It is my great honor to be with you in the course. I'm going to talk a little bit about deep clitoral syndromes. My name is Soushi Uchida from Wakamatsu Hospital of the University of Occupational and Environmental Health, Japan. This is my disclosure. My talk will be the anatomy, mechanism of the entrapment site, and clinical presentation, and how to diagnosis, and how to treat them. Deep clitoral syndrome is a common source of groin pain and posterior hip pain resulting from the entrapment of sciatic nerve and posterior femoral cranius nerve in the deep clitoral space. Other potential causes of DGS are space-occupied regions as well as posterior operative or post-traumatic scarring surrounding the piriformis obturator internalis muscle and proximal hamstrings and sciatic nerves. This slide is showing the posterior aspect of the pelvic. This is the greater sciatic fulamine, and this is the ilium, and this is the ischium, and this is the sacrum. This is the sacro-tuberous ligament and sacro-spinous ligament as well. Obturator internalis muscle is originated on the medial surface of the obturator fulamine, and ischium near the membrane and the limb of the pelvis. It exists the pelvic cavity through the lesser sciatic fulamine. An obturator externalis originated from anterior surface of the obturator membrane and the bony boundaries to the obturator fulamine, and inserted to the trochanteric fossa. It is innervated from obturator nerves. This is the superior gemellus and inferior gemellus. This is the piriformis muscle. It exists the pelvis through the greater sciatic fulamine to insert the greater trochanteric femur. This is the sciatic nerves. It passes beneath the piriformis and through the greater sciatic fulamine existing in the pelvis. And here you can see this is the posterior femoral cutaneous nerves. It innervates to the skin of the posterior surface of the thigh and legs as well as the skin of the perineum. This is the superior gluteal nerves. Superior gluteal nerve is nerve that originated in the pelvis and supplies to the gluteus medius and gluteus minimus, and tensor fasciae latae and piriformis muscle. Inferior gluteal nerve is the main motor neuron innervates gluteus maximus muscles, which is responsible for the movement of the gluteus maximus in the activities requiring the hip to the extent of the thigh, such as climbing the stairs. You can see this is the pudendal nerve. It is the main nerve of the perineum. It carries the sensation from the external genitalia of both sexes and the skin around the anus and the perineum, as well as the motor supplies to the various pelvic muscles. Deep gluteal syndrome is classified according to the locations, inter-pelvis and extra-pelvis. DGS is also classified according to the mechanism, the primary and the secondary. Primary DGS including the piriformis split and the fibrobascular band. Secondary DGS including issue of femoral impingement, femoral torsion, greater trochanter and snapping issues, hamstring syndrome and postoperative DGS. Our study reported postoperative DGS after hip arthroscopic surgeries. The incidence of postoperative DGS after hip arthroscopic surgeries was 0.9%. The predicted work of postoperative DGS are female sex, general joint atrocities, multiple surgeries and hip dysplasia. There are several reports indicating the multiple locations of the nerve entrapment, piriformis, fibrobascular band, ovulatory internals, issue of femoral impingement and hamstrings. Some of the patients of the DGS have two or three locations of the nerve entrapment. 70% of the people's piriformis muscle is pierced by the part or all of the sciatic nerves. There are several variations occur, but the most common type of the anomaly is the beaten type B, which is when the common peroneal nerves pierce the piriformis muscle. Sciatic nerves abnormalities anatomy can be assessed by the MRI imaging. This MRI showing the superior division of the sciatic nerve. Here you can see the piriformis splitted and the sciatic nerves crossing between the two piriformis muscle. A 4 or 5 level examination is mandatory in the diagnosis of the complex disorder of the hips. Examination will adequately assess level 1 osteochondral region, level 2 capsule labrum layer, muscular tenderness level 3 and neurovascular layer level 4. And also in addition the kinematic chain is also assessed and helping to the direct operate test and treatment modalities. This slide is showing a critical key in the evaluation. Take a comprehension of history and physical examination is very important. Make a complement assessment. And imaging T3, TEVX, MRI and ultrasound guided injection is also important. Understand the differential diagnosis about the rural or L-spine disorders. These are key postural hip pain history questions. Psychological screening, interperipheral pathologies including a gynecological history, past or abnormal surgery and sacroiliac joint. And pain medial or lateral to the ischium. And pain greater in sitting or walking. And pain region, maximum origin and piriformis and SI joint. And prior the injection and outcome short or long. Physical examination test require for extra-articular postural hip pains. Long stride, short stride gait assessment. Palpitation in the sitting position. Active hamstrings test. Isofemoral impingement test. And passive piriformis stretch test. And active piriformis test. And muscle strength can be assessed for abduction. This is active piriformis test with the patient lateral decubitus position. Examiner palpates the piriformis. And patient drives the heel into examining the table. Thus initiating external hip rotations. While actively abduction and external rotating against resistance. If patient complains pain. This scheme shows in type 1 bridge-type bands, compressible bridge-type bands limiting the movement of the sciatic nerve from anterior to the posterior, adhesive horses' strap bands which bind strongly to the sciatic nerve structures, anchoring it in single directions, isofemoral impingement, and hamstring syndrome can be assessed by physical examinations. Patient performs active knee flexion against resistance with knee extensions, and normal strength without pain may be observed. The patient performs active knee flexion against resistance with knee at 30 degrees, weakness and recreation of the symptoms in this position is positively assessed. Hamstring tears can compress the sciatic neuropathies, as well as the posterofemoral cutaneous nerves. Treatment of disease is non-surgical medication, NSAIDs, muscle relaxants, gabapentin, and physiotherapies and injections, and surgery. A physiotherapy program should include the stretching of the maneuvers and aimed to the external rotators, and perform stretch or feel, involving the pressing of the hip in the flexion, abduction, and internal rotations. The ultrasound-guided injection is moderately. This is the piriformis muscle, and this is the femur, and this is the sciatic nerves. This is the needle that penetrates into the piriformis, and just above the sciatic nerves and the posterofemoral cutaneous nerves here. So after ultrasound-guided injections, pain completely relieved. Several studies reported endoscopic treatment of sciatic nerves or the DGS. Dr. Halmachin reported endoscopic DGS is at a supine position, 70 degrees standard, and long arthroscopies. Lee is reported in a series of 26 patients undergoing endoscopic DGS surgeries, 19 reported good clinical outcomes, but did not see the pain and were able to sit in a chair for more than 30 minutes, but seven patients better, but required continued narcotic use after surgery. This femoral impingement, IFY, was described in three cases following osteotomy or arthroplasty of the hips by Johnson. The pain and discomfort was relieved after resection of the lesser trochanter. The cardiographic parameters is very useful to diagnose the IFY. Isofemoral distance, the measure on the standing AP views, if the IFD was less than 17 millimeters, and the quadratus femoris space, QFS, measured at the smallest space to the passage of the QF muscle defined by the MRI, the QFS less than 8 millimeter, we have to consider the IFY. So IFY test was performed with the patient in the lateral recubitus positions. The symptomatic hip was passively taken into the extension, and the positive test findings as a reproduction of the posterior hip pain and numbness in extension with a neutral or adducted position. Hamstring syndrome is a traumatic insertional tendinopathy of the proximal hamstrings in which there was formation of the fibrous tissue, also resulting in the compression of the adjacent sciatic nerve and or posterior femoral canis nerve. Fifty years old female long-distance runners presented us with complaining left hip pain and buttock pain for the past 13 years. She had a positive fibro-undial test, a failure test, an IFY test, and a hamstring stretch test. This photo separation of the MRI showing high intensity of the proximal hamstring insertions and diffuse high intensity of the quadratus femoris muscle. We performed endoscopic hamstring repair and IFY surgeries at the prone position under general anesthesia. This movie showing endoscopic technique of the release adhesions. You can see the sciatic nerve here. And this is the ischium tuberosity. This is the posterior femoral canis nerve. It feels like big. You can see here the posterior femoral canis nerve is retracted because there is a fibrovascular band here and then we evaluated the hamstrings. It looks like not healthy but if we cut the hamstrings and we identify the tear, the partial undersurface thickness tendon aversion, posterior lesion was found. And we performed the suture anchor fixation. Here you can see the knot tying was performed. And also we retracted the quadratus femoris muscle and we exposed the lesser trochanter and we performed the lesser trochanterectomy to decompress the sciatic nerves. A postoperative X-ray showing a good rejection of the lesser trochanter. In conclusion, be aware of extra-articular posterior hip pathologies. Good examinations and special testing is useful. MRI and ultrasound-guided injections are useful to diagnose and treat patients with DGS. Endoscopic rejection of the lesser trochanter is less invasive and can provide fibroclinical outcome for the symptomatic patient with IFI. Thank you for your attention.

deep clitoral syndromes

groin and posterior hip pain

entrapment

diagnosis

treatment options