Mrs E is a 38-year-old medical secretary who presented for treatment with a six-week history of left heel pain, posterior thigh pain and left side buttock pain, extending down from the sacral area.
Mrs E reported that the thigh and buttock pain had started approximately four days after the onset of the heel pain, which she initially thought to be due to new shoes.
Approximately one week later, she developed left sided groin pain and a sharp peroneal pain, as well as pressure in the bladder. Mrs E had already seen an urologist regarding this pain and had had ultra sound scans performed on the bladder, which were NAD.
Mrs E also volunteered that approximately six weeks before the onset of the pain she had miscarried and at the time felt a sharp spasm in the left buttock area. |
Key:
Pa - Sharp Intermitent
Pb - Hot Constant
Pc - Tingling Pulling
Pd - Numbness
| Upon presentation, her left heel had improved, however the buttock, groin and thigh pains were still apparent, aggravated by sitting on the left side particularly, slouching, bending forward and walking short distances.
Examination revealed an antalgic gait, with difficulty weightbearing on the left leg. Forward lumbar flexion reproduced her pain and she had a positive slump test. Mrs E also exhibited a positive Straight Leg Raise Test, although power and reflexes were NAD. Palpation also revealed localised hypomobility in the lumbar spine, particularly at L4/5 on the left, although the sacroiliac joint was clear.
Early treatment focused on the lumbar spine as a possible source of Mrs E's symptoms and she had considerable symptomatic improvement, as well as improvement in both forward flexion, walking and slump tests. However, she still complained of buttock pain and a sharp intermittent peroneal pain. Further examination revealed a thickened and very tender sacrotuberous ligament in the buttock area, which reproduced Mrs E's groin, posterior thigh, heel and peroneal pain. Further treatment then aimed at reducing the thickening and fibrous adhesions around this ligament, by deep massage and ultrasound.
Mrs E's symptoms cleared within one week of beginning treatment on this area, although her symptoms had persisted for several weeks prior to this.
In summary it was concluded that Mrs E had sustained a strain or tear of her sacrotuberous ligament, which had developed scarring, resulting in neural entrapment of the pudendal nerve. The pudendal nerve branches off the sacral plexus, originating from rootlets L5 to S2 and normally winds around the sacrotuberous ligament, as it passes into the greater sciatic foramen, passing into the pelvis to innervate the deep pelvic structures and skin around the perineum. This nerve would most likely be responsible for the referred heel pain that Mrs E felt earlier on in the history of the condition.
Thus a process of clinical reasoning involving trial and error was utilised to diagnose and treat Mrs E's symptom complex. |
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