Lower back pain

[scarletblue]

Hi
I was involved in a work related accident 7 months ago while assisting an injured colleague. A heavy box fell from above, landing on my head, causing me to land with a thump on my hip and falling into metal shelves. I suffered whiplash and continue to receive physio, acupuncture and more recently Short Wave Diathermy (trochanteric bursitis /right leg). The physio is concentrating on my lower back and trochanteric bursitis. I now have accupuncture privately for continual neck pain and spasms and tingling in my right arm.

In the past three weeks the lower back pain has increased quite dramatically and on two occasions I have been reduced to kneeling on the floor on all fours. This followed my lower back 'collapsing'. It was like that feeling you get when someone bumps the back of your knees, when you legs go from under you, only it was my lower back. It can take me about half an hour to get the courage to attempt movement and straighten up afterwards. Ironically after the first time my back felt great with no pain. However this has happened again and I am now experiencing pain in my left buttock, thigh and my shinbone when sitting - but now all on my left side, where I've never had any trouble. It is not so bad when I'm on my feet, but when rising from a sitting position, I struggle initially to straighten up.

The trochanteric bursitis in my right leg has improved greatly and the relief between sessions is increasing, however it all seems to have moved to the other side now.

I also purchased a 'Tens' machine for pain relief. I try to avoid prescribed pain relief (Diclofenac, co codamol, Voltarol Emugel), taking it only when I'm desperate. I also use a heated wheat pack.

Can anyone offer any advice. I have a lovely physiotherapist, but I seem to be getting worse instead of better.

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[physiofi]

First of all, sorry to hear you've had what sounds like quite a nasty injury. It's quite common after a trauma (be it a fall or car accident/injury) for things to take a while to settle, unfortunately.

With regards to your neck, are you doing any exercises or things at home aside from the heat / TENS, or just having acupuncture? Is the acupuncture helping with your pain levels in your neck?

Have you had any x-rays or investigations done? I take it from your post that your back pain has been mainly right-sided and is now coming on on the left? Have you ever had leg symptoms prior to these incidents where your legs gave way? Generally, backs don't "give way" the same way legs do when injured...and with most people, it's the excruciating pain that causes your legs to give way, however, it sounds like there is a neural element with regards to the pattern of symptoms you're describing (alternating left-right sides and buttock/thigh/shin pain).

Are you getting any pins and needles / numbness / tingling in your legs or feet? No numbness or pins and needles around your groin? The leg symptoms to me sound like sciatica (is the pain coming down the back of your thigh?). Sciatica can be due to a number of factors....there is a muscle in the buttock (called piriformis) which runs over the sciatic nerve, so if this is irritated/injured or tight, it can cause sciatica symptoms (pain radiating from your buttock into your leg). Is the buttock pain less after a hot shower/bath?

If you have any concerns, I'd definitely discuss with the physio. Bear in mind, most back pain does settle itself eventually, but it sounds like you've bad luck with this injury (with regards to neck/bursitis and back) so give it some more time and if the pain is agonising, take some painkillers to give you some relief.

[scarletblue]

Hi
Thank You so much for your reply.
- I continue to do the neck exercises given to me by the physiotherapist, which have worked well for movement, however I am still experiencing pain between the shoulder blades and up into the back of my head. I am told these are typical symptoms of chronic whiplash and I could have them for sometime. The acupuncture takes the edge of the pain.
- I have had no x-rays, although immediately following the accident, I was seen by a consultant orthopedic surgeon who did a thorough examination of my neck and was satisfied there was no need for further investigation. This was also the case for the head injury. However since then, I took myself off to a chiropracter for an assessment. He examined my neck and also mentioned 'chronic whiplash' and 'pinched nerve'. What he did recognise though, was that the pain in my hip/leg (right side) was coming from my lower back, which then led to further investigation by the physio department, who have said that there is a weakness in my right side. I have a series of exercises that I do as often as I can, usually several times a day, these include pelvic lifts, leg movements and ensuring good posture. The good posture I have found difficult since having the two recent episodes of spasm ? in my lower back, as sitting brings on pain. I took up yoga, but found it difficult, I swim three times weekly which has helped. As well as the short wave diathermy, the physiotherapist works on the lower back, short sharp presses, which I don't feel helps much to be honest.
- No pins and or needles in the legs or feet. The pain is in the lower back, into the hip, top of the thigh where the leg meets the hip (front) and the shin (this is only when sitting), it is all to the front of the leg. The pain in the back is relieved after a warm bath, but the pain in the buttock, shin and thigh only happens when I'm sitting, it feels like sitting is causing it!!
I have been doing really well, the pain was definately improving and still is in my right side, but it all seems to have shifted to my left side, which has until now given me no trouble. I can't help but think I have maybe did some damage while sleeping or maybe overdone the exercises. I am due to see my physiotherapist again on Monday, this is after a two week break (because I had been doing so well) !!! She'll have a fit!! Very Many Thanks for your advice.

[physiofi]

Firstly, the pain you're feeling at the front of your upper thigh/hip and leg could well be referred pain from the trochanteric bursitis. This can be tricky to settle down but it sounds like the pulsed shortwave is working for you - just give it a bit of time. With regards to the buttock pain, I'm tempted to say it may be piriformis syndrome (where the muscle in your buttock gets tight and presses on the sciatic nerve causing pain which can radiating down the leg - sciatica).

To test this theory, have a prod of your buttock when the pain comes on (or even at rest or in a position where you're not sitting or don't have the buttock/shin/thigh pain). Difficult do I know, but if you palpate the buttock on the affected side (left is your buttock pain right?). Have a good feel of all the muscle - put quite firm pressure on. If this reproduces the pain you get when sitting or it feels sharp and uncomfortable when doing this, it's likely piriformis is responsible! Popping a heat pack on and having some friction massage/trigger pointing done to the area will help to force the muscle to relax and ease the pain. (can give further info on this if you find that's relevant)

Sounds like there's definitely an issue with your back - in that your other symptoms seem to be stemming from it. In my experience, although people want a definite diagnosis, this is usually impossible to give and pinpoint one particular structure most of the time. I'd keep going with good posture, heat and gentle back mobilising exercises to maintain the movement in your back. Remember that the exercises shouldn't be causing you agony, but don't worry as some discomfort and pain when doing them is likely due to the fact this problem has been going on for some time - you're not going to do any damage to your back by doing the exercises. If you have any queries or are unsure you're doing an exercise correctly - definitely discuss with your physio as they can advise you and adapt any if necessary.

As far as your neck pain goes - I really can sympathise. I had a whiplash injury last February which I am just about fully recovered from although still getting intermittent pain in my neck. Keep going with the heat pack and do your neck exercises regularly - the chin tuck (retraction) exercises are really good, and it is important to move your neck throughout its full range to stretch any scar tissue and reduce stiffness, even if it is sore and painful. Posture is also really important! So no slouching and sitting with a rolled up towel as a lumbar support in the small of your back will help to keep your posture tiptop. What about your sleeping position? I always used to sleep on 2 pillows and on my stomach with head turned to side but after my whiplash injury I found this aggravated my neck pain too much, so I reduced to 1 pillow and now sleep side on (I know this isn't do-able for you on your trochanteric bursitis side) or flat on my back in order to keep my neck in better alignment. Just something to think about if your pain is worse in the morning or you have difficulty sleeping.

Whiplash is a tricky one and can generally just take a long time to heal up and recover from. Persevere with the exercises and you will see an improvement. How often are you doing your neck exercises? I'd advise little and often throughout the day (at least 3-4x if you can) and not spending too long in one position. Exercise is great too as endorphins are your body's natural painkillers and will make you feel better/help reduce pain.

Edited to add: shoulderblade pain and radiating up into head is also common, as you were told. Sometimes this can be due to tight muscles in the back of the shoulders/lower neck (upper fibres trapezius). Not sure if you're doing a stretch for this, but I find it's a common one to be tight even in people who don't have neck injuries due to poor posture at desks/in general. To stretch the muscle, sit in an upright position and drop your left ear to your left shoulder as far as you can - try not to let your right shoulder hitch up (you can put your right hand under your thigh to increase the stretch). You should feel the stretch down the side and back of your neck, from the base of your skull to the upper part of your shoulder. Hold for about 20-30 seconds and repeat 3x each side.

[scarletblue]

Thank You for a very thorough and detailed response. Much of what you have suggested I am presently doing, although there are a couple of things I will give a go.

I have did as you suggested and had a good prod at my buttock and the pain is reproduced, so I think I've now got a name for it. I am due to see my physiotherapist tomorrow and will discuss this with her. I am presently sleeping on my front, (which is quite unnatural for me) as there is no other position offers me any comfort. I do the pillow thing and the rolled up towel, I think you physiotherapists know all the tricks!!! I am extremely grateful for your advice, it certainly puts my mind at rest. I will continue to keep up the exercises and fingers crossed all will become well.

[physiofi]

Wishing you a speedy recovery - let us know how you get on.

[nmarman]

physiofi is right about most parts of your condition.

Giving way is a sign of knee or hip instability but can also be a sign of back instability with scoliosis.

With your traumatic history and age you are a good candidate for X-ray.

A long story short you are not getting any better and no one knows why, any good practitioner would be asking for extra imaging to either confirm or rule out other diagnosis. Ask your GP for X-ray of the Lumbopelvic and Thoracic spine stating that both acupuncture and physio have offered only limited relief. alternative ask you chiropractor to take the x-rays as chiropractors are trained in musculoskeletal radiology, they should have equipment on site.

Other wise is sounds like you might have had a disc lesion in lumbar region possibly central disc bulge. This would have lead to instability making it hard to recover from treatment alone. to define this a MRI would be the best possible examination.

A history of desk bound occupation or multiple children - would decrease you abdominal/ core strengths making you a slow recovering patient. given the giving way it is apparent that the muscles are failing to provide stability at the moment purchase a good strap, let pain disparate and stop the pain cycle then exercise in water until you feel confident again.

GET EXTRA IMAGING!!

[scarletblue]

Hello nmarman
Thank You for your response. I met with my physiotherapist yesterday and updated her on all recent events. She continues with short wave diathermy, and has suggested we meet more often to 'keep an eye' on the other issues. After a thorough examination, she believes I have a trapped or pinched nerve, and while the matter has not resolved, she considers that as there has been some improvement 'we'll wait and see'. She has suggested additional exercises to increase abdominal/core strengths which is what you have mentioned.

I agree with you regarding further investigation and have suggested an MRI, but GP dismissed it. My visit to a Chiropractor was at my own expense, to allay some concerns I had. It was during this visit that it was recognised that I had an issue with my hip and not sciatica as had been diagnosed.

I have been a civil servant all of my working life, so sitting at a desk is an occupational hassard, I also have 3 children (all adults now). Since the accident, I have not been very mobile, I am usually quite active, hill walking, cycling and swimming but this has not been possible although I still swim. I could believe that my lack of exercise is not helping my situation, but I'm never sure what to do for the best.

I will take your advice and in the first instance arrange a further appointment with the Chiropractor and arrange some x-rays. If anything untoward shows then I'm armed with some evidence to produce to my GP.

You will probably have gathered that despite this being a work related accident, I have made no compensation claim, otherwise I'm sure all of these MRI's, x-rays etc would have been done long ago.

Many Thanks for your advice, I will keep you all posted.

[physiofi]

Hi scarletblue,
Glad to hear how things are progressing for you. Nmarman's advice is good, however, I'm assuming you are having treatment on the NHS? MRI would not be indicated based on your symptoms as they are not severe enough to indicate any serious underlying pathology (not saying that an x-ray shouldn't be done), but just that the treatment is likely to be the same, regardless of whether you have further investigation or not and should all be based on your symptoms, rather than the imaging. Some people can show up as very degenerative and may look very bad on x-ray but in reality have little pain or no pain whatsoever, whereas some individuals will have near-normal looking x-rays or minimal degenerative change, but can have very severe pain levels or decreased function.

Definitely continue with physio and I highly suggest piriformis stretches and heat to your buttock to relax the muscle spasm (although there's obviously an element of irritation coming from your lumbar spine/lower back, this is likely making it worse).

[scarletblue]

Hi physiofi
Thank You again for your input to this long going saga. I am sitting here on a hard backed chair in my dining room, with perfect posture and a hot wheat bag tucked into my jammies keeping my buttock warm and toastie, proof that I am practising what you are preaching, so Thank You. I do believe as you say that there is some ongoing issue with my lower back. The physiotherapist whom I see (NHS) concentrates on the very bottom of my back (below my waist), where she feels 'there is not a lot of flexibility'.

The chap who does acupuncture on my neck (private treatment), has listened with great interest to my woes. He suggested I may benefit from 'Visceral Manipulation', something I discussed with my physiotherapist, but she doesn't know much about it. I did 'google' it, but am no better informed. I did learn that in this area it is physiotherapists who practice it. Any opinions?

[physiofi]

I have no idea about VM I'm afraid - perhaps someone else can advise on this. Have you tried TENS for pain relief? or had any hands-on mobilisations to help your neck? I find a gentle self-mobilisation technique quite helpful when my neck pain onsets or I wake up with a lot of stiffness/headache. If you roll a towel so it is long and thin and you can grip both ends in your hands, wrap the towel around your the middle of your neck (more towards the base). Looking straight ahead, with your hands pulling the towel quite taut and making sure your hands are level with your eyes, keep your chin tucked in and slowly look back towards the ceiling. At the same time, pull upwards with your hands following your eyes to keep a gentle pressure on your neck as you're moving. Try doing about 10 of these slowly and then re-check your neck movement (do whatever movement usually causes pain) to see if it has eased at all.

Some gentle piriformis stretches can be found here - they will be painful but it's important to stretch the muscle in order to reduce the buttock pain and leg symptoms (if these are coming from piriformis being irritated) Piriformis Stretches - Spinal Health Care

[scarletblue]

Hi - Yes I use TENS for both neck and back. I sleep with a rolled up towel behind my neck, but I will certainly try the exercises. Thank you also for the link for the piriformis stretches, my shinbone is particularly painful at the moment, so I'll give them a go before bed.