Acute (and chronic) sciatic pain

[RadGuy]

Hello all, I am a new member chasing an ongoing issue with my own treatment. I'll go over a little background info before getting into my specific issue, but I am hopeful that somebody here can help point me in the right direction.

I am in my early 30s, working as both a Radiologic Technologist (current ARRT and OBMI), and as a soldier. I was a competitive athlete growing up and continued into my mid twenties when a military related injury sidelined me.

My injury was simple enough, a run of the mill ankle sprain sustained during a training exercise. My barracks were on the third floor and there was no elevator, so I was forced to hop up and down the stairs several times daily until my ankle recovered.
The ankle itself isn't the issue (that has long-since healed), but the repeated impact to my opposite leg is the suspected mechanism of injury for my lower back.

Fast forward several months, I began to realize that I could no longer sleep on my back without awakening to intense sciatic pain. Over time, this became more and more frequent and began to affect the opposite sciatic nerve as well. The pain is seldom bilateral, only occurring as such a handful of times in the 4 years that I have been dealing with this. I can squat heavy weight without pain, I run the ranger standard (5 miles in 40 minutes) without pain, and I am 5'10 at 175 pounds while maintaining ~8-10% body fat year round. I hit the gym 4 days each week, I run, bike, and hike frequently, and I am able to do most of this so long as I am careful with my selection of clothing. When my pain is flaring up, my current treatment ranges from Diclofenac Sodium, Voltaren gel, or cyclobenzaprine (if the pain is more mild) to a chiropractic adjustment (SI joint manipulation).

I cannot lay on my back, wear anything restrictive around my waist if I am going to be sitting or laying down at all (even basketball shorts/properly sized underwear are sufficient to cause pain), or even sit on a plush couch or chair. I have to sit with my hips at roughly a 90 degree angle with my core tensed, sleep on my stomach, and wear loose fitting sweatpants or pajama pants if I am not actively moving around. When walking/hiking/running, I can wear athletic pants, but am still unable to wear a belt (at waist level, my uniform belt sits higher and is not problematic), or anything fitted. The only exception that allows me to sit for prolonged periods on a bed or plush furniture, or lay on my back, is positioning myself so that my legs are both "pigeon toed" towards each other. So long as I forcibly hold this position, I can sit in pretty much any position without inflaming my back. The longest trial that I have run is around 90 minutes, anything past that is simply exhausting.

Recently (beginning around the end of 2018), I was finally about to get the VA to work with me and begin chasing the source of my pain. My first lumbar x-ray series showed a mild reduction of spacing at the L4-L5 junction, while oblique SI joint images showed no abnormality. I was able to secure an MRI, which came back normal as well. I have been through 3 rounds of PT with 3 separate providers, chiropractic care, and even acupuncture. Of the 3, chiropractic and acupuncture offered limited relief (Chiropractic manipulation of the SI joint in particular, while PT had no measurable impact. As a result of this trial and error approach, I was able to meet with a pain specialist who provided me with a series of diagnostic nerve blocks at the L4-L5 facets and bilaterally along my SI joints.

The diagnostic block was amazing - I wore my favorite fitted jeans with a leather belt, drove around and ran errands, then laid down and watched a movie with my wife. It was the one and only exception to my chronic pain in 4 long years. As soon as the meds wore off, my situation reverted to the status quo. This was the moment that gave me hope that I could finally return to something resembling normal.

As a result of this breakthrough, my pain specialist and I decided to go through with several Radiofrequency Ablation procedures - The first for my L3-L4 and L4-L5 facet joints, the second for my left SI joint, and the third for my right SI joint.
The results were not what we had hoped for - I had a localized loss of sensation (as was to be expected, a small price to pay), but no significant improvement in my symptoms. The specialist that I worked with suggested that the source of my pain is more superficial, before telling me that she is unable to perform an RFA procedure any closer to the skin than she already has. She suggested that I consult with a Neurologist, however I deployed shortly after that appointment and won't be returning to the states until the end of Winter.

I realize that this was rather back and forth, so hopefully I described my situation fairly well. At the end of the day, I'm just hoping that somebody here can point me towards a specialist or resource that may be of some help. I am developing issues with both shoulders and neck as a result of sleeping on my stomach for so many years, and am at my wits end.

Thank you!

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[pnphysio]

From your description of symptoms - who told you had sciatica? You have had many varied treatments - what kind of home program i.e. exercises have been given? This seems to present as a soft tissue or mechanical dysfunction. If so manipulation or meds would not be very effective. Discovering a muscle imbalance causing a mechanical problem might be the answer. You already stated how active you are without symptoms so that would be where to start. What does not hurt is as important as what does hurt. Are your hamstrings tight? Is there an abnormal tightness in your hip flexors? Is the a weakness or imbalance in the gluts or deep back muscles? these will all contribute to back pain, especially if the back pain is related to some other lower extremity injury.

[ultracarepro]

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