A Case Of Severe, Intermittent Left Gluteal Pain - Page #1

Author: Michelle Gorbonosov, MD
Co Author #1: Jill Kropa, MD
Co Author #2: Jill Kropa, MD
Co Author #3: Jill Kropa, MD
Editor: Kevin Gray, MD

Patient Presentation:
A 46-year-old male was referred to the Sports Medicine clinic for seven years of left gluteal pain. The pain was intermittent, radiated down the left leg, and woke him up at night. The pain was trigged when pressure was applied to his left gluteal muscle. He denied weakness, numbness, saddle anesthesia, and bowel or bladder incontinence. He took naproxen and acetaminophen with some relief. An EMG was completed at the orthopedic office which showed slowing of the left peroneal nerve. He was referred to the office to evaluate for an ultrasound-guided piriformis injection.

The patient had previously completed over twelve weeks of physical therapy focusing on a core strengthening program. Previous imaging of his lumbar spine showed a degenerative disk at L4-L5. He had multiple lumbar epidural injections with minimal improvement. No other pertinent medical history.
Past Surgical History: None
Medications: Naproxen and Acetaminophen as needed
Allergies: NKA
Family History: Noncontributory

Physical Exam:
General: No acute distress and sitting comfortably.
Back: Tender to palpation at the posterior left hip in the area of the piriformis. No tenderness to palpation along the lumbar spine. Strength was 5/5 of the bilateral iliopsoas, quadriceps, hamstrings, and gastrocnemius. Full range of motion of the back and bilateral hips without pain. Deep tendon reflexes were 2+ at the bilateral knees and ankles. Sensation to light touch was intact. Gait was normal.

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