Differential Diagnosis for Upper Buttocks Pain

The patient, a 50-year-old woman, presents with pain in the upper buttocks below the hip, which has been ongoing for 2 days and worsens with movement. Here is a structured approach to her differential diagnosis:

• Single Most Likely Diagnosis

  • Piriformis Syndrome: This condition occurs when the piriformis muscle, which runs from the base of the spine to the thighbone, compresses or irritates the sciatic nerve. The symptoms include pain, tingling, and numbness in the buttocks and, sometimes, down the leg. Given the location of the pain and its exacerbation with movement, piriformis syndrome is a plausible diagnosis.

• Other Likely Diagnoses

  • Trochanteric Bursitis: Inflammation of the bursa over the trochanter (the bump at the top of the femur) can cause pain in the upper buttocks and hip area, especially when moving or lying on the side.
  • Lower Back Strain: Muscle strain in the lower back can refer pain to the buttocks area, particularly if the strain involves muscles that attach to the pelvis or femur.
  • Sciatica: While often associated with lower back pain, sciatica (inflammation or compression of the sciatic nerve) can present with pain in the buttocks that radiates down the leg.

• Do Not Miss Diagnoses

  • Fracture: Although less common, a fracture in the pelvis or femur could present with pain in the upper buttocks, especially if there was a recent trauma. Missing a fracture could lead to serious complications.
  • Infection or Abscess: An infection in the soft tissues or bone of the buttocks or hip area could cause severe pain and would require prompt antibiotic treatment or drainage.
  • Cauda Equina Syndrome: A rare but serious condition where the nerves in the spinal canal are compressed, leading to pain, numbness, and potentially bladder and bowel dysfunction. It is a medical emergency.

• Rare Diagnoses

  • Ischiogluteal Bursitis: Inflammation of the bursa between the ischial tuberosity and the gluteus maximus muscle, which can cause pain in the buttocks.
  • Gluteal Tendinopathy: Similar to trochanteric bursitis but involves the tendons of the gluteus medius and minimus muscles.
  • Osteonecrosis of the Femoral Head: A condition where the blood supply to the head of the femur is interrupted, leading to bone death and potentially severe pain in the hip and buttocks area.

Management

The management of the patient's condition would depend on the final diagnosis. For the most likely diagnosis, piriformis syndrome, treatment might include:

• Physical therapy to stretch the piriformis muscle and strengthen the surrounding muscles.
• Pain management with NSAIDs or other analgesics.
• Avoiding activities that aggravate the condition.
• Considering steroid injections if the pain is severe and does not respond to initial treatments.

For other conditions, management strategies would vary, including rest, physical therapy, medication, and in some cases, surgical intervention. A thorough clinical evaluation, including history, physical examination, and potentially imaging studies, is necessary to determine the correct diagnosis and guide treatment.