The Clinical Coach: The Missing Link in Upper Glute and Low Back Pain

Happy Friday !

Welcome to another Clinical issue of The Performance Doctor!

On Tuesday we sent out our first PRO10 (pro-tein) issue to help you overcome Imposter Syndrome!

What did you think about the exercise we shared? It’s helped me a ton when I get in my own head!

As of right now the PRO10 issue is for subscribers only. You won’t find it in our archives.

, in this issue we are addressing a huge, yet small structure, that can cause upper gluteal & lower back pain!

The superior cluneal nerves!

Upper buttock and lower back pain can be caused by a variety of structures, like disc pain, SIJ dysfunction, QL strains, myfoascial injuries to the TLF, and many more!

One structure that is often neglected and forgotten are the superior cluneal nerves.

These structures may become entrapped in the area where they cross the iliac crest just as they pierce through the thoracolumbar fasica (TLF).

In some patients this can cause low back pain, referred pain to the posterior thigh, calf and occasionally the foot.

You may be thinking, that sounds like sciatica.

You are right — it sounds like it, but it is not. It’s what is known as “pseudo sciatica.”

Entrapments of the superior cluneal nerve (SCN) are not rare, and are most likely a large percentage of patients with upper gluteal pain and low back pain.

Proper assessment of the patient may further reduce unnecessary treatments and avoid surgery overall.

The most common mechanism of injury of the superior cluneal nerves is entrapment of these structures as they cross over the iliac crest piercing through the thoracolumbar fascia.

While epidemiolgical studies suggest its involvement is anywhere between 1.6 -14% of subjects. Out of 220 patients with low back pain, we’ve treated about 10% of them for superior cluneal nerve neuralgia.

Patients usually present with

• Low back and upper gluteal pain mimicking sicatic symptoms

• Pain is deep, achy and sometimes sharp

• It does not improve with position.

• Numbness and tingling across the iliac crest.

• Burning pain to the toes is not present.

There are no orthopedic examinations specific for SCN. In most cases, at The Athlete Spot, we utilize the following orthopedic examinations to rule out other pathologies:

• McKenzie Protocol

• Skin Roll test

• Valsalva Maneuver

• Slumps test

• Bechterew's test

PRO Tip: Skin rolling can be quite sensitive in bigger habitus patients.

If you believe you are working with superior gluteal and low back pain, you can order an ultrasound study to confirm the diagnosis. In some patients with SCN neuralgia these nerves have been enlarged and become visible on ultrasound.

In addition to an ultrasound study, you may also order a variety of studies to confirm your diagnosis, like:

• diagnostic block

• fluoroscopic guided injection

We are a fan of ultrasound studies, but dependent on your network, you may chose to do any of them.

If your patient responds well to a diagnostic block, then you have confirmation the superior cluneal nerve is involved.

Non-conservative approach to treatment.

If you are working in partnership with an MD or DO, you may have access to the following treatments:

• nerve block with corticosteroids

• radiofrequency ablation

• cryoablataion

• pulsed radiofrequency neuromodulation

• peripheral nerve stimulation

• surgical decompression

If you are still developing your network and are unsure who you should connect with - contact a local neuroradiologist and ask for their opinion.

Conservative approach to treatment

From a conservative perspective, dependent on your patient’s body habitus and your skills you may find success with the following treatments:

• ultrasound guided dry needling

• dry needling with e-stim

• dry needling with mechanical stimulation

• cupping

• skin rolling

• weight loss

For most patients suffering of superior cluneal nerver neuralgia, exercises have been proven to be the least effective at reducing pain. However, as always we always recommend patients to stay as active as possible throughout their care.

If you made it this far, share this issue with your friends and colleagues.

You have no excuse now. No more lingering superior gluteal and low back pain in your patients.

How you choose to treat the superior cluneal nerves, will depend on your skills, as well as your experience developing a program that will meet them where they are and will progress them accordingly.

If you found this issue helpful, share it with a friend.

If you find that there’s something missing, or you’d like me to dive into deeper areas, let me know too.

Until our next issue!

In health and strength,

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