Author: Dana Sheng, MD
Co Author #1: Julie Ingwerson, MD
Senior Editor: Margaret Gibson, MD, FAMSSM
Editor: Amy Leu, DO
Chief Complaint: Left buttock pain
14 year old male high school freshman, multi-sport athlete with chief complaint of persistent left buttock pain after fall from a rope swing onto a tree stump, non-penetrating injury (12/2015). Pain increased 24-48 hours afterward, ED care was sought with no imaging obtained. Patient was given diagnosis of contusion and reassurance was provided. Conservative care consisting of rest, heat, NSAIDs, and donut pillow treatment was recommended and followed with poor compliance. Pain further progressed over 2-3 months to the point of wheelchair mobility. Pain then improved over the next 3-6 months to ambulation without pain but continued symptoms with running and forward bending. Patient denied any mechanical, instability, or neurological symptoms.
ROS positive for left low back and buttock pain as well as constipation. No bowel or bladder incontinence, no urinary retention, no saddle anesthesia. No infectious, constitutional, or rheumatological symptoms.
VS: T 36.7, HR 86, BP 110/70, RR 24.
Inspection: no skin changes, tufts of hair, or pelvic obliquity.
Palpation: +tenderness to palpation at left buttock about sacroiliac joint and piriformis. Increased left buttock pain with lateral compression. Non-tender lumbar spinous processes, paraspinals, iliac crest, greater trochanter bilaterally.
ROM: pain-free lumbar flexion, extention, lateral bending, rotation. Symmetric bilateral hip flexion, internal and external rotation.
Muscle stregnth: 5/5 bilateral lower extremities
Sensation: intact to light touch L2-S2
Reflexes: 1-2+ symmetric DTRs BLE, no clonus, normal Babinski
Gait: normal toe, heel, tandem gait.
+Left buttock pain with FABER, Gaenslen, Gillet.
+Impaired SI joint mobility on Gillet test.
Negative SLR, Gower, log roll, FADIR bilaterally.
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