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Bigger Better Butt Summary


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Gluteal Muscles Figure 351b

Attaches proximally on the ilium behind the posterior gluteal line, the sacrum, the coccyx, and the sacrotuberous ligament distally, the muscle attaches at the iliotibial tract and the gluteal tuberosity of the femur. The gluteus maximus muscle is a powerful extensor of a flexed femur at the hip joint and a lateral stabilizer of the hip joint. The inferior gluteal nerve (L5, S1, S2) innervates this muscle. Gluteus medius muscle. Attaches proximally on the ilium between the anterior and posterior gluteal lines distally, the muscle attaches on the greater trochanter of the femur. The gluteus medius muscle abducts and medially rotates the femur at the hip joint. In addition, the gluteus medius holds the pelvis secure over the stance leg, preventing pelvic drop on the opposite swing side during gait. The superior gluteal nerve (L4, L5, S1) innervates this muscle. Gluteus minimus muscle. Attaches proximally on the ilium between the anterior and posterior gluteal...

Buttock And Low Back Pain

It is more difficult to treat pain that is axial (i.e., pain perceived in the middle to lower back) and buttock pain.'82 82 Spinal cord stimulation is very effective when properly applied. 080 As with all of the neuroaugmentative techniques, it is assumed that standard multidisciplinary, noninvasive, systemic treatments have already failed that further surgical intervention has been deemed inappropriate and that there are objective findings and a recognized pain syndrome with plausible etiology to support the pain diagnosis. In addition, a detailed psychiatric assessment should reveal no mental abnormalities, and patients should successfully undergo a stimulator trial. When invasive permanent treatments are required, spinal cord stimulation can be effective. Most important is that the pain pattern is amenable to coverage with a spinal stimulator system. The best use is for neuropathic pain in a patient with single-leg distribution of pain. The use of spinal cord stimulation least...

Pain In Buttocks Hips And Cal When Walking

Pain is the principal symptom of atherosclerosis. Whenever a patient complains of pain in the calf, arch of the foot, thighs, hips, or buttocks while walking, peripheral vascular disease of the arteries must be considered. The symptom of pain in the lower extremity during exercise is called intermittent claudication. The site of the pain is always distal to the occlusive disease. As the disease progresses, pain at rest occurs. This is often severe and is aggravated by cool temperatures and elevation, especially during sleep in bed. Pain may also occur with deep vein thrombosis. If a male patient complains of buttock or thigh pain while walking, the examiner should inquire about erectile dysfunction. Leriche's syndrome is chronic aortoiliac obstruction the patient presents with intermittent claudication and erectile dysfunction. In this condition, the terminal aorta and iliac arteries are involved by severe atherosclerosis at the aortic bifurcation.

Osteology And Surface Anatomy

The spines of the sacrum are fused together in the mid-line to form the median sacral crest. The crest can be felt beneath the skin in the uppermost part of the gluteal cleft between the buttocks. The sacral hiatus is situated on the posteroinferior aspect of the sacrum and is the location where the extradural space terminates. The hiatus lies approximately 5 cm above the tip of the coccyx and beneath the skin of the natal cleft. Coccyx. The tip of the coccyx is located in the upper part of the natal cleft and can be palpated approximately 2.5 cm posterior to the anus. The anterior surface of the coccyx can be palpated via the anal canal.

Patel R Walia and D Patel

A total of 49 participants completed the skills session. Participants included medical students, physician assistants, nurses, obstetric and gynecologic residents and attending staff. The results of the study are depicted in Figure 1. The findings clearly document the inaccurate estimation of blood estimation, as well as the fact that the accuracy of the estimate decreased with increasing blood volume. This was particularly true above 1000 ml. Of interest, the under-buttocks absorbent delivery pad was most deceptive for estimating. In general, underestimates were similar for liquid and clots, but the 4000 ml

Is the pain coming from the back

Back pain may be only one part of a systemic musculoskeletal or rheumatologic problem, but this should be clear from the history. Low back pain often spreads to the buttocks and hips and you should then exclude a hip problem. The patient may describe problems with walking and hip movements. Your examination of the back should always include the range of hip movement and gait pattern. Leg symptoms may be due to peripheral vascular disease. Symptoms of vascular claudication usually affect muscle groups of the leg rather than dermatomes. There are circulatory symptoms rather than sensory symptoms, and peripheral pulses and circulation may be poor.

Fibromyalgia Tired of Being Sick and Tired

The tender points used to diagnose fibromyalgia are - Around the lower neck. - Upper chest by the second rib. - Around the upper thigh. - Middle of the knee joint. - Base of the skull. - Neck and upper back. Mid-back. - Inside of the elbow. - Upper and outer muscles of the buttocks.

What are the pain generators of the spine

Facet joints (zygapophyseal joints or z-jointS) are paired synovial joints in the posterior column of the spine, which are innervated by medial branches of primary dorsal rami. Lumbar facet pathology may result in referred pain involving the buttock, groin, hip, or thigh. Cervical facet joint pathology can manifest as neck pain, referred pain involving the scapular area or headaches.

Leg Pain Claudication

Leg pain caused by a lack of oxygenated blood getting to the leg muscles is referred to as claudication. This typically results from the same atherosclerotic process that blocks coronary arteries. As you exercise your legs, by walking for example, they feel tired and start to ache. Resting causes the aching and tiredness to go away, and you can get up and walk further. The claudication may occur in various portions of the leg, including the calf, thigh, or buttocks, depending on where the artery is blocked. However, tiredness in the legs or leg pain can also be due to other causes, including disc problems in the lower back.

Part One Understanding The Condition Pathophysiology

This cascade of degenerative changes can result in the development of central canal or foraminal narrowing with resulting neural compression characterized by low back, buttock, and lower extremity pain.1 They can also result in varying degrees of spinal instability and, depending on the anatomic predisposing factors, the vertebra develops either anterolisthesis or retrolisthesis. Spondylolisthesis, the slippage of one vertebra relative to the adjacent vertebrae, often results from asymmetric degeneration of the disc, the facet joints, or both.

Clinical Features

In the adult, neurocutaneous melanosis can be asymptomatic, and often, the pigmented leptomeningeal lesions are incidental findings on autopsy.7 In children, however, they are associated with congenital cutaneous lesions that occur as multiple or giant hairy, pigmented nevi found in the head, neck, trunk, lower abdomen, pelvis, buttocks, or upper thighs.14,60 These patients are considered to have neurocutaneous

Classification and symptoms of hypogonadism

Voice mutation will not occur. The frontal hairline will remain straight without lateral recession, beard growth is absent or scanty, the pubic hairline remains straight. Hemoglobin and erythrocytes will be in the lower normal to subnormal range. Early development of fine perioral and periorbital wrinkles are characteristic. Muscles remain underdeveloped. The skin is dry due to lack of sebum production and free of acne. The penis remains small, the prostate is underdeveloped. Spermatogenesis will not be initiated and the testes remain small. If an ejaculate can be produced it will have a very small volume. Libido and potency will not develop. A lack of testosterone occurring in adulthood cannot change body proportions, but will result in decreased bone mass and osteoporosis. Early-on lower backache and, at an advanced stage, vertebral fractures may occur. Once mutation has occurred the voice will not change again. Lateral hair recession and baldness...

Henochschonlein Purpura Clinical Summary

Also known as anaphylactoid purpura, Henoch-Schonlein purpura (HSP) is a systemic vasculitis of small vessels characterized by 2- to 10-mm erythematous hemorrhagic papules in a symmetric, acral distribution usually involving the buttocks and extremities (see Fig. 15.23). It is a disease of children (commonly aged 3-12 years) and young adults. The classic exanthem consists of urticarial wheals, erythematous maculopapules, and larger palpable ecchymotic-looking areas. There is often associated

Lower Back Injuries 31 Lumbar Sprain and Strain

Patients typically present with a history of a minor pain while participating in an activity. For example, a softball player may report feeling a twinge in his back while throwing a ball. Then, later that night the discomfort may increase. When the patient wakes up the next day, the pain may have worsened. He may feel a spasm in his back. The pain may radiate into the buttock but rarely will radiate beneath the knee. The pain will be aggravated by movement and made better by rest. After 24-48 hours, the pain generally starts getting better, although it may not completely heal for 1-3 weeks.

Radiculopathy and Disc Herniation

A typical patient will complain of pain radiating down the buttock into the lower extremity. For example, a 26-year-old football player felt a sudden dull pain in his left buttock that radiated down the outside of his leg following a tackle. The pain subsided but after the game he noticed it returned. Over the last 8 days, he says the pain has gotten much worse. He says the pain has become a sharp pain in his lower back that radiates into his buttock and down the lateral thigh into the lateral calf, foot, and big toe. He complains of mild numbness in his lateral calf but says the rest of the pain feels more electric and shooting in nature. Leaning forward and sitting for a prolonged period of time makes the symptoms worse.

Henoch Schonlein Purpura

Henoch-Schonlein purpura is a small-vessel vasculitis seen mostly in children. Immune complexes are deposited, causing petechiae, nephropathy, or renal disease (40 ) and GI bleeding. The purpura is usually in dependent areas such as the buttocks and lower extremities. Affected children often present with abdominal pain after an upper respiratory infection. Symptoms typically resolve spontaneously without treatment within 2 weeks, but serious GI and renal involvement can occur, requiring steroids. NSAIDs might be helpful for arthralgias.

Neck Back and Myofascial Pain

Occipital musculoligamentous tissues upper trapezius, levator scapula, supraspinatus, and medial scapular rhomboid muscles the upper outer buttocks tissues around the sacroiliac joints and the transverse and interspinous ligaments from C-3 to T-1 and L-1 to S-1. The original, if scientifically unexamined notion from Travell and Simons, was that taut bands or nodules developed local twitch responses and that pain could radiate from pressing on trigger points. The reproducibility of such findings by different examiners has usually failed.131 Rheumatologists have tried to formalize criteria for a diagnosis by consensus, but the exercise led to rather circular reasoning. A committee decided that a diagnosis of fibromyalgia requires widespread pain involving 3 or more body segments and at least 11 of 18 designated tender points.132 Proponents of myo-fascial trigger spots suggest that spinal mechanism causes the problem and the release of acetylcholine causes a local twitch on abnormal...

Acute Hip Injuries 31 Acetabular Labral Tears

Athletes commonly complain of pain in the anterior hip or groin pain with motion. Less often the patient may complain of pain deep in the posterior buttocks. The patient can also report of locking, clicking, or giving way at the hip. These symptoms usually have a gradual onset unless related to trauma.

Differential diagnosis

Arterial claudication involves the posterior leg muscles only, sometimes the buttocks, perhaps the thighs, always the calf, but never the anterior muscles and the groin. Intermittent numbness (hypesthesia) in the sole of the foot may occur after exercise. This should not be confused with paresthesia (pins and needles). It is most likely to be confused with S1 root suffering 9 . In neurogenic claudication elements other than the leg pain are often present sensory-motor disturbances and low back pain. The diagnosis is to be oriented by history (smoking, previous arterial disease, cold feet, previous lumbar problems, postural and occupation pain factors, walking stairs) and by a complete examination including appropriate orthopedic, neurological, and vascular tests. Given the age group involved, both pathologies may be present in the same patient. In these cases the differential diagnosis, especially if surgery is foreseen, may be a headache. Vascular and stenotic problems are maybe more...

Snapping Hip Syndrome

External lateral More common occurs when iliotibial band, tensor muscle of fascia lata, gluteus medius, or gluteus maximus muscle tendon rides back and forth across the greater trochanter. This may also cause bursitis to develop. On physical exam the patient with external snapping hip syndrome may have pain or tenderness over the lateral aspect of the gluteus maximus, proximal iliotibial band, or trochanteric bursa. This patient may also have a leg length discrepancy, iliotibial band tightness on the affected side, and weakness of the external rotators and hip abductors. Patients with internal snapping hip syndrome may demonstrate an anterior pelvic tilt due to a tight iliopsoas tendon and snapping may be reproduced with extension of the flexed, abducted, and externally rotated hip.

Absorption capacity under pressure

Landeryou et al. (2003) measured the absorption capacity under pressure of 75 mm squares of composite core and top sheet cut from their six test products, using the apparatus shown in Fig. 10.5. Each sample was placed on top of a 75 mm plain square block and under a second containing a 25 mm diameter cylindrical cavity used to deliver test fluid. A weight was then applied to achieve a pressure of 1, 2 or 4 kPa, pressures chosen to reflect those measured by Allen et al. (1993) beneath the sacrum and buttocks of supine volunteers on a foam mattress. Water was then run through the sample for three minutes (by keeping the cavity topped up) to ensure full saturation, after which the dry sample weight was subtracted

Iliopsoas And Psoas Minor423

Note Forward rotation of the pelvis with extension of the hip joint shows an attempt to hold with the lower fibers of the gluteus maximus. Anterior tilting of the pelvis, or flexion of the hip joint (with backward rotation of the pelvis on upper side), allows substitution by the hip flexors.

Muscles Of The Lower Limb

The muscles of the gluteal region primarily act on the hip joint, producing extension, medial rotation, lateral rotation, and abduction. In addition to producing motion, the muscles of the gluteal region are important for stability of the trunk and hip joint and for locomotion. These muscles consist of the gluteus maximus, gluteus medius, gluteus minimus, piriformis, superior gemellus, inferior gemellus, obturator internus, quadratus femoris, and tensor fascia lata muscles.

Unspecific low back pain

Tests and the modest effectiveness of specific treatments have turned the focus to interaction of the various structures. Experimental studies have demonstrated the existence of neural pathways between various spinal structures and also between the sacro-iliac joint and the spinal and gluteal muscles (Fig. 6.5.1). Regardless of the cause of low back pain, free nerve endings and mechanoreceptors located in the outer annulus of the intervertebral disk, the zy-gapophyseal joints, the ligaments, the muscles and the tendons provide sensory information needed to regulate muscle tension. Reflex activity, that is, an involuntary response to a specific stimulus, may interfere with previously programmed movement patterns. At the same time, pain and fear of pain influence muscle activity. Low back pain may therefore be regarded as a functional disturbance. Of particular interest is the activation of postural muscles prior to lifting and pulling (or actually any motion of the arms and legs), to...

Hip Abduction Strengthening Back Lying

Balance on one foot with posture erect, keeping pelvis level and abdomen and buttocks firm, and other leg lifted forward off the floor. Keeping weight over supporting leg, slowly bend knee as though stepping off a curb with the other foot. Keep back straight and avoid tilting the pelvis forward, backward, or sideways.

Special Issues for a Romantic Partner to Consider

Physical intimacy can be very difficult to achieve and maintain. In fact, it can be frightening. Many young women who have eating disorders will say they feel fat and ugly even when they're not. The tendency is to perceive the self as body parts, scrutinizing their breasts, stomach, hips, thighs, and buttocks instead of being able to look in a mirror and see the whole person. When a particular woman literally cannot see what her lover sees, humor evaporates, joking is impossible, and trust is replaced with doubt. A silly joke or offhand remark can be absorbed as insulting and scornful.

The Care Of A Patient With A Pressure Sore

Mrs Edna Turner has been admitted for rehabilitation following a stroke. She has a right-sided hemiparesis. She has a pressure sore on her right buttock. Personal cleansing and dressing Mrs Turner requires assistance. Mobilising Mrs Turner is bed- or chair-bound. She can mobilise from bed to chair with the assistance of two nurses. She has a tendency to slip to one side when sitting which is a probable factor in the development of the pressure sore on her buttock. R Buttock

Tests for Weakness Jobes Test

Full Can Test

This test, described by Codman,5,15 attempts to palpate a rent through the deltoid in a patient with a supraspinatus tear. Palpation is accomplished in a relaxed patient at Codman's point, just anterior to the anterolateral border of the acromion with the dorsum of the hand on the buttock. Wolf et al16 have reported on the diagnostic accuracy of this test, noting a sensitivity of 95.7 , a specificity of 96.8 , and a diagnostic accuracy of 96.3 for a rotator cuff tear.

Physical Examination

Vaginal Palpation

The patient should be instructed to empty her bladder and bowels before the examination. The patient is assisted onto an examination table with her buttocks placed near its edge. The heel rests of the table are extended, and the patient is instructed to place her heels in them. If possible, some cloth should be placed over the rests. Alternatively, the patient can be given plastic foam booties to protect her feet from cold metal heel rests. Shortening the heel rest brackets helps the woman bend her knees to lower the position of the cervix. An older patient with osteoarthritis may need the heel rests to be longer because she may have limited hip and knee motion. Offer the patient a mirror that she can use to observe the examination.

Clinical Presentation

MPNSTs usually afflict adults in their third to sixth decade of life however, the mean age is a decade younger in NF1-associated cases. The medium and large nerves are more likely to be affected than small nerves. The buttock, thigh, brachial plexus, and paraspinal regions are the most common sites. The sciatic nerve is the most commonly affected nerve.52 No nerve, however, is immune, including, in rare examples, cranial nerves, especially the trigeminal nerve.7,54

Urinary Incontinence The Solutions

Holistics Antiandrogen

Most urologists encourage patients undergoing prostate cancer treatment to do Kegel exercises to increase continence. These exercises were developed by Arnold Kegel in the 1940s for use by women who wanted to strengthen the muscles in the pelvis after childbirth. The difficulty is locating the correct muscles to be exercised. One set is used to stop urine flow halting the flow in midstream and holding it for several seconds is the recommended way to identify these muscles. The other set is used to tighten the buttocks. One author suggests imagining that ''you're trying to hold a quarter between your cheeks,'' while another, perhaps to greater effect, suggests the following Imagine that you are standing on top of a hill, naked, with a 1,000 bill tucked between the cheeks of your buttocks. You are not able to use your hands, but you need to hold onto the bill during high gusty winds. That squeezing of your buttocks, pulling up internally and tightening down with your pelvic muscles, is...

Rationale for Treatment

Usually, there is tenderness over the affected sacroil-iac area. There also may be diffuse, not easily defined pain through the pelvis, buttock and into the thigh. Pain may be referred to the lower abdomen and groin area, and at times, there may be associated sciatic symptoms. In some cases, there is pain on hip flexion. One who has persistent coccyalgia tends to sit in a very erect position, with hyperextension (i.e., lordosis) of the spine in an effort to avoid undue pressure on the painful coccyx. Years of sitting in such a position can result in tightness in the low back and weakness of the gluteus maximus muscles. Conservative treatment consists of providing some padding for the coccyx by use of a corset, which is worn low to hold the buttocks close together. Preferably, this corset has back laces that cross over and tighten by lateral straps. The corset should be tightened with the patient standing. The gluteal muscles thus form a padding for the coccyx in the sitting position....

Obstetrical and Gynecological Procedures and Surgery

Lumbosacral plexus injuries occur during labor or delivery and can be easily confused with a herniated disc. They occur in fetal-pelvic disproportion or in primiparous patients with large babies that necessitate midforceps delivery. The anterior division of the lumbosacral trunk (L4 or L5) is compressed by the fetal head or the obstetric forceps against the pelvic brim. These patients often complain of buttock or leg pain, which intensifies with uterine contractions. A footdrop or weakness of the tibialis anterior is the most common finding. y

Surgery Hip Arthroscopy

Gluteus Medius Sciatic Nerve

Gluteus medius muscle Figure 45-6 Anterolateral portal pathway. The portal penetrates the gluteus medius, entering the lateral capsule at its anterior margin. The superior gluteal nerve lies well cephalad to this site. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.) Gluteus medius muscle Figure 45-6 Anterolateral portal pathway. The portal penetrates the gluteus medius, entering the lateral capsule at its anterior margin. The superior gluteal nerve lies well cephalad to this site. (Courtesy of Smith & Nephew Endoscopy, Andover, MA.)

Trendelenburg Sign And Hip Abductor Weakness

Trendelen Burg

Figure C illustrates a relaxed postural position in an individual with mild weakness of the right hip abductors. The gluteus medius is the chief abductor, and a test that emphasizes the posterior gluteus medius often demonstrates more weakness than the test for hip abductors as a group. Often, this weakness of the gluteus medius is found in association with other weaknesses in the handedness patterns. (See pp. 74, 75.) Testing the strength of the gluteus medius is important in cases of pain in the region of this muscle or of low back pain associated with lateral pelvic tilt. GLUTEUS MAXIMUS Weakness Bilateral marked weakness of the gluteus maximus makes walking extremely difficult and necessitates the aid of crutches. The individual bears weight on the extremity in a position of posterolateral displacement of the trunk over the femur. Raising the trunk from a forward-bent position requires action of the gluteus maximus, and in cases of weakness, patients must push themselves to an...

Posterior Division Of The Sacral Plexus

Tensor Fascia Lata Nerve

Pierces the sacro-tuberous ligament and travels to the inferior edge of the glu-teus maximus muscle, providing sensory innervation to the skin over the inferior aspect of the gluteus maximus (inferior gluteal fold). Superior gluteal nerve (L4-S1). Exits the pelvis via the greater sciatic foramen and travels superior to the piriformis muscle and between the gluteus medius and minimus muscles, providing innervation to both muscles. The superior gluteal nerve continues anteriorly, providing motor innervation to the tensor fascia latae muscle. Inferior gluteal nerve (L5-S2). Exits the pelvis via the greater sciatic foramen and travels inferior to the piriformis, providing motor innervation to the gluteus maximus muscle. Common fibular (peroneal) nerve (L4-S3). Is the smallest division of the sciatic nerve (half the size of the tibial nerve). The common fibular nerve exits the pelvis via the greater sciatic foramen to enter the gluteal region inferior...

Spondylolysis and Spondylolisthesis

Patients may complain of a history of mild lower back pain that has become worse and progressive to the point that participating in activities that require lumbar extension is not tolerated. Often, the patient may report participation in gymnastics, swimming, football, or soccer. The pain may refer to the buttocks and posterior thighs.

Apparent Leglength Discrepancy Caused By Muscle Imbalance

Tibial Torsion With Pronation

If tightness develops in the tensor fasciae latae and iliotibial band on one side, the pelvis will be tilted downward on that side. With gluteus medius weakness on one side, the pelvis will ride higher on the side of the weakness. The habit of standing with the weight mainly on one leg and the pelvis swayed sideways weakens the abductors, especially the gluteus medius on that side. If tightness of the tensor fasciae latae on one side and weakness of the gluteus medius on the other is mild, treatment may be as simple as breaking the habit and standing evenly on both feet. If the imbalance is more marked, treatment may involve stretching of the tight tensor fasciae latae and iliotib-ial band and use of a heel lift on the low side. The lift will help stretch the tight tensor and relieve strain on the opposite gluteus medius. (For a detailed discussion, see p. 398.) Pain may be limited to the area covered by the fascia along the lateral surface of the thigh or it may extend upward over...

Back Extensors Testing And Grading

Thoracic Extensors

Patient Prone, with hands clasped behind the buttocks (or behind the head). WEAKNESS OF THE GLUTEUS MAXIMUS The moment that back extension is initiated, the curve in the lower back increases because of weakness in the gluteus maximus. Holding the pelvis in the direction of posterior pelvic tilt, in the manner provided by a strong gluteus maximus, enables the subject to complete the full range of motion.

Variations In Length Of Posterior Muscles

Hamstring Lengthening

The low back muscles act with the hip flexors (especially the psoas, with its direct pull from the lumbar spine to the femur) to tilt the pelvis downward and forward (i.e., anterior tilt). They are opposed in action by the combined pull of the anterior abdominals, pulling upward anteriorly, and the hamstrings and gluteus maximus, pulling downward posteriorly, to level the pelvis from a position of anterior tilt. 1. The leg abductors (mainly the gluteus minimus and medius), which arise from the lateral surface of the pelvis, pull downward on the pelvis when the leg is fixed as in standing.

Special Test In Poliomyelitis Therapeutic Exercise By Kisner And Colby

Washington, DC American Physiological Society, 1964 377-384. Fischer FJ. Houtz SJ. Evaluation of the function of the gluteus maximus muscle. Am J Phys Med 1968 47 182. 1987 67(5) 688-693. Frank JS, Earl M. Coordination of posture and movement. Phys Ther 1990 70( 121 855-863. Frese E, Brown M, Norton BJ. Clinical reliability of manual muscle testing-middle trapezius and gluteus medius muscles. Phys Ther 1987 67(7) 1072-1076. Fujiwara M, Basmajian JV. Electromyographic study of Kendall HO. Kendall FP. Gluteus medius and its relation Soderberg GL, Dostal WF. Electromyographic study of three parts of the gluteus medius muscle during functional activities. Phys Ther l978 58(6) 691-696.

Corrective Exercises Low Back And Abdominals

Back-lying Position Bend knees and place feet flat on table. With hands up beside head, tilt pelvis to flatten low back on table by pulling up end in with lower abdominal muscles. Keep low back flat and slide heels down along table. Straighten legs as much as possible with back held flat. Keep back flat and return knees to bent position, sliding one leg back at a time. (Do NOT use buttock muscles to tilt pelvis and do NOT lift feet from floor.) Lower Abdominal Exercise Back-lying Position Place a rolled towel or small pillow under knees. With hands up beside head, tilt pelvis to flatten low back on table by pulling up and in with lower abdominal muscles. Hold back Hat and breathe in and out easily, relaxing upper abdominal muscles. There should be good chest expansion during inspiration, but back should not arch. (Do NOT use buttock muscles to tile the pelvis.)

LIIRII agonist medical castrations or surgical aie equivalent

Like degralix, abarelix is a GnRH antagonist, with the same advantage of reducing testosterone to castrate levels rapidly and avoiding the tumor flare associated with LHRH agonists. Unfortunately, abarelix is also associated with severe allergic reactions, including syncope and hypotension, which occur in approximately 1 of initial doses and an increased frequency with repeat doses, for an incidence approaching 5 overall. Therefore, abarelix is available only through a restricted distribution program (Plenaxis PLUS Program) and is only indicated for men with advanced prostate cancer who cannot tolerate LHRH agonist therapy and who refuse surgical castration, and have one or more of the following (a) risk of neurologic compromise due to metastases (b) ureteral or bladder outlet obstruction due to local encroachment or meta-static disease or (c) severe bone pain from skeletal metastases persisting on narcotic analgesia. The recommended dose of abarelix is 100 mg administered...

The Prevention And Management Of Pressure Sores

Degree Tilt Pressure Care Pictures

Gebhardt (1995) argues that pressure is rarely applied uniformly and that the subsequent distortion leads to shearing. Shearing may occur if the patient slides down the bed. The skeleton and tissues nearest to it move, but the skin on the buttocks remains still. One of the main culprits of shearing is the back-rest of the bed which encourages sliding. Chairs which fail to maintain a good posture may also cause shearing. Traditionally, skin care was provided by rubbing patients' pressure areas, particularly sacrum, buttocks and heels, at regular intervals. A variety of lotions and potions were used. However, this practice has been discredited. Dyson (1978) compared two groups of 100 elderly patients over a six-month period. The control group had their buttocks and sacrum rubbed with soap and water. The other group had their buttocks washed as required only. There was a 38 reduction in pressure sore incidence in the experimental group compared with the control group. A recent review of...

Continuous Sciatic Nerve Infusion

Sciatic Nerve Block Injection Notes

The sciatic nerve is formed from the nerve roots of L4 to L5 and S1 to S3. After formation at the sciatic notch, the nerve passes through the gluteal region between the greater trochanter and the ischial tuberosity. In the buttocks, it runs posterior to the gemelli and the obturator internus. It lies anterior to the piriformis muscle as it descends to the thigh, as first described by Labat in 1923. My approach is based on the identification of the piriformis muscle and the placement of the catheter on the sciatic nerve in the gluteal region.

Lateral Rotators Of Hip Joint

Pelvis Rotated Right

GLUTEUS MINIMUS Note In tests of the gluteus minimus and medius, or of the abductors as a group, stabilization of the pelvis is necessary but often difficult. It requires a strong fixation by many trunk muscles, aided by stabilization on the part of the examiner. Flexion of the hip and knee of the underneath leg aids in stabilizing the pelvis against anterior or posterior tilt. The examiner's hand attempts to stabilize the pelvis to prevent the tendency to roll forward or backward, the tendency to tilt anteriorly or posteriorly, and ifpossible, any unnecessary hiking or dropping of the pelvis laterally. Any one of these six shifts in position of the pelvis may result primarily from trunk weakness alternatively, such shifts may indicate an attempt to substitute anterior or posterior hip joint muscles or lateral abdominals in the movement ofleg abduction. When the trunk muscles are strong, it is not very difficult to maintain good stabilization of the pelvis, but when trunk muscles are...

Degenerative Disc Disease

Herniation is the L5-S1 level, followed by the L4-L5 level and then higher levels. Symptoms of lumbosacral herniation often follow lifting or twisting injuries, or they may result from accumulated low-level trauma. Pain typically occurs in the parasacral area and radiates to the buttocks. Below C8, the roots exit through the neural foramina below the correspondingly numbered vertebral bodies. In patients with the most common posterolateral herniation, dermatomal radicular pain typically Gluteus medius Gluteus maximus The symptom most suggestive of lumbar spinal stenosis is neurogenic claudication. Low back pain radiates to the buttocks and thighs and may extend more distally along the lumbosacral dermatomes. This pain is brought on by walking. Unlike vascular claudication, rest in the upright position does not relieve the pain, but rest while seated or forward bending, such as leaning on a shopping cart, may provide relief. Pain is exacerbated by spinal extension, such as downhill...

Treatment Options Nonoperative Care

It certainly appears that the place to begin the rehabilitation program in an injured lumbar spine, with or without neurologic deficit, should be with neutral-position isometric strengthening. The basis of the trunk stability program is to have the patient find a neutral, pain-free position, lying supine on the ground with the knees flexed and feet on the ground. This is about as atrau-matic as possible a beginning to rehabilitation, but it also forms the basis of an important concept in not only athletic function, but also activities of daily living for everyone. We retrain muscles to work to support the spine while the patient is using his or her arms and legs. It is not only theoretically ideal but is practically possible. Teaching muscle control with tight, rigid contraction of the muscles, controlling the spine through the lumbodorsal fascia, with the gluteus maximus, oblique abdominals, and latissimus dorsi, not only produces protection of the lumbar spine but also improves...

What are externalbeam and conformal externalbeam radiation therapies What are the side effects of EBRT

Ams Artificial Urinary Sphincter

How skin tolerates radiation depends on the dose of radiation used and the location of the skin affected. The perineum and the fold under the buttocks are very sensitive and may become red, flake, or drain fluid. To prevent further irritation, avoid applying soaps, deodorants, perfumes, powders, cosmetics, or lotions to the irritated skin. After you wash the area, gently blot it dry. Cotton underwear and loose fitting clothes can help prevent further irritation. If the irritated skin is dry, topical therapies, such as petroleum jelly (Vaseline), lanolin, zinc oxide, Desitin, Aquaphor, Procto-Foam, and corn starch, can be applied.

Table 305 Glycogenoses

Clinical Features and Associated Disorders. In Von Gierke's disease, hypoglycemia causes many of the clinical difficulties seen in patients during the first year of life. In this period seizures are frequent, and long-standing hemiplegia and mental retardation occur. Failure to thrive, xanthomas, and isolated hepatomegaly are common, and excessive subcutaneous fat over the buttocks, breasts, and cheeks develops. Affected children usually have a protruding abdomen due to enlargement of the liver. Patients often have recurrent stomatitis frequent infections and may have isolated chronic inflammatory bowel disease.

How is the clinical syndrome of lumbar DDD characterized

Presenting symptom is primarily low back pain, which may radiate to the sacroiliac and or buttock region. Common physical examination findings include tenderness with palpation over the lumbar region and limited lumbar range of motion. Low back pain is often more severe with flexion and less severe with extension in the absence of associated facet joint degeneration.

The interpretation of leg pain

Straight Leg Test Interpretation

It is nearly 60 years since Kellgren (1939) showed that stimulation of any of the tissues of the back can cause pain down one or both legs. Seventy percent of patients with back pain have some radiation of pain to their legs. This referred pain can come from the fascia, muscles, ligaments, periosteum, facet joints, disk, or epidural structures. It is usually a dull, poorly localized ache that spreads into the buttocks and thighs (Fig. 2.5). It may affect both legs. It usually does not go much below the knee. Referred pain is not due to anything pressing on a nerve. It is not sciatica.

Stenosis in the Lumbar Spine

Vertebrae Abnormalities Xray

An active 90-year-old man was referred to the spine surgery clinic with a long history of worsening bilateral buttock pain and decreased walking tolerance. He was otherwise in excellent health, but noted a burning pain in his buttocks with radiation down the posterior and lateral thighs after ambulating more than about 50 yards. The pain quickly improved with rest, and would not occur if he had a shopping cart to lean on while ambulating. Descending stairs or inclines would aggravate symptoms but ascending stairs would not. He had been evaluated by the vascular surgery service and was not found to have vascular insufficiency. Despite an intensive program of physical therapy focusing on core strengthening, flexibility, and cardiovascular fitness his symptoms persisted. Interventions by the pain management service, including epidural steroid injections, had been unsuccessful.

Sacroiliac Joint Pain

Sacroi Iac Joint Pain

The typical patient is a young athlete who presents with a dull, achy pain over the sacrum. The patient may be a young woman who was participating in dance class. Following class, she noted soreness in her lower back that did not go away. After a week of persistent soreness, she presented to the doctor. Typically, patients do not have radiating pain into the lower extremities. However, dull, achy referral pain patterns may extend into the buttocks. Pain is worse with activity and better with rest.

Special clinical considerations

Most authors consider internal iliac artery ligation to be a very safe procedure. The available data suggest that this operation does not result in necrosis of vital pelvic structures. The only report to the contrary is by Tajes4 who cited a case of his own in which this operation resulted in necrosis of the buttocks. Tajes also reviewed two previously reported cases in one case, the bladder mucosa sloughed, in the other, scrotal necrosis ensued. However, his report was 50 years ago.

Elbow Your Pain Out of the

The sciatic nerve is located deep in the muscles of the buttocks, so the acupressure techniques used to reach the affected area need to penetrate through layers of muscles. If you used your fingers or thumbs, you'd be sore in a very short time. That is why acu-pros use their elbows or tools to stimulate the points and put an end to your pain.

Thoracic epidemiology

Estimating the true prevalence of thoracic pain is confounded further by the definition of thoracic pain according to site. Pain in the upper thoracic region around the scapulae and upper chest may originate from the cervical as much as the thoracic spine. Has 'thoracic pain' included scapular pain that is referred from the neck Would it include pain possibly referred from the thorax to the shoulder, xiphisternum, and buttock and anterior thigh (Singer and Edmondston 2000)7 The occurrence of thoracic region pain, initially regarded as originating from cardiac, pancreatic, renal or some other visceral disease but after long delays attributed to the thoracic spine, is not uncommon (Bechgaard 1981 Whitcomb et al. 1995 Grieve 1994). The example of the misdiagnosis involved in chest pain is considered in Chapter 2 - initially interpreted as cardiac, it is frequently found to be musculoskeletal in origin.

Lower Extremity Surgery

The hip region is innervated by T12 to S2 nerve roots. The iliohypogastric nerve provides cutaneous innervation to the skin of the buttock and muscles of the abdominal wall. The ilioinguinal nerve supplies the skin at the base of the perineum and adjoining portions of the inner thigh. The genitofemoral nerve arises from the L1 to L2 nerve roots. It supplies innervation to the genital area and the adjacent parts of the thigh. Its lumboinguinal branch supplies the skin over the area of the femoral artery and femoral triangle. The two major procedures in the hip region are total hip arthroplasty and various surgical procedures for fracture of the neck of the femur.


After consent is given, the patient is placed in the prone position. With use of sterile preparation and technique, the back is cleansed with a sterilizing solution from just below the scapula to the lower margin of the buttocks. Preparation of the lumbar region only is appropriate if the upper lumbar region without sciatic involvement is the source of the problem. With use of fluoroscopy, the desired lumbar level and side is identified. The fluoroscope is then moved obliquely 15 to 20 degrees to the ipsilateral side of the desired foramen. Once a Scotty dog image is obtained, the fluoroscope is rotated in a caudal-cephalad direction for 15 to 20 degrees. A caudal-cephalad rotation elongates the superior articular process ( ear of the Scotty dog ). The tip of the ear, or superior articular process, in the gun barrel technique is marked on the skin. This spot is the skin entry site, and local anesthetic is injected for skin infiltration. An 18-G needle is used to make a puncture wound....

The pelvis and sacroiliac joints

The thoracolumbar fascia plays an important role in load transfer between the trunk and legs. It is part of a corset that surrounds the trunk. The erector spinae lies within its layers. Contractions of the latissimus dorsi, gluteus maximus, and abdominal wall muscles tense the fascia, which effectively links the actions of these muscles. The biceps femoris tendon tenses the sacrotuberous ligament below. This all acts as a muscle-tendon-fascia sling that provides a functional link between the trunk, the pelvis, and the legs. This fascia also has rich innervation for both proprioception and nociception.

Nonoral Hormonal Contraceptives

Ortho-Evra is a transdermal patch that contains both an estrogen (20 mcg of ethinyl estradiol) and a progestin (150 mcg of norelgestromin). A new patch is applied to the abdomen, buttocks, upper torso, or upper (outer) arm once weekly for 3 weeks, followed by seven patch-free days.8 Although some women have noted irregular bleeding during the first two cycles of patch use, the patch has been demonstrated to provide similar menstrual cycle control and contraceptive efficacy to that of COCs.34 It is important to note, however, that higher contraceptive failure rates are seen when the patch is used in women weighing more than 90 kg (about 200 lb).8,34 Further, the manufacturer prescriber information for the product indicates that women who take Ortho-Evra are exposed to approximately 60 more estrogen than women who take COCs with 35 mcg estrogen.3 While the clinical significance of this is not well defined, recent studies have suggested a link between the use of the patch and an in

Clinical Manifestations

Color, not peculiarly sensible except in spots, the whole of it being oedematous and pasty. The pain is burning and unbearable in the part itself, while the extension of the disease, generally in a circular direction, may be marked from hour to hour so that in from another twenty-four to forty-eight hours nearly the whole of a calf of a leg, or the muscle of a buttock, or even the wall of the abdomen may disappear, leaving a deep great hollow or hiatus of the most destructive character, exhaling a peculiar stench which can never be mistaken, and spreading with a rapidity quite awful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield the largest nerves are destroyed, and the arteries give way, frequently closing the scene, after repeated hemorrhages, by one which proves the last solace of the unfortunate sufferer. . . . The joints offer little resistance the capsular and synovial membranes are soon...

Subsequent Antenatal Examinations

The first maneuver is used to evaluate the upper pole and defines the fetal part in the fundus of the uterus. Stand facing the patient at her side, and gently palpate the upper uterine fundus with your fingers to ascertain which fetal pole is present. This technique is demonstrated in Figure 23-14. Usually, the fetal buttocks are felt at the upper pole. They feel firm but irregular. In a breech presentation, the head is at the upper pole. The head feels hard and round and is usually movable.

Statureforage and Weightforage percentiles

Thoracic Cutaneous Hemangioma

Is there any evidence of physical child abuse Are any bruises, welts, lacerations, or unusual scars present Inspect the buttocks and lower back for evidence of bruises. Paired, crescent-shaped bruises facing each other on any part of the body may represent human bite marks. Bite marks should be suspected when ecchymosis, lacerations, or abrasions are found in any oval shape. Tooth marks by the canine teeth are the most prominent part of a bite. Bites made by animals tear the flesh bites made by humans crush the flesh. The distance between the maxillary canine teeth in a child is less than 1.2 inches (3 cm) in an adult, it is greater. Figure 24-31 shows a human bite wound. Notice that the intercanine distance is greater than 3 cm. Is there evidence of traumatic alopecia from pulling out of the hair The damaged hair is broken at various lengths. Are small, circular, punched-out lesions of uniform size present These may represent cigarette burns. A large circular-type burn on the...

Fecal Occult Blood Test

Twitsquinten Blake

Figure 17-35 Illustration of the rectal examination. A, The sphincter is relaxed by gentle pressure with the palmar surface of the examiner's finger. B, With the examiner's left hand spreading the patient's buttocks, examination is carried out with the examiner's right index finger. Figure 17-35 Illustration of the rectal examination. A, The sphincter is relaxed by gentle pressure with the palmar surface of the examiner's finger. B, With the examiner's left hand spreading the patient's buttocks, examination is carried out with the examiner's right index finger.

Pathology and Clinical Manifestations

Some studies show recurrences within the first year in 80 percent of infections with HSV-2. Recurrent lesions commonly present with milder symptoms initially, are generally of shorter duration, and are rarely accompanied by overt systemic symptoms. These lesions commonly appear on the genitalia, but may appear on the buttocks and elsewhere adjacent to the genital area. Latent infection presumably is established in the sacral-nerve-root ganglia. From a study of 375 patients, Stanley Bierman (1983) found that recurrences ceased in half of them after some 7 years following the onset of disease. In others, however, the recurrences may span many years.

Inflicted Burns Clinical Summary

In an immersion burn, a child is held firmly and deliberately immersed and will have burn margins that are sharp and distinct. If the child has little opportunity to struggle, few or no burns from splashing liquid will occur. In contrast, a child who accidentally comes into contact with a hot liquid will move about in an attempt to escape further injury. This movement causes the burn margins to be less distinct and may result in additional small burns as hot liquid splashes onto the skin. Children who are dipped into a bath of hot water often show sparing of their feet and or buttocks because they are held firmly against the tub's relatively cooler porcelain bottom. A child who has had a hand dipped into hot water and held there may reflexively close the fingers, sparing the palm and fingertips.

Inflicted Bruises And Softtissue Injuries Clinical Summary

Bruises are the most common manifestation of physical child abuse. Child abuse should be suspected whenever bruises are (1) over soft body areas, such as the thighs, buttocks, cheeks, abdomen, and genitalia (2) more numerous than usual (3) of different ages (suggests repeated episodes of abuse) (4) the shape of objects such as belts, cords, or hands (demonstrates the injuries were inflicted) or (5) noted in young, nonambulating children.

Hand Foot And Mouth Disease Clinical Summary

Are followed by a vesicular eruption characterized by 3- to 7-mm erythematous macules with a central gray vesicle on the hands and feet involving the palmar and plantar surfaces as well as the interdigital surfaces. Nonvesicular lesions may also be present on the buttocks, face, and legs.

Patient Preparation

The patient is put in deflected supine position with the arms at the sides and the legs adducted. Additionally, a 30-degree Trendelenburg decline supported with inflatable balloon pillow was placed under the patient's buttocks, which displaces the bowel cephalad by gravity. The abdomen is shaved from the costal margins to the pubic bone. A rectal balloon catheter is placed and inflated with 70 cm3. Before trocar placement, a 16-French Foley catheter is inserted under sterile conditions and blocked with 15 cm3 saline. The procedure can be divided into several important steps.

When is surgical treatment indicated for lumbar spinal stenosis

Patients with spinal stenosis generally present with varying combinations of low back and buttock pain, neurogenic claudication, and lower extremity radicular symptoms. Severe progressive neurologic deficits are not typically present, although they can occur. Surgery is considered for patients who have failed nonsurgical management patients with persistent functional incapacity patients with neurologic deficits and patients with persistent buttock, thigh, and or leg pain. The patient's general medical condition requires consideration in the decision whether or not to pursue surgical treatment. Patient education regarding realistic expectations and goals following surgical treatment is important. Surgical goals may include improved function, decreased pain, and improvement or halted progression of neurologic deficits.

When are sacroiliac SI joint injections indicated

Sacroiliac Joint Injection Contrast

Patient history and physical examination have been shown to be unreliable in the diagnosis of SI joint pain. An analgesic response to a properly performed diagnostic SI joint block is considered the most reliable test to diagnose SI joint-mediated pain. Patients with low back, buttock, or groin pain not attributed to other causes can be considered for SI joint injection. The patient is positioned in the prone oblique position to facilitate visualization of the inferior portion of the joint. A 22-gauge spinal needle is placed in the inferior aspect of the joint, and a small amount of contrast is injected to confirm needle position. Then a small amount of corticosteroid, combined with a local anesthetic, is injected (Fig. 16-10).

When are children with spondylolysis and spondylolisthesis referred to the spine specialist for evaluation

The presentation of patients with spondylolysis and spondylolisthesis is varied. Symptomatic patients most commonly present with low back pain, which may radiate into the buttocks and thighs. Hamstring tightness or spasm is not uncommon. Some patients will recall an episode of inciting trauma. Occasionally a patient will report radicular symptoms due to nerve compression at the level of the slippage. Patients with severe degrees of spondylolisthesis may present with postural deformity, scoliosis, or gait abnormality. In some cases, spondylolysis and spondylolisthesis are diagnosed as incidental findings on lumbar or pelvic radiographs obtained for unrelated reasons in asymptomatic patients.

What nonspinal disorders must be ruled out during the examination of a patient with degenerative spondylolisthesis

Degenerative arthritis of the hip joint and peripheral vascular disease. Hip joint arthrosis may cause buttock and thigh pain that mimics the symptoms of spinal stenosis. Assessment of hip joint range of motion can determine whether radiographs are necessary to evaluate the hip joints. If both hip arthritis and degenerative spondylolisthesis are present, injection of the hip

What is the typical history of a patient with a lumbar disc herniation

Typically there is an attempt to link the onset of back and leg pain with a traumatic event, but frequently patients have experienced intermittent episodes of back and leg pain for months or years. Factors that tend to exacerbate symptoms include physical exertion, repetitive bending, torsion, and heavy lifting. Pain typically begins in the lumbar area and radiates to the sacroiliac and buttock regions. Radicular pain typically extends below the knee in the distribution of the involved nerve root. Radicular pain may be accompanied by paresthesia and weakness in the distribution of the involved nerve root. Patients with a disc herniation generally report that pain in the leg is worse than low back pain. Pain tends to be exacerbated by sitting, straining, sneezing, and coughing and relieved with standing or bed rest.

What findings may be noted in a pediatric patient with spondylolisthesis

Spondylolisthesis in children may present with a variety of symptoms and physical findings, depending on the degree of slippage and the degree of kyphosis at the level of the slip. Low back pain and buttock pain are the most common presenting symptoms. Physical exam typically reveals localized tenderness with palpation at the level of slippage. Hamstring tightness is a commonly associated finding. In the most severe cases, the patient is unable to stand erect because of sagittal plane decompensation associated with compensatory lumbar hyperlordosis and occasionally neurologic deficit (Fig. 7-6).

How is spondylolysis diagnosed

History and physical examination are important indicators of spondylolysis. A history of hyperextension activities should alert the clinician to the possibility of the diagnosis. Patients typically present with back pain radiating into the buttocks. Physical examination may reveal tenderness to palpation, hamstring tightness, decreased forward flexion of the lumbar spine, a positive single-leg hyperextension test, or a stiff gait. Lateral radiographs may reveal a pars defect. Oblique views can more clearly delineate the pars interarticularis. Bone scan with SPECT can help diagnose pars defects but may be negative if the spondylolysis is chronic. CT scan delineates the defect most clearly.

Describe the typical history reported by a patient with acquired degenerative spinal stenosis

The typical patient reports the gradual onset of low back, buttock, thigh, and calf pain. Patients may report numbness, burning, heaviness, or weakness in the lower extremities. The lower extremity symptoms may be unilateral or bilateral. Symptoms are exacerbated by activities that promote spinal extension such as prolonged standing or walking (neurogenic claudication). Maneuvers that permit spinal flexion such as sitting, lying down or leaning forward on a shopping cart tend to relieve symptoms as these positions increase spinal canal diameter. Changes in urinary function or impotence due to lumbar spinal stenosis are rare but occasionally noted.

Anal Fissure Clinical Summary

An anal fissure is a longitudinal tear of the skin of the anal canal and extends from the dentate line to the anal verge. Fissures are thought to be caused by the passage of hard or large stools with constipation, but may also be seen with diarrhea. The fissures are typically a few millimeters wide and occur in the posterior midline, but may occur elsewhere. An anal fissure that is off the midline may have a secondary cause, such as inflammatory bowel disease or sexually transmitted infection. Although often seen in infants, this condition is found mostly in young and middle-aged adults. Patients present with intense sharp, burning pain during and after bowel movements. They may see bright red blood at the time or shortly after the passage of stool. Gentle examination with separation of the buttocks usually provides good visualization. The diagnosis of inflammatory bowel disease, ulcerative colitis, or Crohn disease should be considered in the differential, particularly if the fissure...

Causes of Erectile Dysfunction

Involves blockages of the lower aorta as well as the arteries in the pelvis coming off the aorta, including the iliac arteries. It is characterized by claudication, which is pain, aching, and tiredness of the legs and buttocks. It is associated with erectile dysfunction.

Brasssv Drape Blood Loss Collection Tool

Reduce the incidence of acute postpartum hemorrhage and hence maternal morbidity and mortality in women delivering in rural villages (away from major hospitals) within Belgaum District, Karnataka, India. The intervention was delivered by local health-care workers. A critical component of this trial was the development of a specially designed low-cost 'calibrated plastic blood collection drape' that would objectively measure the amount of blood collected in the immediate postpartum period. The BRASSS-V drape was developed by the NICHD-funded Global Network UMKC JNMC UIC collaborative team to specifically estimate postpartum blood loss45,46. (The name 'BRASSS-V' was coined by adding the first letter of the names of the seven collaborators who developed the drape.) The drape has a calibrated and funneled collecting pouch, incorporated within a plastic sheet that is placed under the buttocks of the patient immediately after the delivery of the baby. The upper end of the sheet has a belt,...

One Joint Hip Flexor Stretching

In back-lying position, pull one knee toward chest until low back is flat on table. Keeping beck flet, press other leg, with knee straight, down toward the table by tightening the buttock muscle. To stretch right hip flexors, lie on back with right lower leg hanging over end of a sturdy table. Pull left knee toward chest just enough to flatten low back on table. (When there is hip flexor tightness, the right thigh will come up from table.) Keeping beck flet, stretch right hip flexors by pulling thigh downward with the right buttock muscle, trying to touch thigh to table. Keeping thigh down toward table, try to bend knee until a firm pull is felt in front of the right thigh (no more than 80 ).

Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) is a secondary condition that results from repeated mechanical trauma to the skin, usually through rubbing and scratching, which causes lichenification (thickening of epidermis). Skin appears leathery, violaceous to hyperpigmented, and scaly (Fig. 33-29). Involved areas are within the patient's easy reach, such as arms, legs, posterior neck, upper back, buttocks, and scrotum. The cycle of pruritus, which is alleviated by scratching, perpetuates the condition. Pruritus is usually worse during periods of inactivity, usually at bedtime and during the night. Stress also may provoke pruritus, which

Quantitative methods

This approach was used in the World Health Organization (WHO) multicenter, randomized trial of misoprostol in the management of the third stage of labor30. In this trial, blood loss was measured from the time of delivery until the mother was transferred to postnatal care. Immediately after the cord was clamped and cut, the blood collection was started by passing a flat bedpan under the buttocks of a woman delivering in a bed or putting in place an unsoiled sheet for a woman delivering on a delivery table.

Sacral Plexus

Exits the pelvis superior to the piriformis muscle, through the greater sciatic notch. The superior gluteal nerve supplies the gluteus medius and minimus muscles and the tensor fascia lata muscle. Inferior gluteal nerve (L5-S2). Exits the pelvis inferior to the piriformis muscle, through the greater sciatic notch. The inferior gluteal nerve innervates the gluteus maximus muscle.


As noted earlier, sexual assault refers to any type of sexual contact that is not consented to by one of the persons involved. This term thus has a fairly broad definition that includes a wide scope of behaviors ranging from nonconsensual sexual kissing or touching to nonconsensual oral, anal, or vaginal sex.1 According to the Centers for Disease Control (CDC), the term rape refers to a completed nonconsensual sex act in which the perpetrator (person committing the rape) penetrates the victim's vagina, anus, or mouth with a penis, hand, finger, or other object.2 In an attempted rape, the perpetrator attempts, but does not complete, the nonconsensual sex act. Finally, nonconsensual or abusive sexual contact is defined by the CDC as intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or buttocks of any person without his or her consent, or of a person who is unable to consent or refuse (p. 9).2 Consent generally means that...

Inspect the Skin

Eruptive xanthomata are seen in several familial disturbances of fat metabolism, specifically hyperlipidemia types I and IV. The chest, buttocks, abdomen, back, face, and arms are most commonly affected. Figure 14-14 shows eruptive xanthomata on the abdomen of a patient with uncontrolled diabetes mellitus and hypertriglyceridemia. Eruptive xanthomata on the face of a patient are pictured in Figure 14-15. Eruptive xanthomata result from elevations

Clinical Summary

Leukocytoclastic vasculitis (LCV) represents the deposition of immune complexes in small blood vessels with subsequent blood vessel destruction and extravasation of blood. Patients present with nonblanching erythematous papules that frequently coalesce into plaques ( palpable purpura ). The lower extremities and dependent areas of the back and the buttocks are most frequently involved. Pruritus can be significant. The face, palms, soles, and mucous membranes are uncommonly involved. Vesicles, ulcers, and necrosis can be seen within the purpuric lesions. The lesions appear over a few days and usually resolve with hyperpigmentation over 4 to 6 weeks or longer. Associated symptoms include fever, arthralgias, myalgias, malaise, and other disease-specific symptoms. Henoch-Schonlein purpura is a unique form of LCV that presents with palpable purpura of the lower extremities and buttocks. Occasionally, the lesions may be found on the upper extremities, trunk, and face. A recent respiratory...

Wound closure

These grafts comprise the epidermis and some dermal elements but leave sufficient dermis to allow rapid healing with re-epithelialisation of the donor site. Large amounts of skin can be harvested and such grafts are useful for resurfacing large areas of skin loss, such as occurs following burn injuries. The thicker the graft, the more dermal skin appendages it contains, leading to less likelihood of subsequent contracture and a more normal appearance of the skin. Hypopigmentation and poor colour match in the skin of the head and neck is likely particularly with thinner grafts. Common donor sites for split thickness grafts include the thigh the upper arm and buttock. Due to the raw surface that remains prior to re-epithelialisation, donor sites can be painful in the early postoperative period.

Tinea Cruris

Tinea cruris, commonly called jock itch, is a dermatophyte infection of the groin. This dermatophytosis is more common in men than women and is frequently associated with tinea pedis. Tinea cruris occurs when ambient temperature and humidity are high. Occlusion from wet or tight-fitting clothing provides an optimal environment for infection. Tinea cruris involves the proximal medial thighs and may extend to the buttocks and lower abdomen (Fig. 33-46). The scrotum tends to be spared. Patients with this dermatophy-tosis frequently complain of burning and pruritus. Pustules and vesicles at the active edge of the infected area, along with maceration, are present on a background of red scaling lesions with raised borders. Care should be taken to evaluate the feet as a source of infection.


Autosomal Recessive Myotonia Congenita (Becker's Disease). This disorder is very similar to Thomsen's disease except that myotonia appears later in the first decade. However, Becker's disease can be more severe, and patients may have, in addition to severe myotonic stiffness, a disabling phenomenon of transient weakness not seen in Thomsen's disease. In Becker's disease, the patient's muscles are initially weak, and a period of activity is required before full strength returns. At times, this weakness is so severe that the patient requires assistance with ambulation persistent weakness may occur. As in Thomsen's disease, these patients may have muscle hypertrophy, particularly of the legs and buttocks, with some hyperlordosis of the spine.


There is, I suggest, at least one exception to the rule that a low female WHR is typical in ancient works of art. In the upper Palaeolithic period in Europe, small female figurines were sculpted, such as the 'Venus of Willendorf', which is shown, along with a similar example, in Figure 7.11. The fact that these Venus figurines have been unearthed at multiple sites across Europe, dated at 23,000-21,000 years ago, hints at a common cultural basis for their production (Gvozdover 1989 Stringer and Gamble 1993). Typically, the heads of such figures are rudimentary and lack facial details in most cases likewise the arms tend to be thin and poorly modelled. The breasts, buttocks, thighs, and abdomen, by contrast, tend to be very large. Some of these figurines seem to represent mature women of late or postreproductive status. Others have rounded abdomens and probably represent pregnant women. They do not appear to have a low WHR in most cases, but a formal study of their proportions would be...

Spinal Stenosis

Spinal stenosis is a disorder causing narrowing of the spinal canal or the neuroforamen through which nerves exit the spinal column, thereby placing pressure on the spinal cord. It occurs in all areas of the spine, however, most often in the lumbar and cervical areas. Lumbar spinal stenosis-related symptoms include pain, weakness, or numbness in the legs, calves, or buttocks, and are exacerbated when walking short distances and reduced when sitting, bending forward, or lying down. Cervical spinal stenosis demonstrates similar symptoms in the shoulders, arms, and legs, in addition to fine motor skill and balance disturbances. Treatment for spinal stenosis includes drug therapy such as nonsteroidal antiinflammatory drugs to reduce swelling and pain, and analgesics to relieve pain. Further conservative approaches to pain involve corticosteroid injections (epidural steroids) to reduce swelling and treat acute pain. Certain medical conditions may confound the diagnosis and affect treatment...


The most common hereditary myopathy is DMD with its dystrophin deficiency. Dys-trophin reinforces the sarcolemmal membrane of muscle fibers, so mechanical stress from an eccentric contraction could injure fibers. Strengthening is feasible, however, without inducing much of a rise in creatine kinase muscle enzyme. In DMD, weakness evolves in the hip flexors and gluteal muscles and leads to a lordotic stance, The plantar flexors are stronger than the tibialis anterior, so children walk on their toes. Tendon shortening gradually increases across all joints. Gait becomes unsafe. Some patients choose to use a wheelchair, whereas others choose to use a polypropylene knee-ankle-foot orthosis (KAFO) to prolong ambulation for 1 or 2 years. Contractures may require tendon lengthening or casting before fitting the braces, however. A spinal fusion for scoliosis is less likely to be used for DMD than for patients with spinal muscular atrophy, a congenital myopathy, or poliomyelitis, because of the...


Scabies diagnosis can be challenging. Again, patients present with itching that can be anywhere on the body, although often in the genital area or on the buttocks when infection is sexual in origin. The pruritus associated with Sarcoptes scabiei is a result of sensitization to the mite droppings underneath the skin as the mite burrows. The classic burrow or linear papular eruption is not always present. Scraping of lesions with microscopic examination may be performed to identify the mite. As with pediculosis, close contacts should be treated. Linens and clothing should be laundered or dry-cleaned or isolated in plastic containers for 72 hours. The pruritus-associated with scabies can take several weeks to resolve after treatment. Patients living in group settings (dormitories or apartments) may reinfect one another as a result of inadequate primary treatment of all contacts (Table 16-14).

Pliny The Elder

Australopithecine Sexual Dimorphism

Although the genitalia are not visible in Figure 1.3, the larger individual on the left is clearly intended to represent an adult male. As we have seen, however, there is currently no certainty that sexual dimorphism in body size was this pronounced in the australopithecines. If indeed these creatures were markedly sexually dimorphic and polygynous, then the males in particular may also have possessed striking cutaneous secondary sexual adornments, such as capes and crests of hair, or fleshy facial elaborations, as these are often present in males of extant anthropoid species which have polygynous mating systems (Dixson, Dixson, and Anderson 2005). The smaller female has a protruding breast, with an areola area surrounding the nipple, as in H. sapiens. Again, inclusion of this detail owes something to artistic license. Breast enlargement due to fat deposition and the visually prominent pigmented areola area surrounding the nipple may have arisen much later in hominid evolution. As we...

Norwegian Scabies

Eczema Genitals

A month or longer may pass before the symptom of generalized pruritus develops. The diagnostic physical sign is the burrow, which is a serpiginous, palpable track about 1 cm in length that may end in a papule, nodule, or tiny vesicle. The adult female mite is present in the burrow. The extremely pruritic rash of scabies has a predilection for the web spaces of the fingers and toes, as well as the groin. The buttocks are also frequently involved, as are the genitals of men and the nipples of women. A generalized papular or urticarial eruption may ensue after localized scabies infection. The presence of papules on the genitalia in a patient with intense pruritus should raise the strong suspicion of scabies. Outbreaks of scabies are common in population groups in which HIV infection is prevalent. Figure 8-85 shows the hand of a patient with scabies. Notice the classic eruption between the fingers. Figure 18-16 shows another patient with scabies the papular rash in the groin and on the...

Postural Examination

Postural Exam

Muscle strength tests should include back extensors (see p. 181), upper and lower abdominals (see pp. 202 and 212), lateral trunk (see p. 185), oblique abdominal muscles (see p. 186), hip flexors (see pp. 422, 423), hip extensors (see p. 436), hip abductors and Gluteus medius (pp. 426, 427), hip adductors (pp. 432, 433), and in the upper back, the middle and lower trapezius (see pp. 329 and 330). Less understood but equally important is the fact that unilateral weakness can result in a lateral pelvic tilt. Weakness of the right hip abductors as a group or, more specifically, of the right posterior gluteus medius will allow the pelvis to ride upward on the right side, tilting downward on the left side. Likewise, weakness of the left lateral trunk muscles will allow the left side of the pelvis to tilt downward. These weaknesses may be present separately or in combination, but they occur more often in combination (see p. 74). In the sitting position, lateral pelvic tilt accompanied by a...

Nerve entrapment

A sensory mononeuritis of the lateral cutaneous nerve of the thigh is called meralgia paresthetica. The posterior branch of the nerve transmits cutaneous sensations from the superior lateral part of the buttock. The anterior branch, which is the most important clinically, passes through the fascia lata through a small canal and transmits sensations, and occasionally causes skin hyperesthesia. Usually there is no history of any trauma, but factors such as tight belts or corsets or long periods of acute hip flexion may cause the condition.

Palmar Crease Pallor

Transient Neonatal Pustular Melanosis

Large, slate-blue, well-demarcated areas of pigmentation in the sacrogluteal area or elsewhere are called mongolian spots and are normal variants. Ninety percent of all mongolian spots are in the buttock area. These spots fade and disappear by 5 to 6 years of age in 98 of children who have them. Mongolian spots are present in more than 90 of African-American newborns and 70 of Asian-American newborns but in fewer than 10 of white newborns. Figure 24-6 shows a classic mongolian spot.

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