at different regions. We've looked at the lower back and the lumbar spine. We have looked at the sacrum and the sacroiliac joint. We've looked at the hip socket itself and all these different pathologies that could potentially refer into the buttock region. Now we're going to the gluteal region. So your glutes, which isn't PHT just yet. We've got one more region. after this, which is the proximal hamstring region. But the paper talks about the gluteal region and the very first diagnoses or potential source of symptoms. It, uh, they suggest comes from muscle strains or, and myofascial pain. So, you know, the glutes, their muscles, those muscles can get strained. I don't see it too often, but, um, this is what they say. The gluteal muscles, particularly the gluteus medius and the gluteus minimus are responsible for hip abduction, so moving away from the body and for pelvic stabilization. Most muscle strains are caused by eccentric, an excessive eccentric contraction and occur near the musculotendinous junction, meaning that, you know, muscle turns to tendon then attaches to the bone. It's that junction. as that muscle slowly starts to morph and evolve into the tendon before it attaches, it's that little moment when it's subject to these sort of strains, particularly in sports requiring explosive jumping and running movements such as soccer, football or basketball. Muscle strains often present as acute injuries with a sudden pain while contracting the muscle bruising. So I would say straight off the bat, this is quite different to PHT, where it's more slow onset, delayed onset, would probably come on the next day. If you overdid something, very rarely is it a sudden pain, like a one movement, bang, a lot of pain, swelling and bruising, you know, rarely would that happen. But they continue. Myofascial pain can be diagnosed. on examination by palpating the localised areas for tightness, looking for muscle knots, they say, or toward bands of muscle, also referred to as trigger points. Treatment for both strains and myofascial pain includes physical therapy to strengthen the hip and associated areas, trigger point injections, dry needling and manual therapy techniques to reduce muscle pain and improve recruitment. They then have a gluteal tendinopathy. So we're not looking at a hamstring tendinopathy, we're looking at a gluteal tendinopathy as the tendons for the glutes usually insert onto what we call the greater trochanter. If you were to stand and feel the most lateral or the most outside part of your hip, there's that bony prominence there. That's where most of the glutes attach to and can be subject to a tendinopathy in that region. So the paper says, gluteal tendinopathy refers to a degenerative process of the gluteal tendons. While this is a frequently seen entity due to the prevalence of gluteal weakness, this is seen particularly often in long distance runners. Running is primarily a sagittal oriented activity, meaning it's just in one direction, that requires constant abduction to provide pelvic stability. during the single leg stance phase. Essentially saying that the gluteals need to work pretty hard for single leg balance, thereby repetitively loading the gluteus minimus and medius tendons. Weakness or fatigue of these muscles can lead to dynamic hip adduction during running and jumping activities. People might refer to that as like a hip drop, like the opposite hip sort of collapsing downwards. and can lead to developing gluteal tendinopathy. Patients present with pain and tenderness around the greater trochanter, meaning that sort of bony prominence I was talking about before. Worse with physical activities such as walking, running, single leg stance activities, and direct pressure such as side lying on the affected hip. First line treatment options include physical therapy for strengthening. and mobility of the hip girdle muscles to improve tendon load. Um, um, I didn't talk too much about this one because the location is quite different. The location can be around the glutes, but it's mainly just the lateral hip. Um, but then we talk about, and the paper mentions, piriformis syndrome slash deep gluteal syndrome. And I think piriformis, piriformis syndrome, uh, many people have had this. misdiagnosed because it is actually PhD. So we investigate, it says piriformis syndrome. Well, I should actually start by saying the piriformis muscle sort of moves along the, well, attaches kind of where the sacrum is and runs perpendicular through the gluteal muscles and attaches to that greater gantt, to that lateral part. Essentially, if you draw a line from your sacrum to the lateral part, that's the direction and position of the piriformis muscle. And so it says, piriformis syndrome is commonly described in the literature as an enlarged or inflamed piriformis muscle, mechanically compressing the sciatic nerve causing buttock and posterior thigh pain. One thing about the anatomy of this muscle is that it is in very close proximity to the sciatic nerve. And there are some, what we call anatomical variations where some people can have quite a large piriformis and that can press on the sciatic nerve. And some people can have the piriformis, the sciatic nerve itself actually pass through the piriformis. It's like a variation in someone's anatomy that a certain percentage of the population actually have. And that can be very susceptible to compressing that nerve because it actually pierces straight through that muscle rather than normal variance where the psych nerve just passes behind that muscle. So if you do have that variance then the likelihood of piriformis syndrome is quite high, higher than the normal population. Piriformis syndrome is typically diagnosed clinically with increased resting tone of muscle as you palpate the muscle itself. Patients present with diffuse, deep, mid-buttock pain provoked by activities frequently involving hip flexion, internal rotation, adduction, and things such as running, lunging, and kicking. This is where it gets very, you can easily see how some people are diagnosed with piriformis syndrome if they do have PHT because we're looking at deep buttock pain, kind of vague, diffuse. We're looking at activities such as flexing at the hip, like bending forward. and activities such as running and lunging. A lot of crossover symptoms here. Special tests for piriformis syndrome involve stretching and activating the piriformis to exacerbate the symptoms. However, these tests have not been, are not shown to be very, not have high validity so that they must be used with caution. Validity just meaning like the accuracy, like if it is, if you do the test, and the test is positive, how accurate or how likely is it that it is actually positive? Is it a true positive? Conservative management to address the piriformis tension with manual therapy techniques, dry needling, piriformis stretching to restore proper muscle length and release the myofascial trigger points is often helpful. So this is where I sort of step in and say, okay, you can sort of treat, if you think it is piriformis syndrome, you can treat it as such. piriformis syndrome and see if it gets better. So what we're doing is we're letting the treatment itself be our diagnostic tool because, you know, one can argue that like, if you do your stretches, your piriformis releases, your massage, your piriformis stretches, and it doesn't get any better, maybe it's something else and that other thing could be PHT. They continue, physical therapy focuses on hip strengthening. lumbopelvic stability and biomechanics to help reduce piriformis overuse and prevent the pain reoccurring. In patients with true anatomic compression where minimally invasive techniques fail to relieve pain and improve function, endoscopic release of the sciatic nerve can be considered which is far superior to open release in the treatment with fewer complications. So saying if someone has this anatomic variant where the psych nerve is passing through that muscle, and you've tried doing the stretches and the releases, and you've tried doing all that conservative management, that's failed, maybe having some sort of surgical input is the way to go, to which they said that endoscopic, which I'm assuming is just like a minimally invasive like scope to just pass through and try to, they say, what was the term they used? release of the sciatic nerve. I don't know what that means, but they're saying that's probably better outcomes than actually creating an incision, sort of cutting you open and then trying to make the, the corrections. It says that has a lot more complications and we usually prefer the former. Okay. My voice is holding up as it seems. And now we're moving into something that's very rare, but can be very much misdiagnosed. This is what the paper calls ischiofemoral impingement. And so if you are similar to what we discussed with that ball and socket hip joint impingement, think of it very similar, but it's just at the back. It's still the femur and it's still the ball and socket joint, but just when you swing your leg backwards, those... ball and socket structures can pinch and cause discomfort, pain, that sort of stuff. And so the paper says, ischiofemoral impingement is a less common cause of buttock pain, thought to be secondary to narrowing between the lesser trochanter of the femur and the ischium. So just a bump that's on the femur and the ischium is your sitting bone. adduction, so the leg going to the midline, and external rotation, narrow this ischiofemoral space leading to impingement of the quadratus femoris, which is just a muscle, and the sciatic nerve between the bony landmarks. So we're finding that essentially kicking the leg back squeezes the muscle with the sciatic nerve and then that can produce pain. It continues to say that weakness of the hip abductors, essentially like your glute medius and those sorts of surrounding areas, leading to contralateral pelvic drop or hip drop, also narrows the ischiofemoral space and contributes to impingement. This diagnosis has been seen in ballet dancers with the likely mechanism of repetitive hip external rotation and hip extension movements. The condition is predominantly seen in females, 84% is what the paper reports. due to the smaller ischiofemoral space. In addition, a large percentage, in brackets, 40% of cases are bilateral. Ischiofemoral impingement presents with deep buttock pain, which progressively worsens with activity and improves with rest. Specific tests for this syndrome include a long stride walking test. I never heard of this until I read the paper. So just walk. and try and take long strides. And as you do that, it's sort of, you're forced to extend the hip backwards as you walk. And this can impinge that Lesser Trichanta with the lateral ischium, the sitting bone. And the test is designed to produce symptoms. Treatment options include rehabilitation and strength of the hips. ultrasound guided trigger point injection to the quadratus femoris, corticosteroids or toxin injections and surgery to decompress the quadratus femoris and release the sciatic nerve. Like I say that's quite rare. I would sometimes just take someone through passive leg extension because we know with or doing like a shoe off test or kicking in water or lying on your stomach and keeping your leg straight but trying to lift your entire leg off the ground, that can produce symptoms with PHT, but it also can produce symptoms with this ischiofemoral impingement. So what I do is try and take the active component out of it. So the difference being, instead of you lying on your stomach and lifting and actively lifting your straight leg up towards the ceiling, stay completely relaxed and have the therapist pick up your leg so the hamstrings are nice and calm, nice and relaxed, so you can't, it won't initiate pain if you do have pht. But if you have this ischiofemoral impingement that would produce symptoms because it's a passive pinching and so that can be a way to differentiate the two just instead of doing it in an active sense, do it in a passive sense by someone else moving you. while you're relaxed and then that might differentiate the two. Okay, we're moving on away from the gluteal region and we are moving into the proximal hamstring region and it's almost fitting that it finishes with this and thought I would include pretty much most of what the paper included. So the first part or the first section of the proximal hamstring region is... proximal hamstring injury and or tendinopathy. And so we may already know this from previous episodes of the podcast, but let's go through it anyway. The paper says hamstring injuries, including strains, tendinopathy and partial tears of the hamstring tendon are common in a wide range of sports involving sprinting, high-speed kicking, or jumping like soccer or American football because of the increased eccentric load on the tendons during those activities. Proximal hamstring injuries may occur concurrently with ischial gluteal bursitis and inflammation of the ischial gluteal bursa. that is positioned between the ischial tuberosity and the proximal hamstring tendon and can absorb some of the compressive loads. So a bursa is just like a fluid-filled sac that's responsible for lubricating a lot of different structures as they sort of overlap and cross and create friction over one another. And so they're saying that this bursitis that's between the sitting bone and the gluteal muscles can be inflamed. and is sometimes working concurrently with these proximal hamstring injuries. They say that this ischial gluteal bursitis may also result from extended periods of pressure on the ischium in activities such as cycling. Clinically, patients report pain with walking, climbing stairs, sitting and stretching the hamstring muscles. On examination, The passive stretch of the hamstrings reproduces the pain. As lumbar radicular pain may present simile, dual tension tests, or like nerve tests, may help differentiate between lumbar radicular pain and hamstring pain. So essentially it's just saying, we need to differentiate if it is coming from the back or not. Patients also have pain with resisted contraction of the hamstrings, as well as palpation over the ischial tuberosity, where it attaches. and in the proximal hamstring tendons. Treatment of the hamstring involves several phases. Phase one, the goal is to treat pain, protect healing tissue and avoid strength loss. This is done through icing in a short period of time, one to two day period, and followed by progressive hip strengthening beginning with stationary cycling. and isometric strengthening exercises. When walking and isometric contractions are pain-free, I wouldn't say pain-free, I don't say low levels of pain, but nonetheless, the athlete can progress to phase two, incorporating eccentric strengthening exercises such as the Nordic Hamstring Curl, which have been proven to result in significant reductions in re-injury rates. This is probably for more of your sporting athletes like soccer and football. sort of stuff. Note that in these early phases, stretching should be gentle as end range lengthening of the hamstrings, especially if painful in brackets, can aggravate and prolong injuries. Finally, athletes can begin to incorporate sport-specific drills and plyometrics to facilitate their return to sport. Additional treatments such as corticosteroid and platelet-rich or PRP injections for the treatment of proximal hair string issues have been demonstrated or have mixed results. However, shockwave therapy is an emerging therapy for proximal hair string tendinopathy and has demonstrated good efficacy in limited studies thus far. So a good summary and the other. section topic that they talk about is proximal hamstring tendon ruptures and they say complete proximal hamstring tendon ruptures are relatively rare compared to proximal hamstring muscle tears or partial tears associated with tendinopathy but may be seen in sports with a high eccentric load or a sudden or a risk of sudden hip flexion with the knee in full extension. such as water skiing, gymnastics and motocross. So we're looking at like a quite a violent movement, you know, trauma based sort of stuff. The athlete may experience a sudden severe pain associated with a pop or an instability to weight bear. You know, that you think it's pretty serious if you hear a sudden pop and then all of a sudden you've lost all strength to stand on that side, you know, you'd probably. suggest if the incident was very traumatic, like a water skiing accident or being tackled or something, yes you might investigate, maybe get scans and investigate, but they also say significant bruising and swelling are often noted on examination. Management depends on the extent of the injury, single and double leg, single and double tendon with less than 2cm of retraction may be managed non-operatively, however conservative treatment is less successful for injuries that involve all three of the hamstring tendons, regardless of the amount of retraction or two of the three hamstring tendons with greater than a 2cm retraction. So this is good to know if you have if the scans have shown a tear and it's on two of the three tendons and it's less than a two centimeter retraction, meaning like, I guess, retraction just being pulled back. A lot of people might suggest that surgery is the only option, and you might be like pushed or forced into doing surgery because like, oh, we need to reattach these tendons. Well, the research shows that conservative treatment, if you have two of these two of the three tendons ruptured, but the retraction is less than two centimetres. You are better off trying conservative treatment first because it seems to be well managed non-operatively as it says here. But if it's more severe, it's all three of the tendons, or if two of the three have quite a large retraction, then we can discuss some operative, some surgical options. Once daily activities are non-painful, patients can begin strengthening with isometric exercises. Patients can also perform gentle stretching to maintain their range of movement. However, stretching into a painful range should be avoided as this can worsen your injury. As the patient progresses, eccentric exercises such as Nordic hamstring exercises should be included and are the mainstay of re-injury prevention. Finally, a gradual return to athletic activity with plyometrics and sport-specific training can be initiated. In patients with complete avulsion injuries, so including all three of those tendons, or avulsion of two tendons with a retraction of greater than two centimetres may require surgical repair. Studies, current studies demonstrate good success with surgical management. with high levels of patient satisfaction, return to play, improve strength, endurance and decreased pain. So good to finish up with that. They are all the things that we have discussed. So like I say, we went through the lower back region. We discussed the referral from the lumbar spine, the sacrum bone, the hip joint, whether that be from label tears or FAI impingement or femoral neck. bone stress reactions, we looked at the gluteal region and covered muscle strains or myofascial pain or a gluteal tendinopathy. We looked at other areas of the gluteal region looking at piriformis syndrome also known as deep gluteal syndrome and ischiofemoral impingement. And then of course the proximal hamstring region looking at the proximal hamstring either undergoing some sort of muscle tear or tendinopathy or some tendon ruptures. The paper concluded, buttock pain is a common yet challenging complaint for both clinicians and athletes and can arise from many structures in the lumbar spine, gluteal region, the hip and the pelvis. This review highlights some of the more commonly encountered diagnoses in sports medicine that can refer pain to the buttocks. their typical presentations, diagnostic workup, and treatment. Awareness of the potential causes of buttock pain in athletes, an understanding of the complex anatomy, and a thorough knowledge base of the physical examination, diagnostic imaging, and treatment options are essential for the diagnosis and management of patients presenting with buttock pain. Wait, I have one more paragraph to go. Here we go. Treatment options for buttock pain vary significantly. depending on the condition and the mechanism of injury. Ultimately, clinical outcomes are optimized with a multi-dimensional interdisciplinary evidence-based approach to treatment and return to play. Jasmine interrupted me as I was wrapping up that final paragraph, but this is what the paper entails. Like I said, the paper, it's a 2023 paper. It is titled buttock pain in athletes and narrative review if you want to look it up. Thanks, Saeed for bringing this to my attention. I think it's turned out to be a great episode and something that a lot of the listeners will take away. So thanks, guys. Thanks for listening. I hope you've learnt a lot and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format. then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future. And remember, knowledge is power.