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.

ACL TEAR TREATMENT AND RECONSTRUCTION

The treatment options following an ACL tear are individualized for each patient depending on age, activity level, and the presence or absence of injury to other structures within the knee. In general, surgery is recommended for young patients who are active and for those in whom the ACL tear is associated with injury to other structures in the knee. Nonoperative (nonsurgical) treatment may be recommended in older or more sedentary patients.

The main reason to have surgery is to restore stability to the knee so it no longer gives out or slides too far forward, which is often painful. The other reason — perhaps the most important reason — is to protect the articular cartilage in the knee from being damaged. It is also important to protect the medial and lateral menisci in the knee.

The meniscus is a fibrous type of cartilage that sits between the ends of the tibia and femur, and is attached to the lining of the joint. There are two separate meniscal cartilages in the knee, each somewhat C-shaped: one on the inner half of the knee (the medial meniscus), and one on the outer half (the lateral meniscus). [Figure 1] The medial and lateral menisci primarily serve as shock absorbers between the ends of the bones to protect the surface or articular cartilage. With recurrent episodes of giving way, the meniscus can be damaged or torn, causing it to lose its shock-absorbing capability. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and “wears” away, leading to arthritis. Additionally, the articular cartilage may be directly injured or damaged with each episode of giving way.

Nonsurgical Treatment

Nonsurgical treatment consists of physical therapy, activity modification and use of a brace. The goal of physical therapy is to strengthen the muscles around the knee to compensate for the absence of the ACL. Specifically, strengthening the muscles in the back of the thigh (the hamstrings) is helpful. Activity modification can be very successful. Sports that do not involve cutting, such as jogging, cycling or swimming, can often be performed successfully.

In addition to therapy and activity modification, use of a hinged sports brace can be attempted. While bracing may be effective in some patients, in others, instability episodes may continue despite their use.

Surgical Treatment and ACL Reconstruction

Once the ACL tears, it has usually sustained enough damage that attempts to surgically repair it are not successful. Consequently, better results are obtained if the ACL is surgically replaced or reconstructed with another tendon from around the knee. [Figure 2]There are a number of surgical options for reconstructing the ACL. The type of procedure done may vary from patient to patient depending on a specific surgeon’s preference as well as factors unique to an individual patient.

The surgical procedure is most commonly performed using arthroscopic techniques. Using one or two small incisions on the knee, the graft is taken from the patellar tendon or hamstring tendons, and a tunnel is drilled into both the tibia and femur. The graft is threaded across the knee, leaving a piece of bone in each of the tunnels and the patellar tendon in the position of the original ACL, thus reconstructing the ligament. [Figure 2] The graft is then secured in this position, most commonly by “wedging” a screw between the side of the bone and the tunnel. [Figure 3] Alternatively, the graft can be secured by other techniques — staples, sutures, buttons, etc. These fixation devices are usually left in place permanently.

In addition to the ACL reconstruction, additional procedures may be done to other structures within the knee if injury is present. A torn meniscus can be either repaired or trimmed (meniscectomy), and other ligaments can be repaired or reconstructed as well.

Figure 3

Allografts most frequently used today are of the bone-patellar tendon-bone type or from the Achilles tendon at the heel, and come from cadavers that have been screened for infectious diseases, e.g., hepatitis and AIDS. The risk of AIDS from one of these grafts is not known, but it is generally believed to be one out of 1 million. All allografts are carefully screened and tested before they are used in surgery.

How long does rehabilitation take after surgery?

The exact course of therapy may vary somewhat depending on the specific type or reconstruction done, particularly if additional meniscus or ligament surgery was done. Physical therapy is done in a supervised setting in conjunction with a trained therapist. Early in the course of recovery, visits may be two to three times per week, but later, once every week or two is often sufficient. Home exercises are done on days not scheduled for a formal therapy session.

The rehabilitation following ACL reconstruction includes essentially three phases. The first phase of rehabilitation consists of controlling the pain and swelling in the knee, regaining knee motion, and getting early return of muscle strength. The operated leg is typically placed into a brace immediately after surgery.

Initially, weight bearing is allowed with crutches and is progressed to full-weight bearing independent of crutches as swelling, motion and muscle strength allow. Most patients are on crutches for one week, although some may be on crutches longer and some shorter. This phase typically takes six to eight weeks.

The second phase emphasizes recovery of full knee motion and muscle strength. Cycling, running on the treadmill and light jogging are started in this phase. In some patients, a sport brace is obtained to replace the postoperative knee brace. This phase typically lasts from two to four months after surgery.

The final phase consists of graduated return to full activity. Normal muscle strength, coordination and the absence of swelling are required for successful return to activity. A brace may be recommended early in the return to cutting and pivoting sports. This phase occurs at four to eight months after surgery, depending on the particular patient and the nature of his or her activities.

A patient’s rehabilitation is monitored closely by both the therapist and surgeon for evidence of potential problems. Most significantly, patients are cautioned not to attempt a too premature return to full activity, which may cause the knee to be inflamed or reinjured. In every patient, the graft must both heal into place and be incorporated into the knee. Too much stress too soon may increase the risk of graft failure.

What are the potential complications after surgery?

Most patients experience no complications and return to full activity between six and eight months after surgery. However, the most common complications include pain in the front of the knee and loss of knee motion.

Pain in the front of the knee occurs in 10 to 20 percent of patients. Fortunately, it can usually be controlled by modification in the physical therapy protocol. Loss of motion occurs in less than 5 percent of patients and is most common in patients with limited motion before surgery. In some individuals, intermittent pain and swelling occur with activity despite a successful ligament reconstruction. This is often related to the amount of meniscal or cartilage injury that was present and identified at the time of surgery.

In the absence of identifiable causes, a small percentage of patients will end up with a persistent detectable increased amount of motion in their knee (a “loose” graft). This may be related to stretching of the graft over time or due to an additional injury.

Will I be able to return to my previous sporting activities?

Approximately 85 percent of patients return to their previous level of activity without restrictions. In the other 15 percent, full return may be limited by a number of causes: pain, swelling, persistent laxity, change in lifestyle related to age, intentional choice or other unidentifiable causes.