POSSIBLE CAUSES OF THAT PAIN IN YOUR BUM

Sciatica is one of the most common diagnoses that we see in physical therapy. But what exactly is sciatica and how do physical therapists treat this complex diagnosis? The simple answer is the treatment is all dictated by the source.

Generally, Sciatica is a term that is commonly used to describe pain, weakness, numbness, or tingling that radiates down the back of the leg. Typically, the symptoms follow the distribution of the sciatic nerve, but there can be some confusion as to the source of the pain especially when the patient’s symptoms are referred. Our job as PTs is to determine the source of the nerve irritation or referral origin and treat it accordingly. This is often accomplished with a thorough musculoskeletal exam and typically without the need for costly medical imaging. Alongside misalignment caused as a result from weak musculature of the hip, below are the most common causes of sciatica seen in PT and how we typically treat them.

1. Disc Herniation:

The most common source of sciatica is pressure on the sciatic nerve from a herniation or protrusion of a spinal disc. This pressure on the nerve can create an irritation and inflammatory response causing symptoms to radiate down the leg following the path of the nerve that is compressed.

What can physical therapy do to help patients with sciatica caused by a disc herniation?

• Studies have shown that patients respond well to repetitive lumbar range of motion in improving sciatica symptoms related to lumbar disc herniation. Typically the direction that most patients report relief of their symptoms is lumbar extension. However, a thorough physical therapy assessment will help decide a patient’s specific “directional preference”.
• Core stabilization exercises in conjunction with lumbar range of motion are also effective at reducing sciatica symptoms. PTs tend to focus on strengthening the transversus abdominis and gluteal muscles in both static and dynamic activities.
• Patient education is probably the most important component of the rehab of disc herniation. Patients are educated on proper sitting and standing postures as well as proper body mechanics with lifting activities to avoid causing further disc herniation.

2. Stenosis:

Narrowing of the space where the spinal cord or nerve roots exit the spinal canal is called stenosis. If the space is narrowed, that can create pressure on the cord or the nerves causing pain to radiate down the leg.

Stenosis is typically seen in a condition called degenerative disc disease. Our discs are located between the bony vertebrates and over time they can start to lose some of their height. This loss of height causes the narrowing of space seen in stenosis.

Another cause of stenosis is tiny little bone spurs called osteophytes that can form in the spinal cord or nerve root space.

What can physical therapy do to help patients with sciatica caused by stenosis?

• Our goal in PT is typically to help improve ROM in the lumbar spine to help open up the narrowed space. Patients with stenosis often respond well to lumbar flexion or bending exercises, which is in contrast to the lumbar extension exercises often seen in disc herniation. However, a thorough physical therapy exam will help determine the appropriate stretches/range of motion exercises.
• As with disc herniation, core stabilization and posture/movement retraining are important for patients with sciatica caused by stenosis.
• Functional dry needling (i.e. Trigger point dry needling) is also very effective for patients with lumbar stenosis. By using tiny, hair thin needles, we can quickly decrease the muscle tightness of spinal muscles, resulting in decreased compression of the lumbar vertebrae. We will discuss dry needling more in the last section.

3. Piriformis Syndrome:

Deep in your buttock/gluts is a muscle that runs diagonally from the outside of your hip to the lowest part of your spine. This muscle, called the piriformis, can get short and tight or even be in spasm. In 85% of the population, the sciatic nerve runs just beneath the piriformis and in the other 15% it runs through the muscle. The sciatic nerve can become compressed and irritated when the piriformis is taught or in spasm creating symptoms of sciatica down the back of the leg.

What can physical therapy do to help patients with sciatica caused by piriformis syndrome?

• Typically, a physical therapist will prescribe a thorough home exercise program that includes stretches for the piriformis, hamstrings, and glute muscles (see linked video for example of a piriformis stretch).
• Sciatic nerve glides/flossing can be effective at getting the sciatic nerve moving again if it is trapped by the piriformis, especially in conjunction with the stretches above (see linked video for example of a sciatic nerve glide).
• A common theme with all of the causes of sciatica is core stabilization. Core and glute strengthening exercises will help to reduce the demands put on the piriformis muscle with daily and recreational activities (see linked video for an example of a core exercise).
• Trigger point dry needling has also been found to be very effective at quickly reducing the tension of the piriformis.

7 EXERCISES YOU CAN DO NOW TO SAVE YOUR KNEES LATER

1. You have healthy knees – and you’d like to keep it that way. That’s not a job you can tackle sitting down, though getting into a 90-degree position could help. First, though, you’ll want to heed a simple but central lesson roughly adapted from age-old song lyrics: “The hip bone’s connected to the knee bone.” Physical activities that strengthen your hips, quads, calves, and ankles are also good for your knees, while weakness in any of those areas can increase knee strain and risk of injury. So think “holistic” leg health.

2. Indelicate squat discussion first. You’re going to be doing that kind of loading on the knee joint just to get on and off the toilet. It’s important to do exercises that prepare the knee for regular day-to-day activities. Squatting really affects all the muscles around the knee joint, including strengthening the muscles around the knee joint. Haven’t done squats in a while – or ever? Start by doing at least 8-12 reps with just your weight, going down to just above 90 degrees, or right at 90 degrees if you don’t have any discomfort, injuries or issues that prevent that. Alternative: try leg press if you have back problems or other issues preventing you from doing squats.

3. Like squats, lunges can also be an excellent exercise to improve strength in your quads and butt o help support your knees. With both exercises, he notes, make sure you’re in good position – feet firmly planted. So that you’re not coming too far forward and putting more stress on the joint. Talk to your doctor before doing lunges if you’re concerned about a preexisting issue, like osteoarthritis or a knee injury, to keep from exacerbating it.

4. Whether you’re familiar with step-ups or not, you get the general idea. You’re lifting your body weight using one hip, one leg to get that weight, like you’re going up the stairs. Keeping the hip joint muscles strong and well-conditioned along with muscles around the ankle strong and well-conditioned will help minimize the risk of injury at the knee joint. To get started with step-ups, place your foot on a high step, weight bench or plyo boxes, so that your leg is bent at about a 90-degree angle. Then bring your other foot up onto the surface. Repeat for 12-15 reps, and add weight as you’re able.

5. A weak back and stomach can put extra stress on the joints that support your body. A good core strengthening program is important and paramount to the health of your knees, hips, and lower extremities. It’s important to do plenty of back and abdominal strengthening exercises. A range of activities can help in core strengthening, experts say, while improving flexibility, balance, stability, which are also protective of joint strength.

6. Running has taken a pounding for the pounding it can take on the knees. For most people, it’s a safe activity. It’s easy, low cost, and we’re all designed to run for the most part. IT’s just being smart about what you can tolerate. That goes for not ramping up too quickly to longer distances or pushing through the pain of an injury – and taking time off to heal as needed. While some who have arthritis in their knees are still able to run, experts say it’s important to talk with a physician about any existing knee issues to determine what’s safe, including when walking might be more appropriate.

7. Whether you’re biking with friends or riding alone, racing the clock or just catching a cool breeze, taking to two wheels can strengthen your quads and calves – and even improve overall leg strengthening to bolster the knee health. Cycling is also a low-impact activity. The circular, rhythmic pedaling is easy on the knees and it can provide a great aerobic workout to boot.

8. Though many do just fine running on a treadmill, trying alternating an elliptical machine for an aerobic workout that works the legs while being easy on the knees. With your foot planted against a platform, there’s not repetitive impact that leads to the degredation of cartilage over time. And! It can help maintain muscular endurance.

9. While certain exercises target muscles are the joint, at the end of the day any strength training or aerobic exercise that helps you maintain a healthy weight reduces pressure on your knees. When you stand on one foot, 5-8x your body weight goes through your knee joint. If you gain 5 pounds, that’s an extra 25-40 pounds of pressure going through your knee joint. If for no other reason, exercise to keep your weight in check to decrease the stress on joints. That goes for knee-friendly exercises ranging from the elliptical machine to cycling, experts say, and anything else that gets you moving. 

ARE YOUR HIPS SNAPPING MORE THAN YOUR FINGERS?

What is Snapping Hip Syndrome?

Snapping hip occurs when a muscle, tendon, or ligament rolls over a bony prominence in the hip. Snapping hip can occur in different areas of the hip:

• Front. Snapping at the front of the hip can involve the hip flexor muscle rolling over the front of the hip bone, or the hip ligaments rolling over the thigh bone or tissues of the hip joint.
• Side. This condition involves the ITB (iliotibial band) rolling over the outer thigh bone or the big muscle on the back of the hip (gluteus maximus) sliding over the outer thigh bone.
• Back. This condition involves one of the hamstring muscles rolling over the bottom of the hip bone.

Snapping hip can occur when the hip muscles are excessively used and become fatigued, tight, and/or swollen.

Athletic activities like track and field, soccer, horseback riding, cycling, gymnastics, and dance can trigger the condition. It can also occur during everyday activities that require repeated forceful movement of the legs.

How Does it Feel?

Snapping hip causes a snapping sensation and sound that can be felt in the front, the side, or the back of the hip. Often, the snapping can be pain-free. If it causes pain, the pain usually ceases when the leg movement causing the snapping is stopped. In athletes and dancers, the snapping can be accompanied by weakness and may diminish performance.

The snapping is most commonly felt when kicking the leg forward or to the side, when bringing the leg behind the body, when rising from a chair, or when rotating the body or the leg.

Often, walking and running in a straight line are snap-free and pain-free, although in some people these activities are limited by the pain of the structure that is snapping.

Signs and Symptoms

With snapping hip, you may have:

• Snapping or popping in the front, side, or back of hip when lifting, lowering, or swinging the leg
• Weakness in the leg when trying to lift it forward or sideways
• Tightness in the front or back of the hip
• Swelling in the front or side of the hip
• Difficulty performing daily activities such as rising from a chair and walking

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will ask you:

• How you injured your hip and if you heard a pop when you suffered the injury
• If you feel snapping, popping, or pain
• Where you feel the snapping or pain
• If you experienced a direct hit to the leg
• If you saw swelling in the first 2 to 3 hours following the injury
• If you experience pain when lifting your leg forward or backward, walking, changing directions while walking or running, or when lifting the knee
• If you participate in any repetitive, forceful, or plyometric (quick explosive jumping) sport activities.

Your physical therapist also will perform special tests to help determine whether you have a snapping hip, such as:

• Asking you to lift your leg quickly
• Asking you to push against the physical therapist’s hand when he or she tries to push your leg outward, backward, and forward (muscle strength test)
• Gently feeling the muscle to determine the specific location of the injury (palpation)

Your therapist may use additional tests to assess possible damage to other parts of your body, such as your hip joint or lower back.

To provide a definitive diagnosis, your therapist may collaborate with a physician or other health care provider. The physician may order further tests—such as an x-ray or magnetic resonance imaging (MRI)—to confirm the diagnosis and also to rule out other potential damage. However, these tests are not commonly needed for snapping hip syndrome.

How Can a Physical Therapist Help?

Your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should perform at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may advise you to:

• Rest the injured hip by avoiding walking or any activity that causes pain. In rare cases, crutches may be recommended to reduce further strain on the muscles when walking.
• Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
• Consult with another health care provider for further services such as medication or diagnostic tests.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electricity, taping, exercises, and special hands-on techniques that move muscles and joints (manual therapy).

Improve Motion

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with movements of the leg and hip joint that the therapist gently performs, and progress to active exercises and stretches. Treatment for snapping hip often involves manual therapy techniques called trigger point release and soft tissue mobilization, as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your injury at each stage of recovery, and your physical therapist will choose and teach you the appropriate exercises that will restore your strength, power, and agility. These may be performed using free weights, stretchy bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For snapping hip syndrome, muscles of the hip and core are often targeted by the strength exercises.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport, as well as design your plan of care to help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work retraining activities. Athletes will be taught sport-specific techniques and drills to help achieve sport-specific goals.

Prevent Future Re-injury

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core (abdomen) to help prevent future injury. These may include strength and flexibility exercises for the hip, thigh, and core muscles.

If Surgery Is Necessary

Surgery is rarely necessary in the case of snapping hip syndrome. If it is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Snapping hip syndrome can be prevented by:

• Warming up before starting a sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including those for the muscles on the front, side, and back of the hip.
• Gradually increasing the intensity of an activity or sport. Avoid pushing too hard, too fast, too soon.
• Following a consistent strength and flexibility exercise program to maintain good physical conditioning, even in a sport’s off-season.
• Wearing shoes that are in good condition and fit well.