Trevine Albert, D.O. PGY-2 David Joyce, D.O. PGY-3 Steven Licata, D.O. Program Director, FM/NMM 2017 Annual FOMA Convention - PDF Document

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  1. Trevine Albert, D.O. PGY-2 David Joyce, D.O. PGY-3 Steven Licata, D.O. Program Director, FM/NMM 2017 Annual FOMA Convention Department of Family Medicine, Neuromusculoskeletal Medicine

  2. • Build a differential diagnosis for gluteal pain • Briefly discuss sciatica as a leading diagnosis • Describe four other commonly seen etiologies • Review relevant anatomy • Describe relevant orthopedic tests • Review applications for ultrasound-guided musculoskeletal injections • Discuss Osteopathic diagnosis and treatment of the pelvis and sacrum

  3. • A common complaint to the primary care office • One of the top 3 workman’s compensation expenses • US healthcare costs: $33 billion annually • Disability and costs are related to pain, not to the disease process

  4. Thoracolumbar fascia Tensor fascia latae Gluteus maximus Iliotibial tract

  5. Gluteus medius Piriformis

  6. Gluteus minimus Superior Gemelus Inferior Gemelus Obturator internus Quadratus femoris

  7. Gluteus maximus Inferior cluneal (bbr of PFCN) Posterior femoral cutaneous nerve Sciatic nerve Perineal (bbr of PFCN)

  8. A 68 y/o woman presents for constant left sided lower back pain, varying in intensity from 3-7/10, occasionally radiating down the back of the left side of her thigh to above her knee. She states this happened when she bent down to pick up some boxes. The pain is minimally improved with chiropractic treatments and Advil OTC PRN and worse with walking. She denies acute onset, muscle weakness, numbness/tingling down either lower extremity, or loss of bowel or bladder function.

  9. • Sciatica • Piriformis syndrome • Hip joint arthritis • Lumbosacral radiculopathy • Spinal stenosis • Gluteus medius / minimus tendinosus • Greater trochanteric bursitis • Proximal hamstring strain • Somatic dysfunction (Innominate, Sacral, Lumbar) • Myofascial pain syndrome • Mononeuritis • Ischial bursitis • Sacroiliac joint pain • Sacroilitis (eg Ankylosing spondylitis) • Infected Pilonidal cyst • Gluteal abscess • Coccygodynia

  10. M54.30 Pathophysiology Pain in the lower extremity resulting from irritation of the sciatic nerve, which is typically felt from the low back to the buttock and radiating down and below the knee

  11. G57.00 Pathophysiology Sciatica-like pain caused by compression of the sciatic nerve by the piriformis muscle

  12. G58.9 Pathophysiology • Disease or trauma involving a single peripheral nerve • Posterior gluteal irritation or pain

  13. Superior gluetal N

  14. Gluteus medius

  15. Gluteus minimus

  16. M76.0 M70.6 Pathophysiology • Lateral hip pain • Insidious onset • Exacerbated with activity • Pain may be exacerbated in lateral recumbent position • Pain may radiate down the lateral thigh

  17. M53.3 • Posterior hip pain • Most commonly mechanical • Reproducible on palpation

  18. M53.3 Identify Locating via anatomic landmarks • Palpate medial and deep to PSIS • Pain on palpation along lateral margin of sacrum

  19. Sacral canal Iliac crest Iliac wing PSIS Greater sciatic notch Sacral hiatus Ischial spine Obturator foramen Lesser sciatic notch Ischial tuberosity Coccyx

  20. • Diagnosis of somatic dysfunction relies on physical exam findings (TART): 1) Tissue texture changes 2) Asymmetry 3) Restriction 4) Tenderness • Treatment (OMT) relies on a diagnosis of somatic dysfunction • Eg M99.01 Segmental and somatic dysfunction of cervical region. • Billable procedure = OMT

  21. PELVIS & SACRUM RELATED REGIONS •Lumbar spine •Lower extremities