What is the best approach for a 14-year-old patient with left lower buttock pain and a tilted pelvis?

Approach to a 14-Year-Old with Left Lower Buttock Pain and Tilted Pelvis

In a 14-year-old with left lower buttock pain and tilted pelvis, immediately rule out acute surgical causes (appendicitis, trauma-related injury) with focused clinical examination and targeted imaging, then address the pelvic tilt through specific strengthening exercises for the appropriate muscle groups once serious pathology is excluded.

Initial Diagnostic Evaluation

Rule Out Acute Surgical Pathology First

• Obtain urinalysis immediately to exclude urinary tract infection or nephrolithiasis, as these can present with lower abdominal/pelvic pain in adolescents 1
• Assess for peritoneal signs including guarding, rebound tenderness, or rigidity, which would indicate a surgical abdomen requiring immediate intervention 1
• Check for fever with inability to pass gas or stool, and abdominal distension with absent bowel sounds, as these are critical red flags requiring immediate surgical consultation 1
• Document any history of trauma to the buttock region, as posttraumatic piriformis syndrome can cause buttock pain following blunt trauma, though this typically presents with pain on hip flexion, adduction, and internal rotation 2
• Do not dismiss left-sided pain as "not appendicitis" since the appendix can be elongated and project into the left lower quadrant, and children under 10 present atypically more often 1

Initial Imaging Strategy

• Start with ultrasound as the mandatory first-line imaging due to zero radiation exposure in this adolescent patient, which can identify appendicitis, mesenteric adenitis, and other acute causes 1
• If ultrasound is equivocal or non-diagnostic and clinical suspicion for appendicitis remains high, proceed directly to CT abdomen and pelvis with IV contrast, which offers 98-100% sensitivity for diagnosing appendicitis 1
• Consider constipation as a potential diagnosis, which should be assessed clinically and can be managed with osmotic laxatives and dietary modifications if confirmed 1

Assessment of Pelvic Tilt

Determine Direction of Tilt

• Clinically assess whether the pelvic tilt is anterior (excessive lordosis) or posterior (flat back), as this fundamentally determines the treatment approach 3, 4
• Excessive anterior pelvic tilt is associated with increased lumbar lordosis and may cause low back pain radiating to the buttock region 3, 5
• Posterior pelvic tilt (flat back) presents with decreased lumbar lordosis and can also cause low back pain in the L3-5 region 4
• Pelvic tilt is relevant for musculoskeletal conditions affecting the hip and groin, and should be assessed in the context of the patient's symptoms 6

Treatment Based on Pelvic Tilt Direction

For Excessive Anterior Pelvic Tilt (Excessive Lordosis)

• Implement individual strengthening exercises for posterior pelvic tilt muscles, specifically targeting the rectus abdominis, gluteus maximus, and hamstring muscles 3
• These exercises have been shown to reduce pain, normalize pelvic tilt angles, and increase limited lumbar range of motion in patients with low back pain and excessive lordosis 3
• Individual resistance exercises are necessary for effective and fast strengthening of the pelvic posterior tilt muscles 3

For Posterior Pelvic Tilt (Flat Back)

• Implement individual strengthening exercises for anterior pelvic tilt muscles, specifically targeting the erector spinae, iliopsoas, and rectus femoris 4
• These exercises can recover pelvic tilt angles to normal ranges, increase lumbar ROM, and decrease low back pain in patients with flat back 4
• Individual resistance exercises are a necessary approach for effective and fast strengthening of pelvic anterior tilt muscles 4

Critical Pitfalls to Avoid

• Never assume pelvic tilt is the primary problem without first excluding acute surgical pathology, particularly appendicitis, which can present atypically in adolescents 1
• Do not rely solely on clinical examination for diagnosing appendicitis in children, as they often present with atypical symptoms leading to higher rates of delayed diagnosis 1
• Avoid initiating physical therapy for pelvic tilt correction before obtaining appropriate imaging if there are any concerning features such as fever, inability to pass gas/stool, or severe pain 1
• Be aware that the evidence for non-surgical treatment of excessive anterior pelvic tilt is of very low quality, though case studies suggest benefit from targeted strengthening exercises 5
• Consider that buttock pain with history of trauma may represent piriformis syndrome, which presents with tenderness at the greater sciatic notch and pain with hip flexion, adduction, and internal rotation 2