Lower Back Pain…Where is it coming from?

Lower back pain is a common injury seen at my practice, both in the sporting and non-sporting population. There are multiple pain producing tissues of lower back pain (muscles, facet joints, ligaments, fascia etc) however, two of the most commonly affected tissues are the disc and nerve. This short article should give you an idea of the difference in symptoms between the two structures.

What is the disc?

The Intervertebral Disc, is made up of two different tissues…On the outside, we have a thick, tough ring called the Anulous Fibrosus, and on the inside, we have a “jelly-like” material called the Nucleus Pulposus. The disc sits between two vertebral bodies and is not a true “joint”, but acts as more of a shock absorber and allows for one vertebra to move on another. I often tell my patients to imagine a thick layer of jam between two pieces of hard toast. If you squash the toast on one side, the jam gets pushed out the opposite side. For example, when you bend forwards, the jelly inside gets squashed and moves backwards, allowing the two vertebra to move, but not “collapse”.

The problem occurs when we put too much loading through the disc, and then force the jelly in a certain direction.  A typical example of this is when you bend over to move a heavy box and then you are unable to stand up straight due to the pain in your lower back. The position of the jelly combined with the added weight of the box causes the jelly to be forced backwards and it pushes into the outer ring (see images 1 and 2 below).

This is referred to as a DISC BULGE and can be compounded by a small amount of wear-and-tear of the outer ring (small tears and cracks with ageing). Symptoms of a disc bulge include a broad “band” of pain across the lower back (and sometimes into the buttock) as well as sharp pain with changing positions (sit to stand). Coughing and sneezing are often painful (due to the increase in abdominal pressure, pushing the disc material out further). Usually these disc bulges heal well with physiotherapy techniques (we try to gently squeeze the damaged tissue back in) and anti-inflammatories, and depending on the extent of the damage, can take anywhere from a few days to a few weeks to heal…

If the injury is more severe, we speak of a DISC HERNIATION (Image 3- it has now broken through the outer ring) OR DISC SEQUESTRATION (image 4- part of the jelly has “broken away”).   At this point, the inflamed disc and its material often starts to push on the nerve exiting the spine, and now we also have NERVE ROOT IMPINGEMENT.

This is usually accompanied by pain, numbness, weakness and pins/needles of the affected nerve root (pain usually radiates down a part of/or the whole leg), and the pain in the leg usually outweighs the pain in the lower back. These injuries take longer to heal and conservative therapy does have a high rate of recovery, however surgery is sometimes needed.

A nerve can also get trapped where it exits the spine through a little opening called the foramen. Generally this happens in older patients with arthritic degeneration, where the opening becomes narrower due to extra bone formation, enlarged joints and narrowed discs. This produces similar symptoms of pain, numbness and pins/needles but generally, the symptoms gradually appear and get worse with time.

Hopefully this helps you have a better understanding of whats going on in your back.

Ric@Physiopro

Im often faced with patients that are suffering from lower back pain for one or other reason. Part of my usual advice is on how to find a comfortable position so that you can get a decent nights rest…

Sleep is an integral part of the bodies ability to heal, so when you are being kept awake due to pain, you often feel worse, your nervous system is more “on edge” and you are generally more miserable from this.  As a result, you feel more pain and then cant get the sleep you need. Its quite a vicious cycle…

So to start with, the basic principles of getting some decent shut-eye is to place the least amount of strain on the lower back. By that i mean having the back in a “neutral” position where it is neither rotated nor over extended/flexed.

So here they are:

TOP LEFT- Lying on your side with a pillow between the knees. The height of the pillow does matter here. If you lay with both knees bent, then a small pillow should fill the “gap” between your knees, however if one knee is bent and the other is straight (TOP RIGHT), a bigger pillow is required. You could also place a soft pillow or rolled up towel under your side to fill the gap between hip and ribs.

Or try lying on your back with 1-2 pillows under the knees (BOTTOM LEFT). If this doesnt help alleviate your pain, then up to 4 pillows (BOTTOM RIGHT) can be used to get comfortable. This helps flatten the lower back and also reduces the stretch normally placed on a muscle connected to your spine (iliopsoas).

So there you have it, and I hope it helps you get a good nights rest!

Ric@PhysioPRO

Now before you start panicking, NO, we are not going to be doing the stretch you see above, but we are going to show you a REALLY important stretch…

Most people are aware of the importance of stretching, and we have covered the topic on the benefits of stretching in an older post that you can read here, but what I would like to focus on today is the importance of stretching your HIP FLEXORS. As a Physiotherapist, I consider this muscle group to possibly be the most important muscle group to stretch, as it not only affects athletic ability but also your posture, and subsequently, chronic pain.

First for some anatomy. Your hip flexors are comprised of 3 distinct muscles namely: Iliacus, Psoas Major and Rectus Femoris (bet you probably never heard of them?).

Iliacus and Psoas Major (often grouped together and called Iliopsoas) are pure hip flexors (bringing your knee to your chest), whilst Rectus Femoris is a hip flexor and knee extensor (as it crosses both the hip and knee joint).

If you have a look at the first picture above (left), you will notice that the Psoas muscle is attached to the lower part of your spine. Thus, if it is tight, it actually pulls your spine down and exaggerates the curve of your lower back (anterior pelvic tilt). Together with the other two muscles being tight, this can account for “hyperlordosis” and lead to lower back problems and pain.

So why do they get so tight? Surely if you are not exercising these muscle, there is no reason for them to become overly tight?

There are two main causes for this. Firstly, we sit way too much, and secondly, we all like to have a six-pack, so if we do get a few minutes to exercise, we tend to do sit ups…

Now I’ve said it before, “Humans were just not designed to sit all day long!”, so for the majority of people that sit most of their day, these hip flexor muscles are in their shortened position for hours on end, and as a result, they become shortened and tight. Then when you do finally stand up, they are “fixed” in this position.

The second point was on sit ups and most other stomach exercises. Most people don’t realize this, but if you do a standard sit up (i.e. lying on your back, knees bent and then curling your back to bring your chest to your knees), your hip flexors are doing about 70% of the work…. Whether you bring your chest to your knees, or your knees to your chest, its the same movement– HIP FLEXION! (on a side note, thats the reason a lot of people get lower back pain when doing sit ups-tight hip flexors).

So here come the Rescue Remedy:

Its called many different names, but we like to call it the PROPOSAL STRETCH- for obvious reasons

I teach 2 different ways of doing this, either as you see above (more effective as you are bending the knee as well, so you are also stretching Rectus Femoris), or by placing your back leg on a chair (below). If you are doing it right, you should feel the stretch in the front of your hip, and possibly also slightly on the front of your thigh. People that do a lot of squatting movements (Crossfit, gym, skiing etc), or lunges (squash, tennis etc) would benefit immensely from this stretch, as It could limit your ability to get into those positions.

Hold this for 30 seconds and repeat for 3 sets,  at least 2-3 times a day (more if you are sitting all day long).

Happy Stretching

Ric@PhysioPRO

Following on from Andrew’s last article on joint laxity, I expect many of you would have felt that touching your toes was impossible due to the pull in your hamstrings. But was it your hamstrings…?

Just like muscles get placed on stretch during certain movements, so too do your nerves. Very often, what we perceive to be the “muscle” pulling tight during a stretch, is often the nerve being stretched or “tensioned”. The ability of your nerve to tension to its normal length is referred to as Neural Mobility. A trained Physio will often test your neural mobility to detect if your symptoms are due to reduced movement/tension of the nerve.

Now before you do this next quick test, PLEASE READ CAREFULLY: If you have back or posterior thigh pain (or both) at present then avoid this test as it may flare up your symptoms. Rather go see a trained Physio who can assess the appropriateness of this test for you.

The SLUMP TEST

1) Begin by sitting on the edge of a desk or chair with your thigh fully supported by the desk/chair (FIG 1.1).

2) Place your hands behind your back, sit badly (get your shoulders down towards your hips, thus curving your upper back) and drop your chin to your chest by flexing your neck (FIG 1.2) *At this point, if you already feel lower back or posterior thigh pain, then STOP. That would be considered a positive test and you definitely have NEURAL TENSION**

3) With your neck still flexed, try straightening your ONE knee until you feel the tension/pain in your posterior thigh develop (FIG 1.3).

4) Now bring your toes up towards your head, by moving your ankle (FIG 1.4)

5) Keeping your knee, ankle and back in that position, look up at the ceiling (i.e. ONLY move your neck backwards- FIG 1.5)

6) What happened?

If the tension/pain at the back of your thigh got better when you looked up, that would indicate you do have NEURAL TENSION. Think about it, we didn’t move your leg, so if the tension/pain got better, it could only be related to something else-your nerve.

If there was no change to the symptoms with the neck movement, then your hamstring is most likely the culprit.

Now try it with the other leg. There could be a side to side difference.

So you had a positive test and have neural tension, now what? Its advisable to go see your Physio at this point so he/she can assess the extent of your symptoms and advise an appropriate stretching program. One exercise we at PhysioPRO recommend to try “lengthen” or loosen up the nerve is neural flossing/sliding.  We use a similar setup as above, however, we don’t  “tension” the nerve, but rather “floss” the nerve.

So start as per steps 1 and 2 (see image below)

Then, as you straighten your leg (step 3), SIMULTANEOUSLY extend your neck (step 5).

Do 10-15 repetitions per side, 2-3 times per day. This “flossing” technique has been proved to result in the greatest tensioning of the sciatic nerve in recent research, and is an effective tool at improving your neural mobility.

Once you have done your flossing, try stand and touch your toes again. If you had neural tension, you should notice a significant improvement now…

Happy Flossing

Ric@PhysioPRO

This one is mainly for the ladies, but given some of today’s men’s shoes (think Nike Air Max), guys listen up…

Lets start off by saying: Women’s legs look great in high heels, and ladies do love their heels, but from a bio-mechanical point of view, they are the devil! Apart from nasty looking toes and blisters, they are actually causing serious damage to your back, hips, knees and ankles.

Do this quick test- take off your shoes and stand sideways on to a mirror. Now go up onto your toes whilst watching yourself in the mirror. What you will notice is that your body moves FORWARD (because your centre of gravity also moves forward). To stop yourself from falling forwards, your lower back has to arch BACKWARDS (thus moving your centre of gravity back again). Net result, you are putting a lot of extra strain on your lower back…

It does’nt stop there though…Now that you are on your toes, your Achilles Tendon (and Calf muscle) is in it’s SHORTENED position, so over time, you get a shortening of this tissue and less ankle movement. As a result, you will very likely over-pronate (to try get normal ankle motion during walking) and that sets up a whole host of other problems (e.g. shin splints, knee pain, ITB etc…).

In our previous three part series on running barefoot we discussed how you should be wearing  thin, flat and very mobile shoes and this also applies for your everyday shoes.

So if you have been wearing heels a long time (or even a slightly elevated heel in the case of guys shoes) and want to start helping yourself out a bit, start doing these stretches for tight calf muscles and ditch the heels.

Also, please do your kids a favour and don’t let them get into these bad habits. I strongly recommend letting your kids run barefoot around the house as often as possible.

You evolved over millions of years to have Achilles tendons that allowed your heel to rest on the ground…don’t mess with Evolution!

As physiotherapists we often deal with a lot of myofascial problems. Most people understand the first part of this word i.e. Myo-referring to the muscular system but I want to explain the second component of this word a little better – Fascia – and its relevance to how your body functions.

Firstly – what is Fascia?

Fascia is a slightly mobile connective tissue spread throughout the body in a three dimensional web. It surrounds every muscle, every fascicle, every fibril (fibre) and every microfibril that make up your muscles. It mainly consists of collagen and elastin.

Think of your body’s fascial system as a multi-layered body stocking, with fascial sheaths wrapping the muscles and weaving in layers throughout the body. Because of this, stress in any area of the body has an effect on every other part of the body. The Fascia basically connects everything!

What does the Fascia do?

Fascia plays an important role in supporting, stabilizing and protecting the structures it surrounds. In other words, it provides postural balance. The Fascial system conveys mechanical information via tension and compression and has a role in cellular nutrition. The deep fascia also provides a surface area for muscles attachment.

 In its optimal condition, fascia is a loose, moist tissue. When there is continual loose movement and balance in the body, the fascial body stocking stays loose and mobile, facilitating movement between different parts of the body.

However, under continual stress (caused by poor postures and mechanical forces exerting abnormal tension on muscles) as well as lack of movement, fascia becomes rigid and loses its fluidity causing muscle undernourishment. Layers of fascia begin to stick to one another, causing the “knots” you may have experienced in your muscles (trigger points). The sheaths of fascia stick in a systematic way, based on your habitual patterns of movement, or for some, lack of movement.

Therefore Myofascial release aims to reverse myofascial deformation and re-open the tissue to increase the fluid flow to affected areas (restore the viscosity of the tissue), muscle function and improve motor and sensory input. It is also very important to decrease the abnormal pull (stress) on the myofascia to correct altered joint alignments.

As you can see the fascial system plays a major role in muscular injuries and pain and if overlooked by your therapist could contribute to recurring and prolonged aches and pains.

Andrew@PhysioPRO

So as promised, following my last article “Sitting posture and (D)evolution of man”, here are a few stretches that you can do at your office or home to help loosen up those stiff muscles affected by poor sitting posture.

Please note that these are general stretches for people without neck or lower back pain. If you are already suffering from pain,  you should rather consult your physio before attempting any of these stretches.

1)Neck Retractions- Whilst sitting upright, try bringing your chin in, towards your neck.

You want to imagine that you are trying to make the back of your neck get longer (as if someone is pulling you up by your hair), whilst still looking forwards. If you are tight, you may feel a stretch at the base of your skull. Hold 10 seconds and repeat 10 times

2) Neck flexion stretch- First retract your neck as shown above. Then, whilst still holding your chin tucked in, grab the top of your head using both hands and gently pull down.

If done correctly, you should feel the whole back of your neck getting stretched. Hold 30 seconds and repeat 2-3 times.

3) Seated rotations- Whilst sitting, turn to your right. Use your right arm to grab the back of the chair. Place your left hand on your right knee and then gently pull. Hold 30 seconds and repeat to the other side

4) Seated back extensions- Interlock your fingers behind your head. With your elbows pointing upwards, towards the ceiling, extend your upper back and try push your elbows further back. Hold 30 seconds and repeat 5 times.

5) Side stretch-This stretch targets those tight muscles on the side of your neck (scaleni and upper fibres of trapezius) where most of us feel “knots”.

Whilst sitting, grab the seat of the chair with your left hand (this stops your left shoulder from lifting up). Bend your neck to the right side as shown, and using your right hand, gently assist the stretch to the right.

You should feel a stretch down the left side of your neck. Repeat to the other side, holding each stretch for 30 seconds.

NB-If you feel pain on the right hand side whilst bending to the right, then please STOP, and consult your physio.

6) Corner chest stretch-this stretch can’t be done in sitting, however it is one of the most important stretches to do as it stretches your chest, the culprit for your rounded shoulders.

As shown, stand facing a corner and place your elbows at about 90 degrees, forearms resting against the wall. Then step forward with one leg and allow your chest to fall in, towards the corner. You should feel a stretch in the front of your shoulder and into your chest. Hold 30 seconds and repeat 2-3 times.

7) Lying McKenzi stretch- The last stretch I want you to do is one we often use in Physio to help people with lower back pain caused by a disc problem.

You should start by lying on your stomach with your arms at your sides. Gently push up onto your elbows at first, and allow your lower back to completely relax. Repeat 8-10 times.

As the stretch improves, you might be able to lock your elbows out as shown in the picture, but do this slowly as sudden extension may cause some pain.

This stretch also targets your hip flexors (front hip muscles) which get shortened over time by sitting.

NB-If you have pain referring down your leg/s or into your bum then please stop and see your physio

So there you have it, a few stretches to get you going and hopefully reverse some of your poor posture. You should try aim to do these stretches at least once a day (even if its not all of them at once) and the more often you do them, the less painful and more flexible you will become.

Ric @PhysioPRO

FACT: Human beings were not designed to sit for hours on end…

Sitting posture is a constant topic that raises its “crooked” head up at nearly every physio appointment. Why? Well because as physiotherapists, we are constantly battling the negative effects of sitting for hours on end.

The human spine is divided into 4 distinct curves: neck (cervical), middle (thoracic), lower back (lumbar) and sacrum. These curves are designed to distribute the load that gravity places on the spine (like a spring), absorb shock and obviously allow movement.

The problem with sitting is that these curves are “imbalanced”. The neck and middle back curves become exaggerated and the lower back’s curve is almost completely lost (see pic above).  This results in adaptive muscle shortening or stretching, depending on which side of the curve we look at. This then translates to poor standing posture and difficulty with functional movements, with the end result being an injury. So what im trying to say is the way you sit at your desk could very well be the reason why you pulled your hamstrings whilst you were running….

Another scary fact is the amount of pressure that you place on the discs (the “cushions” between the vertebras). As you can tell from the diagram above, the difference in pressure between standing and forward lean sitting (i.e. sitting on the edge of your chair leaning forwards) is an ASTONISHING 90% increase!!!! That’s the equivalent of having someone with your own body weight standing on your head!!!

So what can you do if you are one of those office bound monkeys? Well, start off by assessing your posture by comparing it to the “ideal” posture below. Make changes where you can and stick to those. You can have the most expensive “ergonomically” designed office chair, but if you’re not sitting in it properly it’s worthless.

Secondly, STAND!!! Every 30-40minutes, get up and walk around, or if you have some privacy try stretching a bit. Try standing whilst you talk on the phone or walk over to that colleague to deliver a message rather than sending an email.

Look out for my next article on some of the stretches you should be doing at the office or home to improve your posture.

Regards

Ric@PhysioPRO

I thought I would just share  a neat little trick that I teach most of my patients to manage their own muscular issues. Its so easy and effective that most of my patients end up saying ,”Why didn’t I think of that??”.

All you need is a wall or floor and a tennis ball….Place the tennis ball against the wall or floor (depending on the area you are treating) and then find that knot (trigger point) with the ball. Now apply pressure to the area using your body weight.

You want to apply a even steady pressure at first, till you feel a moderate ache and hold it there. You should feel it easing off after 30-45 seconds, so either push harder or find a new spot. If you feel up to it, you could even rub up-and-down or side-to-side over the ball to free up that tissue.

Whats so great about this technique is that YOU can decide how much pressure to apply and the ball never gets tired (unlike your partner). This also works great for loosening up stiff muscles after a heavy training session. Just make sure you are not doing this with an acute muscle tear (i.e. a “pulled” hamstring) as it could cause further damage.

So there you have it, your very own “physio” that fits in the palm of your hand and you can even take him on holiday with you…

Ric@PhysioPRO