1. Buttock Pain In Athletes: C ase Examples Michael Fredericson, MD Professor and Director, PM&R Sports Medicine Team Physician, Stanford Athletics Stanford University

2. Disclosures  Grants:  Ipsen, Inc.  American Medical Society for Sports Medicine  Medical Advisor:  Cool Systems, Inc.  Journals/Magazines:  Founding Senior Editor, PM&R  Scientific Advisor, Runner’s World

3. Illustrative Case  21 y.o. previously healthy female collegiate XC runner  CC: R. low back & sacral pain that began after run 3 days ago  No prior hx of LBP or stress fractures  History of old bilateral pars defect at L5 w/ minimal anterolisthesis of L5 on S1  History of amenorrhea & osteopenia

4. Physical Exam  Tenderness to deep palpation sacrum  Localized sacral pain w/ hopping on affected leg

5. Diagnostic studies  DEXA scan:  L1-L4 Z score= -2.0  L. hip Z score = 0.6  MRI:  negative for sacral stress response, fracture, or pelvic injury

6. Differential dx l Broad differential dx l Lumbar disk disease l Facet arthropathy l Spondylolysis l Musculotendinous strain l SI joint dysfunction/Sacrolilitis l Sacral stress fracture

7. 3-day f/u  Pain improved slightly w/ PT  Felt less “ tight” in sacrum; no pain walking around campus  Pain after a few minutes when attempted to run again  Bone scan & SPECT ordered  All 3 phases bone scan negative  SPECT: increased tracer uptake in L5- S1 pars- intrarticularis ( compatible w/ old pars defect)

8. Further w/u  Repeat MRI showed old L5 pars defect & broad central disk protrusion @ L4-5 without central canal or neuroforaminal stenosis  Pain thought to be referred from L- spine; prescribed diclofenac 75 mg bid x 1 week without relief

9. Further w/u  Tried easy run again, but symptoms returned  Underwent fluoro guided injection to L. L5 facet & pars  Symptoms mildy improved, but still pain w/ running  Given persistent pain, repeat MRI of sacrum ordered

10. Repeat MRI

11. Sacral stress fractures: MRI not always definitive for early stage injuries. Fredericson M, et al. American Journal of Sports Medicine. 2007; 35:835-839.

12. Concerns for Osteopenia  A cancellous stress fracture in a female may be a warning sign of early onset osteopenia. Marx et al. Stress fracture sites related to underlying bone health in athletic females. CJSM, 2001.

13. Stress fx and bone health  Marx, et al study ( 2001) 20 female pts w/ stress fx  Found 8/9 pts w fx of cancellous bone had osteopenia; 3/11 w fx of cortical bone w/ osteopenia ( p=0.01)

14. Stress fx and bone health  Also found association between hx of eating disorder or restrictive eating & stress fx of cancellous bone  Recommend that females < 40 y.o. w/ stress fx of cancellous bones have bone density evaluation

15. Pelvic stress fx and bone health  Fredericson, et al ( 2003): case study of 21 runners w/ sacral stress fx  9/12 females had history of amenorrhea  7 females met criteria for osteopenia; 2 w/ osteoporosis  2 men w/ osteopenia

16. Illustrative Case  A 32-year-old female elite middle-distance runner with right upper hamstring and buttock pain related to running. She had seen another physician for lumbar disk bulge, treated with lumbar epidural injections and physical therapy. Her low- back pain improved sufficiently to allow her to compete in the Olympic Finals. However, the upper-thigh and buttock pain persisted, preventing her from competing at maximal capacity.

17. Illustrative Case Cont.  After the Olympics, she continued to experience a viselike squeezing of her proximal thigh that caused a throbbing pain at the end of a race. She discontinued racing for the next several months, and by midautumn her symptoms had resolved except for occasional left buttock pain with prolonged sitting. During this period, she became pregnant but continued to stay in shape with gentle running, aerobics, and light weight lifting.

18. Illustrative Case Cont.  The following autumn, she started running again without significant pain; however, as her training intensified, she noted increasing pain in the right buttock and decided to seek a second opinion at our clinic. Her symptoms were present even at rest or sitting on a hard surface and most pronounced with track work and faster speeds. She did not have any current low- back pain, numbness, or tingling in the lower extremities.

19. Differential Diagnosis  Sacroiliac dysfunction  Piriformis syndrome  Lumbar radiculopathy  Obturator internus bursitis  Ischiofemoral impingement  Proximal hamstring tendinopathy

20. Pelvic MRI * Sciatic nerve inflammation/adhesions

21. Proximal Hamstring Tendinopathy  Distance runners  Lower gluteal pain  Worse with faster speeds  Focal ischial pain with prolonged sitting Fredericson et al. High Hamstring Tendinopathy in Runners. Phys Sportsmed, 2005.

22. Patient Evaluation  Soft tissue palpation  Strength  Hamstring flexibility  Neural tension

23. Supine Plank Test Fredericson et al. 2005

24. Bent Knee Stretch Test Fredericson et al. 2005

25. Cacchio et al. Reliability and Validity of Pain Provocation Tests Used for the Diagnosis of Chronic Proximal Hamstring Tendinopathy, BJSM 2012. Modified Bent Knee Stretch Test

26. Prone Curls

27. Anatomy  Swollen and thickened proximal tendon insertion (semimembranosus)  Impingement of sciatic nerve Lempainen et al. Proximal Hamstring Tendinopathy. AJSM, 2009

28. Ischial Tuberosity Edema

29. Rehab: Progressive Eccentric and Core Strengthening

30. Hamstring Injection Therapy Recommended after failed physical therapy!

31. Unpublished Data Amer J Radiology, 2010

32. Clinical Outcomes

33. Imaging Results

34. PRP and tenotomy for proximal hamstring tendinopathy

35. Platelet-rich Plasma as an Effective Treatment for Proximal Hamstring Injuries Wetzel et al. Orthopedics 2013  Retrospective review  PRP 12 injured hamstrings (10 subjects) vs 5 injured hamstrings (4 subjects) treated only with rehab  Blind injection to ischial tuberosity  PRP group followed up 4.5 months. The rehab only group followed up 2 months  The PRP group demonstrated significant reduction in VAS and Nirschl Phase Rating Scale vs rehab only group

36. Ultrasound-Guided Intratendinous Injections With PRP or Autologous Whole Blood for Treatment of Proximal Hamstring Tendinopathy: A Double-Blind Randomized Controlled Trial. Davenport et al. J Ultrasound Med. 2015  Both PRP and WB groups showed improvements in all outcome measures at 6 months.  No significant between-group differences were observed at any time pointt.  Ultrasound imaging showed no significant differences between PRP and WB group tendon appearances.

37. Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial. Hamilton et al. Br J Sports Med. 2015  90 professional athletes with MRI positive hamstring injuries were randomised to injection with:  PRP-intervention,  Platelet-poor plasma (PPP-control)  No injection.  No benefit of a single PRP injection over intensive rehabilitation

38. Summary: Proximal Hamstring Tendinopathy  Common overuse injury in distance runners  Lower gluteal pain with running, especially at faster speeds  Detailed exam to rule out other potential causes of buttock/posterior thigh pain

39. Summary (cont.)  Percutaneous corticosteroid injection recommended for peritendinitis  PRP/tenotomy injections recommended for chronic tendinopathy  Ultimate goal is transition to a progressive core, gluteal, and eccentric hamstring protocol

40. Thank You! mfred2@stanford.edu m