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Myofascial Pain Syndrome of Gluteus Minimus Mimicking Lumbar Radiculitis -A Case Report

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Myofascial Pain Syndrome of Gluteus Minimus Mimicking Lumbar Radiculitis -A Case Report Anesth Pain Med 2015; 10: 16-20 http://dx.doi.org/10.17085/apm.2015.10.1.16 ￭Case Report￭ Myofascial pain syndrome of gluteus minimus mimicking lumbar radiculitis -A case report- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea Joong-Ho Park, Kwang-Suk Shim, Young-Min Shin, Chiu Lee, Sang-Gon Lee, and Eun-Ju Kim Myofascial pain syndrome (MPS) can be characterized by pain difficult. Delays in making the correct diagnosis can result in caused by trigger points (TrPs) and fascial constrictions. Patients longer hospital stays, higher hospital fees, and unnecessary with MPS of the gluteus minimus muscles often complain of diagnostic tests and inadequate treatments. The authors have symptoms such as hip pain, especially when standing up after sitting or lying on the affected side, limping, and pain radiating down to successfully diagnosed and treated a patient with MPS of the the lower extremities. A 24-year-old female patient presenting with gluteus minimus initially diagnosed with lumbar radiculitis. motor and sensory impairments of both lower extremities was With thorough physical examination and injection of TrPs referred to our pain clinic after initially being diagnosed with lumbar radiculitis. Under the impression of MPS of the gluteus minimus under ultrasonography guidance, the patient was relieved of her muscles following through evaluation and physical examination of symptoms. We report this case to emphasize the importance of the patient, we performed trigger point injections under ultrasonography physical examination in patients presenting with symptoms guidance on the myofascial TrPs. Dramatic improvement of the suggestive of lumbar radiculitis. patient’s symptoms was observed following this treatment, and she was discharged without any further remaining symptoms. (Anesth Pain Med 2015; 10: 16-20) CASE REPORT Key Words: Myofascial pain syndromes, Radiculitis, Trigger A 24-year-old female patient (39 kg, 162 cm) was referred points, Ultrasonography. to the pain clinic complaining of tingling sensation and weakness of both legs. The patient was working as an Myofascial pain syndrome (MPS) of the gluteus minimus operating room nurse in a local medical center, and had no usually presents with symptoms such as hip pain and pain previous history of underlying diseases. She had a traumatic radiating down to the lower extremities [1]. However, since history of slipping and landing on her buttocks during duty six various other conditions, such as lumbar radiculitis, spinal weeks prior to her presentation. The patient's initial symptoms stenosis, trochanteric bursitis, trigger points (TrPs) of other hip included lower back pain with a tingling sensation in both abductor muscles, and articular dysfunction [2] may also buttocks and posterior thighs. She was admitted to the local present with such symptoms, differential diagnosis may be medical center and underwent extensive diagnostic work-up including lumbar magnetic resonance imaging (MRI), pelvic Received: October 6, 2014. MRI, radiographic studies, and an ankle-brachial index test Revised: October 10, 2014. Accepted: October 18, 2014. (ABI), of which all the results were unremarkable. During a month of admission, the patient was treated with three Corresponding author: Kwang-Suk Shim, M.D., Department of Anesthesiology interlaminar epidural steroid injections (IL ESI) and one and Pain Medicine, Daegu Fatima Hospital, 99, Ayang-ro, Dong-gu, Daegu 701-724, Korea. Tel: 82-53-940-7434, Fax: 82-53-940-7443, E-mail: transforaminal epidural steroid injection (TF ESI). She was [email protected] also treated with physical therapy and oral medications. Following the treatments, her lower back pain improved, but This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) the tingling sensations of the buttocks, posterior thighs, calves, which permits unrestricted non-commercial use, distribution, and reproduction in any and feet persisted in spite of unremarkable findings on medium, provided the original work is properly cited. 16 Joong-Ho Park, et al：Myofascial pain syndrome of gluteus 17 Fig. 1. Imaging of the gluteus region, transverse view. (A) The transducer is placed transversely over the gluteus minimus (red marking). (B) Transverse view of the gluteus region under ultrasonography guidance shows the gluteus minimus (arrow head) located deep beneath the gluteus medius (asterisk). The needle (arrows) is being inserted using the in-plane technique. diagnostic tests. The patient complained of these tingling and TrPs were located on both gluteus minimus muscles. sensations gradually aggravating, especially when she was When pressure was applied on the TrPs, symptoms identical to standing or walking. The symptoms were relieved when she those that were present when the patient was standing or was resting. Eventually, the symptoms were aggravated to the walking were observed. Other diagnostic physical examinations point at which the patient required a wheelchair for such as the straight leg raising test and FABER test were ambulation. For further evaluation and management, the patient unremarkable. was transferred to the department of neurosurgery in our Under the impression of MPS due to TrPs of the gluteus hospital. minimus muscles, we administered trigger point injections The patient was initially admitted to the neurosurgery under ultrasonography guidance using the in-plane approach on department, where she underwent an extensive work-up, the gluteus minimus muscles with 5 ml of 0.5% mepivacaine received physical therapy, and was given oral medications. on each side (Fig. 1). Mepivacaine was initially injected in the Lumbar radiography performed after admission showed no right gluteus minimus muscle. The insertion site was first definite fracture lines visible. Electromyography (EMG) results identified with palpation of the TrP, and was clarified by were unremarkable with no definite signs of neuropathy. More ultrasonography. A 23G 60 mm needle was inserted using the extensive imaging work-ups such as pelvic computed in-plane approach under ultrasonography guidance. When the tomography (CT) and lumbar MRI scans also showed no needle was inserted into the TrP, a local twitch response was definite lesions. The patient was referred to the pain clinic observed. Stretch therapy was applied following the injection. from the department of neurosurgery for further management. The patient’s symptoms were markedly reduced five minutes The patient initially arrived at the pain clinic in a wheelchair. after the injection. Her symptoms were reduced five minutes The patient complained of limping and a tingling sensation in after the injection, followed by stretch therapy, on the left side the buttocks during ambulation, especially when she was as well. After 20 minutes, the patient was able to walk back putting pressure on her heels. The symptoms were aggravated to the general ward without much difficulty. One day after the by walking, while they were relieved by resting or lying in initial injections, the patient reported mild tingling sensations, bed. Evaluations of the patient’s motor and sensory functions but did not experience much difficulty in walking. Two days revealed weakness during dorsiflexion (grade 4) and movement after the initial injections, the patient complained of the same of both great toes (grade 3), without significant sensory symptoms as the day before, and was given repeated trigger deficits. Palpation revealed severe tenderness on both buttocks, point injections with 5 ml of 0.5% mepivacaine under 18 Anesth Pain Med Vol. 10, No. 1, 2015 ultrasonography guidance on each of her gluteus minimus gluteus minimus muscle originates from the faces glutea of the muscles followed by stretch therapy in the same manner as the ala ossis ilium between the lineae gluteae anterior and initial injections. When she attempted ambulation 20 minutes posterior, while it inserts at the tip and lateral margin of the after the injections, her tingling sensations were resolved trochanter major [5]. dramatically. Upon her follow-up visit to the pain clinic two Myofascial TrPs of the gluteus minimus muscle can be days after the secondary injections, the patient reported almost activated by acute overload caused by falls, by walking too far no tingling sensations during ambulation, and the department or too fast, or by overuse. They can be perpetuated by of neurosurgery decided to discharge her. When she visited for prolonged immobility, such as prolonged standing or sitting. follow-up one week later, the patient was completely relieved Sacroiliac joint dysfunction can also activate and perpetuate of her symptoms, without any recurrence or adverse events. these gluteal TrPs [2]. Three months later, the patient visited the outpatient Patients with gluteus minimus TrPs usually complain of hip department for a follow-up, where she continued to report pain that may cause a limp during walking. Gluteus minimus doing well, with no the recurrence of her symptoms. The TrPs are accompanied by referred pain which can be persistent patient was subsequently lost to follow-up. and severe. The pain patterns vary depending on the location of the TrPs. TrPs in the anterior part of the gluteus minimus DISCUSSION muscle tend to affect the lower lateral buttock down to the lateral aspect of the lower extremity and can be similar to the Delays in diagnosis can result in
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