Lateral Hip & Buttock Pain Contemporary Diagnostic & Management Strategies Potential sources of nociception in the lateral hip & buttock Lateral Hip & Buttock Pain Contemporary Diagnostic & Management Strategies Introduction Dr Alison Grimaldi BPhty, MPhty(Sports), PhD Australian Sports Physiotherapist Practice Principal Physiotec Adjunct Senior Research Fellow University of Queensland, Australia 12 Myofascial Structures Superficial Nerves Latissimus Dorsi Thoracodorsal IHGN Fascia EO SubCN TFL SCN’s: Superior Cluneal Nerves IO SCN’s MCN’s: Middle Cluneal Nerves GMed MCN’s ICN’s: Inferior Cluneal Nerves GMax Gluteal ITB Fascia PFCN: Posterior Femoral PFCN Cutaneous Nerve VL ICN’s IHGN: Iliohypogastric Nerve AM SubCN: Subcostal nerve ST SM BFLH EO:External Oblique; IO:Internal Oblique; GMed:Gluteus Medius; GMax:Gluteus Maximus; AM:Adductor Magnus; SM:Semimembranosis; ST:Semitendinosis; BFLH:Biceps Femoris Long Head; TFL: Tensor Fascia Lata; ITB:Iliotibial Band 34 Deeper posterolateral musculotendinous structures Major Bursae of the Lateral Hip & Buttock Axial MRI: Level of HOF Coronal MRI: Level of HOF Axial MRI: Level of IT GMed GMin Quadratus Lumborum Gluteus Medius SGMi HOF Gluteus Minimus Piriformis OI SGMe SGMa IS HO Superior Gemellus SGMa SGMi F Gluteus Medius & SGMe IT Minimus Tendons Obturator Internus Inferior Gemellus GMax OIB IG Quadratus femoris Obturator Internus Proximal hamstring tendons SGMa: Subgluteus Maximus (Trochanteric) Bursa; SGMe: Subgluteus Medius Bursa; SGMi: Subgluteus Minimus Bursa; OIB: Obturator Internus Bursa; IG: Ischiogluteal Bursa HOF: Head of Femur; IS: Ischial Spine; IT: Ischial Tuberosity; OI: Obturator Internus; GMax: Gluteus Maximus; GMed: Gluteus Medius; GMin: Gluteus Minimus 56 Copyright Alison Grimaldi 2019 1 Lateral Hip & Buttock Pain Contemporary Diagnostic & Management Strategies Deeper Nerves Bones & Capsuloligamentous Structures Nerves: SGN: Superior Gluteal IGN: Inferior Gluteal SGN SN: Sciatic PN: Pudendal Long Dorsal Ilium Ligament nOI SN PFCN: Posterior Femoral PN Cutaneous Greater Sciatic nQF Foramen IGN PR: Perineal Ramus Ischiofemoral PR nOI: nerve to Obturator Ligament Lesser Sciatic Foramen Internus PFCN Capsule nQF: nerve to Quadratus Femoris 78 The Peritrochanteric & Deep Gluteal Spaces The Peritrochanteric Space Coronal MRI: Level of HOF Axial MRI: Level of HOF Axial MRI: Level of Ischial Tuberosity Axial MRI: Level of HOF Peritrochanteric Peritrochanteric GMed GMin space space HOF HOF OI HOF A F A QF IT Between ITB & GT GT GMax SN GMax GMax PHT Deep gluteal space GMax: Gluteus Maximus; Piri:Pififormis; HOF: Head of Femur; A: Acetabular column; OI: Obturator Internus; GMax: Gluteus Maximus; HOF: Head of Femur; A: Acetabular column; GT:Greater Trochanter; QF: Quadratus Femoris; F: Femur; IT:Ischial Tuberosity; SN: Sciatic Nerve; PHT: Proximal Hamstring Tendons GMed: Gluteus Medius; GMin: Gluteus Minimus Byrd 2015 Byrd 2015 910 Contents of the Peritrochanteric Space The Deep Gluteal Space Muscles/Tendons/Bursae: Coronal MRI: Level of HOF Tendinous insertions of GMed GMin Gluteus Medius & Minimus Origin of vastus lateralis HOF Subgluteus maximus STL (trochanteric) bursa Between GT G- Subgluteus medius bursa ITB & GT O Subgluteus minimus bursa Q I Borders of the deep gluteal space: F Superiorly: greater sciatic notch Inferiorly: distal ischium Laterally: gluteal tuberosity of femur GMax: Gluteus Maximus; HOF: Head of Femur; A: Acetabular column; GT:Greater Trochanter; Medially: sacrotuberous ligament GMed: Gluteus Medius; GMin: Gluteus Minimus Byrd 2015 Martin et al 2015 11 12 Copyright Alison Grimaldi 2019 2 Lateral Hip & Buttock Pain Contemporary Diagnostic & Management Strategies The Deep Gluteal Space Contents of the Deep Gluteal Space Axial MRI: Level of GSNotch Axial MRI: Level of HOF Axial MRI: Level of ITuberosity Piri Muscles/Tendons/Bursae: Piriformis Obturator Internus & Gemelli & bursa HOF Quadratus Femoris HOF OI Proximal Hamstring Tendons & Ischiogluteal bursa A OI A F QF IT GMax Piri GMax GMax SN PHT Borders of the deep gluteal space: Posteriorly: gluteus maximus F QF IT Anteriorly: posterior acetabular column, hip capsule & proximal femur GMax: Gluteus Maximus; Piri:Pififormis; HOF: Head of Femur; A: Acetabular column; OI: Obturator Internus; SN PHT QF: Quadratus Femoris; F: Femur; IT:Ischial Tuberosity; SN: Sciatic Nerve; PHT: Proximal Hamstring Tendons 13 14 Focus Modules The Deep Gluteal Space Axial MRI: Level of ITuberosity Neurovascular structures: Joint Related Pain & Soft Tissue Related Pain Referred & Nerve Bony Impingements Muscle, Fascia, Tendon, Bursa Related Pain Sciatic Nerve (SN) Posterior Femoral Cutaneous Nerve (PFCN) Nerves to short & long heads of Biceps Femoris (nSHB; nLHB) PFCN nLHB APCFA Inferior Gluteal Artery & Nerve nSHB SN IGA & N Gluteus Maximus Ascending posterior circumflex femoral artery (APCFA) 15 16 Copyright Alison Grimaldi 2019 3.