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Lumbar Spine Referred Pain
Disorders of the lumbar discs or ‘facet’ joints may refer pain to the buttock. Symptoms include a vague ache in the buttock area of varying intensity. Low back pain may or may not be present. When the referred pain has been present of an extended period of time local tightness may be apparent in the gluteal muscles, especially in the upper gluteal and low lumbar spine area.
The piriformis muscle is a small muscle located in the buttocks that rotates the hip. It runs horizontally, and the sciatic nerve runs vertically directly beneath or though the piriformis muscle . The muscle can become tight due to a number of reasons and place pressure on the sciatic nerve, resulting in leg pain which may be difficult to distinguish from a radiculopathy (nerve pinching in the spine), which is also commonly called sciatica.
The patient’s spinal imaging studies will not show any nerve pinching, and on physical exam, motion of the patient’s hip will generate the pain.
Treatment typically consists of:
Physiotherapy that includes manual release (deep massage), along with hip range of motion exercises and gluteal stretching exercises.
For severe cases, the muscle may be injected with lidocaine to decrease spasm and help the patient make progress in physical therapy.
Sacro iliac joint
Sacroiliac joint disorders are a common cause of low back and buttock pain. Most problems are thought to arise from either arthritic conditions, such as ankylosing spondylitis or rheumatoid arthritis, or from poor stabilization in the area leading to an overstretching of the ligaments of the sacro-iliac joint. Another source of injury is a fall onto one side of the low back/buttock area such as during ice-skating or snowboarding. Symptoms are usually described to be a vague aching and stiffness in the very low back. Pain can be on one or both sides. Pain may also radiate towards the back of the thigh, hip joint or groin.
This problem is commonly encountered by short distance sprinters or after an inadequately managed hamstring strain. The upper part of the hamstring is most commonly affected and symptoms are subsequently felt in the buttock. Pain will tend to arise slowly after exercise and may feel like a deep burning or sharp pain, low down in the buttock. As the injury progresses untreated, weakness and tightness may be felt in the hamstring area (back of the thigh). Pain may ease in the short term with light hamstring stretching.
Iliolumbar ligament Strain
The iliolumbar ligament is one of the ligaments that join the hip bones to the spinal bones. It is possible to sprain this ligament during high velocity sports such as skiing and football especially during side bending or rotational movements of the low spine or after falling onto one side. This ligament is also prone to injury during lifting. Symptoms are very similar to that of a sacroiliac joint disorder.
Ankylosing spondylitis represents a relatively rare condition in which the spine ossifies (lays down bone). It typically affects young males and will initially produce pain in the sacroiliac joints.
As the spine becomes more rigid, multiple small stress fractures may develop. Gravity tends to tip the body forward, and the patient may develop a flexed forward posture.
The same process can develop in the cervical spine (neck) and result in a “chin on chest” deformity. If the deformity becomes severe, the spine may be surgically realigned, although this is a large surgical procedure with significant risk of neurological injury.
Generally, treatment for ankylosing spondylitis is conservative and the symptoms can be managed with NSAID’s and physical therapy exercises that concentrate on maintaining motion in the lumbar spine and hips.
Early Injury Management
For approximately the first 72 hours following an injury, the RICE regime should be followed to ensure control of inflammation and pain relief.
R – Rest
I – Ice
C - Compression
E – Elevation
Rest from aggravating activity.
Ice should be applied in the first 72 hours or when inflammation persists. Ice should be applied for 15 to 20 minutes at a time. Ice should not be applied directly to the skin, but through a wet towel or cloth.
Compression can be achieved with an elastic bandage.
Elevation is used to help swelling to return to the heart through the blood stream.
The injured area should be elevated above the level of the heart.
Upper Gluteal Stretch
Knee To Chest
Lumbar Spine Stretch
The following lumbar spine stretches can be used to relieve tension in the low spine. This will, in turn, lead to a decrease in gluteal muscle tightness if the cause is lumbar spine related.
1. Lumbar Spine Rotation
2. Lumbar extension
Commonly hamstring tightness is associated with gluteal tightness. This stretch will help alleviate this problem.
Strengthening programs should only be commenced when:
1. No weight
Note: All levels of the spine should be kept in a neutral position whilst completing the squat exercise. Power for the squat should be generated from the legs, that is the quadricpts and gluteal muscles.
2. With weight
3. Progression – 1 leg squat