A 35-year-old female athletics coach complained of deep buttock pain over the past six months. She noticed it initially while doing a hurdler's stretch, and it was now nearly a constant pain, aggravated by walking and sitting. She was unable to participate in any running and was finding coaching difficult.

She had a history of low-back pain which was not causing her any problems at present. On examination the pain was located deep in the buttock region. There was no groin pain, no referred leg pain, no pins and needles. Lumbar flexion increased her pain but was clear on palpation. The sacroiliac joints moved freely and the hip joints were clear apart from reduced medial rotation. On testing the muscles around the pelvic region, piriformis muscles were both tight and reproduced her pain on stretch. On palpation the muscles were acutely tender and thickened, and straight-leg raise at 60 degrees reproduced her pain. Slump test was also positive. Her problem was an adherent sciatic nerve root exacerbated by tight piriformis muscles; both of these structures lie in close relation to each other.

Treatment consisted of deep soft-tissue massage to piriformis, as pain allowed, to release and relax the muscles. This reduced the tenderness and thickening, allowing more rotation at the hip. On rechecking her straight-leg raise and slump, there was full pain-free movement. She was given a home exercise regime to maintain the length of piriformis and neural structures.

On her next visit to the Sports Injury Centre, she reported three days of complete relief from pain, but the structures had started to tighten again, with return of some buttock pain. On re-examination, there was again some tightness of piriformis but reduced thickening and local tenderness. The neural structures were only positive at end of range. Again, the symptoms cleared with treatment and once adequately maintained, by sticking diligently to the regime, she was able to return to running and coaching.

These two case-studies are examples of how an isolated muscular dysfunction can have an adverse effect on joint and neural structures, causing considerable pain and functional restriction.

Peter Pope

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