Can a patient with a stage three pressure ulcer on the right buttocks experience referred pain in the right hamstring during physical therapy?

Can a Stage 3 Pressure Ulcer on the Right Buttock Cause Referred Pain in the Right Hamstring During Physical Therapy?

Yes, a stage 3 pressure ulcer on the right buttock can absolutely cause pain perceived in the right hamstring during physical therapy, as the ulcer involves full-thickness tissue loss extending into subcutaneous tissue, and the anatomical proximity means that deep tissue damage, inflammation, and potential underlying infection can irritate adjacent muscle groups and nerve pathways.

Anatomical and Pathophysiological Basis for Referred Pain

Deep Tissue Involvement in Stage 3 Ulcers

• Stage 3 pressure ulcers involve full-thickness skin loss with damage extending into subcutaneous tissue, creating localized areas of tissue necrosis that can affect structures beyond the visible wound surface 1
• The majority of pressure ulcers develop in areas adjacent to the ischium, sacrum, and greater trochanter—precisely where the buttock meets the hamstring origin 1
• Deep tissue damage may be more extensive than what appears on the surface, potentially involving fascia and muscle tissue that connects to or lies adjacent to the hamstring 2

Pain Mechanisms During Physical Therapy

• Physical therapy movements that engage the hamstring (hip extension, knee flexion) will create tension and movement in tissues directly adjacent to the buttock ulcer, transmitting mechanical stress to the damaged area 1
• The inflammatory response surrounding a stage 3 ulcer releases cytokines and pain mediators that can sensitize nearby nerve endings, causing pain to be perceived in adjacent anatomical regions 2
• Pressure ulcers are typically polymicrobial infections involving both aerobes and anaerobes, and when infection occurs, spreading cellulitis can extend beyond the visible wound margins into surrounding muscle tissue 1

Critical Assessment Considerations

Rule Out Serious Complications

• Evaluate for deep tissue infection or osteomyelitis, as stage 3 ulcers can predispose patients to bacteremia, osteomyelitis, and sinus tracts that extend into deeper structures 3
• Assess for systemic signs of infection (fever, elevated white blood cell count, spreading erythema) that would indicate the need for systemic antibiotics rather than just local wound care 1
• If the patient has new-onset hamstring pain during therapy, examine for spreading cellulitis or abscess formation that may require urgent surgical debridement 2

Differentiate True Referred Pain from Direct Extension

• Palpate the hamstring insertion at the ischial tuberosity to determine if pain is from direct pressure on the ulcer versus true muscle involvement 2
• Document whether pain occurs with passive hamstring stretch (suggesting tissue inflammation) versus only with active contraction (suggesting muscle strain) 1
• Assess for undermining or sinus tracts extending from the buttock ulcer toward the posterior thigh, which would indicate direct tissue involvement rather than referred pain 2

Management Implications for Physical Therapy

Modify Therapy to Protect Healing

• Complete pressure offloading from the affected buttock area is essential during all therapy activities to prevent progression and allow healing 4
• Avoid exercises that place tension on tissues adjacent to the ulcer, including aggressive hamstring stretching or strengthening, until the wound shows signs of healing 1
• Reposition the patient at least every 2 hours with special attention to the affected buttock area, using a 30-degree tilt position rather than 90-degree lateral rotation 4

Pain as a Wound Healing Indicator

• Pain is recognized as an important outcome in pressure ulcer treatment guidelines, and increasing pain during therapy may indicate inadequate wound management or progression 1
• If pain persists or worsens despite appropriate wound care and pressure relief, reassess all risk factors and interventions within 2 weeks 4

Essential Concurrent Wound Management

Surgical Debridement Requirements

• Surgical debridement is necessary to remove necrotic tissue in stage 3 ulcers, and inadequate debridement may leave infected tissue that causes ongoing pain 1
• Urgent sharp debridement should be performed if advancing cellulitis or sepsis occurs, which could explain worsening hamstring pain 2

Infection Control

• Antibiotic therapy should be used for patients with severe pressure ulcer infections, including those with spreading cellulitis or systemic signs of infection 1
• Therapeutic regimens should be directed against both Gram-positive and Gram-negative facultative organisms as well as anaerobic organisms, as these infections are typically polymicrobial 1

Nutritional Support

• Protein or amino acid supplementation should be provided to reduce wound size and support healing, which may indirectly reduce pain by promoting tissue repair 1

Common Pitfalls to Avoid

• Do not assume hamstring pain is unrelated to the buttock ulcer without thorough assessment for deep tissue involvement, infection, or undermining 1, 2
• Do not continue aggressive physical therapy if it exacerbates pain, as this may indicate inadequate pressure relief or wound progression 1
• Do not delay assessment for osteomyelitis if pain persists despite optimal wound care, as bone involvement requires different treatment approaches 2, 3
• Avoid using advanced support surfaces without ensuring complete pressure offloading during therapy sessions, as intermittent pressure during exercises can negate benefits 4