A long-time friend of mine is a great personal trainer down in Miami. He travels from Miami to the Bahamas on occasion to work with private clients on their private island... sounds nice right? But from time to time he'll call me with a medical questions that he's a bit unsure of. Most of the time it's an injury that isn't responding to exercise. Since his background is in exercise he usually thinks that if you exercise more the pain will go away. He (as most of us do) sometimes falls prey to that old saying... if you were a hammer everything would look like a nail... meaning since he's a personal trainer everyone should respond well to exercise. But to his credit, when things aren't responding he looks for answers elsewhere, which every health provider should do. This post is dedicated to one of his questions... and of course the names and locations have all been changed to protect the innocent :)
Question:
"I'm working with this woman who is complaining of tingling and pain down the back of her gluteal muscle that sometimes goes into the front of her thigh, but not all the time. We've been doing core exercises and back stabilizing exercises to strengthen the low back. But after 1 month of exercise she's not getting any better. And she heats the area every night, takes Advil, even takes some stronger stuff too. But nothing is changing. Oh and it started when she bent down to pick up her baby one day, who is obviously tiny, but she could hardly stand after it happened. What do you think?"
Let's delve into this case. First off, whenever I hear tingling, pain, or numbness going down the back of someones leg or into the thigh I put that into a more sever category. It's in a category called "disc or pinched nerve." Which means that this could very possibly be a disc problem or a pinched nerve problem. Then we think about how the original injury happened... bending forward to pick up her child... this puts her in another category... "hurt bending forward." Which means that it's more likely to be a disc or nerve impingement problem as opposed to a muscle or joint problem. Of course, these are just generalizations, but it's how most health providers go through the thought process.
I follow up with a few more questions:
1. Does the pain get worse with sitting?
2. Does the pain get worse with sneezing?
3. Does heat seem to help for a few minutes, but does the pain then come back soon after?
The answer to all 3 questions was "yes." Before we go over why the "yes" answer is important we have to discuss the basics of a disc in the back.
In between each vertebrae of the spine are shock absorbers called discs. They are like large pads of cartilage that prevent each bone from rubbing against each other. Similar to how a knee has cartilage to keep it moving, the spine has discs to keep it moving. I like to think of a disc as a jelly doughnut because each disc has an outer layer which is stronger, and an inner layer that is more fluid. Similar to a jelly doughnut. When someone bends forward the jelly in the middle of the disc will naturally be pushed towards the back of the doughnut, and when someone bends backward the jelly will move a bit forward, it's normal physics. Similar to how when you pinch one side of a jelly doughnut the jelly will move away from your hands.
A problem arises when the outer part of the jelly doughnut (disc) becomes weak from inactivity, obesity, trauma, sitting too much, old age, etc. When the outer part becomes weak the jelly can push out towards the edge, like when you push down on one side of a jelly doughnut and the other side bulges outward. This is what's called a bulging disc. This causes inflammation, pain, and sometimes causes a pinched nerve since the nerves are very close to the disc itself. If the outer part of the doughnut becomes weak enough the jelly may leak out of the doughnut (disc) which is a big problem. The jelly then irritates and pinches off nerves near the spine causing extreme pain and dysfunction. Luckily most problems are simply bulging or irritated discs, and not the kind where the jelly actually breaks through the disc wall.
So lets go over the questions.
1. does sitting make it worse? Yes... this is important because when we sit the pressure on the disc increases by 50% because now the legs don't take any of the force. Also, when in a sitting position our bodies are actually flexed forward... and thus the jelly in the disc will naturally flow toward the back or our bodies. For someone with a disc problem this will cause an increase in pain.
2. Does the pain get worse with sneezing? Another important disc irritation question. When we sneeze the internal pressure increases dramatically. For someone with a disc problem this can cause more pain. As the pressure inside increases it will push on any areas of weakness. With a disc problem this means that the weaker outer crust of the disc will be pushed upon buy the jelly inside and thus make the disc bulge a bit worse, and the pain worse as well.
3. Does heat seem to help for a few minutes, and then come back soon after? This question is not really specific to a disc problem, but I see this problem so often that I thought I'd throw it in here. Heat is the #1 most deceiving healing modality on the planet. On a daily, literally daily, basis I have a new patient walk into the office with a disc problem or a nerve problem and they say this... "My doctor said use heat and it helps me for a little while but then I wake up in pain again." Here's the issue with heat, and the reason why many doctors and therapists use it so much. Heat increases blood flow and decreases muscle tension so that people feel better right away. If you have a party to go to and your back hurts, heating it will help for a little while. Similar to how you can get in a bath and your pain will most of the time get better. This is also why many people say "oh just heat it" and they sound like they know what they're talking about... if it gets immediate results most people think it helps. So by the time I see someone they are pretty well convinced that using heat is the way to go.
Any injury, any injury at all, causes swelling. It's just how the body works. If an area is damaged the body sends out more blood flow with healing blood cells to start in the healing process. The redness we see around a simple scratch is a form of swelling. It's a vital part of healing, but when the swelling gets too great it irritates nerves and causes pain. We've all sprained an ankle, seen the swelling and felt the pain. The same thing happens in the back, but unfortunately it doesn't swell up like an ankle, so most of us can't see the swelling. The back normally swells deeper than an ankle would, and since there are larger nerves in the back that deep swelling causes a lot of pain.
When you heat the back it improves blood flow and decreases muscle tension, but it also increases swelling. This causes a feeling of improvement for an hour, maybe a couple hours, and then the symptoms come right back. Many therapists and doctors use heat in an office setting because it makes the patient relax and feel better while they're in the office, and makes them "feel" like coming to the office is helping... but usually it's not helping the problem. It sets up a vicious cycle of heating, feeling better, going to bed, waking up with pain again. So unless the problem is arthritis or truly just a muscle tightness issue, do not heat an injury... ICE IT!!!! But I digress...
Since I didn't have a chance to examine my friends client there was nothing else we could use to come up with a diagnosis. Most of the time I can use reflex tests, orthopedic tests, spinal palpation and even an MRI to make a proper diagnosis. But many cases can be solved just by hearing the history of the problem. In this case, we came to the conclusion that a disc in her lower back had probably become irritated, perhaps bulged, when she bent down to pick up her baby. The exercise wasn't helping because it was increasing swelling, and the problem wasn't that she had a weak back, the problem was that she had an irritated nerve. She was also keeping herself injured by heating every day and sitting too much. After my friend listened to my thoughts on disc injuries he decided to have the woman rest and ice the back for the next 2 weeks and within a week she was not experiencing the neurological symptoms any more. Within a month she was back working out with her trainer. Sometimes it just takes an understanding of spinal anatomy and a couple small lifestyle changes to see a dramatic effect.
Doctors Note:
1. Do not heat an injury! It may help your pain momentarily but it's deceiving! Ice should be used!
2. Do not try to exercise through a back or neck injury... although injuries may occur because of a weakness in the back, they very rarely get better by exercising more. Most people need to get the inflammation down, perhaps seek some treatment, and then after the pain has decreased start to exercise again.
3. Avoid anything that flexes your body. Examples: sitting, bending forward, biking, stair climbing, etc. These all push the jelly of the disc back towards the nerves that cause pain.
4. Disc issues are hardly ever surgical cases, unless the "jelly" has really gotten out of the "doughnut." Most cases respond to small adjustments in the spine to get some pressure off the discs and allow the inflammation to go down.
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