Tell someone you have sciatica and chances are they will know you have shooting leg and buttock pain. Tell someone you have piriformis syndrome and they don’t know what you’re saying.
The term “Sciatica” is so over used and common that to some people the first sign of buttock pain automatically means it is sciatica. The term sciatica is more of a description than a clinical diagnosis but it is so common doctors have accepted the term and use it freely. “Sciatica” is actually an irritation of the sciatic nerve. This large nerve runs from the back through the buttock muscle and continues down into the back of the leg, splitting when it gets to the back of the knee cap. True sciatica is irritation of this nerve. The nerve can be irritated by joints in the low back, a disc herniation, or a muscle entrapement. Each one of these scenarios has its own proper clinical term which accurately defines the reason for the “sciatica”.
When the sciatic nerve becomes entraped in the piriformis muscle the resulting pain is called Piriformis Syndrome. Piriformis syndrome, in addition to causing gluteal pain that may radiate down buttocks and the leg, may also present with pain that is relieved by walking with the foot on the involved side pointing outward. This position externally rotates the hip, lessening the stretch on the piriformis and relieving the pain slightly. Piriformis syndrome is also known as “wallet sciatica” or “fat wallet syndrome,” as the condition can be caused or aggravated by sitting with a large wallet in the affected side’s rear pocket
There are several ways a doctor or chiropractor can assess where the sciatic pain is coming from. Often that means ruling out conditions like joint problems, disc herniations, spinal stenosis and lumbar muscle strain and performing tests that stress and stretch the piriformis muscle.
Below are a few of the tests for piriformis syndrome:
Freiberg’s maneuver of forceful internal rotation of the extended thigh elicits buttock pain by stretching the piriformis muscle, and
Pace’s maneuver elicits pain by having the patient abduct the legs in the seated position, which causes a contraction of the piriformis muscle.
Sciatic notch tenderness elicits pain by manual pressure on the sciatic nerve where is exits at the back bony pelvis (ilium bone) and passes under the piriformis muscle.
Dr. Beatty, in a 1994 journal article, proposed another test, where the patient is lying with the painful side up, the painful leg flexed, and the knee resting on the table. Buttock pain is produced when the patient lifts and holds the knee several inches off the table. It relies on contraction of the muscle, rather than stretching, which the author believes better reproduces the actual syndrome.
Recently I had a patient come in with a 15 year plus complaint of chronic low back pain, with associated posterior thigh and buttock pain. However the patient also stated he has constant numbness in the front outside area of his thigh. The thigh wasn’t painful it just felt numb all the time. The man was middle aged and obese with a large protuberant abdomen wearing his jeans low and belted under his belly.
After the history and physical exam I diagnosed the numbness in the thigh as Meralgia Paresthetica.
What is Meralgia Paresthetica?
It is a mononeuropathy (injury to one nerve) which causes numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a peripheral nerve that travels from the spinal cord to the thigh. This nerve is called the lateral femoral cuntaneous nerve.
The nerve most often becomes injured by entrapment or compression where it passes between the upper front of the hip bone (ilium) and the inguinal ligament near the attachment of the anterior superior iliac spine (the upper point of the hip bone). Less commonly it could be entrapment by other muscles or structures like the psoas muscle or the tensor fascia latae, or damaged by diabetic or other neuropathy.
What the causes of Meralgia Paresthetica?
The most interesting aspect of meralgia paresthetica is the multiple different causes. MP has been reported to be caused by obesity, pregnancy and compression from tight pants, belts, uterine fibroids and tumours. Furthermore, MP can be due to direct trauma, like seat belt incidents, surgery complications and even associated with disorders such as diabetes and leprosy. Recent reports have also surfaced regarding MP being caused by exercise or even prolonged periods of standing that increase compression on the inguinal ligament.
The Pelvic Compression Test
Nerve conduction studies can often help confirm one’s diagnosis but aren’t easily accessible to manual therapists, like chiropractors. The following is a fairly new test which can be used by manual therapist to help diagnose Meralgia Paresthetica
This test is based on the premise the LFCN is compressed by the inguinal ligament and by relieving this compression symptoms will temporarily be alleviated. With the patient focusing on their symptoms the examiner attempts to apply a downward and lateral compressive force on the pelvic. The pressure is held for 45 seconds and a positive result is when patients report an alleviation of their symptoms. By compressing the pelvic in this manner the two attachments of the inguinal ligament are brought closer together causing the ligament to become slacker.
Conservative manual therapy from a chiropractor or other trained manual therapist should be tried before seeking drugs or surgery. A chiropractor can manually release (or stretch) the muscles and ligaments that may be entrapping the lateral femoral cutaneous nerve. Soft tissue therapy such as Active Release Techique, Graston therapy, or deep tissue massage may provide relief of symptoms. However proper education and at home advise must be followed to ensure the benefits of in clinic treatment have a longer lasting effect. Chiropractic assessment of the pelvis and ilium bone can detect any bony misalignments where adjustments may have an effect. If conservative treatment is not effective speak to your medical doctor about other options like NSAIDs for pain, or surgical nerve block or release.
Shimizu, S. (2008). A Novel Approach to the Diagnosis and Management of Meralgia Paresthetica Neurosurgery, 63 (4) DOI: 10.1227/01.NEU.0000325683.55646.90
Dr. Wayne Button DC. Sports Injuries and Wellness Ottawa.
As a Chiropractor, I often get ask questions from parents of autistic children on how a chiropractor can help?
During my time at the Canadian Memorial Chiropractic College, I had the opportunity to intern at the Muki Baum Treatment Centre for children with complex disabilities, in Toronto, ON. At Muki Baum, the staff understood the importance and could see the benefits that chiropractic care had on these children, many of whom had autism. After treatment, teachers would report improvement in mood and attention levels, less aggression and more tolerance to physical stimulation and touch. In fact, chiropractic re-assessments showed improvements in physical strength, balance, mobility and coordination.
The importance of chiropractic care is essential to children with disabilities. These kids often have hypotonia (low muscle tone), poor posture, decreased body awareness and as a result have more pronounced musculoskeletal problems such as restrictions on movement and stiff joints. Furthermore autistic kids are often have sensory stimulus deficits, either hypo (too little) or hyper (too much) sensitive. Receiving the proper chiropractic adjustments can be like hitting the information reset button on the nervous system. Either calming or turning up the nervous system when the body requires.
Children with developmental disorders can benefit from chiropractic treatment focused to improve joint mobility, gross motor training, core muscle strengthening, vestibular (balance) exercise and sensory stimulation. However, chiropractic care is only part of the treatment puzzle. Other avenues of care including biochemical, nutritional, cognitive and emotional components should be addressed to offer the best possible outcome for the patient.
Positional plagiocephaly is the medical term for flattening of the skull bones due to pressure on the back of the babies head. Torticollis is the term for to muscle tightness and decreased range of motion in the neck. These two conditions are often present together in infants. Torticollis is typically there since birth and as the infant grows the head and neck movement has some restriction on turning to one side and there is a preference to keep the head tilted to one side more than the other. The muscle and joint restrictions in conjugation with pressure on the back of the baby’s head can lead to positional plagiocephaly.
Many times, infants will need an evaluation by a pediatric chiropractor who can assess muscle tone as well as joint placement. The chiropractor can treat the infant as well as teach the parents neck stretching exercises to do at home. If torticollis is not treated, it will make the decrease the success of improving the positional plagiocephaly.
Over the years there are been a dramatic increase in the number of babies with flat heads. In the 1970’s doctors reported seeing 1 in 300 infants with this condition and now it is more like 1 or 2 in 10 babies.
So what are we doing that our parents didn’t?
This flat head pattern is linked to the “back to sleep” movement that encourages parents to put infants on their backs to sleep as a way to protect babies from Sudden Infant Death Syndrome. While SIDS deaths have decreased the plagiocephalgy has increased. A small price to pay for reduction in SIDS.
Car seats and swings
The technology, comfort and style of new travel systems available today enable parents to easily transport their sleeping baby from his car seat to the stroller back the car seat and home without disturbing the precious little one’s sleep. However, this trend is a contributor to positional plagiocephaly. Think of the time spent during the day where the infants head is in contact with the back of a car seat or bouncy swing
Lack of touch
Babies left in car seats or swings are being deprived of the ultimate comfort and warmth of their parents. Think of the potential for interaction and stimulation your baby is missing out on by being in the carseat during family visits or out shopping. Babies who were transported in a soft wearable baby carrier were significantly more likely to show a strong bond of attachment to the parents than those left in a car seat or swing during activities.
Plagiocephaly is more than just comestic
A new study says that up to one-quarter of babies with flat heads may have “disadvantaged” motor skills compared to babies without flat heads. It may be that these flat headed babies will simply catch up at one year of age with they are sitting up and moving but pediatricians should monitor closely the development of infants with this condition.
What you can do at home
Frequent changes in your child’s position are recommended to improve your baby’s neck mobility and prevent or treat abnormal head shaping and torticollis. Most importantly try to limit the time the baby has pressure on the back of the head while he is awake. Below are some tips.
- If your baby is diagnosed with plagiocephaly, ask the doctor to screen for developmental delays in both motor and cognitive skills. Talk about the results.
- Always place babies to sleep on their backs: this remains the safest way to sleep. Place your baby’s head at one end of the crib and switch to the other end the next night.
- Encourage active supervised ‘tummy time’ when babies are awake: find ways to for baby to engage, play and move while on their tummy, several times each day building up from just one to two minutes at the beginning. Tummy time will help improve your child’s muscle and strength and development.
- Alternate the end of the changing table in which you place your infant’s head and stand to the side to encourage your baby to move his head. Also perform neck-stretching exercises at each diaper chance, as prescribed by your doctor.
- Choose different positions and ways for babies to play and be held: variety of stimulation is important. Switch the arm you use to cradle your baby each feeding session; right one time, left the next.
- Use strollers, car seats, infant seats, bassinets, cribs and play pens when necessary, but remember that babies need frequent lap time, cuddling, active play times and chances to move that aren’t limited to being in stationary positions.
- Invest in and learn to use a good quality soft baby carrier to transport your baby when outside of the car. The soft malleable material will exert less pressure of the baby’s head and the practice of baby wearing will strengthen the parent child bond.
- Develop motor skills: play with babies to get them moving. Encourage crawling, rolling, reaching, pushing, pulling, holding, grasping.
- Develop cognitive skills: play with babies to get them thinking and talking. Encourage interactions with their environment, looking, listening, imitating, babbling, singing, talking, reading.
LITTLEFIELD, T., SABA, N., & KELLY, K. (2004). On the current incidence of deformational plagiocephaly: An estimation based on prospective registration at a single center Seminars in Pediatric Neurology, 11 (4), 301-304 DOI: 10.1016/j.spen.2004.10.003
Speltz, M., Collett, B., Stott-Miller, M., Starr, J., Heike, C., Wolfram-Aduan, A., King, D., & Cunningham, M. (2010). Case-Control Study of Neurodevelopment in Deformational Plagiocephaly PEDIATRICS, 125 (3) DOI: 10.1542/peds.2009-0052
I often recommend Yoga to my patients as an excellent way to strengthen and relax the body and mind. I fully believe it is an excellent practice but as a health professional I must ensure the safety and well being of my patients so I have the research to back up my recommendation.
Research into yoga for back pain
A literature review done in 2007 found three published randomized controlled studies evaluating the effectiveness of yoga for low back pain (LBP) and one feasibility study. All 3 studies found yoga to be beneficial for low back pain.
Galantino et al., in 2004 studied the effects of a modified yoga protocol on patients with CLBP (chronic low back pain). 22 subjects were randomized into 2 groups including 11 in the yoga group and 11 in the control group. The yoga group received 1 hour session twice weekly for 6 weeks and asked to practice as often as possible throughout the week. Results were not powered for statistical significance (small group sizes) but the potentially important trend appeared of decreased depression and improved flexibility and balance in patients with CLBP undergoing a yoga intervention.
In 2005 Williams et al., evaluated a lyengar yoga intervention where the yoga group received a 90 min class weekly for 29 weeks and patients were encouraged to practice yoga at home for 30min, 5 days per week. The control group received periodic educational material as well as two 1-hr lectures. The authors of this study concluded yoga therapy could significantly reduce disability and pain and decrease use of medications in patients with CLBP.
Sherman et al., conducted an RCT in 2005 to compare yoga classes to conventional exercise and self care books in patients with LBP. 101 Participants were randomly assigned to one of the three interventions including 36 participants to the yoga class, 35 to the conventional exercise class, and 30 to the self-care book. The authors concluded that yoga was more effective than a self-care book in reducing pain and improving functional status in patients with CLBP. Furthermore, they stated these benefits appeared to persist for at least several months after intervention. On the other hand, while the yoga group consistently reported superior outcomes compared to the exercise group, none of these differences was statistically significant. Finally, the authors noted the yoga intervention was safe and had moderately good adherence. In conclusion, the authors suggested that the Viniyoga style of yoga was an effective and safe treatment for patients with nonspecific CLBP.
Take home points:
- Yoga can be an effective management tool for people suffering with low back pain
- Yoga can decrease pain, disability, and medication use as well as increase flexibility
- Patients and practionner should understand that differently styles of yoga exist and some may be better suited for low back pain than others.
- Patients should be directed to seek out experienced instructors who have worked with low back pain patients in the past.
Sorosky, S., Stilp, S., & Akuthota, V. (2007). Yoga and pilates in the management of low back pain Current Reviews in Musculoskeletal Medicine, 1 (1), 39-47 DOI: 10.1007/s12178-007-9004-1
Approximately 80 per cent of Canadians will experience back pain at some point in their lives. Add this to our stressful schedules and work-related back injuries, and we have a virtual back pain epidemic.
Back Pain 101
Our inactive lifestyle is damaging our backs. Many of us spend our days driving or hunched in front of computers, often without any postural support. Studies show that sitting places significantly more pressure on the joints and discs of the spine than either standing or walking. After all, our bodies were built to move!
We spend upwards of $21 billion annually on back pain products, including over-the-counter pain medication. Yet, amazingly, most people wait up to six months to seek treatment, while 30% do nothing at all in the hope that the back pain will eventually go away. Nearly a third of back pain cases last longer than a month and a significant portion become chronic and persist for months to years.
Research suggests that back pain treatments are most effective in the acute and early stage, and that the longer the problem is allowed to linger, the more difficult and lengthy the healing process may be.
Doctors of chiropractic are specialists, who provide drug-free, hands-on treatment that targets the source of pain. Studies show that chiropractic treatment is increasingly recognized as one of the safest and most effective solutions for most back pain sufferers.
Are you holding back from taking charge of your back pain? Click HERE to take an online quiz from the Canadian Chiropractic Association to find out!
I was out last evening at an event in Oakville and a woman I was speaking with told me her story of how a chiropractor, after several painful months seeking help from any and all types of doctors, diagnosed her with Polymyalgia Rheumatica (PMR). We discussed her condition and I thought it would be an informative blog topic.
How common is PMR?
Polymyalgia rheumatica (PMR) is a common disorder in the elderly population. It is rare in people younger than 50 years of age. The overall incidence in the general population ranges from 20 to 50 new cases per year per 100 000 people, with a four fold higher risk of women being affected compared to men. However the incidence is often underrated because it occurs in the elderly and physicians may mistake the symptoms for simple aches and pains of aging. When in fact a simple blood test showing elevated ESR can lead to a diagnosis.
The typical presentation of a person with recent onset of PMR would generally be pain in the neck, referred pain in the shoulders down to the elbows, and referred pain in the hip region down to the thigh; the pain is generally worst at night and in the early morning. Morning stiffness and limited range of motion of the upper and lower extremities are also frequently reported. The pain of PMR is usually felt on both sides of the body but in some cases it may affect a single side. Problems performing morning activities are frequently reported because such activities depend on functionality of the shoulder and hip girdle. These symptoms of PMR are often accompanied by anorexia, weight loss, fever, fatigue, depression and night sweats.
The diagnosis of polymyalgia rheumatica is based upon recognition of a clinical syndrome, consisting of pain and stiffness in the shoulder and pelvic girdle, muscle tenderness of the upper and lower limbs and nonspecific somatic complaints. In addition, an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentration, and joint effusion as shown by ultrasound or MRI, are hallmarks of the diagnosis of PMR.
Corticosteroids are the gold standard for treatment. Most patients when properly diagnosed have an excellent prognosis and resolution of symptoms shortly after beginning corticosteroid treatment. Proper monitoring and doses of the drugs is important as there are many known side effects of prolonged use of corticosteroids such as; osteoporosis, diabetes and infection.