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.

UNDERSTANDING BALANCE

Balance is a complex process involving the reception and integration of sensory input and the planning and execution of movement. It’s the ability to control the center of gravity over the base of support in any given sensory environment. Reflexes are automatic responses by the peripheral or central nervous system to help support postural orientation and maintain balance; they occur rapidly enough to not be under volitional control.

Balance is a result of the interaction of three separate systems in the body:

• The Visual System, which helps us see things in the environment and orient us to the hazards and opportunities presented.
• The Vestibular System (the inner ear), which provides the brain with information about the position and motion of the head in relation to gravity.
• The Proprioceptors/ Somatosensory Receptors which are located in joints, ligaments, muscles, and the skin to provide information about joint angle, muscle length, and muscle tension all of which is gives information about the position of the limb in space.

The brain needs input from all three systems to distinguish motion of the self from motion of the environment. Any mismatch in these inputs can produce nausea, vomiting and dizziness. Some common examples that we all experience are

• The sense of perceived motion when sitting in a car at a stop light and the car next to you creeps forward, causing you to slam on your brakes
• When on a boat, proprioceptors perceive a rocking boat under your feet, but your eyes see a steady horizon.

More long-term complications with balance can make an affected person feel persistently unsteady or dizzy. In fact, as many as four out of ten Americans will at some point experience an episode of dizziness significant enough to send them to a doctor. These issues can be caused by improper function of the systems mentioned above, health conditions, or as a side effect from some medications. In severe forms, a balance disorder can intensely impact day-to-day activities resulting in an inability to function and cause psychological distress.

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.