Sciatic Pain

Hi folks,

My patient 37yr old male, v.keen golfer had a sciatic pain yrs ago, which settled quickly. Recently with no trauma, he got right sciatic pain, which is two pains, pain A and B. pain.A is on on his right bum cheek and pain.B on post thigh. no radiating pain under knee, no paresthesia of feet. The agg.factors are twisting and turning of spine, and when doing service in golf, tat rotn movt brings his pain. cough and sneeze. his x-ray is normal. he has no redflags, and no signs of ankloysing spondylitis/hip pathology.

On obj assessment, he has sway back, v.limited movt of his lumbar spine. he has very little isolated movt of lum spine. Pt acheives spine extension by flexing hip and knee. On palpn, the lumbar joints are v.stiff as if u push against a brick. Spinal ext reproduces his pain, and quadrant make it worse. He has v.tight hamstring and piriformis, which makes him naturally restricted sp.flexion. His dermatomes and myotomes are fine. He has a postive slr and slump test.

I am sure sc.n is irritated. I have treated with rotn,lat.flexion and pa mobs of lumbar spine. home prog, nerve gliding movts(david butlers), and flexion exercises, ql and piriformis stretches.

My patient reports of slight improvement of symptoms.My patient could cycle for miles with no pain, but when he twist he get tat sharp pain. he is not on any pain medications or amytripillin. he is nt off work. But he is still not hughely improved. My prob is how can i get him, back to golf. i feel manual therapy is only of short effect and is the stiffness is beyond its remit. Every time after manual therapy, his agg movts is making less painful, but no longlasting effect. I have advised the pt, to get onboard with home ex's. We are actually a bit stuck now.

i know it is muddled, Any suggestions will be deeply appreciated.

As he maintains his lumbar spine in an extension position and then trying to rotate in this extreme position he is stressing a certain motion segment. Teach him to play golf with a slightly flexed lumbar spine. As he develops a more neutral spine his ability to rotate painfree will probably improve. Mobs/manips will only have a short term effect (as in most cases of chronic problems from my clinical experience) if you don't address his habitual movement pattern first.

Hallamshire Physiotherapy

Perhaps consider core stability programme. As mentioned above, retrain and educate the patient's resting posture and movement pattern. Also rule out SIJ involvment as pain A and pain B could also be SIJ referred.

limit Sx Flexion, try to stretch the spine. then add core strengthening. Good flexibility and Good stability give good activity......

i have to say that you have not proved where the symptoms come from and the suggestions about treatment are moot. you have not shown in the symptoms are coming from the hip, SIJ, or lumbar spine. if the lumbar spine is tight then any of those structures could be too.

take an irritating movement and test it. for example, trunk rotate to cause irritation and have the pt stop just into the onset of symptoms. then, use unloading to see if it changes the pain. first, unload the hip (you will be kneeling next to the pt). put one hand on the anterior superior iliac spine and one on the ischeal tuberosity. push upward. if this decreases the pain then it is perhaps coming from the hip (which has been shown to radiate pain as far away as the foot in research studies). likewise, unload around the trunk which usually requires wrapping your arms around the lower rib cage. if this helps but the hip unload didn't then perhaps it means the pain is coming from lumbar or SIJ.

for SIJ testing Laslett 2005 (good testing cluster since any one test is a poor indicator).

if you aren't sure where it is coming from and the patient is tight mobilize one area: hip, lumbar spine, or SIJ. then retest him (standing trunk rotation sounds like a good one - remember, the hip is rotating with this). whatever helps decrease the pain go with it.

as for the previous lumbar treatment you haven't mentioned a hip flexor/iliopsoas stretch. i would include that if he is tight as well as a quad stretch. they are often overlooked.

Hello folks,

Let me thank all for your time.

Firstly to the notice of smshaffe, i cud see where u r coming from. i did mentioned that i have cleared his hip and SI jts. He got negative hip scour and SI Shear. I can reproduce his symptoms by adjusting his lumbar spine, and switch off symptoms by easing movts of lumbar spine. i know u mean by easing hip and si joints, and to check if tat eases symptoms. but as i say, his lumbar flexion itself eases his symptoms. He was never able to touch his toes, for a long time( tight hamstring++++). I will add hip flexor stretches, if needed.

If you look at him, he has sway back posture, there is no huge movt of lumbarspine on palpation, he also might be having some associated hip and SI stiffness, as said by sm shaffe. But i am trying to target the first tissue, which makes his symptoms, and also indeed to treat secondary impairments.

To Hallamshire, his symptoms are easily brought by spine ext and rot, when he does service during golf( i feel doing a quadrant action of lumbar spine, is the culprit). How much can he sustain symptom free, by keeping his spine on flexion when playing golf. specifically during service actions of golf. He only had two episodes of sciatic pain. this second episode is worse.

He is doing QL,piriformis stretches, pelvic tillts n gymball. He certainly feels an improvement, but no longlasting effect. He is labourer, not been off work so far. I agree with all you of compensatory impariments of hip and SI, but how can i ease his lumbar spine.

Thanks
Naveen

Hi there,

I highly recommend taking pictures and/or video of static postural stance, and then during golf swing.

Have the patient uncover themselves enough so that you can see trunk action, and hamstrings, and as many muscles as you can during this activity. You may be surprised by what you find. Then take the same golf swing and ask them to repeat it to their other side (obviously their weaker and perhaps less efficient side), but it will help spot any differences. You may find that along witht he stiffness in the spine, there is rapid contraction of the obliques which may be promoting spasm, or the lat dorsi, which is related across a muscular sling to the hamstrings.

Ideally, stiffness aught to be decreased, but in relation to the type of overload/activity the patient performs. As well this posture also need be taken in reference to the specific movement pattern as Hallamshire mentioned.

Regards

Hello there,

Hope you have had done screening for redflags. My response, from just from wat u said is; if you could produce pain by closing a joint( spine ext)--It may well be facetal stiffness. u also need to check for muscle tightness, QL,hamstring,piriformis. Other thing, you also you want to check, if any change in position or rest eases symptoms. If it is a stenotic pain, symptoms will ease on flexed position. Exclude vascular issues.

To be honest if i was in your case, i will do PA MObs on the stiff joints and Rotn mobs if needed and give Lum FlxN EX'S as home program. I knew this is a broad statement, i am jst telling an option. My understanding about sciatic pain, is looking for interfaces, it might be bony ( stiff lumbar joints, spondlyosis, spondylisthesis) or muscle imbalances( tight muscular structures) There is no box standard answers for sciatic pain, treat as you go.. Do update how u went on.
gud luck

Dear naveenedin

Thank you for this lovely post and well done for all your hard work with this client. may I just add to what has already been said so far...I more or less going to reiterate what everyone has said...

First of all, you didnt mention which rotation causes the pain left or right...also, does rotation to the contralateral side ease this pain even if its slightly...?
what about flexion and rotations? does this influence the pain...
also are his symptoms new? i know you said the problem was over a year ago? but has this just gradually worsened before meeting you or it went away and they suddenly came back? it is unclear when you say quickly settled and then he has right buttock and posterior thigh pain?
thirdly, does extension/turning bring the exact intensity of pain with the same referral even though you have treated? or is their any evidence of sacralization?
can this client extend better and rotate better?
what happens when he carries out the aggravating movements more slowly?

Symptoms you have described generally fit an extension-rotation impairment problem...and any of the spinal dysfunctions that will result in closure of posterior structures may be the cause as we all know...your facet joint problems, your large disc herniations, your degenerative spinal issues, spondylos etc
the problem for you is not reducing the symptoms however it seems its in maintaining whatever you gain in your sessions...

you seem to have done most of what needs to be done to be honest...

If the client cannot extend without pain or rotate without pain the travels the same distance then perhaps there isnt any change clinically...

I think the problem is your client is unable to maintain the right lumbopelvic relationship to keep the posterior structures open enough during extension and turning...

for this to happen we need range of motion and control

so yes you have mobilized with PAs and rotations but does that mean the vertebrae can move freely in rotation without constricting ? maybe not...maybe mobilization with movement is necessary, maybe muscle energy techniques may help to generally increase spinal ROM...he is 37, you have mentioned that x-ray is normal...by normal i presume all joint spaces are preserved with no real evidence of severe degenerative changes if any at all...

so flexion eases the pain and he can ride for miles...obviously because you are opening the posterior structures in flexion...yes, we need to give flexion exercises but the ultimate aim is to improve extension and rotation really, so maybe our management is not complete yet...
what happens when your client maintains a posterior pelvic tilt to the point of neutral and gradually extends his spine? does his pain lessen? what about when he does this and rotates...? does his pain lesson..?

if this is the case, your clients problem is with control and inability to recruit his spinal stabilizers when carrying out extension and rotation...

so yes he is doing all the right things but he needs to incooperate this into his activities of daily living with sound advice...for instance, you could advice him to always find that neutral spine before reaching up to th top cabinet in his kitchen...perhaps it is a good idea for him to come back with a list of activities that aggravates his back at ahome and at work...
if he is able to carry out these activities pain free...then you are on the right track...something that has been there for a year is not likely to clear quickly...

he should continue his pelvic tilts and flexion exercises...he should start spinal stabilization exercises in bed and using the gym ball...he can learn how to maintain that neutral spine in various positions, four foot kneeling, side lying, supine, sitting etc...he can gradually increase the time he is able to keep this position...his spinal stabilizers that have been switched off due to his initial back pain will turn back on helping to elongate his spine, this problem is neurally mediated...he can gradually include various activities maintaining this neutral spine...for instance...sitting, neutral spine and bringing knee up, or side lying , neutral spine and abduction or standing, neutral spine and upper limb elevation...
movements being slowly carried out to fully turn on these little muscles...

once he is able to extend his back with no pain, rotation can be added...all movements being slow...
you can gradually introduce him to activities that are similar to the movements in golfing...

The key to this clients maintenance is increase ROM and core stability...I agree most with Hallamshire Physiotherapy on this one