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Diagnosis of Pain States

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A 59-year-old female comes to your office complaining of moderately severe low back pain and right buttock pain which is exacerbated with prolonged sitting. On physical examination there is sciatic notch tenderness and the pain is exacerbated with flexion, adduction, and internal rotation of the right hip. Which of the following is the most likely diagnosis?

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(A) L5-S1 facet syndrome

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(B) Piriformis syndrome

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(C) Sacroiliac (SI) joint syndrome

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(D) Sciatica

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(E) L3 radiculopathy

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(B) The piriformis syndrome was originally described by six common characteristics (1) trauma; (2) pain in the muscle with sciatica and difficulty in walking; (3) worsening with squatting or lifting; (4) a sausage-like mass within the muscle; (5) positive Lasègue sign; and (6) gluteal atrophy. The female to male ratio is 6 to 1.

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There are many approaches to evaluate piriformis syndrome. One method is in the sitting position which involves the examiner stretching the piriformis muscle by passively moving the hip into internal rotation reproducing buttock pain which is relieved by the examiner passively moving the hip into external rotation. The patient then actively rotates the hip against the resistance which reproduces buttock pain. Furthermore, there is generally point tenderness on palpation of the belly of the piriformis muscle. There tends to be prolongation of the H-reflex with flexion, adduction, and internal rotation.

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A 77-year-old female comes to your office complaining of 6 months of severe right buttock pain radiating into the right lower leg. The pain is also present at night and not uncommonly interferes with sleep. The pain is severe with sitting or lying on her back or right side, however, quickly dissipates with normal erect posture. Which of the following is the most likely diagnosis?

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(A) Snapping bottom

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(B) Sciatica

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(C) Radiculopathy

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(D) Piriformis syndrome

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(E) Weaver's bottom

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(E) In classic weaver's bottom (ischiogluteal bursitis)—the patients invariably get pain sitting which goes away upon standing or lying on their contralateral side. However, the pain promptly returns upon resuming a seated position. Typically, the patient can consistently point to the spot where it hurts with their finger and state "it hurts right here." On physical examination, tenderness is evoked with palpation over the ischiogluteal bursa.

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A 53-year-old male comes to your office complaining of foot pain (predominantly in the heel—but also with diffuse plantar symptoms) which also occurs at night ...

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