Buttock Pain Research Articles

Extracellular matrix protein turnover markers are associated with axial spondyloarthritis—a comparison with postpartum women and other non-axial spondyloarthritis controls with or without back pain

BackgroundAxial spondyloarthritis (axSpA) is a common chronic inflammatory disease, associated with extracellular matrix (ECM) remodeling of the cartilage, bone, and connective tissues. The primary symptom of axSpA is back pain, caused by inflammation. However, there is a medical need to truly identify patients with axSpA from other subjects with buttock or low back pain attributable to other reasons. We aimed to investigate circulating biomarkers of ECM/inflammation (MMP-degraded type I (C1M), II (C2M, T2CM), III (C3M), IV (C4M), VI (C6M), and X (C10C, COL10NC) collagens, CRPM, PROM and VICM) and ECM formation of type II (PRO-C2), III (PRO-C3), IV (PRO-C4), and VI (PRO-C6) collagens as potential biomarkers to identify patients with axSpA.MethodsWe measured biomarkers from a cross-sectional study with 204 participants by enzyme-linked immunosorbent assay (ELISA). The study included axSpA patients (N = 41), women with postpartum buttock/pelvic pain (N = 46), disc herniation (N = 25), and a group of healthy subjects (including women without postpartum pelvic pain (N = 14), subjects with various types of physical strain (cleaning staff (N = 26) long-distance runners (N = 23)), and healthy men (N = 29)). Differences between the groups were calculated by ANCOVA and AUC, while Spearman’s correlations were performed with ECM biomarkers and clinical scores.ResultsPatients with axSpA expressed significantly higher levels of C1M, C4M, and VICM (p < 0.05-p < 0.0001) compared to all the non-axSpA control groups. Further, C6M and PRO-C4 were significantly higher in patients with axSpA (both p < 0.0001) compared to women with postpartum pelvic pain and healthy subjects, whereas PRO-C3 was significantly lower compared to healthy subjects (p = 0.01). The best ECM common biomarker to differentiate between axSpA and the non-axSpA control groups was PRO-C4 (AUC ≥ 0.75; specificity ≥ 0.79, sensitivity = 0.65). Mild correlations were observed between collagen turnover and inflammation biomarkers and CRP and MRI (ρ ≥ 0.3; p < 0.05-p < 0.001).ConclusionsBiomarkers of type I, IV, and VI collagen and biomarkers of inflammation showed an altered turnover in patients with axSpA compared with the non-axSpA control groups. Such biomarkers may be useful in combination with MRI or independently to separate patients with axSpA from other back pain conditions.

Open Ischiofemoral Impingement Decompression

Ischiofemoral impingement is a relatively rare cause of posterior hip pain associated with narrowing of the space between the lateral aspect of the ischium and the lesser trochanter. Symptoms typically consist of lower buttock, groin, and/or medial thigh pain, which is commonly exacerbated by adduction, extension, and external rotation of the hip. This condition can be treated nonoperatively in many circumstances; however, recalcitrant cases may require surgical intervention. Whereas described operative treatment options for this pathology range from endoscopic to open procedures, this Technical Note describes a safe and reliable technique for open ischiofemoral decompression with sciatic nerve neurolysis through a posterior approach for treatment of ischiofemoral impingement refractory to conservative treatment.

Sacral myolipoma with involuntary contraction causing tethered cord syndrome: illustrative case

BACKGROUNDSpinal lipomas sometimes involve various ectopic tissues originating from the ectoderm, mesoderm, and endoderm in the process of morphological development.OBSERVATIONSA 29-year-old male patient with myolipoma of the conus medullaris at the S2 and S3 levels was described. The unusual finding, involuntary muscle contraction, was presented in an operative video and a literature review. In the present case, sacral myolipoma with involuntary contraction caused tethered cord syndrome in adulthood, and untethering surgery resolved continuous buttock and leg pain.LESSONSThis rare finding is considered a surgical indication for adult patients with myolipoma.

Minimally Invasive Sacroiliac Joint Fusion vs Conservative Management in Patients With Sacroiliac Joint Dysfunction: A Systematic Review and Meta-Analysis.

The sacroiliac joint (SIJ) is affected in 14% to 22% in individuals presenting with chronic low back or buttock pain. This percentage is even higher in patients who underwent lumbar fusion surgery: 32% to 42%. Currently, there is no standard treatment or surgical indication for SIJ dysfunction. When patients do not respond well to nonsurgical treatment, minimally invasive sacroiliac joint fusion (MISJF) seems to be a reasonable option. This systematic review and meta-analysis evaluates the current literature on the effectiveness of MISJF compared to conservative management in patients with SIJ dysfunction. A systematic search of health-care databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were randomized controlled trials (RCTs) or prospective and retrospective comparative cohort studies that compared MISJF with conservative management. Primary outcome measures were pain, disability, and patient satisfaction measured by patient-reported outcome measures. Secondary outcomes were adverse events (AEs), serious AEs, financial benefits, and costs. Two RCTs and one retrospective cohort study were included comparing MISJF and conservative management with regard to pain and disability outcome, encompassing 388 patients (207 conservative and 181 surgical). In a pooled mean difference analysis, MISJF demonstrated greater reduction in visual analog scale-pain score compared to conservative management: -37.03 points (95%CI [-43.91, -30.15], P < 0.001). Moreover, MISJF was associated with a greater reduction in Oswestry Disability Index outcome: -21.14 points (95% CI [-24.93, -17.35], P < 0.001). AEs were low among the study groups and comparable across the included studies. One cost-effectiveness analysis was also included and reported that MISJF is more cost-effective than conservative management.001). AEs were low among the study groups and comparable across the included studies. One cost-effectiveness analysis was also included and reported that MISJF is more cost-effective than conservative management. This systematic review and meta-analysis suggest that MISJF, using cannulated triangular, titanium implants, is more effective and cost-effective than conservative management in reducing pain and disability in patients with SIJ dysfunction. Further well-powered, independent research is needed to improve the overall evidence.

Validation of screening criteria for spondyloarthritis in patients with inflammatory bowel disease in routine clinical practice.

Spondyloarthritis (SpA) is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). Diagnostic delay must be avoided. We assessed the validity of SpA screening criteria (any of the following characteristics: chronic low back pain with onset before 45 years of age; inflammatory lower back pain or alternating buttock pain; arthritis; heel enthesitis; dacylitis; HLA-B27 positivity; sacroiliitis on imaging). This was a multicenter cross-sectional observational study in IBD patients aged ≥18 years. After evaluating the SpA screening criteria, the gastroenterologists referred the participants to the rheumatologists, who determined whether the patient fulfilled the screening criteria and carried out the necessary tests for SpA diagnosis. 35 (11.7%) out of 300 patients were diagnosed with SpA. The combination with the best balance between sensitivity and specificity (91.4% and 72.1%, respectively, when applied by the rheumatologists; 80% and 78.9%, when applied by the gastroenterologists) for SpA screening, was fulfillment of any of the following: chronic low back pain with onset before age 45 years, inflammatory low back pain or alternating buttock pain, arthritis, or dactylitis. This is one of the first studies to validate SpA screening criteria in IBD patients in routine clinical practice.

Aseptic Abscess Syndrome With Ulcerative Colitis and Pyoderma Gangrenosum

A 76-year-old female patient was admitted to our hospital with buttock pain, difficulty in walking, watery diarrhea, melena, abdominal pain, and skin eruption in the lower limbs. Computed tomography revealed abscesses in the right subgluteus maximus and right pectineus. Two weeks of broad-spectrum antibiotics were not effective. The abscesses were still apparent on magnetic resonance imaging acquired at 2 weeks after initiation of antibiotics (Figure A). A lower gastrointestinal endoscopy revealed left-sided ulcerative colitis (Figure B). The skin eruption was diagnosed as pyoderma gangrenosum based on neutrophil-dominant inflammation seen in tissue from skin biopsy (Figure C). No significant bacterial growth was detected in aspiration cultures from the abscess. The final diagnosis was aseptic abscess syndrome by exclusion diagnosis, and subsequent corticosteroid medication resulted in rapid clinical improvement, disappearance of both abscesses (Figure D), and no relapse following immunosuppressive therapy with azathioprine. If multiple deep organ abscess formations occur in patients with inflammatory bowel disease complicated by a neutrophil-induced eruption, regardless of the activity of intestinal lesions, a good prognosis can be obtained by the prompt use of immunosuppressive agents, such as corticosteroids, rather than antibiotics or surgery, with consideration to the possibility of aseptic abscess syndrome. Statement of confirmation: Informed consent was obtained from the patient for the publication of their information and imaging.

Core outcome set development for proximal hamstring tendinopathy (COS-PHT): a study protocol

Background Proximal hamstring tendinopathy is a common cause of buttock pain in running based sports. A recent systematic review found outcome measures used in research studies on this condition were inconsistent, which impedes synthesis of evidence. To understand the impact tendinopathy has on patients an international collaboration (International Scientific Tendinopathy Symposium Consensus Group) agreed on nine core health domains that should be measured in research on tendinopathy. The aim of this study is to develop an outcome set for proximal hamstring tendinopathy that covers all nine tendinopathy core health domains. This protocol describes the steps taken to develop this core outcome set. Methods This mixed method study will follow two key phases. Phase one: a systematic review will produce a comprehensive list of outcome measures that have been used in studies evaluating proximal hamstring tendinopathy. Outcome measures extracted will be matched to the tendinopathy core health domains by a steering committee of clinicians and researchers. Phase two: following a Delphi process, outcome measures will be considered by experienced clinicians, researchers, and patients. Within this study, outcome measures will be screened and selected using the Outcome Measures in Rheumatology filters of truth, feasibility, and discrimination, with a threshold of 70% agreement set for consensus. Discussion This project aims to provide and disseminate a core outcome set that can be recommended for use in future studies related to proximal hamstring tendinopathy. This will have the potential to improve research quality, allow pooling of studies in meta-analysis and assist in directing future research. Trial registration Protocol registered with the Core Outcome Measures in Effectiveness Trials in May 2021 (http://www.comet-initiative.org). Key points There is no agreed set of outcomes that are consistently used when researching proximal hamstring tendinopathy This protocol outlines the methods to derive a set of outcome measures to use when researching proximal hamstring tendinopathy Researchers, clinicians and patients will participate in a process of selecting outcome measures against the nine core health domains for tendinopathy Where core health domains do not have an outcome measure recommendations for future research will be provided Consistent use of outcome measures will allow pooling of data in meta-analysis and minimise research waste

Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome.

Piriformis syndrome (PS) is the common entrapment neuropathy causing buttock pain. Patients are conventionally treated with lifestyle modification, exercise, non-steroidal anti-inflammatory drugs, corticosteroid or botulinum toxin injections. However, some patients may not respond to these conventional treatment methods. Platelet rich plasma (PRP) injection has been shown to be beneficial in various muscular injuries, but its effects have not yet been investigated in PS. The aim of this study was to explore the effect of PRP on pain and functional status in patients with PS, and to identify any correlations between clinical changes and demographic features. A total of 60 patients with PS were randomly separated into two groups (PRP and control groups). All patients received one session of either PRP or saline injection performed under ultrasound guidance. The pain was measured with a visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were noted at three intervals in both groups: before treatment, 1week after treatment and 1month after treatment. The VAS and ODI scores were improved in both groups. The improvement was more obvious in the PRP group in the first week, and the results were similar for both groups when measured 1month after the treatment. Ultrasound-guided PRP injection provided greater improvements in both pain and functional status in patients with PS, starting in the early period after treatment. A repeat injection might be needed for a long-term effect.

Intraneural ganglion cysts originating from the hip joint: A single-center experience.

Intraneural ganglion cysts (INGCs) are non-neoplastic mucinous cysts within the epineurium of peripheral nerves. Characteristics of INGCs around the hip joint have not been adequately described. We aimed to describe clinical features, imaging findings, and treatment outcomes in patients with INGCs originating from the hip joint. We retrospectively included cystic lesions around the hip joint satisfying the following inclusion criteria over 6 years: (1) multilocular elongated hyperintense cystic mass on T2-weighted imaging; and (2) distribution along the course of the peripheral nerve and its branches on magnetic resonance imaging (MRI). Six patients with an INGC around the hip joint were identified. Parent peripheral nerves were the sciatic nerve (four patients), the superior gluteal nerve (one patient), and the nerve to quadratus femoris (one patient). Buttock, groin, or lower extremity pain/paresthesias were the initial symptoms in all patients. INGCs within the articular branches of the hip joint were identified on MRI. Four patients underwent arthroscopic debridement and capsulotomy. All patients showed generally favorable outcome regardless of treatment. Physicians should consider the possibility of INGCs originating from the hip joint as a cause of nontraumatic hip, buttock, or lower extremity pain. This can occur in any nerve innervating the hip joint, and usually it originates in the posterior capsule of the hip joint. Arthroscopic surgery shows promising results; however, more information about the surgical technique and long-term follow-up results are needed.

Dumbbell-type tenosynovial giant cell tumor of the buttocks: a report of two cases

BackgroundTenosynovial giant cell tumor (TSGCT) is a benign tumor derived from the synovium of the joints, bursa, and tendon sheaths, which is mainly located around the tendon sheath of hand and foot. Extra-articular TSGCT are relatively rare and are mainly found in the soft tissue around the large joint. They are rarer when located purely intramuscular or subcutaneous, and mostly in the lower extremities.Case DescriptionWe report two rare cases of completely extra-articular TSGCT located at the buttocks. One case was a 23-year-old young male presenting with left buttock swelling and pain for 1 year. Magnetic resonance imaging (MRI) examination revealed a dumbbell-type cystic solid mass in the left buttock, growing anteriorly from the deep surface of the gluteus muscle along the medial of the lesser trochanter. The lesion showed a heterogeneous mixed signal and was well-defined. MRI presentation needs to be differentiated with neurogenic or mesenchymal tumors, and radical resection of left gluteal tumor + neurovascular exploration surgery was performed. Another case of TSGCT we present here was diagnosed in a 55-year-old male elderly patient. Computed tomography angiography (CTA) revealed an irregular soft tissue mass in the left buttock involving the sacroiliac joint. T1-weighted imaging (T1WI) on MRI showed a mixed signal with predominantly isosignal, well-defined, and seemingly enveloped. A left buttock tumor resection with the scraping of the sacroiliac joint lesion was performed.ConclusionsBased on histopathological examination, the diagnosis was diffuse-type TSGCT for both cases. Both patients were periodically monitored after surgery, and one of them showed no imaging findings of recurrence or metastases seven years after surgery; the other case showed recurrence one year after surgery, which was resected and treated with radiotherapy, and there has been no recurrence so far. TSGCT occurring completely intramuscular is rare, with atypical clinical symptoms and imaging presentation, requiring differentiation with mesenchymal and giant cell-rich tumors.

Tuberculosis of ischial tuberosity as a rare cause of gluteal pain: A case series of 9 patients with review of literature

BackgroundOsteo-articular Mycobacterium tuberculosis infection of the ischial tuberosity is a rare cause of gluteal pain. MethodsA retrospective clinico-radiological review of nine patients with Mycobacterium tuberculosis infection of the ischial tuberosity was undertaken. The spectrum of presenting features, diagnostic challenges, radiological findings with particular emphasis on Magnetic resonance imaging (MRI) and clinical course was reviewed. ResultsAll the 9 patients (5 male: 4 female) aged between 8 and 50 years of age (mean 15.3 years) developed insidious onset of buttock pain over a period of weeks to months with difficulty in walking. Microbiological and/or histopathological confirmation of Mycobacterium tuberculosis infection was undertaken in all cases. Complementary MRI revealed diffuse bone marrow signal hypointense or isointense on T1-weighted and hyperintense on T2-weighted and STIR images. MRI was able to provide anatomic details of soft tissue lesions and extensions. MRI illustrated the sinus tract in one patient. Ultrasound imaging allowed diagnostic and therapeutic management of in 3 patients. ConclusionTuberculosis of ischial tuberosity can be a rare cause of gluteal pain. Delay in diagnosis could be due to an indolent natural history, unusual presentation and clinical features. A high index of suspicion especially in endemic areas with complementary imaging and microbiological or histopathological confirmation of Mycobacterium tuberculosis infection is necessary for definitive diagnosis. Targeted treatment under the umbrella of Anti-Tubercular Therapy is crucial in achieving successful clinical outcome.

"Posterior Hip and Buttock Pain: Relation to Deep Gluteal Syndrome"

"Posterior Hip and Buttock Pain: Relation to Deep Gluteal Syndrome"

Urinary basement membrane graft-augmented sacrospinous ligament suspension: a description of technique and short-term outcomes.

Since the discontinuation of manufacture and distribution of surgical mesh for transvaginal prolapse repair, the use of biologic grafts for transvaginal apical suspension has gained renewed attention. However, there is no FDA-approved device and minimal published data describing such an approach. The objective of this video is to describe a technique and to present limited short-term outcomes utilizing a porcine urinary basement membrane (UBM) graft to perform an augmented bilateral sacrospinous ligament suspension (SSLS). We present a step-by-step overview of our technique to perform an augmented SSLS with off-label utilization of a 7- × 10-cm porcine UBM graft. We demonstrate graft shaping and application during transvaginal repair along with data describing perioperative outcomes associated with a series of 25 cases performed at our institution using the technique described. No perioperative complications related to the graft were observed in our cohort. The most common postoperative concern was buttock pain, which spontaneously resolved within 6 months. Two individuals (8%) developed recurrent prolapse within 1 year of surgery. The UBM-augmented apical suspension allows for reinforced transvaginal prolapse repair without the use of permanent mesh material. We have observed good clinical success in our application of this technique, but dedicated research assessing long-term outcomes compared with a native tissue repair is needed.

Autologous rectus fascia graft in the treatment of high-stage apical vaginal prolapse: preliminary results of a new surgical approach with native tissue.

Since vaginal meshes in pelvic organ prolapse have been associated with more complications in the last decades, native tissue vaginal repair is still the mainstay of prolapse surgery. This study introduces a new transvaginal approach with bilateral sacrospinous ligament fixation augmented by autologous rectus fascia graft to repair high-stage apical vaginal wall prolapse. Between December 2018 and June 2020, 13 patients with high-stage apical vaginal wall prolapse (point C ≥ + 1) accompanied by high-stage anterior vaginal wall prolapse (paint Ba ≥ + 1) were included. In this procedure, the central part of the anterior rectus fascia graft (6-8cm in length and 1-1.5cm in width) is sutured to the underlying tissue of the vaginal apex or cervix and the arms of the rectus graft augmented to the sacrospinous ligament with a Capio suture capturing device (Boston Scientific). The patients are evaluated by history taking, physical examination, Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Floor Distress Inventory (PFDI-20) Questionnaire. The patient's mean age was 61.2 ± 2.7years and they were followed up to 12months. The anatomical success rate was 92.3%. The PFDI-20 and PFIQ-7 were significantly improved (P < 0.001). There were no significant perioperative complications. Three patients complained of unilateral groin or buttock pain which resolved gradually at the first post-operative month. The transvaginal bilateral sacrospinous ligament fixation augmented by autologous rectus fascia graft is an effective and safe surgical approach in treating high-stage apical vaginal prolapse with short-term follow-up.

Acute motor weakness of lower extremity after a novel balloon-inflatable catheter for percutaneous epidural adhesiolysis and decompression: A case report

Background: As our population ages and the rate of spine surgery continues to rise, the use of epidural lysis of adhesions has emerged as a popular treatment for spinal stenosis and disc herniation. Percutaneous Epidural Adhesiolysis (PEA) causes pain by preventing the release of increased spinal nerve movement and nerve sensitivity due to nerve compression. PEA and decompression with a newly developed inflatable balloon catheter have been widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. Case presentation: A 64-year-old female patient who had lower back pain and right buttock pain radiating to the leg caused by an L4- L5 severe spinal stenosis underwent PEA and decompression using a Zigzag-motion Inflatable Neuroplasty (ZiNeu®, JUVENUI, Seoul, Korea) catheter. After the procedure, the patient complained of acute motor weakness in the right leg. After conservative treatment, motor weakness and paresthesia gradually improved over time. At the follow-up visit after 3 weeks, there were no signs of motor or sensory abnormalities. Conclusions: Practitioners should be aware that these complications can occur at any time, and a skilled practitioner should undertake the procedure. Keywords: cute motor weakness; percutaneous epidural adhesiolysis and decompression; spinal stenosis. Abbreviations: HIVD: Herniated Intervertebral Disc; MRI: Magnetic Resonance Imaging; NRS: Numeric Rating Scale; ODI: Oswestry Disability Index; PEA: Percutaneous Epidural Adhesiolysis.

Remodeling of the Lumbar Facet Joint After Full Endoscopic Resection for Lumbar Osteoid Osteoma: Case Report and Literature Review.

Osteoid osteoma (OO) is a common benign bone tumor; however, approximately 25% of cases have spine involvement. It is often treated by image-guided radiofrequency ablation to break down the nidus. Few reports have described full endoscopic resection of the lesion, but none have described postoperative remodeling of the lumbar facet joint after surgical resection of an OO. The study aimed to describe a rare case of remodeling of the lumbar facet joint and then delineate the least invasive surgical technique of endoscopic resection of an OO. A 26-year-old man presented with severe left buttock pain and sciatica that worsened at night and was relieved by ibuprofen. Magnetic resonance imaging indicated a left inferior facet of an L3 mass-like lesion. A thin-section computed tomography image revealed a nidus, which was compatible with an OO. Full endoscopic resection was performed to completely remove the nidus of the OO. At the 2-year follow-up, the patient was symptom-free and computed tomography images indicated new bone formation. The present case and literature review demonstrate that endoscopic resection is safe and effective for managing a posterior element of lumbar OO. Furthermore, this technique allows complete removal of the nidus with minimal damage to surrounding structures and leads to remodeling of the resection site. Patients with OO involving the posterior element of the spine can present with buttock and radicular pain, mimicking lumbar disc herniation. OO can be successfully removed by the full endoscopic method and remodeling of the resected site can be anticipated.

Abstract No. : ABS0801: Prevalence of ‘Bertolotti Syndrome’ in patients with chronic low back pain coming to pain clinic- out patient department in an urban tertiary care hospital.

Background and Aims:Bertolotti syndrome(BS) was first identified in 1917, as a common cause of lower back pain(LBP), especially in the younger population. This study aimed to estimate the prevalence of BS in LBP patients and produce frequency estimates of BS for different demographics.Methods:Five hundred patients of both sex aged >18 years, presenting with lumbago, pygalgia or lower back or buttock pain, isolated or with radiculopathy with pain persisting for >3 months, numereical rating scale(NRS) score >5, were recruited. Patients with painful symptoms associated with other obvious etiology were excluded. Patients were investigated by ferguson view of antero-posterior lumbar spine radiograph. If pain was present at pseudoarticulation site on palpation then a diagnostic injection of 3 ml of 2% lignocaine was given at the pseudoarticulation or sacro-iliac neo joint. NRS was evaluated before and after injection. >50% improvement in NRS score were differentiated as BS.Results:The prevalence of lumbosacral transitional vertebra(LSTV) in the sample was 29.2%.The prevalence of BS was 15.2% which was higher in the study population (table 1). There were no statistically significant differences between men and women who had BS. No statistically significant difference was found between different age groups regarding the prevalence of BS.Conclusion:We conclude that Bertolotti syndrome is an underdiagnosed condition and a suitable analysis of a low back pain patient should be done to rule out BS Confirmation of pain originating from the pseudo articulation site can be made with local anaesthesia injections.Table 1Prevalence of BS and LSTVTotalMaleFemaleNumber of patients500341159Number of patients with LSTV146 (29.2%)113 (33.13%)33 (20.75%)Number of patients diagnosed as BS76 (15.2%)58 (17%)18 (11.32%)

Infectious sacroiliitis due to group A streptococcus infection during pregnancy: a case report

BackgroundGroup A streptococcus infection during pregnancy can be concerning. It may cause toxic shock syndrome, which can be fatal. Here, we report a rare case of a pregnant woman who developed infectious sacroiliitis due to group A streptococcus infection. To the best of our knowledge, this case is the first of its kind to be reported.Case presentationA 32-year-old multiparous Japanese woman presented with fever and right buttock pain at 28 weeks of gestation. Based on our clinical findings and investigations, she was diagnosed with group A streptococcus bacteremia and infectious sacroiliitis caused by group A streptococcus. A cardiotocography performed to assess the fetal status showed fetal tachycardia. To prevent the patient from progressing to toxic shock syndrome caused by group A streptococcus, we performed an emergency cesarean section. The patient and her infant had a good course after the cesarean section.ConclusionA pregnant woman diagnosed with group A streptococcus infection needs to be monitored closely because a timely decision to deliver the fetus before rapid deterioration to toxic shock syndrome is crucial.

Unusual cause of lumbar pain in elite sports: 2 case reports of sacral stress fractures

Nonspecific lower back and buttock pain can significantly limit performance in athletes and can be of different origins. Sacral stress fractures are a rare and, in many cases, undiagnosed cause of lower back pain, which can lead to a substantial loss of time before a full return-to-sports is achieved with full athletic performance. The main risk factors of sacral stress fractures include repetitive full weight-bearing activities, short-term increases in exercise intensity or duration, and excessive energy deficit. Knowledge of the injury pattern, high clinical suspicion, and early MRI examination lead to a timely diagnosis. Therapeutically, load reduction with avoidance of high impact activities for at least 6 weeks is indicated initially, followed by dosed and progressive load increase. In parallel, supplementation with calcium and vitamin D is recommended. Athletes with recurrent stress fractures, regardless of region, should be evaluated for a “Female Athlete Triad” or its male counterpart, as well as endocrinologic risk factors. Preventive measures are possible for stress fractures but are not specific to sacral stress fractures. We describe two clinical case scenarios, one of a professional soccer player and one of an elite track and field athlete with sacral stress fractures as the cause of nonspecific lumbar pain. Key Words: Lower Back Pain, Sacrum, Football,Middle Distance Running

Prevelance of Piriformis Syndrome among female Physiotherapy students of Gujranwala, Pakistan, A Cross-Sectional Survey

Piriformis syndrome is a neuromuscular disorder that is caused when piriformis muscle compresses the sciatic nerve. Its prevalence is very high in sedentary population and young people have more risk factors of getting affected with piriformis tightness that causes piriformis syndrome and later on lower back pain. Its etiology can be primary or secondary. Primary will be anatomical variation and secondary will be due to any other causes (trauma or local ischemia). It is more common in females with ratio of 3 to 1. Objectives: To determine the prevalence of piriformis syndrome among the female physical therapy students of Gujranwala. Material and methods:It was a cross-sectional study conducted in physical therapy female students of different physiotherapy institutes of Gujranwala. Data was collected from 195 students with Convenient sampling technique. The Diagnostic tool used was Piriformis syndrome diagnostic criteria. Results: Out of 195 female physical therapy students 72 (36.9%) had a high score and had a high probability of having piriformis syndrome. Only (4) 2.1% were unlikely of having piriformis syndrome while in majority of the participants 119 (61%) piriformis syndrome was not considered. Conclusion: This study concludes that female physical therapy students of Gujranwala have a low to moderate probability of having piriformis syndrome, with increased probability of buttock pain associated with prolonged sitting.