A Pain in the Butt…

If you are suffering with low back pain that radiates into your butt, hip and leg, you may have a herniated disc in your low back that is pinching and irritating nerve roots that make up the sciatic nerve and you might be suffering miserably from a condition known as “sciatica.”  An MRI may confirm the herniation and your doctor may recommend epidural steroid injections (shots of cortisone) to try and alleviate the swelling and pain.  If you start to get neurological deficits—like progressive muscular weakness or the loss of reflexes—you may be a candidate for surgery to remove the herniated disc altogether.

Doctors who specialize in the examination and treatment of the spine rely on differential diagnostic testing to provoke the disc and nerve roots to see if they are the culprits that are causing the symptoms.  If provocative tests are performed and they are positive (ie, they reproduce the pain and especially, they increase the radiation of pain into the leg), you most likely have an active/symptomatic herniated disc that needs to be treated accordingly.  Research has shown that gentle manipulative therapy can be employed even if there is a herniation present.  If the provocative tests are negative—they do not reproduce your symptoms and you do not have an increase in pain going down the leg—your pain may not be coming from a herniated disc.  Sometimes patients show up in my office and tell me that they have had an MRI of their spine that definitely shows a disc herniation.  Upon examination though, all the disc provocation tests are negative.  In this case, we consider the disc herniation to be inactive, latent, or asymptomatic.  Studies have confirmed the fact that it is very common to find disc bulges, herniations, and advanced arthritis in the spines of people who are completely asymptomatic (this study showed 33% of asymptomatic patients had abnormalities).  Researchers now conclude that the presence of disc herniations on an MRI indicates that there has been aging and “wear and tear” on that disc—but it does not necessarily mean that the bulging disc is producing pain.  It is tricky business to figure out if a disc is symptomatic or not and specialists must correlate their exam findings with the imaging studies to try and determine the diagnosis and ultimately, the best course of treatment.  We don’t want to be doing surgery on herniated discs that are not causing pain while leaving the real cause of the symptoms untreated.

SI JointsAs a chiropractor, one of the most common conditions that I treat is Sacroiliac Joint Dysfunction with an associated Piriformis Muscle Syndrome.  The sacroiliac joint may be strained after a twisting or lifting injury or it may come on over time due to postural stresses like sitting all day.  Pain is usually caused by the spasm and swelling from the strain.  Scar tissue that is laid down as the body heals may impede with normal joint mechanics causing the joint to malfunction.  Sacroiliac joint dysfunction can cause localized low back pain (usually in one of the “dimples” of your low back) or pain that radiates into the butt, hip and leg.  Spasm of the Piriformis muscle, which is located deep beneath the gluteus muscles in your buttocks, can pinch and irritate the sciatic nerve and cause sciatica that mimics a herniated disc.  I have to note that the SI joint dysfunction/fixation and the Piriformis Muscle Syndrome are not common medical diagnoses.  The fixation of the joint and the spasm of the muscles are not something you see on an x-ray or MRI—it is something that you feel.  Literally.  Doctors who have been trained in the art of palpation (ie, osteopaths and chiropractors) can feel the restriction in a fixed joint and they can feel the tightness of a muscle in spasm.  The diagnosis is based on these palpatory findings as well as the negative disc provocation tests.  As the positive research on spinal manipulation continues to be published, MDs will start to embrace the terminology (spinal joint dysfunction, sacroiliac fixation, etc) as well as the recommended treatment (manipulation of the fixed SI joint and deep tissue pressure point therapy and stretching of the Piriformis muscle).

imagesSo, if you suffer from low back pain that radiates into the hip and leg, get your butt into a chiropractor’s office!  Chiropractors can be accessed relatively quickly—usually within a couple days—and they do not require a medical referral.  Trying to get in to see a medical specialist (like an orthopedist or neurosurgeon) requires a referral and it may take several weeks.  Chiropractors can examine the spine, do the disc provocation tests, diagnose a herniated disc (or rule it out), check the sacroiliac joint for fixation and probably most importantly, treat that fixation immediately with SI joint manipulation.

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