Lower Back Pain

Back pain is not only one of the most common reasons patients comes to Miami Spine and Performance, but also one of the most common reasons patients sees any type of doctor around the country. Back pain can be both scary and debilitating if the condition is not properly understood.

A proper medical history combined with a comprehensive movement assessment can give us great indications as to how to proceed with your care.

What causes back pain?

Part of what makes back pain a challenging puzzle to solve is that there is a wide variety of issues that can ultimately present as pain in the back. This could range anywhere from too much time in one posture to a more serious condition involving internal organs.

Once a serious condition has been ruled out, it is our job to determine whether or not the pain you are experiencing is related to an obstruction to movement (bending forwards, backwards, or side to side), a soft tissue injury, or a compensation for a deficiency in movement in the lower extremity (tight hips, tight upper back) putting excessive pressure on the lower back. Once the condition can be placed into one of these categories, the intervention and treatment plan necessary become very clear and direct.

How do we treat lower back pain?

Once the root cause of the issue has been identified, the treatment will be governed by the goal at hand (improve range of motion, reduce tension, decrease perceived threat in the brain). If you are experiencing lower back pain in addition to pain down one or both legs, our first goal is to take the pain out of your leg and bring it locally to the lower back. Once we find the appropriate movement that “centralizes” your symptoms to your lower back, we can then focus on being sure that your back moves fully and freely and return you to the activities you love.

Can we prevent back pain from coming back?

Though the most common predictor of back pain is previous episodes of back pain, there are a number of steps an individual can take to maintain a resilient back and live an active and fruitful life free of pain or restriction. The three major goals we look to accomplish at Miami Spine and Performance for all of our patients with lower back pain is free and full motion in the joints of the back itself, full and free motion of the hips and proper breathing patterns ultimately leading to a stable core and adequate protection for the structures of the spine. Regularly working on these three elements will significantly reduce you chance of having another episode of back pain.

lower back pain

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).

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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).

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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.

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

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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.

Our chiropractor in Greenville typically finds that sciatica 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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