Inferior gluteal pain with sitting, unrelated to ischial bursitis

A 64-year-old woman presented to an academic medical centre with postoperative left ischial pain following a left total hip replacement. Her pain was exacerbated by sitting down and with forward flexion of the spine, and the pain radiated from the left ischial tuberosity to the left perineum, groin and medial thigh. An ischial bursa injection was performed, but only resulted in 1 day of excellent pain relief. A diagnosis of inferior cluneal neuralgia was then made. Subsequent inferior cluneal nerve radiofrequency ablation was performed, and provided sustained 50% relief in pain. The patient had a concomitant sensation of ‘ball like’ pressure at her rectum which was determined to be due to levator ani syndrome. She was prescribed pelvic floor physical therapy and botulinum toxin injection, which resulted in further notable improvement of her symptoms.

Thigh lift

The skin of the medial thigh is thin and inelastic, and laxity here is often the earliest sign of ageing in the thighs. The medial thigh skin is also one of the areas most affected following weight loss. The majority of skin laxity occurs at the junction of the anterior and medial thigh, where the skin tends to hang in a dependent, pleated fashion. This can interfere with walking, toileting, and various other day-to-day activities, resulting in irritation due to chaffing between the thighs. Body contouring techniques are routinely combined in stages to achieve a more harmonious result. Medial thigh lift is frequently combined with upper body lift or breast surgery, or both, whereas brachioplasty is usually combined with abdominoplasty/lower body lift. Opposing vectors of pull and excessive damage to local vascularity are thereby avoided. However, staging surgical procedures has the potential to reveal additional areas of dissatisfaction to the patient. Abdominoplasty patients often report increased dissatisfaction with the medial thighs as a consequence of this previously hidden deformity becoming visible to them postoperatively. In fact, massive weight-loss patients’ dissatisfaction with their thighs is almost as great as with the changes to their breasts in terms of their severely decreased self-esteem, sexuality, and quality of life.

Case Report: Extrapelvic Endometriosis in the Medial Thigh

Extrapelvic endometriosis, although rare, can present in the musculoskeletal system of reproductive-age women and cause significant pain and morbidity. The pathophysiology of this disease is not well understood. In this study, we described the case of a 39-year-old women with an inner-thigh mass causing catamenial pain. Core-biopsy of the mass confirmed endometriosis and she was referred to minimally-invasive gynecology for management. Surgical excision was performed by a multidisciplinary team and she remains pain-free postoperatively on hormonal therapy. Unique to this case, the patient had a history of pelvic fracture. Through this case report, we discuss possible pathophysiologic mechanisms of extrapelvic musculoskeletal endometriosis including the stem/progenitor cell theory and the role that musculoskeletal trauma may have in the development of this condition. Gynecologists play an important role in the recognition, diagnosis, and management of musculoskeletal endometriosis.