Background: Deep gluteal syndrome (DGS) is an underdiagnosed cause of sciatica-like pain, involving the entrapment of the sciatic nerve by various structures within the subgluteal space. While cases of ossification or calcification in the context of severe pelvic imbalance have been rarely reported, isolated SSL calcification as a primary cause of DGS remains largely unexplored and undocumented. This case report presents the first documented instance of sacrospinous ligament (SSL) calcification identified as the primary cause of DGS and its successful management with ultrasound-guided prolotherapy. Case Presentation: A 51-year-old female presented with severe, worsening left-sided sciatica of several months’ duration. Physical examination revealed an antalgic gait, positive sacroiliac joint tests, and multiple positive DGS-specific provocative tests (FAIR, Pace sign, Seated Piriformis Stretch). Radiographs and musculoskeletal ultrasound (MSK-US) confirmed calcification within the left sacrospinous ligament, with associated sciatic nerve swelling. The patient underwent three sessions of ultrasound-guided prolotherapy (dextrose 10% with lidocaine) targeting the calcification site, followed by a structured rehabilitation program. Results: The patient reported a significant reduction in pain, from a Visual Analog Scale (VAS) score of 10/10 to 1/10 within one month. All previously positive provocative tests converted to negative, indicating a resolution of the nerve entrapment. Functional mobility was fully restored. Conclusions: This case highlights isolated sacrospinous ligament calcification as a potential and previously overlooked pathological entity responsible for deep gluteal syndrome. To our knowledge, this is the first report to implicate ligamentous calcification as a primary etiological factor in DGS. Musculoskeletal ultrasound proved indispensable for both diagnosis and treatment guidance. Furthermore, ultrasound-guided prolotherapy emerged as a successful and minimally invasive therapeutic option in this case, potentially by stabilizing the ligament and reducing neurogenic inflammation. This case expands the differential diagnosis of sciatica, introduces a new target for intervention in refractory cases, and underscores the need for future studies in larger patient cohorts to validate these findings.

Deep Gluteal Syndrome (DGS) has traditionally been defined as a clinical entity caused by sciatic nerve (SN) entrapment. However, recent anatomical and imaging studies suggest that muscle- and tendon-origin pathologies—including enthesopathy—may also serve as primary pain generators. This narrative review aims to broaden the current understanding of DGS by integrating muscle and tendon pathologies into its diagnostic and therapeutic framework. The literature was selectively reviewed from PubMed, Cochrane Library, Google Scholar, PEDro, and Web of Science to identify clinically relevant studies illustrating evolving concepts in DGS pathophysiology, diagnosis, and management. We review clinical features and diagnostic tools including physical examination, MRI, and dynamic ultrasonography, with special attention to deep external rotator enthesopathy. Treatment strategies are summarized, including conservative therapy, ultrasound-guided injections, hydrodissection, and prolotherapy. This narrative synthesis underscores the importance of recognizing muscle-origin enthesopathy and soft-tissue pathologies as significant contributors to DGS. A pathophysiology-based, multimodal approach is essential for accurate diagnosis and effective treatment.

Background/Objectives: Iatrogenic abductor muscle injury following intramedullary nailing for proximal hip fractures can negatively impact postoperative rehabilitation and clinical outcomes. To quantify iatrogenic abductor muscle injury after intramedullary nailing and detect the degree of degenerative change in muscle around the entry point of trochanteric fractures. Methods: This cross-sectional study used data from a single center database from May to December 2023. This study utilized ultrasound examinations performed by a single expert orthopedic surgeon. This study included 61 patients who underwent intramedullary nailing surgery for adult hip fractures. All surgeries were performed by a single experienced hip surgeon. Patients who declined sonographic evaluation or did not undergo ultrasound during their admission were excluded. For more accurate comparison, sonography was also conducted on the healthy, non-operative limb. Descriptive statistics were used to summarize patient and ultrasound findings. A subgroup analysis using Fisher’s exact test was performed to assess the association between implant type and the incidence of iatrogenic gluteus medius tendon injury. Results: Of the 61 patients, tendon tears were identified in 35 cases (57%) on the affected side, with 20 cases (33%) involving gluteus medius tendon tears without fractures on the ipsilateral facet. Gluteus minimus tendon tears were observed in 13 cases (21%), while gluteus medius tendon tears were noted in 31 cases (51%). In the unaffected limbs, tendon degeneration was detected in the form of tendinosis and calcification. Overall, 39 patients (64%) exhibited abductor tendon tendinosis, and 30 patients (49%) were diagnosed with calcification. Conclusions: Gluteus medius and Gluteus minimus are important abductors for hip disease rehabilitation. Iatrogenic gluteus medius tendon injury during the intramedullary nailing showed 33%. Abductor degeneration also showed 92% of the unaffected limbs. This study suggests that abductor degeneration can be a risk factor of falling among the elderly population and an iatrogenic abductor injury can be an obstacle for the early recovery of ambulation in the hip fracture patients. Prevention of abductor degeneration and iatrogenic abductor injury might be important for the hip fracture prevention and rehabilitation.

Ultrasound-guided hydrodissection and dextrose prolotherapy have evolved into anatomically explicit but mechanistically distinct strategies for musculoskeletal pain. This State-of-the-Art narrative review aimed to synthesize major recent clinical and technical developments and to interpret them within a target-based framework. PubMed and Embase via Ovid were searched for English-language publications from 1 January 2021 through 29 July 2026, supplemented by selected pre-2021 landmark studies identified through backward citation tracking. After initial deduplication, 1662 records entered Title/Abstract screening. The final narrative synthesis cited 67 publications, including selected landmark and methodological sources. One author performed screening, and a second author reviewed the final publication selection; study selection was purposive and designed for a narrative synthesis rather than exhaustive systematic inclusion. Four questions guided the review: recent refinements in hydrodissection technique and indications; increasing condition specificity of prolotherapy evidence; areas of overlap and distinction between the two procedures; and the evidentiary status of emerging applications. Hydrodissection research remains concentrated in carpal tunnel syndrome and increasingly addresses injectate, volume, tissue-plane spread, and procedural configuration, whereas evidence beyond the carpal tunnel remains incompletely replicated. Prolotherapy research has shifted from broad claims toward condition-specific studies in tendinopathy, plantar fasciopathy, knee osteoarthritis, periarticular disorders, and temporomandibular joint pathology. Across both fields, variations in concentration, volume, anatomical site, session number, comparator, rehabilitation, and procedural expertise limit generalization. Hydrodissection is defined by observable, fluid-mediated separation of a tissue interface, whereas prolotherapy involves dextrose delivery to a symptomatic connective-tissue target without requiring immediate tissue-plane separation. The proposed framework is intended to standardize terminology, organize evidence maturity, and guide future comparative research rather than prescribe a validated treatment algorithm.

Background: Deep gluteal syndrome (DGS) has traditionally been attributed to sciatic nerve entrapment within the deep gluteal space. However, increasing evidence suggests that enthesopathy and soft tissue pathology of the short external rotators may also contribute to its pathogenesis. Conventional ultrasound-guided interventions primarily target the sciatic nerve through perineural hydrodissection (HD), which may not address enthesis-related pathology. However, the anatomical feasibility of delivering injectate along the deep gluteal fascial plane has not yet been investigated in cadaveric studies. Methods: This cadaveric anatomical demonstration evaluated whether an ultrasound-guided fascial plane injection within the deep gluteal space could simultaneously reach the enthesis of the short external rotators and the region of the sciatic nerve. Ultrasound scanning protocols were first demonstrated in a healthy volunteer to establish anatomical orientation for the injection pathway. Injection experiments were then performed in a fresh-frozen cadaver (83-year-old male) using a cranial-to-caudal in-plane approach. Ten milliliters of methylene blue dye was injected along the fascial plane overlying the short external rotator enthesis, followed by layer-by-layer cadaveric dissection to assess dye distribution. Results: Cadaveric dissection demonstrated that methylene blue injected along the deep gluteal fascial plane extended to the enthesis of the short external rotators and spread toward the surface of the sciatic nerve. Comparable distribution patterns were observed in both hips. These findings suggest that a single ultrasound-guided fascial plane injection trajectory may anatomically access both the enthesis region and the adjacent sciatic nerve within the deep gluteal space. Conclusions: Ultrasound-guided fascial plane HD in the deep gluteal space provides an anatomical pathway that can simultaneously access the enthesis of the short external rotators and the region of the sciatic nerve. This approach may represent a potential anatomical basis for a fascial plane-based intervention strategy in DGS. Further studies are required to evaluate in vivo behavior and clinical effectiveness.

Vitamin C (L-ascorbic acid) is an essential micronutrient involved in collagen biosynthesis, redox regulation, immune function, endothelial biology, carnitine synthesis, neurotransmitter metabolism, and non-heme iron absorption. Dietary reference values are designed primarily to prevent deficiency in general populations, but vulnerability to low-vitamin C status may increase during trauma, surgery, chronic inflammation, malignancy, metabolic disease, smoking, poor intake, environmental exposure, and tissue repair. This narrative review synthesizes mechanistic, pharmacokinetic, clinical, and safety evidence on vitamin C as a stress-responsive micronutrient. Evidence is reviewed across tissue repair and wound healing, orthopedic recovery and selected complex regional pain syndrome risk contexts, fatigue, neuropsychiatric vulnerability, cancer-supportive care, vascular homeostasis, dermatologic biology, and preliminary microbiota–gut–brain axis hypotheses. The strength of evidence differs substantially across domains: biochemical functions and deficiency correction are well established, whereas benefits of supraphysiologic oral supplementation in vitamin C-replete patients remain uncertain. Oral nutritional supplementation is distinguished from intravenous pharmacologic ascorbate, with attention to route, formulation, dose division, gastrointestinal tolerance-limited adjustment, and safety monitoring. Because evidence for high-dose oral supplementation remains limited and condition-specific, such use should be individualized, time-limited, and clinician-monitored rather than presented as a population-level recommendation or evidence-defined therapeutic target. Taken together, the clinical value of vitamin C depends on baseline status, patient vulnerability, route, formulation, dosing interval, clinical endpoint, and safety review.