How to Differentiate and Diagnose Hip-Gluteal-Back Pain
It is common for runners to develop pain in their back, hips, gluteal or upper thigh region. They are also often misdiagnosed by undertrained or misinformed doctors and therapists not to mention well intentioned friends, family, loved ones and the internet. Accurately differentially diagnosing these injuries and then providing effective treatment plans is rare in most clinics but not at San Diego Running Institute. The reason we are so good at doing this is due to our specialty in running injuries. I know, lots of clinics treat runners and other athletes but are lots of those clinics owned and operated by a doctor that runs ultra marathons, owns a trail racing company, owned a running shoe retail store for 10 years and has been treating 80-90% running injuries for 15 years? Probably not. The reason this is important is that there is more learned “in the trenches” than can ever be taught in school. It is also called “being in practice” because every day we come to work we are “practicing” on patients. When you do the same thing over and over for 15 years you get much better at it. What I know now after 15 years dwarfs the knowledge I had when coming out of school. Couple that experience with all of the “tricks of the trade” regarding running shoes, orthotics, running injuries, foam rollers, etc and what you have is a highly specialized doctor with intricate and intimate knowledge of running injuries and how to fix them. So how do you know what type of back, hip or gluteal problem you have? The answer is to list them all out and then in a fashion similar to what a crime detective might do, eliminate the usual suspects.
There are 7 major issues that affect the posterior, upper 1/3 of a runner’s lower body. I will list them from high (superior) to low (inferior).
Symptoms – Pain that will radiate from the back or gluteal region past the knee and down to the foot. It is caused by a swollen, bulging or herniated lumbar disc. The pain will typically be made worse if trying to stretch your hamstring. The runner may also notice weakness in the foot, calf or ankle and or numbness.
Differentiation – If you DO NOT have pain shooting past your knee into your foot you probably DO NOT have Sciatica or Piriformis Syndrome. However, pain that radiates past the knee and down to the foot is almost always indicative of Sciatica with Piriformis Syndrome also a small possibility.
Testing – Manual orthopedic/stress testing can be performed that can differentiate between Sciatica and Piriformis Syndrome. X-rays are not useful in differentiating these. An MRI would be the appropriate special test to help diagnose the conditions.
Treatment – Both Sciatica and Piriformis Syndrome can be treated effectively without surgery. San Diego Running Institute treats both of these conditions regularly with excellent results.
Gluteus Medius Syndrome
Symptoms – Pain that is diffuse throughout the gluteal region and may radiate into the upper hamstring but DOES NOT radiate past the runners knee. Often the pain will hurt worse if running uphill or sprinting and may even hurt some while sitting.
Differentiation – If you have pain shooting down your leg past your knee and into your foot you DO NOT have Gluteus Medius Syndrome but most likely either Sciatica or Piriformis Syndrome. If you have pain that remains in the Gluteal Region than it will be important to differentiate between Gluteus Medius Syndrome, Ischial Bursitis and High Hamstring Tendonopathy.
Testing – An X-ray will be useless in helping to differentiate these conditions. An MRI may be useful but often does not prove completely useful. Manual/provocative testing is the preferred testing method to differentiate these 3 conditions. If there are no trigger points in the Gluteus Medius Muscle or Pain while applying pressure on the Ischial Bursa than one must suspect High Hamstring Tendonopathy. By manually muscle testing the hamstring it is easy to decide if it is a factor as it will be painful during contraction. If however there is pain when pressure is applied to the Ischial Bursa than the most likely diagnosis is Ischial Bursitis. If there is no pain while applying pressure to the Ischial Bursa and no pain in the hamstring during manual testing then Gluteus Medius Syndrome should be suspected.
Treatment – The treatment protocols for these 3 conditions are dramatically different and incorrect application can further worsen one’s condition. For example; using a foam roller and applying direct pressure to Ischial Bursitis will only provoke and aggravate the condition. San Diego Running Institute has highly effective treatment plans for all 3 of these conditions typically getting runners back on the roads or trails within a couple of weeks.
Symptoms – While similar to Sciatica symptoms the origin is at the Piriformis muscle deep to the Glutes instead of due to a bulging disc in the runners back.
Differentiation – Pain that radiates from the Gluteal region, past the knee and down into the calf and foot. Sciatica is the primary differential diagnosis and is a more common condition.
Testing – X-rays are useless in this situation. MRI is effective in ruling out Lumbar disc bulges, protrusions, herniations and extrusions. It is important to rule these out as they would be the likely cause of the person’s radicular (radiating) pain. Orthopedic/provocative testing is also useful in differentiating Piriformis Syndrome from Sciatica and should be correlated to the MRI. In the absence of MRI evidence orthopedic/provocative testing should be used to eliminate sciatica first as it is the more common condition.
Treatment – Piriformis Syndrome responds extremely well to conservative treatment when it is directed directly at the Piriformis Muscle. In our experience most clinics fail to isolate the Piriformis Muscle and provide therapeutic interventions that actually cause more pain. San Diego Running Institute has tried and proven protocols that have helped hundreds overcome their Piriformis Syndrome without surgery and return to normal, pain free running.
Symptoms – The pain is typically localized to the runners SITS bone (Ischial Tuberosity) and is made worse while running and sitting.
Differentiation – Ischial Bursitis must be differentiated from Gluteus Medius Syndrome and High Hamstring Tendonopathy. Pain with direct pressure on the affected SITS bone is usually indicative of Ischial Bursitis.
Testing –X-ray is useless in diagnosing Ischial Bursitis. MRI often shows the swollen bursa.
Treatment – There a couple of effective options for an injured person to choose from. Once the correct diagnosis is obtained the patient is provided with treatment options all of which are effective with some being less conservative.
Symptoms – The pain is located on the outside (lateral) of the thigh near and around the Greater Trochanter. Will usually hurt on impact while running or jumping and will hurt to sleep on the affected side hip.
Differentiation – It is usually easy to differentiate Trochanteric Bursitis from other hip conditions as it causes pain on the outside (lateral) side of the hip. The most important condition to differentiate would be stress fracture. Since both conditions hurt on impact an MRI may be necessary to help make the correct diagnosis. However, if the person has sharp pain in the lateral hip at night, especially while lying on the affected hip the suspected diagnosis is Trochanteric Bursitis vs. Stress Fracture
Testing – An X-ray is useless in diagnosing Trochanteric Bursitis and will often not show a stress fracture. Manual palpation can elicit pain and be suggestive of Trochanteric Bursitis. A MRI would be able to differentiate between a stress fracture and Trochanteric Bursitis as it is sensitive enough to show both injuries.
Treatment – We have conservative treatment protocols to fix Trochanteric Bursitis and hip stress fractures. Now with Altered Gravity Technology runners can run on the AlterG treadmill with fractures and while they are healing!
High Hamstring Tendonopathy
Symptoms – Pain is usually located beneath (inferior) to the Sits bone and is made worse by running faster and uphill. Runners will report that if they shorten their stride it feels somewhat better.
Differentiation – Should be differentiated from Ischial Bursitis and Gluteus Medius Syndrome. Hamstring tendonopathy implies degeneration to the hamstring near its insertion on the Ischial Tuberosity. When manually muscle testing the hamstring the degenerated tendon should have pain and/or be weaker when compared to the non-affected side. The patient can often point precisely to the injured tendon during manual testing.
Testing- Orthopedic/provocative testing is highly effective in diagnosing the hamstring as the problem but not in HOW SEVERE the problem is. It is not uncommon for the hamstring to suffer tearing over time. An MRI provides detailed insight into the degree of tendonopathy and help to not only direct treatment but sets expectations as to how long it will take to heal.
Treatment – For Tendonosis and tendonopathy of low grade status conservative treatment is highly effective. When the patient has a severe hamstring tear they will usually fail conservative treatment and require surgery. For this reason we prefer an MRI when this condition is diagnosed in order to help set realistic expectations and provide a timeline for healing.
Hip Stress Fracture
Symptoms – Pain on impact while running or jumping is common after the fracture has developed. In early stages runners will deny pain while running but describe pain afterwards that causes limping. This is known as a “pre-stress fracture” and if an MRI is taken will usually show bone marrow edema.
Differentiation – The single leg hop test is typically used but can not necessarily rule out Trochanteric Bursitis. MRI is useful and is considered the Gold Standard for stress fracture diagnosis as it will also eliminate Trochanteric Bursitis.
Testing – In addition to Orthopedic/provocative tests such as the single leg hop test a pulsed ultrasound test and tuning fork test may be used on the painful area in an attempt to diagnose stress fracture. It is important to note that neither one of these tests are sensitive enough to necessarily diagnose a stress fracture. Manual muscle testing can be used to stress the TFL muscle. Often, during abduction contraction the muscle will further compress a swollen bursa and cause pain. An increase in pain without weight bearing is suggestive of bursitis vs. stress fracture
Treatment – Therapy for the 2 conditions are very different. Stress fractures are normally rehabilitated using AlterG technology (Antigravity Treadmill) while if the diagnosis of Trochanteric Bursitis is given many conservative treatment options are available. San Diego Running Institute differentiates and corrects these conditions regularly.
Ask The Doctor
If you have any questions regarding your injury please fill out the “Ask the Doc” form on the right of your page or email Dr. Runco directly at DrRunco@sdri.net. You may schedule an appointment with our clinic by calling 858-268-8525