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Lisa is an avid recreational runner. During the past six months, she has trained hard for an upcoming marathon. For the last month, she has had a low-level, dull, aching pain in the left-lateral hip region. She did not actively address it, because she thought it was a simple overuse issue associated with her training regimen. Two weeks ago, when leaving her apartment, Lisa stumbled and fell on the stairs. She landed on her left hip, but was unable to significantly break her fall because her hands were full. That night, she had pronounced pain in her left-lateral hip, and the next day it was swollen and very tender to the touch. Walking was painful for the next two days, and running was out of the question. After about five days, most of the swelling subsided and the pain was reduced but still present. Lisa resumed a very limited running schedule, but continued to experience prominent left-lateral hip pain and a dull, aching pain in her gluteal region on the same side when running. She was also aware of a sharp pain in her posterior thigh aggravated by her running that was not there previously and seemed to be increasing. EVALUATION Lisa sought treatment two weeks after her incident. A detailed history from Lisa provided valuable clues and helped direct the physical examination. There was no longer any visible swelling in her lateral hip region or other visible indicators of tissue disruption, nor was there any apparent pathology in the hip, gluteal region, or posterior thigh (the regions where she reported pain). Palpation revealed significant tenderness in her lateral hip region directly over the greater trochanter of the femur. There was also significant tenderness in the soft tissues superior to the trochanter that have attachments on that bony landmark. The gluteus maximus on each side appeared normal, but there was palpable tightness deep to the gluteus maximus on the left side, which appeared to indicate hypertonicity in the piriformis muscle. In the active, passive, and resisted movement assessment, Lisa reported lateral hip pain when performing active abduction of the left hip. There was a slight limit to range of motion for active internal rotation on the left side compared to the right. No other active movement caused any discomfort or limited range of motion. While active abduction reproduced her pain, passive abduction did not. Passive internal rotation performed in a prone position also showed a limited range of motion on the left side compared to the right. This was the same motion limitation that was apparent with active movement. She also reported mild pain sensations in the gluteal region at the end of the passive internal rotation movement on the left side. Lisa's lateral hip pain was reproduced with resisted abduction on the left side. There was no similar pain with resisted abduction on the right side, and the right side resisted action was strong and normal. No other resisted movements reproduced any pain or discomfort. The information derived from the history, observation, and initial physical examination provided further key clues about the nature of Lisa's hip and gluteal pain. 96 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 5 technique CLINICAL APPS Gluteal Pain on the Run By Whitney Lowe Stretching position of the piriformis from a supine position. The piriformis in relation to the sciatic nerve. Mediclip image copyright (1998) Williams & Wilkins. All Rights Reserved. 1 2

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