Back Pain

Back pain is the most common complaint we treat. More than 80 percent of Americans experience back pain at some point in their lifetime. For many, the effect of back pain is an everyday battle which immensely impacts the quality of life. The pain we feel — whether in the back, the hip(s), or down the leg(s) — is the body’s request for change.

Back pain is not an indication something is broken, needing to be “fixed.” By taking the time to understand the problem and how it behaves, we can apply the right tool for the job — only then can we achieve a solution.

What it is

Back pain is most commonly of mechanical nature, meaning coming from how we move and use our body. If your back-pain changes — for better or worse — with varying movement and positions accompanied by stiffness or loss of normal motion, you likely suffer from mechanical back pain. Back pain can be coming from muscle, facet joint, nerve, disc, referral from another location, chemical irritation, and more. Treatment for each is different, which illustrates the importance of making an accurate diagnosis. There is no such thing as “nonspecific” low back pain or a one-size-fits-all treatment protocol.

The exact source of back pain is one of the most difficult diagnoses to make, if done correctly. An example? Many avid golfers come in with chronic back pain. A very common cause? Lack of hip mobility causing the low back to excessively twist and turn during swinging, leading to hypermobility and instability in the lower spine. Without a thorough assessment, a clinician could “chase the pain,” start adjusting the spine where it hurts, causing more movement, exacerbating the current problem and leading to a worsening of pain. At Nexus Spine & Sport, Dr. Annas takes the time to find the true cause of pain, and tailor care towards the individual patient.

The more common, acute back pain is an episode lasting no longer than six weeks. Back pain is considered chronic when lasting greater than three months.

The nerve supply to your legs stems from the spinal cord within the spine. Poor spinal mechanics and joint movement can alter the way the muscles of the legs and pelvis function, perpetuating pain and poor mechanics, and vice versa. This can hinder the ability of the muscles to function, which impacts the way the surrounding joints move. Sound like a circle? It’s because it is. Chronically tight and spastic muscles can impact the health of the joints and ligaments. Proper movement is vital for joints to receive nourishment and stay healthy. It is not uncommon to experience symptoms such as pain, muscle weakness, or numbness and tingling anywhere down your leg(s), with or without local back symptoms!

In rare cases, back pain can be non-mechanical in nature and be indicative of something more serious. Although rare, it is possible and Dr. Annas will make sure you have the necessary referral immediately and collaborate with your primary care provider.

Because back pain is incredibly complex and multifactorial, a through patient history and examination is critical in order for the clinician to understand the problem.

What it isn’t

The pain we feel is simply a request from our brain to change. Pain is usually unassociated with damage, rather it’s an alert we need to change our physical behavior or else serious problem may result.

Mechanical back pain does not have to be debilitating and just because you have back pain does not mean you’re broken, needing to be “fixed”.

Just because you have pain doesn’t mean you need an MRI; just because your MRI shows “degeneration,” “disc bulges,” or “arthritis,” doesn’t mean it’s causing your pain. Back pain is often unassociated with aforementioned structural changes commonly found from imaging, e.g. X-ray, CT scan, MRI. These diagnoses are present in a large percentage of completely asymptomatic people! Including elite athletes. Your pain and dysfunction are likely from another source. Furthermore, there’s a high prevalence of interpretive errors between radiologists. So, not only does imaging your spine result in a high rate of unrelated findings, the professionals interpreting them cannot concisely agree upon diagnoses!

Another interesting phenomenon is that of disc herniations, and their vast prevalence in ASYMPTOMATIC patients! This article HERE highlights the percentages of people with disc herniations and no symptoms, and how the percentage increases as we age. People often come to us saying “My back hurts because I have a disc herniation” Which definitely may be the case at that instant, but this isn’t a reason for you tolerate pain as being acceptable. Conservative care is an effective method of managing this condition in most cases. After an exam, we will determine if surgical consult or other referral is deemed necessary, and the appropriate calls will be made.

A final consideration is what this article HERE discusses, and how disc bulges can actually resorb themselves with time! We are here to help expedite that process and ease the back pain, leg pain, or hip pain that may accompany the healing process. Get your case looked at by an expert! Track any bowel, bladder, incontinence, sensory changes especially after a trauma as this can be a serious condition. If

In quality non-surgical care, it’s important to minimize variables and rule out the spine as the pain generator.

Many medical diagnoses need to be thoroughly examined so that we don’t “chase pain” and can understand WHY you’re dealing with discomfort:

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Sacroiliitis

The sacroiliac joint (SIJ) is the load-bearing, shock-absorbing union between the spine and pelvis. It is a mechanical link that connects the chain of locomotion to the rest of the body. This irregular, synovial and fibrocartilaginous joint is surrounded by a strong ligamentous-reinforced capsule and is minimally mobile (1,2).

Approximately 13% of low back pain is attributable to the SIJ (3). Sacroiliac joint dysfunction (SIJD) can be divided into two general categories: mechanical and arthritic. “Mechanical” SIJD results from any process that alters normal joint mechanics. Common culprits include: leg length inequalities, gait abnormalities, lower extremity joint pain, pes planus, improper shoes, scoliosis, prior lumbar fusion, lumbopelvic myofascial dysfunction, repetitive strenuous activity and trauma- especially a fall onto the buttocks. Studies show that over half of mechanical SIJD results from an inciting injury (4). Pregnancy creates an array of sacroiliac joint issues with weight gain, gait changes and postural stressors occurring contemporaneously with hormone-induced ligamentous laxity. “Arthritic” SIJD results from either osteoarthritis or from an inflammatory arthropathy including; ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and Reiter’s/reactive arthritis which produce sacroiliitis and resulting pain. Morning pain that resolves with exercise is characteristic of arthritic SIJD.

The clinical presentation of SIJD is quite variable and shares several common characteristics with other lumbar and hip problems.The patients lumbar spine must first be ruled out since it’s a common referral for low back discomfort. When asked to point specifically to the site of pain, the SIJD patient will often place their index finger over the PSIS. Pain may or may not refer to the lower back, buttock, thigh or rarely into the lower leg via chemical radiculopathy of the neighboring L5 or S1 nerve roots (5). Symptoms may be exacerbated by bearing weight on the affected side and relieved by shifting weight to the unaffected leg. Pain may be provoked by arising from a seated position, long car rides, transferring in and out of a vehicle, rolling from side to side in bed or by flexing forward while standing. Pain is often worse while standing or walking and relieved by lying down.

References

1. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: A roentgnen stereophotogrammetric analysis. Spine. 1989;14:162–165.

2. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine. 2000;25:214–217.

3. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21: 1889–1892.

4. Bernard TN Jr, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop Relat Res. Apr 1987;217:266-80.

5. Fortin JD, Washington WJ, Falco FJE. Three pathways between the sacro-iliac joint and neural structures. AJNR. 1999;20:1429–1434.

Piriformis Syndrome

Piriformis syndrome arises when a irritated piriformis muscle compresses the sciatic nerve (1). This pressure causes ischemia, congestion, local inflammation and radicular complaints (2). Researchers estimate that piriformis syndrome contributes to up to one third of all back pain (3,4).

The piriformis muscle originates on the anterolateral surface of the mid-portion of the sacrum and inserts on the superior medial aspect of the greater trochanter. When the hip is extended, the piriformis functions primarily as an external rotator of the thigh, with secondary contributions toward flexion. The muscle assists in abduction when the hip is flexed to 90 degrees. (3) The sciatic nerve has a variable relationship to the piriformis muscle. In the majority of the population, the sciatic nerve travels deep to the muscle. Approximately one fourth of the population is anatomically predisposed to piriformis syndrome because their sciatic nerve passes through the muscle, splits the muscle or both. (5,6)

Symptoms of piriformis syndrome may begin abruptly as the result of a traumatic event, or may develop slowly in response to repeated irritation. Piriformis muscle irritation and hypertonicity can result from a strain, a fall onto the buttocks or catching oneself from a “near fall”. In other instances, the process may begin following repetitive microtrauma, like long distance walking, stair climbing or from chronic compression- i.e.sitting on the edge of a hard surface or a wallet. (8,9)

Presenting complaints for piriformis syndrome include pain, paresthesia or numbness beginning in the gluteal region and radiating along the course of the sciatic nerve. Additional symptoms may develop from local trigger point referral into the proximal thigh, sacroiliac and hip regions. (9) Symptoms are often provoked by holding any one position for longer than 15-20 minutes- particularly prolonged sitting or standing. Positional changes may provide transient relief. Patients may report increasing discomfort when walking, running, stair climbing, riding in a car or arising from a seated position. Activities that involve hip internal rotation, like sitting cross-legged, may exacerbate symptoms (10).

Piriformis syndrome shares several common characteristics and may even co-exist with other lumbopelvic problems. The differential diagnosis for piriformis syndrome includes; hip pathology, fracture, lumbar compression fracture, discitis, trochanteric bursitis, sacroiliitis, sacroiliac joint dysfunction, lumbar radiculopathy, spinal stenosis and viscerosomatic referred pain.

References
1. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet. 1928;ii:1119-22.
2. Williams PL, Warwick R. Gray’s Anatomy. 36th ed. Philadelphia, Pa: WB Saunders Co; 1980.
3. Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004;35:65-71.
4. Pace JB, Nagle D. Piriformis syndrome. West J Med. 1976;124:435-439.
5. Beason LE, Anson B.J. The relation of the sciatic nerve and its subdivisions to the piriformis muscle. Anat Record. 1937;70:1-5.
6. Pecina M. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat (Basel). 1979;105:181-187.
7. http://physioplus.blogspot.com/2008/09/piriformis-syndrome.html, retrieved 10/13
8. Foster MR. Piriformis syndrome. Orthopedics. 2002;25:821-825
9. Travell J, Simons D. Myofascial Pain and Dysfunction, Vol 2. Williams and Wilkins 1992. pp 186-214
10. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1997.

IT Band Syndrome

Iliotibial band syndrome (aka Iliotibial Band Friction Syndrome) describes an irritation of the tissues near the distal attachment of the iliotibial band. This overuse syndrome is particularly common in runners and cyclists. (1-3) This is a common issue Dr. Annas treats.

Iliotibial band syndrome (aka Iliotibial Band Friction Syndrome) describes an irritation of the tissues near the distal attachment of the iliotibial band. This overuse syndrome is particularly common in runners and cyclists. (1-3) This is a common issue Dr. Jolson treats with the Hincapie Racing Team.

The ITB is divided anatomically into two distinct portions- a proximal “tendinous” segment and a distal “ligamentous” component. (4) The proximal portion begins as a sheath encasing the tensor fascia lata muscle. This sheath anchors the tensor fascia lata to the iliac crest and also receives the majority of the gluteus maximus tendon. (5) The dense fibrous ITB then courses distally with a deep component that attaches to the femoral shaft via the strong lateral intermuscular septum and linea aspera. (4) Distally, the tendinous portion “fans” before terminating near the lateral epicondyle. (4) The ITB then transitions to its ligamentous component, spanning from the lateral epicondyle of the femur to Gerdy’s tubercle on the anterolateral aspect of the tibia. (5)

The iliotibial band is a conduit for forces generated by the TFL and gluteus maximus (i.e. thigh abduction, flexion, extension, and external rotation). The deep fascial component, which attaches to nearly the entire length of the femur, is most taut when the gluteus maximus and TFL contract. This “tensile” action significantly increases during single leg stance and serves to counteract medial bowing of the femur, while lateral bowing is minimized by “compression”. (4,6)

ITB syndrome is common in populations exposed to repetitive knee flexion and extension while in a single leg stance. (9) The problem is particularly prevalent in runners, where it comprises almost ¼ of all lower extremity injuries. (2,3,10-17) Ultimately, ITB syndrome affects up to 12% of all runners. (10) The condition is also frequently seen in cycling, weight lifting, skiing, soccer, basketball, field hockey, and competitive rowing.

The typical presentation for ITB syndrome is a runner or cyclist complaining of “sharp” or “burning” pain approximately 2 cm above on the outside of the knee – near the lateral femoral condyle. (9) Pain may radiate slightly above or below. (9) Symptoms are provoked by activities that require repetitive knee flexion and extension. Symptoms are more likely as activities proceed. (9) Less severe presentations may report pain only during activity, but as the condition progresses, symptoms become more persistent.

References
1. S. P. Messier, D. G. Edwards, D. F. Martin et al., “Etiology of iliotibial band friction syndrome in distance runners,” Medicine and Science in Sports and Exercise, vol. 27, no. 7, pp. 951–960, 1995.
2. Ellis R, Hing W, Reid D. Iliotibial band friction syndrome–a systematic review. Man Ther. Aug 2007;12(3):200-8.
3. Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band strain in runners. Clin Biomech (Bristol, Avon). Jun 24 2008
4. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat, 2006;208:309-316.
5. Standring S. Gray’s Anatomy: the Anatomical Basis of Clinical Practice. 39. Edinburgh: Elsevier/Churchill Livingstone; 2004.
6. Michaud T. The Real Cause of Iliotibial Band Syndrome Dynamic Chiropractic November 18, 2012, Vol. 30, Issue 24
Fetto J, Leali A, Moroz A Evolution of the Koch model of the biomechanics of the hip: clinical perspective. J Orthop Sci. 2002; 7(6):724-30.
7. Drogset JO, Rossvoll I, Grøntvedt T Surgical treatment of iliotibial band friction syndrome. A retrospective study of 45 patients. Scand J Med Sci Sports. 1999 Oct; 9(5):296-8.
8. Fetto J, Leali A, Moroz A Evolution of the Koch model of the biomechanics of the hip: clinical perspective. J Orthop Sci. 2002; 7(6):724-30.
9. M. Fredericson and A. Weir, “Practical management of iliotibial band friction syndrome in runners,” Clinical Journal of Sport Medicine, vol. 16, no. 3, pp. 261–268, 2006
10. Linenger JMCC. Is iliotibial band syndrome overlooked? Phys Sports Med. 1992;20:98–108.

Sciatica Treatment

Sciatica is not a true medical diagnosis but rather a symptom of an underlying medical condition. There are a few common lower back problems that can cause sciatica symptoms. These include a radiculopathy, bulging disc, degenerative disc disease, spondylolisthesis, or spinal stenosis

Sciatica is often characterized by one or more of the following symptoms: constant pain in one side of the buttock or leg (rarely in both legs), pain that is worse when sitting, leg pain that is often described as burning or tingling, weakness or numbness, sharp pain that may make it difficult to stand up or walk, and pain that radiates down the leg and possibly into the foot and toes.

Dr. Annas of Shelby Twp typically finds that sciatica pain and symptoms aren’t always as black and white as it’s drawn up in the books. The patient typically can’t draw a straight line with a pen from the back straight down the leg. Rather, the symptoms are variable and change based on positions and movements. The patient may sometimes have pain the glute, their hamstrings feel “different”, and they have an odd sensation in the calf. Sciatic pain can vary from intermittent and irritating to constant and debilitating.

Symptoms are usually based on the location of the pinched nerve. The sciatic nerve is the largest single nerve in the body and is made up of individual nerve roots that start by branching out from the spine in the lower back and then combine to form the “sciatic nerve.” Sciatica symptoms occur when the large sciatic nerve is irritated or compressed at or near its point of origin around the lower back. The sciatic nerve starts in the low back, typically at the third lumbar segment. At each level of the lower spine, a nerve root exits from the inside of the spinal canal, and each of these respective nerve roots then come together to form the large sciatic nerve.

The sciatic nerve runs from the lower back, through the buttock, and down the back of each leg. Portions of the sciatic nerve then branch out in each leg to innervate certain parts of the leg—the thigh, calf, foot, and toes. The specific sciatica symptoms—the leg pain, numbness, tingling, weakness, and possibly symptoms that radiate into the foot—largely depend on where the nerve is pinched.

Often, a particular event or injury does not cause sciatica— the most common cause of sciatica is “for no apparent reason” – it tends to develop over time. Our chiropractor in Greenville helps you understand your sciatica symptoms and will quickly find you a solution or get you to the provider who can help.

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