What is the best course of action for a 14-year-old patient experiencing left lower buttock pain?

Left Lower Buttock Pain in a 14-Year-Old

Begin with a thorough musculoskeletal and neurological examination focusing on lumbar spine pathology, particularly lumbar disc herniation, which commonly causes buttock pain in adolescents and responds well to conservative management.

Initial Clinical Assessment

The differential diagnosis in a 14-year-old with left lower buttock pain differs substantially from adult presentations and should prioritize:

• Lumbar disc herniation - the most common cause of buttock pain with neurological symptoms in this age group 1, 2
• Hamstring origin tendinopathy - particularly in athletic adolescents 3
• Referred pain from lumbar spine or sacroiliac joint 3, 4
• Peripheral nerve entrapment (deep gluteal syndrome, sciatic nerve compression) - though less common in adolescents 4

Key Physical Examination Findings to Elicit

• Straight leg raise test - positive if reproduces buttock/leg pain, suggesting nerve root compression 1
• Neurological examination - assess for motor weakness, sensory deficits, and reflex changes (L3-S1 distribution) 2
• Palpation of ischial tuberosity - tenderness suggests hamstring tendinopathy 3
• Range of motion testing - lumbar flexion/extension and hip internal rotation 1, 4
• Sitting tolerance - inability to sit suggests nerve compression or entrapment 5

Critical Red Flags Requiring Urgent Evaluation

• Progressive motor weakness - suggests worsening nerve compression requiring urgent intervention 1
• Saddle anesthesia or bowel/bladder dysfunction - indicates cauda equina syndrome requiring emergency surgery 1
• Constitutional symptoms (fever, weight loss, night pain) - raises concern for infection or malignancy 3
• Severe pain unresponsive to position changes - may indicate serious pathology 1

Imaging Strategy

For adolescents with buttock pain and neurological symptoms, MRI lumbar spine without contrast is the initial imaging of choice 1, 4. The ACR guidelines for left lower quadrant pain focus on intra-abdominal pathology in adults and are not applicable to isolated buttock pain in a 14-year-old 6, 7.

When to Order MRI Immediately

• Neurological deficits present on examination (motor weakness, sensory loss, reflex changes) 1
• Symptoms persisting >6 weeks despite conservative management 1, 4
• Progressive worsening of pain or functional limitation 1
• Red flag symptoms present (as listed above) 1

MRI Findings to Assess

• Disc herniation location and type (contained vs. uncontained) - contained herniations more commonly cause buttock pain (85.8% vs 69.7%) 2
• Nerve root compression at L3-S1 levels - buttock pain is common with L3-4, L4-5, and L5-S1 herniations 2
• Sciatic neuritis - nerve signal changes or enlargement 4
• Peri-neural pathology - compression or fibrosis in the subgluteal space 4

Initial Management Approach

Conservative Treatment (First-Line for Most Patients)

Most adolescents with lumbar disc herniation and buttock pain improve with nonsurgical measures 1. This approach should be tried for 6-12 weeks unless red flags are present:

• Activity modification - avoid aggravating activities but maintain general activity 1
• Physical therapy - core strengthening and flexibility exercises 1
• NSAIDs - for pain control (age-appropriate dosing) 1
• Time - natural history favors improvement in most cases 1

When Conservative Management Fails

If symptoms persist or worsen after 6-12 weeks of conservative treatment, or if there are progressive neurological deficits, surgical consultation is appropriate 1. Endoscopic discectomy has shown excellent outcomes for buttock pain in lumbar disc herniation, with 91.2% complete resolution at 1 year 2.

Special Considerations for Adolescents

Athletic Participation

• Hamstring tendinopathy should be considered in athletes, particularly runners 3, 5
• Posterior femoral cutaneous nerve injury can occur with repetitive athletic activity, though rare 5

Rare but Important Diagnoses

• Peripheral nerve sheath tumors - consider if pain is unremitting despite appropriate treatment for common causes 3
• MRI with contrast may be needed if soft tissue mass is suspected 3

Common Pitfalls to Avoid

• Do not assume buttock pain is simply "back pain" - buttock pain in lumbar disc herniation is an independent symptom distinct from both back pain and radiating leg pain 2
• Do not delay imaging in the presence of neurological deficits - progressive weakness requires urgent evaluation 1
• Do not order CT abdomen/pelvis for isolated buttock pain in adolescents - this is appropriate for adult intra-abdominal pathology, not musculoskeletal buttock pain 6, 7
• Reassess the diagnosis if symptoms fail to improve with appropriate intervention - consider rarer causes like nerve sheath tumors or peripheral nerve entrapment 3, 4