w w w . r b o . o r g . b r
Technical
Note
Gluteal
pain
in
athletes:
how
should
it
be
investigated
and
treated?
夽
Guilherme
Guadagnini
Falótico
∗,
Diogo
Fernandes
Torquato,
Ticiane
Cordeiro
Roim,
Edmilson
Takehiro
Takata,
Alberto
de
Castro
Pochini,
Benno
Ejnisman
UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received30April2014 Accepted1July2014 Availableonline18July2015
Keywords:
Pain Buttocks Athletes
a
b
s
t
r
a
c
t
Glutealpainisafrequentsymptominathletes,anddefiningitetiologicallyisachallengefor orthopedists.Inthepresentstudy,usingananatomicalapproachtotheposteriorregionof thepelvisandtheproximalfemur,dividedintofourquadrants,systematizedinvestigation isproposedwiththeaimofoptimizingthetreatmentandacceleratingathletes’returnto theirsport,throughcorrectdiagnosis.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Dor
glútea
em
atletas
–
como
investigar
e
tratar?
Palavras-chave:
Dor Nádegas Atletas
r
e
s
u
m
o
Adorglúteaéumsintoma frequenteematletas.Suadefinic¸ão etiológicaéumdesafio paraoortopedista.Nopresenteestudo,osautorespropõem,pormeiodeumaabordagem anatômicadaregiãoposteriordapelveedofêmurproximal,divididaemquatroquadrantes, ainvestigac¸ãosistematizadadolocal,visando,pormeiododiagnósticocorreto,aaperfeic¸oar otratamentoeaceleraroretornodoatletaaoesporte.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.
Introduction
Gluteal pain is a common manifestation among athletes, althoughitsinvestigationisquitechallenginginorthopedic
夽
WorkdevelopedintheHipSector,CentrodeTraumatologiadoEsporte(Cete),EscolaPaulistadeMedicina,UniversidadeFederalde SãoPaulo,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](G.G.Falótico).
practice because the pain can originatenot onlyfrom the glutealstructuresthemselves,butalsofromthelumbosacral spine,sacroiliacjointandhips.1
Thisissue,althoughfrequentinthedailyroutineofsports orthopedists,islittlediscussedinthecurrentliterature.
http://dx.doi.org/10.1016/j.rboe.2015.07.002
Thepresentstudyproposesamodelforinvestigatingthis conditionamongathletes.
Description
of
the
method
Theareatobestudiedwasdelimitedbyfourimaginarylines: superiorly,ahorizontallinetangentialtotheupperborderof theiliac crest;inferiorly,ahorizontallinetangentialtothe lowerborderoftheischialtuberosity;medially,averticalline thatpassesthroughthecenterofthesacrum;andlaterally, averticallinetangentialtothelateralborderofthegreater trochanter.
Within this imaginary rectangle, four quadrants were delimited starting from the posterosuperior iliac spine (Fig.1).
Superomedial
quadrant
(A)
Thepalpablestructuresofinterestarethespinousprocesses ofL4andL5andthejointinterlineofthesacroiliacjoint.
Themostfrequentdisordersofthisquadrantarechronic lowerbackpain duetomuscle-ligamentinjury, radiculopa-thy due to a herniated disc and pain from the sacroiliac joint.
Other diagnoses include stress fractures ofthe sacrum, spondylolysis/spondylolisthesisandfacetarthropathy.
Lowerbackpainduetomuscle-ligamentinjury
Thisconditionaccountsforapproximately97%ofthechronic lesionsinthelumbosacralspineofathletes.2Lowerbackpain
isusuallycausedbyvigorouseccentricmuscle contraction, andthelesionisusuallynexttothemyotendinousjunction.3
Moreover,injurytotheiliolumbarligamentisalsoacauseof lowerbackpainandglutealpainandevensimulatessacroiliac disorders.1
Fig.1–Posteriorphotographoftheboneanatomyofthe pelvisandrightproximalfemurwithdivisionintofour quadrantsstartingfromtheposterosuperioriliacspine.
Radiculopathy
Approximately90%ofradicularcompressionsoccuratthe lev-elsofL4-L5andL5-S1.4Thisconditionhasbeenwellstudied
throughmagneticresonanceimaging.
Insportsthatrequireextremetorsionalmovementsofthe lumbosacralspine(e.g.tennisorbaseball),largernumbersof participantsareaffected.5
Thephysicalexaminationmaydemonstrateneurological alterationsintheaffecteddermatomeandLasègue’stestmay bepositive.
The majority of patients respond tonon-surgical treat-ment.Surgeryisindicatedincasesofprogressiveneurological deficit,sphincterdysfunction,sexualdysfunctionand refrac-torypain.2
Sacroiliacpain
Thesacroiliac jointisessentialforproperloadtransference fromthelowerbackspinetothepelvis.6Hyperor
hypomobil-ityofthisjointcanleadtopainfulsymptoms.7,8
Thepain typicallyaffects thesuperomedial quadrantof theglutealregion,althoughitcanalsoaffectthelowerback region,thighs,lateralregionofthehipsandinguinalregion,7,8
becauseoftheextensivelocalinnervation.9–11
Various sports activities can triggersacroiliac pain. The mostfrequentonesarethosethatinvolverunning,jumping and abruptchangesindirection.Approximately 64%ofthe patientshaveahistory ofchronictraumaormicrotraumas duetorepetition.12
Theclinicalexaminationmayrevealalterationsofpelvic inclination and lower back curvature, discrepancy in the lengths ofthe lower limbsand pelvic hypermotion during gait. Thepatientsoftenfeel pain uponlocalpalpation and therearevarioustriggerpointsintheadjacentmusculature.13
Provocativemaneuversmaybepositive.Moreover,thethigh compressiontesthasgreatdiagnosticspecificity.14,15
Imagingexaminations,including radiographs, computed tomography(CT)andmagneticresonanceimaging(MRI),can help inthe diagnosis, althoughthe gold standardis injec-tion ofananesthetic,guidedbymeansoffluoroscopy,with disappearanceofthesymptoms.8
Treatment should focus on muscle strengthening and pelvisstabilization.Bracestocompensatefordiscrepanciesof thelowerlimbsareuseful.Localinjectionsofcorticoidsshould berecommendedforcasesthatarerefractorytoclinical treat-mentafter1monthor,iftheinitialpainisveryintense,in ordertoacceleraterehabilitation.16–20
In addition, patientswho are refractoryto conventional treatment,especiallyyoungmenwhoarebilaterallyaffected andpresentassociatedsystemicsymptomsormorningjoint stiffness,shouldbemorethoroughlyinvestigatedregarding ankylosingspondylitis.21
Fractureduetosacralstress
Youngwomenwithahightrainingload,nutritional defi-ciencyandirregularitiesintheirmenstrualcyclesare more affected.7,24–26Thisconditionhasalsobeendescribedamong
malesoldiers.23
Physicalexaminationshowspainduetopalpationofthe sacrum, exacerbated byprovocative tests on the sacroiliac joint.
MRI is an excellent complementary diagnostic method because fractures are already visible within 72h of evolution.24,27
Treatmentdemandsprotectionfromloadsontheaffected sideuntilpainreliefhasbeenachieved.Aftertheanalgesic phase,arehabilitationprotocolfocusingonpelvicandlower backstabilizationshouldbedrawnup.
Thereturntosportspracticeinitiallyincludeslow-impact activities. Competitive practice is usually allowed after 12 weeks.CalciumandvitaminDreplacementisrecommended forwomenwithosteopenia.25
Spondylolysis/spondylolisthesis
Spondylolysisiscausedbyadefectoftheparsinterarticularis. Itsincidenceamongathletesrangesfrom8%to15%.Themost commontraumaticformoccursamonggymnasts,soccer play-ers,ballerinasandweightlifters.28
Spondylolisthesiscomprisessliding ofonevertebraover another.Bilateralspondylolysisisariskfactor.Slidinggreater than25%isfrequentlyassociatedwithapainfulcondition.29
Conservative treatmentis successfullyindicated forthe majority of cases. The return to the sport usually occurs between4and6monthsafterthebeginningofrehabilitation. Surgeryisindicated amongapproximately 9–15%ofthe patientsbecauseofrefractorypainmorethan6monthsafter thetreatment,neurologicaldeficitorvertebralinstability.28
Facetarthropathy
Facet joints are located in the posterior area of the spine between adjacent vertebrae. Local pain is more frequent amongathletesover40yearsofage.
Torsionaltraumaofthespine,withpainthatworsenswith lumbarextensionandwhichcanirradiatetotheuppergluteal area,suggeststhedisease.30Magneticresonanceimagingcan
berequestedtoconfirmthediagnosis.
In short, pain from the superomedial quadrant of the glutealregioncanoriginatefromthelumbosacralspineand thesacroiliacjoint.Wesuggestthat,intheroutineofthe clin-icalexaminationfordiseases inthis quadrant, stress tests onthe sacroiliac joint shouldbe included(Gaenslen,thigh compression,sacralcompressionandFabere),aswellasthe straightlegelevationtestandLasègue.
Patients with persistent pain that is refractory to the conventionaltreatment, i.e.nonsteroidal anti-inflammatory drugs (NSAIDs), reductionoftraining load and physiother-apy,must undergo imaginginvestigation.Theexamination suggestedforstudyingthisquadrantismagneticresonance imagingofthelumbosacralareaincludingthesacroiliacjoint. Electromyographyisalsosuggestedforpatientswith neuro-logicalsymptoms.
Superolateral
quadrant
(B)
Thepalpablestructureofinterestistheposteriorborderofthe iliaccrest.
Themostfrequentdisorderinthisquadrantismyofascial painsyndrome,whichaffectsthegluteusmaximusand glu-teusmediusandischaracterizedbytheformationofpainful triggerpointsinthemusclemassitselforinthefascia inser-tion.Triggerpointsareusuallyassociatedwithchronictrauma orrepeatedmicrotraumaofthemusclesinvolvedandleadto musclefatigue,whichfavorscreationofothertriggerpoints, thusgeneratingapathologicalviciouscircle.31
Thediagnosisisclinical,throughinvestigationoftrigger points, and the treatment involves reduction of the train-ingloadandphysiotherapy,withmanipulationofthepainful spots andsubsequentmuscle stretchingand strengthening anduseofdrugs:anti-inflammatorydrugs,musclerelaxants, tricyclicantidepressantsoranticonvulsants(e.g.gabapentin), dependingonthedurationofthepainandtheprofileofthe patient.Infiltrationoftriggerpointsisalsoveryusefulincases thatarerefractorytotheinitialmeasures.31
Thepossibledifferentialdiagnosesincludechronicmuscle lesionsandenthesopathyoftheoriginoftheglutealmuscles intheiliaccrest.
Forpatientswhoarerefractorytoconventionaltreatment, the complementary examinations indicated are magnetic resonanceimagingofthepelvis,toevaluatethemuscle inser-tionsintheiliaccrest,andelectromyography,toinvestigate possiblepainirradiatingfromnervecompressionthatwasnot clinicallysuspected.
Inferolateral
quadrant
(
C
)
Thepalpablestructuresofinterestaretheischialtuberosity, ischialspineandgreatertrochanter.
Inthisquadrant,themostfrequentdisordersareinjuries attheoriginofthehamstrings,greatertrochantericpain syn-drome,piriformissyndromeandischialbursitis.
Otherdiagnosesare:ischiofemoralimpingement/lesionof thequadratusfemoris,fractureduetostressintheischiopubic ramusandischialtumors.Themostfrequentdiagnosesinthis locationareosteochondromasandchondrosarcomas.
Hamstringinjuries
Tendinopathy ofthe origin ofthe hamstrings occurs quite frequentlyinmiddleandlong-distancerunners.Muscle weak-nessorfatigue,associatedwitheccentriccontractionduring thelateswingphaseoftherun,predisposestowardinjuries.32
Thepaincanbereproducedthroughpalpationoftheischial tuberosity or through passive flexion ofthe hipassociated withactiveflexionofthekneeagainstresistance.Localized paindistaltotheischiumisgenerallyassociatedwith ham-string muscle injuries, while pain proximal to the ischial tuberositymayberelatedtopiriformissyndrome.1
painduetochemical irritationoranextrinsiccompression effectonthesciaticnervecausedbyhematoma.33
Radiographymaydemonstratecalcificationadjacenttothe ischiumandboneavulsion.However,thepreferred examina-tionforthediagnosisismagneticresonanceimaging.34,35
Thetreatmentinvolvesanti-inflammatoryand analgesic medication,aswellasphysiotherapy.
In refractory cases, infiltration of corticoid guided by ultrasound, injection of platelet-rich plasma and surgical debridementcanbeperformed.36
In cases ofbone deinsertion or avulsion, early surgical treatment(4–6weeksaftertheinjury)presentsgoodresults.3
Greatertrochantericpainsyndrome
Greatertrochantericpainsyndromeisdefinedaspainful pal-pationofthegreatertrochanterwiththepatientpositioned inlateraldecubitus.Itinvolvesvariousdisordersofthe per-itrochantericspaceofthehip,suchastrochantericbursitis, tendinopathy/lesionofthegluteusmediusandgluteus min-imusandexternalhipsnapping.37
Patientsoftencomplainaboutpaininthelateraland pos-teriorareas ofthegreater trochanter,which becameworse duringthesupportphaseoftheaffected limbduring walk-ingorrunning.Anassociationwithchroniclowerbackpainis quitefrequent.37
Inthephysicalexamination,inadditiontopainon palpa-tionofthetrochanter,theTrendelenburgtestcanbepositive andthe pain canbeexacerbated throughabductionofthe affectedhipagainstresistance(Beattytest).1,37
Thediagnosis isclinical andimagingexaminationsmay beindicatedforpatientswithinadequateresponsesto treat-ment.Themostusefulexaminationsareultrasonographyand magneticresonanceimaging.
The treatment involves medication, physiotherapy and localinfiltrationofcorticoid.Surgicaltreatmentisindicated inrefractorycases,especiallywhenthereisaruptureofthe gluteusmedius/minimus(inthesecases,suturing)orexternal snapping(in thesecases, surgicallengtheningofthe ham-stringmuscles).3,37
Piriformissyndrome
Piriformissyndromeisdescribed asglutealpainassociated withsciatic painthatwassecondarytocompressionofthe sciaticnervebythepiriformismuscle.
Approximately5%ofthecasesoflowerbackpain,gluteal pain and pain radiating from the posterior aspect of the lower limb are associated with the syndrome.38 However,
thereiscontroversyregardingthedefinitionofthesyndrome, becausealargeproportionofthepatientswiththis diagno-sisdonotpresentclinicalorelectromyographicneurological alterations.39
It can also be attributed to piriformis myalgia, result-ing from its relative weakness in relation to the gluteal musculature.1
Clinicalexaminationoftenshowspainonpalpation proxi-mally to the ischial spine, in the area of the greater sciaticnotch,overthepiriformismuscle,whichisfrequently hardened in comparison with the unaffected side. The
clinical tests described are the Freiberg, Pace, Beatty and Faduritests.40–43
Becausethisisadiagnosisthroughexclusion,othercauses ofneuropathyneedtobeinvestigated.
In this context,magnetic resonance neurographyforms an important diagnostic option. In this technique, high-resolution 1mm slices are used, with T1and T2-weighted sequenceswithfatsuppression.Thisenablesthorough eval-uation of the sciatic nerve, from its formation by the lumbosacralrootstoitspaththroughtheglutealregionand thigh.Inthismanner,theexactanatomicalstructure respon-sibleforcompressionofthenervecanbeshown.44
Thetreatmentisbasedonstretchingandstrengtheningof theexternalrotatormusclesofthehips andglutealregion. Casesthatremainedrefractoryafter6weeksofrehabilitation canundergoinfiltrationofcorticoid,anestheticorbotulinum toxin.41
Surgicalreleaseofthepiriformis(openorendoscopic)has beencitedbysomeauthorsinsmallcaseseriesandshould beindicatedwithcautionafterrulingoutthemorefrequent diagnosesforsciaticpain.45–47
Sciaticbursitis
Sciaticbursitisisassociatedwithexcessforceexertedbythe hamstring muscles on the bursa. These patients generally complainofpainwhentheyremainsittingforlongperiods and the clinical examination reveals pain over the ischial tuberosity. It can appear separately or in association with tendinopathyofthehamstrings.
Thediagnosticconfirmationcanbeobtainedthrough ultra-sonographyormagneticresonanceimagingandmostpatients evolvewellafter6–8weeksofconservativetreatment.Again, refractorycasescanundergolocalinfiltration.
Chroniccasesassociatedwithtendinopathymayrequire surgicaltreatmentforbursectomyandtendondebridement ortenotomy.26,37
Ischiofemoral
impingement
Some authors have correlated the reduction of the ischiofemoral interval with compression of the quadratus femorisandtheemergenceofglutealpainsymptoms.
Femalemorphology,withabroadandshallowpelvis, pre-disposes thesepatientstowardischiofemoralimpingement. All the casesdescribed in the literaturehave been among women.
Theclinicaldiagnosisisusuallydifficultbecausethe com-plaintsarevagueandclinicalexaminationisimprecise.
Thetestsdescribedforevaluatingthepiriformissyndrome canbepainfulbecausethequadratusfemorisisalsoan exter-nal rotator of the hip. There is no record of neurological symptomsassociatedwithischiofemoralimpingement.
Table1–Diagnosesofglutealpain.
Quadrants Maindiagnoses Clinicalexamination Examinations
Superomedial Chroniclowerbackpain Lasègue LumbosacralMRI Radiculopathy Axialcompressionofthethigh ENMG
Sacroiliacpain Fabere Gaeslen
Superolateral Myofascialpain(gluteusmaximus andmedius)
Investigationoftriggerpoints MRIofthepelvis(patients refractorytotreatment)
Inferolateral Greatertrochantericpainsyndrome Lasègue MRIofthehip Piriformissyndrome Freiberg/Beatty DynamicENMG(Faduri) Tendinopathyofthehamstrings Flexionofthekneeagainst
resistance
Neurographyofthesciatic nerve
Inferomedial Coccydynia Detailedpalpation Dynamicradiographyofthe coccyx
Pelvicfloordysfunction Neurologicalexamination (sacralroots)
MRIofthepelvicfloor
Sacralplexuslesion ENMG
ordertoreproducetheimpactwiththetensionedquadratus femoris.
Magneticresonanceimagingisessentialforthe diagno-sisandusuallyshowsalterationsinthemusclebellyofthe quadratusfemoris.
Non-surgical treatment has been described as effective and involves a protocol of stretching exercises, corticoid infiltrations,neurostimulationandphysiotherapyusing per-cutaneousultrasound.
Surgicaltreatmenthasonlybeendescribedincases sec-ondarytofemoraldeformityortumors.48
Fractureoftheischiopubicramusduetostress
Fracturesoftheischiopubicramusarerareinjuries.This con-ditionevolveswithinsidiousoccurrenceofglutealpainandis generallyassociatedwithintensificationoftrainingintensity. Thediagnosisdependsonahighlevelofsuspicion.23
Clinicalexaminationcanshowaworseningofthepainin anuprightstandingpositionwithweight-bearingononefoot ontheaffectedside,aswellaspaininthehoptest.23,49
Magneticresonanceimagingusuallyconfirmsthe diagno-sisandthetreatmentincludesanalgesicdrugsandtraining loadreductionfor6–8weeks.
Tostandardizationdiseaseevaluationsinthis quadrant, werecommend that, after thorough palpationof the bone pointsofinterest,theclinicaltestsofFreiberg,Pace,Beattyand Faduri,thetestofpassiveflexionofthehipwithactive flex-ionofthekneeandthetestforischiofemoralimpingement shouldbeperformed.
Investigation through examinations, when required, shouldinvolvemagneticresonanceimagingofthehipand, whenneurologicalsymptomsarepresent, electroneuromyo-graphy.Iftheoriginofthesciaticpainisnotclarifiedthrough these techniques, neurography ofthe sciatic nerve can be requested.
Inferomedial
quadrant
(D)
Thepalpablestructureofinterestisthecoccyx.
Thedisordersinthisquadrantarecoccydynia,chronic dys-functionofthepelvicfloor,lesionsofthesacralplexusand tumorsofthesacrum.Chordomasarethemostcommontype oftumorinthislocation.
Coccydynia
Thecoccyxisfrequentlyinvolvedinchronicperinealpain.In astudyinvolving208patientswithpaininthecoccyx, exces-sivemobilitywastheetiologicalfactor in27%ofthecases. Thepainwascausedbyposteriordislocationofthecoccyxin 22%;itwasrelatedtothepresenceofbonespiculesin14%; itoriginatedfromanteriordislocationin5%;anditsetiology remained undefined(idiopathic)in31%.Trauma isanother etiologicalfactorofconsiderableimportancebecauseitmay beassociatedwithinstabilityofthecoccyx,especiallywith posteriorsubluxationofthecoccyx.50
The diagnosis can beestablishedby means ofdynamic radiography(withthepatientsittingandinanupright stand-ingposition)andbymagneticresonanceimaging,whichcan present localinflammatoryhypersignal,aswell asthrough evaluationofpossibleneoplasia.51
The treatment involves anti-inflammatory drugs, along withmechanicalprotectionofthecoccyxwithcushionsfor patients who spend long time sitting. Physiotherapy with pelvicstabilizationmayaidinthis.
Refractorycasescanundergoinfiltrationsofanestheticand corticoid andalsosurgicalresection(partialortotal)ofthe coccyx.52
Chronicdysfunctionofthepelvicfloor
Chronic dysfunction of the pelvic flooris a condition that canbepresentinwomenafterpregnancy,insituations sub-sequent to pelvic trauma or in cyclists. Usually there is insufficiencyofthecoccygeusmuscleandlevatorani(which comprisethepelvicfloor)andthepubococcygeusligament.
Thetreatmentinvolvesstrengtheningandstabilizationof thepelvicfloor.53
Lesionsofthesacral-coccygealplexus
Lesions of the sacral-coccygeal plexus are rare in ath-letes. When symptoms are present, extrinsic compression by neoplasia or endometriosis should be suspected. The investigationincludeselectroneuromyographyandmagnetic resonanceimagingofthepelvis.
Athleteswiththisconditionmusthalttheirsportspractice untiltheinvestigationiscompleteandpropertreatmenthas beeninstituted.1,54,55
Themaindatafromthephysicalexaminationinthis quad-rantcomesfrompalpationofthebonestructuresofinterest. Caseswithoutanyresponsetosymptomatictreatmentshould beinvestigatedbymeans ofdynamicradiographyto evalu-atethecoccyx,aswell asbymeansofmagneticresonance imagingofthepelvis.Incasesofneurologicalsymptoms, elec-troneuromyographyshould beincluded inthe sequence of examinationsrequested.
Asummary ofthediagnoses,clinical examinationsand complementaryexaminationsrequiredfordiagnosinggluteal paininathletescanbeseeninTable1.
Final
remarks
Investigationofglutealpainrequireswideknowledgeofthe various possible diagnoses as well as establishment of a routineofclinical examinationandcomplementary exami-nations.
Throughananatomicalapproachaccordingtothe quad-rants,weproposeamodelforsystematizingtheevaluationof athleteswithglutealsymptoms,thusaimingtoensureproper treatment.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1. VasudevanJM,SmuckM,FredericsonM.Evaluationofthe athletewithbuttockpain.CurrSportsMedRep.
2012;11(1):35–42.
2. TrainorTJ,TrainorMA.Etiologyoflowbackpaininathletes. CurrSportsMedRep.2004;3(1):41–6.
3. AndersonK,StricklandSM,WarrenR.Hipandgroininjuries inathletes.AmJSportsMed.2001;29(4):521–33.
4. LawrenceJP,GreeneHS,GrauerJN.Backpaininathletes.JAm AcadOrthopSurg.2006;14(13):726–35.
5. WatkinsRG.Thespineinsports.St.Louis:Mosby;1996.
6. FoleyBS,BuschbacherRM.Sacroiliacjointpain:anatomy, biomechanics,diagnosis,andtreatment.AmJPhysMed Rehabil.2006;85(12):997–1006.
7. BruknerP,KhanK.Clinicalsportsmedicine.Sydney:McGraw Hill;2010.
8. ChenYC,FredericsonM,SmuckM.Sacroiliacjointpain syndromeinactivepatients:alookbehindthepain.Phys Sportsmed.2002;30(11):30–7.
9.AtlihanD,TekdemirI,AteˆsY,ElhanA.Anatomyofthe anteriorsacroiliacjointwithreferencetolumbosacralnerves. ClinOrthopRelatRes.2000;376:236–41.
10.FortinJD,WashingtonWJ,FalcoFJ.Threepathwaysbetween thesacroiliacjointandneuralstructures.AJNRAmJ Neuroradiol.1999;20(8):1429–34.
11.FortinJD,KisslingRO,O’ConnorBL,VilenskyJA.Sacroiliac jointinnervationandpain.AmJOrthop(BelleMeadNJ). 1999;28(12):687–90.
12.SlipmanCW,PatelRK,WhyteWS.Diagnosingandmanaging sacroiliacpain.JMusculoskeletMed.2001;18:325–32.
13.BrolinsonPG,KozarAJ,CiborG.Sacroiliacjointdysfunctionin athletes.CurrSportsMedRep.2003;2(1):47–56.
14.SolonenKA.Thesacroiliacjointinthelightofanatomical, roentgenologicalandclinicalstudies.ActaOrthopScand Suppl.1957;27:1–127.
15.LaslettM,WilliamsM.Thereliabilityofselectedpain provocationtestsforsacroiliacjointpathology.Spine(Phila PA1976).1994;19(11):1243–9.
16.BroadhurstNA,BondMJ.Painprovocationtestsforthe assessmentofsacroiliacjointdysfunction.JSpinalDisord. 1998;11(4):341–5.
17.DreyfussP,ColeAJ,PauzaK.Sacroiliacjointinjection techniques.PhysMedRehabilClinNorthAm.1995;6:785–814.
18.KinardRE.Diagnosticspinalinjectionprocedures.Neurosurg ClinNorthAm.1996;7(1):151–65.
19.MaigneJY,AivaliklisA,PfeferF.Resultsofsacroiliacjoint doubleblockandvalueofsacroiliacpainprovocationtestsin 54patientswithlowbackpain.Spine(PhilaPA1976). 1996;21(16):1889–92.
20.SchwarzerAC,AprillCN,BogdukN.Thesacroiliacjointin chroniclowbackpain.Spine(PhilaPA1976).1995;20(1):31–7.
21.HarperBE,ReveilleJD.Spondyloarthritis:clinicalsuspicion, diagnosis,andsports.CurrSportsMedRep.2009;8(1):29–34.
22.DelvauxK,LysensR.Lumbosacralpaininanathlete.AmJ PhysMedRehabil.2001;80(5):388–91.
23.FredericsonM,JenningsF,BeaulieuC,MathesonGO.Stress fracturesinathletes.TopMagnResonImaging.
2006;17(5):309–25.
24.BottomleyMB.Sacralstressfractureinarunner.BrJSports Med.1990;24(4):243–4.
25.FredericsonM,SalamanchaL,BeaulieuC.Sacralstress fractures:trackingdownnonspecificpainindistance runners.PhysSportsmed.2003;31(2):31–42.
26.TiborLM,SekiyaJK.Differentialdiagnosisofpainaroundthe hipjoint.Arthroscopy.2008;24(12):1407–21.
27.JohnsonAW,WeissCBJr,StentoK,WheelerDL.Stress fracturesofthesacrum.Anatypicalcauseoflowbackpainin thefemaleathlete.AmJSportsMed.2001;29(4):498–508.
28.StandaertCJ,HerringSA.Spondylolysis:acriticalreview.BrJ SportsMed.2000;34(6):415–22.
29.SarasteH.Long-termclinicalandradiologicalfollow-upof spondylolysisandspondylolisthesis.JPediatrOrthop. 1987;7(6):631–8.
30.HeckJF,SparanoJM.Aclassificationsystemforthe assessmentoflumbarpaininathletes.JAthlTrain. 2000;35(2):204–11.
31.LavelleED,LavelleW,SmithHS.Myofascialtriggerpoints. MedClinNorthAm.2007;91(2):229–39.
32.KollerA,SumannG,SchobersbergerW,HoertnaglH,HaidC. Decreaseineccentrichamstringstrengthinrunnersinthe TirolSpeedMarathon.BrJSportsMed.2006;40(10):850–2.
33.PuranenJ,OravaS.Thehamstringsyndrome.Anewdiagnosis ofglutealsciaticpain.AmJSportsMed.1988;16(5):517–21.
35.ZissenMH,WallaceG,StevensKJ,FredericsonM,BeaulieuCF. Highhamstringtendinopathy:MRIandultrasoundimaging andtherapeuticefficacyofpercutaneouscorticosteroid injection.AJRAmJRoentgenol.2010;195(4):
993–8.
36.FredericsonM,MooreW,GuilletM,BeaulieuC.High hamstringtendinopathyinrunners:meetingthechallenges ofdiagnosis,treatment,andrehabilitation.PhysSportsmed. 2005;33(5):32–43.
37.StraussEJ,NhoSJ,KellyBT.Greatertrochantericpain syndrome.SportsMedArthrosc.2010;18(2):113–9.
38.PapadopoulosEC,KhanSN.Piriformissyndromeandlow backpain:anewclassificationandreviewoftheliterature. OrthopClinNorthAm.2004;35(1):65–71.
39.StewartJD.Focalperipheralneuropathies.3rded. Philadelphia:LippincottWilliams&Wilkins;2000.
40.BeattyRA.Thepiriformismusclesyndrome:asimple diagnosticmaneuver.Neurosurgery.1994;34(3): 512–4.
41.FishmanLM,DombiGW,MichaelsenC,etal.Piriformis syndrome:diagnosis,treatment,andoutcome–a10-year study.ArchPhysMedRehabil.2002;83(3):295–301.
42.FreibergAH,VinkeTH.Sciaticaandthesacroiliacjoint.JBone JointSurg.1934;16:126.
43.PaceJB,NagleD.Piriformsyndrome.WestJMed. 1976;124(6):435–9.
44.PoleselloGC,QueirozMC,LinharesJPT,AmaralDT,OnoNK. Variac¸ãoanatômicadomúsculopiriformecomocausadedor glúteaprofunda:diagnósticoporneurografiaporRMeseu tratamento.RevBrasOrtop.2013;48(1):114–7.
45.BensonER,SchutzerSF.Posttraumaticpiriformissyndrome: diagnosisandresultsofoperativetreatment.JBoneJointSurg Am.1999;81(7):941–9.
46.DezawaA,KusanoS,MikiH.Arthroscopicreleaseofthe piriformismuscleunderlocalanesthesiaforpiriformis syndrome.Arthroscopy.2003;19(5):554–7.
47.MizuguchiT.Divisionofthepyriformismuscleforthe treatmentofsciatica.Postlaminectomysyndromeand osteoarthritisofthespine.ArchSurg.1976;111(6):719–22.
48.YanagishitaCMA,FaloticoGG,RosárioDVA,PuginaGG,Wever AAN,TakataET.ImpactoIsquiofemoral–umaetiologiade quadrildoloroso.RevBrasOrtop.2012;47(6):780–3.
49.DanielD,MalcomL,StoneML,PerthH,MorganJ,RiehlB. Quantificationofkneestabilityandfunction.Contemp Orthop.1982;5:83–91.
50.MaigneJY,DoursounianL,ChatellierG.Causesand
mechanismsofcommoncoccydynia:roleofbodymassindex andcoccygealtrauma.Spine(PhilaPA1976).
2000;25(23):3072–9.
51.FogelGR,CunninghamPY3rd,EssesSI.Coccygodynia: evaluationandmanagement.JAmAcadOrthopSurg. 2004;12(1):49–54.
52.PennekampPH,KraftCN,StützA,WallnyT,SchmittO, DiedrichO.Coccygectomyforcoccygodynia:does pathogenesismatter?JTrauma.2005;59(6):1414–9.
53.AlmeidaMBA,BarraAA,FigueiredoEM,etal.Disfunc¸õesde assoalhopélvicoematletas.Femina.2011;39(8):395–402. Availablefrom:http://files.bvs.br/upload/S/0100-7254/2011/ v39n8/a2695.pdf
54.KrivickasLS,WilbournAJ.Peripheralnerveinjuriesin athletes:acaseseriesofover200injuries.SeminNeurol. 2000;20(2):225–32.
55.WilbournAJ,AminoffMJ.AAEMminimonograph32:the electrodiagnosticexaminationinpatientswith
