Thread by @DrJN_SportsMed

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Thread 🧵

'Deep gluteal syndrome' or piriformis syndrome - a patient's journey

Over-diagnosed & a diagnosis of exclusion really...
the neurogenic thoracic outlet syndrome of the pelvis? 🧐

It does exist though

Female ex international handball - now marathon training, HIIT, Cross Fit

Worsening inferior gluteal pain - diagnosed as proximal hamstring tendinopathy, but no improvement with physio input & load management

6 months later, Sx evolving - pain radiating down posterior leg, calf, foot

Intermittent parasthesiae, subjective loss power & gait coordination

Constantly stretching & massaging piriformis

Sitting😡

LSp & hip joint clear; seated stretch & active piriformis tests provocative

MRI lumbar spine - no discogenic or radicular source

MRI hip - peri-trochanteric inflammation (common in sporty people), but no response to guided injection

Is it this hip joint? IT can refer pain in myriad ways - but no change with diagnostic hip joint injection- see pain map

3D CT & motion analysis normal - no hip dysplasia

Nothing to find on EUA with hip ortho surgeon

Could it be rheumatological?

MRI SI joints show mild bone oedema.

But bloods all normal, negative HLA-B27, no family history. SCREENDEM clear.

Bone oedema around SI joints can be normal is exercising population - see paper

Electrophysiology studies normal - rarely helpful in DGS or piriformis syndrome

If abnormal, typically affects peroneal fascicle, as this is the one that takes an aberrant course around / through piriformis

US guided hydrodissection inj around sciatic nerve - temporary response

In meantime, increasingly disabled, walking tolerance reduced, can't play with kids, tearful

Distressing for all involved

So agreed to proceed to open exploration & decompression of sub gluteal space

Images show how challenging this is - 'deep' is accurate! SN = yellow band

Early days post op, but will update about outcome. Thank you Prof Tom Quick for your expertise here.

Some useful review papers here that describe DGS subsets, anatomy, concepts to digest until the next instalment

@TJQPNI

@thomas_jesson

@pdkirwan