1. AAPM&R Annual Assembly October 2 nd, 2015 Matthew Smuck, MD Chief, Physical Medicine & Rehabilitation Associate Professor, Department of Orthopaedics Director, Wearable Health Lab Stanford University The Evaluation of The Athlete With Buttock Pain: An Approach To Diagnosis And Management

2. 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)

3. C ASE 1 – “A C HALLENGE 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

4. C ASE 1 – “A C HALLENGE 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

5. C ASE 1 – “A C HALLENGE 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

6. C ASE 1 – “A C HALLENGE 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 S URGERY THE F OLLOWING D AY

7. V ASCULAR B UTTOCK P AIN Aneurysms and pseudoaneurysms - Iliac arteries (common, internal, external) - Sciatic artery - Gluteal arteries (superior, inferior) Dissections and AV Fistulas - Iliac arteries Endofibrosis and kinking - Iliac arteries Evaluation of The Athlete With Buttock Pain

8. V ASCULAR B UTTOCK P AIN Evaluation of The Athlete With Buttock Pain

9. V ASCULAR B UTTOCK P AIN Evaluation of The Athlete With Buttock Pain

10. C ASE 1 – “A C HALLENGE FOR THE 4 DIAGNOSTIC SENSES ” Look Feel Evaluation of The Athlete With Buttock Pain Listen

11. C ASE 1 – “A C HALLENGE FOR THE 4 DIAGNOSTIC SENSES ” Look Feel Evaluation of The Athlete With Buttock Pain Listen Smell

12. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” 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

13. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” 15 yo competitive baseball player with severe left upper gluteal pain when batting. Evaluation of The Athlete With Buttock Pain

14. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” 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

15. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” 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 L ET IT H EAL !

16. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” 15 yo competitive baseball player with severe left upper gluteal pain when batting. Evaluation of The Athlete With Buttock Pain L ET IT G O !

17. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” DX: Pars Stress Fractures Evaluation of The Athlete With Buttock Pain S TANDARD E XAM  Inspection, Palpation, ROM, Neurovascular, Special tests O NE LEGGED HYPEREXTENSION  “No association between test and presence or absence of active spondylolysis” Masci 2006 Thanks to D.J. Kennedy! Masci 2006

18. C ASE 2 – “L ET IT H EAL OR L ET IT G O ” DX: Pars Stress Fractures Evaluation of The Athlete With Buttock Pain Masci 2006 MRI - B EST DEMONSTRATION OF OTHER PATHOLOGY - L ACKS 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!

19. 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!

20. 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 L IKELIHOOD TO H EAL Thanks to D.J. Kennedy!

21. Why CT scan? V ERY GOOD BONY ANATOMY  Sensitivity less than bone scan C ORRELATION 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!

22. Thank You! Matthew Smuck, MD Chief, Physical Medicine & Rehabilitation Associate Professor, Orthopaedic Surgery Director, Wearable Health Lab Stanford University msmuck@stanford.edu