Case Report: Uncommon presentation of a common condition: an easily missed cause of hip pain

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BMJ Case Rep. 2013; 2013: bcr2013008619.

Published online 2013 May 24. doi: 10.1136/bcr-2013-008619

Case Report

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Conventionally, patients presenting with hip pain and restricted mobility to accident and emergency (A&E) department are thought to have musculoskeletal pain. Occasionally, patients with significant abdominal pathology can present with hip pain. Such atypical presentation causes the delayed diagnosis leading to significant morbidity and possible mortality. We report a 63-year-old man who had been treated in A&E on numerous occasions with left hip pain for over 6 weeks. On this occasion, he had been brought in septic shock. On examination, he had subcutaneous emphysema of left lower limb. A CT scan showed a large psoas abscess resulting from retroperitoneal perforation of sigmoid diverticulitis tracking into his left lower limb. He underwent a Hartmann’s procedure and drainage of his intra-abdominal sepsis. The thigh was not drained with separate incisions at the index operation. Residual thigh abscess was managed by image-guided drainage.

Conventionally, patients presenting with hip pain and restricted mobility to accident and emergency (A&E) department are thought to have musculoskeletal pain. Rarely, patients with significant abdominal pathology such as appendicitis and diverticulitis can present with hip pain. Diverticulitis presenting as hip pain is rare with only 15 reported cases in the literature.¹² Such atypical presentation causes delayed diagnosis leading to significant morbidity and possible mortality.²

We report a case of psoas abscess secondary to retroperitoneal perforation of sigmoid diverticulitis presenting with hip pain. The patient had been examined in A&E on numerous occasions over a 6-week period with hip pain and restricted mobility that was misdiagnosed as musculoskeletal pain. He presented in septic shock, and on examination was found to have surgical emphysema of his left lower limb. After appropriate imaging, he underwent a Hartmann’s procedure. The soft tissue infections of his left lower limb were treated with radiological drainage.

Through this report, we would like to highlight the need for a high index of suspicion for other causes of hip pain, especially in patients returning to A&E with the same or unresolved complaints.

A 63-year-old man was brought out of hours into A&E in a state of circulatory collapse. He had been seen and treated in A&E with left hip pain and restricted mobility on numerous occasions over the preceding 6 weeks. He also reported a fall prior to the onset of his symptoms. In addition, he presented with diarrhoea, weight loss and poor appetite that started about 2 weeks prior to onset of his left hip pain. In this same duration, his mobility had progressively reduced to the point of needing help with basic activities of daily living. His medical history included type 2 diabetes and degenerative spinal discs.

On examination, he was feverish, tachypnoeic, tachycardic and hypotensive. His oxygen saturation was 96% on air. He had signs of localised peritonitis in his left iliac fossa (LIF). The rest of his abdomen was soft with no signs of generalised peritonitis. He had some degree of fixed flexion deformity of his left hip and knee and painful movement of his left hip. He also had an oedema of left lower limb.

Routine blood tests taken on admission showed a haemoglobin 9.4 g/dl, white cell count 17.6×10⁹/l, neutrophils 16.9×10⁹/l and C reactive protein 168 mg/l. Glucose, liver function tests, urea, creatinine and electrolytes were all normal. No abnormalities were found on chest and abdominal x-rays. Pelvic and left thigh x-rays were requested in view of the patient’s presentation. These are shown in and . As seen, both these x-rays showed surgical emphysema, but these were initially misinterpreted as radiological artefact.

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X-ray of the pelvis showing extensive surgical emphysema.

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X-ray of the left thigh showing extensive surgical emphysema.

The gentleman continued to deteriorate and the x-rays were discussed with the radiologist the next morning. A CT of the abdomen, pelvis and lower limbs was performed in view of the x-ray findings. The CT images are shown in A,B.

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(A) Axial section of the CT showing retroperitoneal abscess and surgical emphysema. (B) Coronal section of the CT showing retroperitoneal abscess and surgical emphysema of left lower limb.

A large complicated ilio-psoas collection, at least 15 cm×5.5 cm diameter, was identified. There is also surgical emphysema extending distally along the left thigh to the level of the upper calf and posteriorly to the left gluteal muscles. The amount of gas present suggested communication to the colon.

Initial working diagnosis was the septic arthritis of the left hip. A surgical consultation was only sought in view of LIF tenderness. In view of his general condition, a diagnosis of complicated diverticulitis was also entertained by the surgical team.

Post-CT scan, the ilio-psoas abscess was thought to be most likely to be secondary to perforated sigmoid colon. In view of paucity of bowel symptoms and the protracted presentation and a history of fall prior to the onset of symptoms, differential diagnoses of the infected haematoma and pyonephrosis were also considered.

This man was initially treated with a broad-spectrum of antibiotics from sepsis of unknown origin. After the CT scan, the following day, he was taken to theatre for a laparotomy. At laparotomy, a large inflammatory mass was found in relation to the sigmoid colon secondary to posterior perforation of sigmoid diverticulitis. He underwent a Hartmann’s procedure. This also drained the retroperitoneal abscess. Suction drains ×2 were inserted into the thigh through the infra-inguinal communication along the psoas tendon. No formal incisions were made to drain the soft tissue infection of the left lower limb.

Postoperatively, he needed level 1 care for 2 weeks duration. He had a slow, but full, recovery. He did develop small collections in the leg which needed radiological drainage.

The patient made a complete recovery and was discharged home fully ambulant following a period of rehabilitation.

Diverticulitis presenting as leg pain is very rare. There are about 15 reported cases in the literature. ¹ Of these patients, 13 had surgical emphysema of soft tissue spaces of the thigh. Their management has been heterogeneous with variable results. Most of them have been reported in the pre-CT era and management has involved exploration and debridement of the thigh with faecal diversion.¹

Psoas abscess is a condition traditionally associated with tuberculosis of the spine.³⁴ In recent years, gastrointestinal (GI) diseases such as appendicitis, malignancy, Crohn’s disease and, less frequently, diverticulitis have been reported as causes for psoas abscess.²³⁴ In their study, Tabrizian et al⁴ found that the inflammatory bowel disease was the most common cause of GI causes for psoas abscess.

More recently, CT is being increasingly used for the diagnosis and assessment of both diverticulitis and psoas abscess. Image-guided aspiration and percutaneous drainage are the preferred treatment of non-tuberculous psoas abscesses greater than 3 cm. ⁴ However, those secondary to GI causes usually need a subsequent surgical intervention to treat the underlying primary pathology.⁴

Mekhail² has reported safe usage of conservative approach for treating the psoas abscess following treatment of the primary pathology (appendicular abscess in their case).

We adopted a strategy of treatment of the primary pathology and conservative approach to treat the surgical emphysema of the leg. In our case, there was extensive surgical emphysema extending to the leg, but no obvious collections in the thigh or leg. Also, the abscess was limited to the retro-peritoneum on the CT. We placed a drain from above at the index operation and closely monitored the leg for any signs of spreading infection. The limb was imaged when appropriate, and collections were drained with image guidance with good outcome.

We suggest that, where image-guided percutaneous drainage is available, a treatment of primary GI pathology followed by percutaneous drainage of the limb may be the way forward to manage this rare presentation of diverticulitis and to avoid the morbidity associated with leg surgery.

Learning points

• High index of suspicion for rare presentation of common diseases.

• ‘Looking outside the box’ when interpreting investigations.

• Evidence-based management of uncommon presentations.

• Conservative approach to limb problems after dealing with the primary cause.

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

1. Haiart DC, Stevenson P, Hartley RC.
Leg pain: an uncommon presentation of perforated diverticular disease. J R Coll Surg Edinb
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2. Mekhail P, Saklani A, Philobos M, et al.
Thigh subcutaneous emphysema: is that a clear indication for thigh exploration?
JSCR
2011;2013:1 [PMC free article] [PubMed] [Google Scholar]

3. de Jesus Lopes Fihlo G, Matone J, Arasaki CH, et al.
Psoas abscess: diagnostic and therapeutic considerations in six patients. Int Surg
2000;2013:339–43 [PubMed] [Google Scholar]

4. Tabrizian P, Nguyen SQ, Greenstein A, et al.
Management and treatment of iliopsoas abscess. Arch Surg
2009;2013:946–9 [PubMed] [Google Scholar]

Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group

Can IBS Cause Hip and Groin Pain?

Introduction

Referred Pain

Chronic Pelvic Pain

Food Poisoning & Joint Pain

Can constipation and IBS cause groin pain?

Ehlers–Danlos Syndrome

Joint Issues

Labral tear

Hip tendonitis

Strained groin

Gut Health Nutritionists

Introduction

IBS is often a chronic condition that has an impact on a wide number of the general population. This can be in the range of 14% to 21% of the general population, with women 2-3 times more likely to experience symptoms than men. [Source: Pubmed]  

The diagnosis of IBS is not made on the results of specific tests but based on a set of symptoms. These symptoms are outlined in the ROME criteria, which state that for someone to be diagnosed with IBS, they must be experiencing abdominal pain and at least 2 of the following:

• altered frequency, consistency, and/or passage of stools






• and/or associated feelings of abdominal distension or bloating.

These symptoms must also have been present for at least 3 months. 

The feature of abdominal pain can improve once passing a stool. However, when it’s present in the abdominal region and doesn’t resolve after a bowel movement, this pain’s precise location and/or origin can be hard to locate.

It can be tempting to link the problem to a specific area or cause when we suffer from health issues. However, this is not usually the case. 

The human body is a series of closely connected parts constantly interacting with one another. As such, what happens in one area can lead to symptoms in another. This may make it hard to distinguish the location of the discomfort and contribute to referred pain.

Referred Pain

Referred pain is when the pain originates in one part of the body and can be felt in another.  This is true for IBS, where pain can be felt in multiple locations. It’s also clearer to see where a heart attack leads to pain in the jaw.

This movement of pain can be due to 2 reasons:

From a digestive perspective, the increase in abdominal girth seen in bloating can place additional pressure on the organs in the abdomen. This can be seen in those where bladder symptoms are also present. These changes in the abdominal cavity may then place pressure on nerves, triggering sensations in other areas of the body.

It’s also possible for the pain to be ‘created’ in the brain. This can be due to the neurons responsible for locating the pain processing this information in a manner that leads to the incorrect location of the pain.

An example of this is the referred pain that is experienced during a heart attack. This is where pain can be felt in the teeth or jaw without there being an issue in this region.

Similar issues can be seen in other chronic pain conditions such as fibromyalgia, and chronic low back pain.

A test that can be carried out for dental or jaw pain is administering a local anaesthetic. If the pain is originating from this region, the pain will subside. If the issue is due to referred pain then the pain will continue. [Source: Pubmed]

This test is not suitable for gut issues, especially when there is hip and groin pain. However, it does illustrate the way referred pain can appear.

It’s also possible that digestive issues can lead to pain in the back. For example, gallstones can lead to pain in the back between the shoulder blades. [Source: Pubmed]

Chronic Pelvic Pain

There is a clear crossover in symptoms in those with IBS and those experiencing chronic pelvic pain.

Research into procedures to address chronic pelvic pain founds a link between this and IBS. The procedures in question were laparoscopies and hysterectomies specifically for chronic pelvic pain.

The results indicated that 50% of women undergoing laparoscopy and 40% undergoing hysterectomy (due to chronic pelvic pain) also had additional symptoms that were compatible with IBS. [Source: Pubmed]

As well as gut issues such as IBS and SIBO, other factors and conditions can contribute to chronic pelvic pain. These are:

• chronic cystitis






• endometriosis






• adhesions






• painful bladder syndrome






• musculoskeletal injury [Source: Pubmed]

99% of those with chronic pelvic pain are female. Additionally, those with a history of pelvic trauma or surgery are at a significantly higher risk of chronic pelvic pain.

It has also been reported that almost 50% of women with chronic pelvic pain have a history of physical or sexual abuse. [Source: Pubmed].

These are both factors that can increase the risk of developing IBS. [Source: Pubmed]

As in IBS, one study indicated that individuals with chronic pelvic pain have higher rates of:

• affective disorder (such as depression or bipolar)






• anxiety






• sexual abuse in early childhood






• history of hysterectomy [Source: Pubmed]

Food Poisoning & Joint Pain

Food-borne illnesses (such as Campylobacter, Salmonella, Escherichia coli) are also highly associated with both gastrointestinal symptoms (abdominal pain and bloating) but also joint pain.

Post-infectious symptoms may not manifest for weeks or months following exposure, but a clear link has been linked with reactive arthritis. [Source: Pubmed]

This is believed to take place due to the potentially harmful organisms reaching the general circulation, which activates specific immune cells called T-cells.

It is then possible for these T-cells to mistakenly attack the tissue in the joint by mistake leading to an inflammatory response and pain. [Source: Pubmed]

Can constipation and IBS cause groin pain?

IBS with constipation is one of the subtypes of IBS. This means that along with the other symptoms of IBS (such as bloating and pain) it may be difficult to pass a stool. This can lead to straining and increase the risk of heammoaroids. [Source: Pubmed]

Constipation can also lead to or contribute to strains or muscular issues in the groin areas. This can be in the form on the following groin issues:

• hernia or muscle strain






• tendonitis






• avulsion fracture (where a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) [Source: Pubmed]

Other factors can be taken into consideration when assessing groin pain. These include urinary, joint related conditions. One of the most common joint issues that lead to groin pain is an issue with the hips.

Also Read: How To Reduce Inflammation In The Gut

Ehlers–Danlos Syndrome

Ehlers-Danlos syndrome refers to a group of disorders that impact the connective tissue. 

These are characterised by:

• skin hyperextensibility






• tissue fragility






• joint hypermobility and instability

Due to the impact suboptimal connective tissue health plays in the body, this syndrome can lead to a wide range of symptoms. These include:

• Gastrointestinal symptoms, such as IBS






• Fibromyalgia






• Chronic pain syndrome






• Chronic fatigue syndrome






• Multiple allergies






• Pelvic floor disorders






• Psychological disorders






• Musculoskeletal complaints such as joint pain. [Source: Wiley]

One study found that out of 228 patients diagnosed with IBS, 42% also had a diagnosis of EDS, with the highest prevalence being the constipation subtype of IBS. [Source: Wiley]

There is a crossover of risk factors before these 2 conditions also, which include: 

• altered psychopathology






• abnormal pain processing






• autonomic dysfunction






• motility disorders

Due to the changes in bowel motility (the result of suboptimal connective tissue functioning), SIBO is highly associated with EDS. [Source: The American Journey of Gastroenterology] 

Ehlers–Danlos Syndrome is a complex syndrome that we will be covering in a future article in more depth.

Joint Issues

While there are clear links between what’s happening inside the digestive system, both on a bacterial level and through referred pain, there can also be structural issues in the joints themselves.   

These include:

Labral tear

The hip is a form of a ball-and-socket joint. The rounded tip of the femur slots into the socket of the hip, hence the name. Surrounding this socket is a seal of hardy cartilage, which acts as a shock absorber and allows us to move about without issues. 

The labrum can be damaged through excessive use or considerable trauma, resulting in a labral tear. This can cause an intense, sharp pain that is amplified by the movement and strain of the affected area, flexing your leg as an example. If you are suffering from a labral tear, your hip will feel stiff and locked up, with audible pops accompanying movement. Scans are the most common method of identifying a labral tear. [Source: Pubmed]

Hip tendonitis

The hip and groin area house a great many bodily structures. Tendons, for example, are present to hold bone and muscle together, allowing for movement. These tendons can become damaged through considerable use or trauma and suffer from inflammation. When this happens around the hip, it is known as hip tendonitis.

Hip tendonitis often results in radiating pain. This means that although it starts in the hip, the pain doesn’t just stay there. Usually, the pain radiates to the groin, given the close proximity. If you have pain there, hip tendonitis could be the answer. [Source: Pubmed]

Strained groin

One of the most common causes of hip and groin pain is a strained groin. It is a reasonably easy injury to sustain, with athletic people being most susceptible. A strained groin can be suffered by over-exerting your body, most often when running, stretching, or putting excessive strain on the hip or groin by making unnatural movements.

A strained groin will involve various levels of pain and inflammation, depending on the severity of the strain. It will make it difficult to move, sapping a great deal of strength and flexibility from the affected area. Continuous movement and stretching will cause more pain. [Source: Pubmed]

Gut Health Nutritionists

As outlined, there are several physical issues that are isolated to the gut joints, particularly in the groin and hip area.

However, when these pains are also happening at the same time as the symptoms of IBS, there may be a direct link between what is happening inside the digestive system and elsewhere in the body.

How to Diagnose Bowel Pain with Defecation

How to Diagnose Bowel Pain with Defecation : Bowel pain is an unpleasant or painful sensation in the bowel, an experience of physical or emotional suffering. Serves as a protective signal of real or suspected tissue damage. The primary diagnosis of pain in the intestines during and after defecation requires a consultation with a proctologist and a rectal examination with anoscopy. As an additional examination, the doctor may prescribe:

• CT colonoscopy
• colonoscopy
• sigmoidoscopy
• MRI of rectum
• laboratory tests (coprogram).

Which doctor treats pain in the intestines during bowel movements: If you have symptoms of pain in the intestines during and after defecation, you should first consult a proctologist, based on the results of the initial examination, the doctor may prescribe an additional consultation with an oncologist or gastroenterologist.

Quick navigation

Bowel pain during bowel movements is not uncommon. But some conditions that lead to painful bowel movements require medical evaluation and treatment.

Causes of pain in the intestines during and after defecation

Anal fissure and pain in the intestines during defecation

Anal fissures are small cuts that occur due to cracking of the skin of the anus. Symptoms of the disease include:

• Anus tear detected during examination
• pain in the intestines during and after defecation
• skin growths near the tear
• Burning or severe pain near the anus during bowel movements
• blood in stool or on toilet paper
• anal itching

These symptoms are not very serious and usually go away without medical attention after a month. If self-healing does not occur, the main treatments for anal fissures include: various laxatives, increasing fiber in the diet, warm baths to improve blood flow and relax muscles, use of creams and corticosteroid ointments to reduce inflammation, use of pain-relieving ointments such as lidocaine.

Hemorrhoids and pain in the intestines during bowel movements

Hemorrhoids occur when the anus or rectal veins swell. The patient may not notice internal hemorrhoids in the anus, but external hemorrhoids can cause pain in the intestines and make sitting difficult. Pathological symptoms:

• intestinal pain during defecation
• severe anal itching and pain
• hemorrhoids near the anus
• fecal incontinence
• bleeding from the rectum.

Treatments and tips for preventing hemorrhoids:

• warm bath for 10 minutes every day to relieve pain.
• topical cream for hemorrhoids.
• increasing the amount of fiber in the diet
• anal hygiene, rinsing with cold water after each bowel movement
• using soft toilet paper when wiping
• bidet option
• cold compress for swelling
• non-steroidal anti-inflammatory drugs for pain.

More severe hemorrhoids can be removed surgically.

Constipation and pain in the intestines during bowel movements

Constipation is a condition that is accompanied by a small number of bowel movements and pain during rectal emptying.

Its symptoms include hard, dry stools that come out in small pieces, pain in the anus or intestines during a bowel movement, lack of relief after a bowel movement, bloating, and cramps in the lower intestine or back. Recommendations for the prevention of constipation:

• drinking enough water to stay hydrated and stimulate digestion
• reduce caffeine and alcohol intake
• consumption of products with probiotics
• reduce the intake of foods that can cause constipation, such as meat and dairy products.
• warm bath
• laxatives for severe cases of constipation.

Proctitis and intestinal pain during defecation

Proctitis occurs due to inflammation of the lining of the large intestine. It is a common symptom of sexually transmitted infections, radiation therapy for cancer, or inflammatory bowel disease such as ulcerative colitis. Symptoms of the pathology include: pain in the intestine during defecation, diarrhea, bleeding, mucous discharge from the anus, lack of relief after defecation, feeling of an urgent urge to defecate. Recommendations for the treatment and prevention of proctitis:

• protected intercourse
• any prescribed antibiotics or antivirals for infections
• any prescribed medication for the side effects of radiation therapy
• laxatives
• medicines for inflammatory bowel disease or immunosuppressants
• surgery to remove any damaged portions of the colon
• additional treatments such as argon plasma coagulation or electrocoagulation.

Inflammatory bowel disease and bowel pain during bowel movements

Inflammatory bowel disease refers to any condition that involves inflammation in the digestive tract. Examples are Crohn’s disease, ulcerative colitis and irritable bowel syndrome. Many of these conditions cause severe bowel pain during bowel movements, accompanied by the following symptoms: diarrhea, fatigue, pain or discomfort in the abdomen, blood in the stool, unreasonable weight loss, loss of appetite. The main treatments for gastrointestinal pain include: anti-inflammatory drugs, immunosuppressants, drugs to control the immune system, antibiotics for infections, drugs for diarrhea, pain relievers, iron supplements to limit anemia from intestinal bleeding, calcium or vitamin D supplements to reduce the risk of osteoporosis from Crohn’s disease, removal of parts of the colon or rectum, possible use of a stoma, a diet low in meat and dairy products.

Diarrhea and bowel pain after a bowel movement

Diarrhea does not always cause bowel pain during a bowel movement. But the frequent use of toilet paper and the passage of a large amount of stool can irritate the skin of the anus and cause pain. Symptoms of the condition are nausea, abdominal pain or cramps, a feeling of bloating, dehydration, blood in the stool, frequent urination, fever. Treatment for diarrhea usually consists of rehydration or antibiotics. diarrhea prevention recommendations:

• regular and meticulous hand hygiene
• observing the rules of food preparation, thoroughly washing fruits and vegetables before eating
• taking antibiotics
• do not drink tap water without boiling.

Endometriosis and bowel pain with bowel movements

Endometriosis occurs when the tissues that make up the lining of the uterus, known as the endometrium, develop outside the uterus. They can attach to the colon and cause pain from irritation or scar tissue formation along with the following symptoms: pain during menstruation, pain in the abdomen or back, as well as cramps before the onset of menstruation, pain during or after intercourse, infertility. Pain management tactics include:

• painkillers
• hormonal therapy to regulate tissue growth
• birth control, such as medroxyprogesterone injections, to reduce tissue growth and symptoms
• gonadotropin releasing hormone (GRNH) to reduce estrogen that causes tissue growth
• minimally invasive laser surgery for tissue removal
• Surgical removal of the uterus, cervix and ovaries to stop menstruation and tissue growth

Chlamydia or syphilis and bowel pain during bowel movements

Infections such as chlamydia or syphilis are spread through anal sex and can lead to bacterial infections that cause rectal swelling and painful bowel movements. Both infections are spread through unprotected sexual contact with an infected person. Painful swelling of the rectum can also accompany symptoms such as pain during bowel movements, burning during urination, discharge from the genitals, and pain during sex. Some tips for treating and preventing disease: antibiotics, penicillin injections for severe syphilis, abstaining from sex during treatment, protected intercourse, regular testing for sexually transmitted infections.

Human papillomavirus and bowel pain with bowel movements

A viral infection that can cause warts to form near the anus, genitals, mouth, or throat. Anal warts can become irritated during bowel movements and toilet paper use, causing pain. Left untreated, the human papillomavirus can cause cancer of the cervix or anus. This virus cannot be completely cured. Warts may come and go, and a doctor may use laser or cryotherapy to remove them. Prevention recommendations include getting a vaccine, having protected sex, having a Pap test, and regular health screenings.

Anal or rectal cancer and bowel pain with bowel movements

Anal or rectal cancer is highly unlikely to cause painful bowel movements. However, some symptoms that may indicate cancer include: sudden, abnormal changes in stool color or shape, loose stools, blood in the stool or on toilet paper, new or unusual growths near the anus that hurt during bowel movements, itching around the anus, frequent constipation or diarrhea, bloating, severe weight loss, persistent abdominal pain or cramps. Early treatment can help stop the spread of cancer and limit complications. Therapy tactics include:

• chemotherapy injections or tablets to kill cancer cells
• surgery to remove tumors of the anal or rectum and prevent the spread of cancerous tissue, possibly removing the entire rectum, anus, and parts of the colon if the cancer has spread
• radiation therapy.

When to see a doctor for bowel pain with bowel movements

Seek immediate medical attention from a proctologist if you experience any of the following symptoms:

• bowel pain or bleeding lasting a week or more
• fever or unusual tiredness
• unusual bleeding or discharge during bowel movements
• pain or other symptoms after intercourse
• severe abdominal or back pain, convulsions
• Neoplasms near the anus.

Diagnosis of the causes of bowel pain during bowel movements

Primary diagnosis of the underlying cause of bowel pain during bowel movements begins with a rectal examination by a proctologist. Based on its results, the doctor may recommend additional examination methods, such as

• Ultrasound of the anus of the rectum
• Colonoscopy
• Sigmoidoscopy
• MRI of rectum
• Virtual colonoscopy
• coprogram.

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Specialization: Surgeon, Proctologist

Medical experience: since 2007

Where does the reception: SM-Clinic on Danube

Author: Telegina Natalya Dmitrievna

Specialization: Therapist

Where does the reception: MRI center and clinic RIORIT

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Literature

1. Afendulov S.A., Krasnolutsky N.A., Nazola V.A. Endoscopic treatment and sanitation of the abdominal cavity in perforated gastroduodenal ulcers. Endoscopic Surgery. 1999. – No. 2. – S. 6.
2. Basos S.F. Modern tactics of treatment of amoebic liver abscesses // Abstracts of the conference. VMEDA. SPb. – 1996. – S. 11-12.
3. Vyrenkov Yu.E., Shevkhuzhev ZA, Akhundov I. Lymphogenic methods of therapy for inflammatory diseases of the abdominal organs // Annals of Surgery. 1999. – No. 4. – S. 74-78.
4. Efimenko N. A. Postoperative peritonitis: diagnosis and treatment. Diss. doc. honey. Sciences. – Moscow, -1995, – 324 p.
5. Nechaev E.A. Surgical infection clinic, diagnosis, treatment // Guide for military doctors. – M. – 1993. – 296 p.

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Clinic for piriformis syndrome

Very often, pain in the buttocks and sacrum provokes spasm or inflammation of the musculus piriformis, a small triangular muscle responsible for the functioning of the hip joint. In this case, they speak of piriformis syndrome. As a result, pathological seals, the so-called myofascial painful points (triggers), will form in the muscle tissue. Even with the formation of one trigger point, the muscle becomes less functional. The clinical picture will combine local symptoms with signs of sciatica, especially when the sciatic nerve does not pass under it, but through its fibers. It often masquerades as other diseases, so the diagnosis is rarely made in a timely manner. The main complaint is persistent pain in the buttocks, radiating to the thigh and knee. In addition, rotational movements of the hip (for example, turning over in bed, bringing the leg to the groin) become especially painful. Patients may complain of difficulty walking and leg pain caused by sitting cross-legged. Sometimes patients may note a violation of sensitivity in the lower extremities.

Due to compensation or relief mechanisms, piriformis syndrome can contribute to cervical, thoracic and lumbar pain, as well as gastrointestinal disturbances and headaches.

The main signs of pathology musculus piriformis

1. Exhausting pulling pain in the lumbar region, buttocks, thighs.
2. Pain that does not respond well to drugs.
3. Increased pain after sitting for more than 15-20 minutes.
4. Spasmodic in the form of a strand, a muscle that is painful on palpation.

Symptoms of vascular compression

1. Sometimes there may be intermittent claudication with numbness and coldness of the toes. The patient is forced to stop, and after the vascular spasm subsides, he can continue walking. This is due to compression of regional vessels.
2. Pale coloration of the foot.
3. Local temperature reduction.

Symptoms of nerve compression in piriformis syndrome

1. Pain is aggravated by prolonged sitting, when lifting an object. It is affected by walking, running, squatting. The pain may radiate to the perineum.
2. The condition is aggravated by rotation of the hip or an attempt to cross the legs.
3. When spreading the legs in a sitting or lying position, the condition improves.
4. Sensory disturbances. Feeling of numbness in the back of the thigh, a feeling of “crawling”.
5. Possible paresis of the leg muscles (in rare cases).

Additional symptoms

Occasional urethral and rectal sphincter dysfunction, discomfort during defecation, sexual dysfunction due to pudendal nerve compression, and male impotence.

These symptoms may be aggravated by sitting, hip adduction and extension, hip flexion and internal rotation, and physical activity. Why is this happening? With all these movements, the piriformis muscle becomes tense and changes shape. If there is too much tension, the change in length and thickness can lead to increased symptoms and pain.

How long does Piriformis syndrome last?

The duration and intensity of pain can be partially regulated by the patient himself, avoiding all triggers. But this, of course, does not solve the problem itself. Without medical and physiotherapeutic treatment, pain will occur again and again with each new load. An aggravating moment is the difficulty of making a diagnosis. Doctors often put it wrong, believing that they are dealing with lumbago or with a herniated disc. Medical unprofessionalism can delay recovery for months, as the treatment will not be prescribed correctly. Delay in diagnosis of this syndrome can lead to pathologic sciatic nerve disease, chronic somatic dysfunction, and compensatory changes leading to pain, paresthesia, hyperesthesia, and muscle weakness.

If the pain lasts more than a month, it will be a chronic illness. And, if an acute syndrome, which was correctly diagnosed at an early stage, can be cured within four weeks, then in advanced conditions, recovery is much longer – up to several months.