Back Clinic Severe Back Pain Treatment Team. Severe back pain goes beyond the pain that is above the normal sprain and strain. Severe back pain requires in-depth assessment due to the cause/s or ideology that is not easily diagnosed or apparent. This requires additional diagnostic procedures in order to determine the cause of the severity presentations. Nociceptive and neuropathic pain can be further broken down into acute and chronic pain, which differ in form and function.
With acute pain, the severity of pain depends on the level of tissue damage. Individuals have a protective reflex in avoiding this kind of pain. With this type of pain, there is a reflex to pull back quickly after moving or being in a certain position. Acute pain can be a sign of injured or diseased tissue. Once the problem is cured the pain is cured. Acute pain is a form of nociceptive pain. With chronic pain, the nerves continue to send pain messages after the earlier tissue damage has healed. Neuropathy falls into this type.
The thoracic spine, also known as the upper or middle back, is designed for stability to anchor the rib cage and protect the organs in the chest. It is highly resistant to injury and pain. However, when thoracic back pain does present, it is usually from long-term posture problems or an injury. Thoracic back pain is less common than lower back and neck pain, but it does affect up to 20% of the population, particularly women. Treatment options include chiropractic for quick and long-term pain relief.
Thoracic Back Pain and Soreness
The thoracic area is vital for various functions related to:
Upper back pain usually feels like a sharp, burning pain localized to one spot or a general achiness that can flare up and spread out to the shoulder, neck, and arms.
Types of Upper Back Pain
These include:
Myofascial pain
Spine degeneration
Joint dysfunction
Nerve dysfunction
General spinal misalignments
Depending on what specific tissues are affected, pain can occur with breathing or arm use. It is recommended to have a healthcare professional perform an examination and get an accurate diagnosis. A chiropractor understands the delicate balance and functions that the thoracic spine provides and can develop a proper treatment plan.
Chiropractic
Treatment options will depend on the symptoms, underlying dysfunctions, and individual preferences. Recommendations for treatment often include:
Spine adjustments to improve alignment and nerve integrity.
Posture training to maintain spinal alignment.
Therapeutic massage.
Exercise training to restore muscular balance.
Non-invasive pain-relieving techniques.
Health coaching.
Body Composition
Plant-Based Diets for Weight Loss
Individuals who follow vegan, vegetarian, and semivegetarian diets have reported and shown they are less likely to be overweight or obese. This can indicate that reducing intake of meat and animal products is beneficial for weight loss. Studies have found that individuals who follow a vegan diet may lose more weight than individuals on a more conventional weight loss diet, even with similar calories consumed, and often have significant improvements in blood sugar and inflammation markers.
Plant-Based Protein and Muscle Gain
Some plant-based proteins are just as effective as animal protein at promoting muscle gain. A study found that supplementing rice protein following resistance training had similar benefits to whey protein supplementation. Both groups had:
Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
Cichoń, Dorota et al. “Efficacy of Physiotherapy in Reducing Back Pain and Improve Joint Mobility in Older Women.” Ortopedia, traumatologia, rehabilitacja vol. 21,1 (2019): 45-55. doi:10.5604/01.3001.0013.1115
Fouquet N, Bodin J, Descatha A, et al. Prevalence of thoracic spine pain in a surveillance network. Occup Med (Lond). 2015;65(2):122-5.
Jäger, Ralf et al. “Comparison of rice and whey protein isolate digestion rate and amino acid absorption.” Journal of the International Society of Sports Nutrition vol. 10,Suppl 1 P12. 6 Dec. 2013, doi:10.1186/1550-2783-10-S1-P12
Joy, Jordan M et al. “The effects of 8 weeks of whey or rice protein supplementation on body composition and exercise performance.” Nutrition journal vol. 12 86. 20 Jun. 2013, doi:10.1186/1475-2891-12-86
Medawar, Evelyn et al. “The effects of plant-based diets on the body and the brain: a systematic review.” Translational psychiatry vol. 9,1 226. 12 Sep. 2019, doi:10.1038/s41398-019-0552-0
Newby, PK et al. “Risk of overweight and obesity among semivegetarian, lactovegetarian, and vegan women.” The American journal of clinical nutrition vol. 81,6 (2005): 1267-74. doi:10.1093/ajcn/81.6.1267
Pope, Malcolm H et al. “Spine ergonomics.” Annual review of biomedical engineering vol. 4 (2002): 49-68. doi:10.1146/annurev.bioeng.4.092101.122107
Individuals with ankylosing spondylitis have a new treatment option that was previously used for rheumatoid arthritis. It is a medication that belongs to a class known as JAK inhibitors. Ankylosing spondylitis combines joint pain with reduced mobility. Ankylosing spondylitis is different because in severe cases, the bones in the spine can fuse together, literally reducing mobility.
The disease typically begins with pain and stiffness in the back. This is usually after some time of inactivity. Symptoms start before the age of 45 and develop gradually. There is no cure for ankylosing spondylitis but there are treatments that can improve symptoms and put the condition into remission. Ankylosing spondylitis treatment is the most successful when addressed early before irreversible damage to the joints begins.
Janus Kinase Inhibitors
Janus kinase inhibitors have traditionally been used to treat:
Rheumatoid arthritis
Psoriatic arthritis
Ulcerative colitis
The medication works by decreasing the immune system�s activity. Janus kinase inhibitor drugs affect several cellular compounds that are important in the development and progression of ankylosing spondylitis. Currently, there are only three Janus kinase inhibitor medications available in the United States and FDA-approved to treat rheumatoid arthritis:
Xeljanz
Rinvoq
Olumiant
Each of the approved inhibitors targets specific enzymes
Current Ankylosing Spondylitis Treatments
Janus kinase inhibitors are not given to individuals right away. However, it could be an option if first and second-line treatments are not working. Treatments usually consist of:
First-Line Treatments
NSAIDs
Nonsteroidal anti-inflammatory medications are the most commonly used to treat ankylosing inflammation, pain, and stiffness.
Chiropractic
Chiropractic physical therapy is a major part of ankylosing spondylitis treatment keeping the spine flexible and as healthy as possible. A chiropractic/physical therapy team design and develop specific exercises to fit individual needs, which include:
Stretching and Range-of-motion exercises help maintain flexibility in the joints
Sleeping and walking posture adjustment exercises
Abdominal and spinal exercises to maintain a healthy posture
If nonsteroidal anti-inflammatory medications do not relieve symptoms, then biological medications could be prescribed. This class of medications includes:
Tumor necrosis factor blockers work by targeting cell protein that is part of the immune system, known as tumor necrosis alpha. This protein causes inflammation in the body, and the blockers suppress it.
Interleukin 17 Inhibitors
Interleukin 17 in the body’s immune system defends against infection. It uses an inflammatory response to fight infections. The IL-17 inhibitors suppress the inflammatory response and help reduce symptoms.
Other Treatment Options
Lifestyle Adjustments
Following a medical treatment plan is often combined with diet and lifestyle adjustments that are recommended to help with the condition, these include:
Most individuals with ankylosing spondylitis do not require surgery. However, a doctor could recommend surgery if there is joint damage, the hip-joint needs to be replaced, or if the pain is severe.
Inhibitor Potential
Studies are ongoing in the treatment of ankylosing spondylitis. The drug is currently in Phase 3 trials for the treatment of adults. The trial results have shown patients with active ankylosing spondylitis showed improvement in:
Fatigue
Inflammation
Back pain
The study enrolled adults with active ankylosing spondylitis who took at least two NSAIDs that were ineffective at treating symptoms. Most of the participants were men, average age of 41, and no prior usage of biologic disease-modifying antirheumatic drugs.
Janus kinase could become a standard treatment
There is still not enough research to make a prediction, but the data is promising. The inhibitors seem to be a safe option when used in a properly screened, well-matched setting that includes regular monitoring. The inhibitors appear to be effective and have the advantages of being taken orally and working fast.
Body Composition
Osteoarthritis and weight loss
Being obese has shown to be a high-risk factor for the development of osteoarthritis. This is not only from the effects of extra weight on the body’s joints but also as a result of the inflammatory effects of adipose tissue. The lower back, hips, and knees, bear the majority of the body’s weight.
An excess amount of adipose tissue on the body’s midsection and legs has been shown to negatively impact the weight-bearing joints. Promoting Lean Body Mass and encouraging weight loss lowers the risk of osteoarthritis and improves an individual’s quality of life. Exercise is regarded safe for individuals with osteoarthritis and should be incorporated to improve body composition, reduce Body Fat Mass, improve Lean Body Mass and maintain a healthy weight.
Dr. Alex Jimenez�s Blog Post Disclaimer
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*
Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
References
Hammitzsch A, Lorenz G, Moog P. Impact of Janus Kinase Inhibition on the Treatment of Axial Spondyloarthropathies. Frontiers in Immunology 11:2488, Oct 2020; doi 10.3389/fimmu.2020.591176.�www.frontiersin.org/article/10.3389/fimmu.2020.591176, accessed Jan 21, 2021.
van der Heijde D, Baraliakos X, Gensler LS, et al. Efficacy and safety of filgotinib, a selective Janus kinase 1 inhibitor, in patients with active ankylosing spondylitis (TORTUGA): results from a randomized, placebo-controlled, phase 2 trial.�Lancet.�2018 Dec 1;392(10162):2378-2387. doi: 10.1016/S0140-6736(18)32463-2. Epub 2018 Oct 22. PMID: 30360970.�pubmed.ncbi.nlm.nih.gov/30360970/�accessed Jan 19, 2021.
There are a variety of products and gadgets that claim to provide quick fast acting back pain relief. Here is a little information about which deliver and hold up to their claims. Back pain stops us in our tracks and we want relief fast. Other than taking pain meds, most of us want a way to achieve natural relief. That’s where back pain products and gadgets come into the picture.
For the most part, a lot of the gadgets online, even expensive ones don�t necessarily provide the back pain relief that most of us are expecting. This means they don’t remove the pain completely and life goes back to normal. These are made for temporarily relieving pain when symptoms present and through consistent use to strengthen, lengthen,� and stretch out the sore muscles, ligaments, tendons, etc, in a preventative fashion.
We are not knocking these products/gadgets, as we use these ourselves. But remember these are tools that are made to help out with back pain conditions, just like the tools chiropractors, physical therapists, massage therapists utilize in their practices. That being said this article is to help you make wise decisions about which back pain gadgets can help.
Posture Training/Trainers
These are wearable sensors that vibrate when you begin to slouch, sway forward, hunch over, etc. The pain-relief claims that slouching puts a strain on your spine and that improving posture will help prevent strain and pain.
While this is true what the experts thought about this product was that, while it does help maintain proper posture it is not meant to relieve immediate pain, but rather to re-train your body in maintaining good posture. Therefore pass on this product if your goal is back pain relief.
Slouching places added stress on�the lower back that leads to strains and back pain. These devices can be helpful, just be aware to not hold yourself in an abnormal position causing more problems.
If poor posture contributes to your back pain, try these:
Exercise, specifically movements that strengthen the core
Wear comfortable shoes with low heels
Foot orthotics
Balance make sure your head is not too forward
Dr. Jimenez adds that if you exhibit constant poor posture, consult a spine doctor or chiropractor to see if it is a structural issue.
Transcutaneous Electrical Stimulation
The QUELL�TENS transcutaneous electrical stimulation is a new brand unit that is worn on the calf. The pain-relief claims that it sends out safe electrical pulses that trigger the body’s natural pain relief response. The QUELL can help and is just like most other TENS units.
These units activate opioid nerve receptors, which is one of the reasons they provide pain relief. You can get them for under $50 at drug stores and online. Instead of being applied directly to the sore areas,�it’s worn on the calf and operates on the same TENS principle.� The cost currently is around $300. However, with any TENS unit, be aware that there can be a�relief tolerance that builds up and eventually might not work anymore. TENS units work well, but they�re best used in a physical therapist�s/chiropractic clinic because individuals can become habitually used to them.
Percussive Massager/s
This is a handheld massager that generates pulses of deep pressure along with strong vibrations to loosen and release tight areas. The pain-relief claims that it is similar to a deep tissue massage. These work and do help ease pain symptoms, but are not like a real therapeutic massage. There is limited research on these products but most state that percussive/vibrating massage tools, that can cost hundreds of dollars, could be a little better than a traditional massage for relieving muscle soreness. This has yet to be determined.
High-force massagers could exacerbate or cause further/new injury/s other than muscle soreness when used by untrained individuals. However, in a professional clinic setting research suggests that high vibration applied to the back is an effective physical therapy for low-back pain.
Low-Level Laser Therapy
Low-intensity light therapy is used in treating neuropathy pain. The principal is that it triggers biochemical changes in the cells. The pain-relief claims that it reduces inflammation alleviates pain and promotes healing. There is not a great deal of evidence that it helps back pain, but that is only because there is not enough research yet. It doesn�t mean you won�t benefit from it. Laser therapy, which is sometimes utilized in physical therapy and chiropractic clinics, can provide relief for a range of conditions, and this includes back pain.
Simple Massage Tools
These consist of foam rollers, lacrosse balls, wraps, massage pads, and handheld muscle rollers. The pain-relief claims that they provide mini-massages for sore muscles. These work and can help when used correctly.
These products do not have a great deal of published material on the benefits of these tools. But physical therapists have recommended using these tools along with professional chiropractic/physical therapy. These low-tech massage tools can make your back feel better. They are effective for muscle spasms, are gentle to the soft tissues and improve blood flow circulation with very little risk of tissue damage.
Exercise balls can be included in exercise programs that function in extension and flexion postures. Sitting on them to safely engage and strengthen the core muscles is an added benefit and they are great for maintaining proper posture.
Hip pain is a well-known health issue which can be caused by a wide array of problems, however, the site of the patient’s hip pain can provide valuable information regarding the underlying cause of this common health issue. Pain on the inside of the hip or groin can be due to problems within the hip joint itself while pain on the outside of the hip, upper thigh and outer buttocks may be due to problems with the ligaments, tendons and muscles, among other soft tissues, surrounding the hip joint. Furthermore, hip pain can be due to other injuries and conditions, including back pain.
Abstract
Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.
Introduction
Hip pain is a common presentation in primary care and can affect patients of all ages. In one study, 14.3% of adults 60 years and older reported significant hip pain on most days over the previous six weeks.1 Hip pain often presents a diagnostic and therapeutic challenge. The differential diagnosis of hip pain (eTable A) is broad, including both intra-articular and extra-articular pathology, and varies by age. A history and physical examination are essential to accurately diagnose the cause of hip pain.
Anatomy
The hip joint is a ball-and-socket synovial joint designed to allow multiaxial motion while transferring loads between the upper and lower body. The acetabular rim is lined by fibrocartilage (labrum), which adds depth and stability to the femoroacetabular joint. The articular surfaces are covered by hyaline cartilage that dissipates shear and compressive forces during load bearing and hip motion. The hip’s major innervating nerves originate in the lumbosacral region, which can make it difficult to distinguish between primary hip pain and radicular lumbar pain.
The hip joint’s wide range of motion is second only to that of the glenohumeral joint and is enabled by the large number of muscle groups that surround the hip. The flexor muscles include the iliopsoas, rectus femoris, pectineus, and sartorius muscles. The gluteus maximus and hamstring muscle groups allow for hip extension. Smaller muscles, such as gluteus medius and minimus, piriformis, obturator externus and internus, and quadratus femoris muscles, insert around the greater trochanter, allowing for abduction, adduction, and internal and external rotation.
In persons who are skeletally immature, there are several growth centers of the pelvis and femur where injuries can occur. Potential sites of apophyseal injury in the hip region include the ischium, anterior superior iliac spine, anterior inferior iliac spine, iliac crest, lesser trochanter, and greater trochanter. The apophysis of the superior iliac spine matures last and is susceptible to injury up to 25 years of age.2
The hip joint is one of the larger joints found in the human body and it serves in locomotion as the thigh moves forward and backward. The hip joint also rotates when sitting and with changes of direction while walking. A variety of complex structures surround the hip joint. When an injury or condition affects these, it can ultimately lead to hip pain.
Dr. Alex Jimenez D.C., C.C.S.T.
Evaluation of Hip Pain
History
Age alone can narrow the differential diagnosis of hip pain. In prepubescent and adolescent patients, congenital malformations of the femoroacetabular joint, avulsion fractures, and apophyseal or epiphyseal injuries should be considered. In those who are skeletally mature, hip pain is often a result of musculotendinous strain, ligamentous sprain, contusion, or bursitis. In older adults, degenerative osteoarthritis and fractures should be considered first.
Patients with hip pain should be asked about antecedent trauma or inciting activity, factors that increase or decrease the pain, mechanism of injury, and time of onset. Questions related to hip function, such as the ease of getting in and out of a car, putting on shoes, running, walking, and going up and down stairs, can be helpful.3 Location of the pain is informative because hip pain often localizes to one of three basic anatomic regions: the anterior hip and groin, posterior hip and buttock, and lateral hip (eFigure A).
Physical Examination
The hip examination should evaluate the hip, back, abdomen, and vascular and neurologic systems. It should start with a gait analysis and stance assessment (Figure 1), followed by evaluation of the patient in seated, supine, lateral, and prone positions (Figures 2 through 6, and eFigure B). Physical examination tests for the evaluation of hip pain are summarized in Table 1.
Imaging
Radiography. Radiography of the hip should be performed if there is any suspicion of acute fracture, dislocation, or stress fracture. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg lateral view of the symptomatic hip.4
Magnetic Resonance Imaging and Arthrography. Conventional magnetic resonance imaging (MRI) of the hip can detect many soft tissue abnormalities, and is the preferred imaging modality if plain radiography does not identify specific pathology in a patient with persistent pain.5 Conventional MRI has a sensitivity of 30% and an accuracy of 36% for diagnosing hip labral tears, whereas magnetic resonance arthrography provides added sensitivity of 90% and accuracy of 91% for the detection of labral tears.6,7
Ultrasonography. Ultrasonography is a useful technique for evaluating individual tendons, confirming suspected bursitis, and identifying joint effusions and functional causes of hip pain.8 Ultrasonography is especially useful for safely and accurately performing imaging-guided injections and aspirations around the hip.9 It is ideal for an experienced ultrasonographer to perform the diagnostic study; however, emerging evidence suggests that less experienced clinicians with appropriate training can make diagnoses with reliability similar to that of an experienced musculoskeletal ultrasonographer.10,11
These are numerous causes for hip pain. Although some hip pain may only be temporary, other forms of hip pain can become chronic if left untreated for an extended period of time. Several common causes of hip pain include, arthritis, fracture, sprain, avascular necrosis, Gaucher’s disease, sciatica, muscle strain, iliotibial band syndrome or IT band syndrome and hematoma, among others described below.
Dr. Alex Jimenez D.C., C.C.S.T.
Differential Diagnosis of Anterior Hip Pain
Anterior hip or groin pain suggests involvement of the hip joint itself. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a �C.� This is known as the C sign (Figure 1A).
Osteoarthritis
Osteoarthritis is the most likely diagnosis in older adults with limited motion and gradual onset of symptoms. Patients have a constant, deep, aching pain and stiffness that are worse with prolonged standing and weight bearing. Examination reveals decreased range of motion, and extremes of hip motion often cause pain. Plain radiographs demonstrate the presence of asymmetrical joint-space narrowing, osteophytosis, and subchondral sclerosis and cyst formation.12
Femoroacetabular Impingement
Patients with femoroacetabular impingement are often young and physically active. They describe insidious onset of pain that is worse with sitting, rising from a seat, getting in or out of a car, or leaning forward.13 The pain is located primarily in the groin with occasional radiation to the lateral hip and anterior thigh.14 The FABER test (flexion, abduction, external rotation; Figure 3) has a sensitivity of 96% to 99%. The FADIR test (flexion, adduction, internal rotation; Figure 4), log roll test (Figure 5), and straight leg raise against resistance test (Figure 6) are also effective, with sensitivities of 88%, 56%, and 30%, respectively.14,15 In addition to the anteroposterior and lateral radiograph views, a Dunn view should be obtained to help detect subtle lesions.16
Hip Labral Tear
Hip labral tears cause dull or sharp groin pain, and one-half of patients with a labral tear have pain that radiates to the lateral hip, anterior thigh, and buttock. The pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. About one-half of patients with this injury also have mechanical symptoms, such as catching or painful clicking with activity.17 The FADIR and FABER tests are effective for detecting intra-articular pathology (the sensitivity is 96% to 75% for the FADIR test and is 88% for the FABER test), although neither test has high specificity.14,15,18 Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears.6,19 However, if a labral tear is not suspected, other less invasive imaging modalities, such as plain radiography and conventional MRI, should be used first to rule out other causes of hip and groin pain.
Iliopsoas Bursitis (Internal Snapping Hip)
Patients with this condition have anterior hip pain when extending the hip from a flexed position, often associated with intermittent catching, snapping, or popping of the hip.20 Dynamic real-time ultrasonography is particularly useful in evaluating the various forms of snapping hip.8
Occult or Stress Fracture
Occult or stress fracture of the hip should be considered if trauma or repetitive weight-bearing exercise is involved, even if plain radiograph results are negative.21 Clinically, these injuries cause anterior hip or groin pain that is worse with activity.21 Pain may be present with extremes of motion, active straight leg raise, the log roll test, or hopping.22 MRI is useful for the detection of occult traumatic fractures and stress fractures not seen on plain radiographs.23
Transient Synovitis and Septic Arthritis
Acute onset of atraumatic anterior hip pain that results in impaired weight bearing should raise suspicion for transient synovitis and septic arthritis. Risk factors for septic arthritis in adults include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.24 Fever, complete blood count, erythrocyte sedimentation rate, and C-reactive protein level should be used to evaluate the risk of septic arthritis.25,26 MRI is useful for differentiating septic arthritis from transient synovitis.27,28 However, hip aspiration using guided imaging such as fluoroscopy, computed tomography, or ultrasonography is recommended if a septic joint is suspected.29
Osteonecrosis
Legg-Calv�-Perthes disease is an idiopathic osteonecrosis of the femoral head in children two to 12 years of age, with a male-to-female ratio of 4:1.4 In adults, risk factors for osteonecrosis include systemic lupus erythematosus, sickle cell disease, human immunodeficiency virus infection, smoking, alcoholism, and corticosteroid use.30,31 Pain is the presenting symptom and is usually insidious. Range of motion is initially preserved but can become limited and painful as the disease progresses.32 MRI is valuable in the diagnosis and prognostication of osteonecrosis of the femoral head.30,33
Differential Diagnosis of Posterior Hip and Buttock Pain
Piriformis Syndrome and Ischiofemoral Impingement
Piriformis syndrome causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral radiation down the posterior thigh from sciatic nerve compression.34,35 Pain with the log roll test is the most sensitive test, but tenderness with palpation of the sciatic notch can help with the diagnosis.35
Ischiofemoral impingement is a less well-understood condition that can lead to nonspecific buttock pain with radiation to the posterior thigh.36,37 This condition is thought to be a result of impingement of the quadratus femoris muscle between the lesser trochanter and the ischium.
Unlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated by active external hip rotation. MRI is useful for diagnosing these conditions.38
Other
Other causes of posterior hip pain include sacroiliac joint dysfunction,39 lumbar radiculopathy,40 and vascular claudication.41 The presence of a limp, groin pain, and limited internal rotation of the hip is more predictive of hip disorders than disorders originating from the low back.42
Differential Diagnosis of Lateral Hip Pain
Greater Trochanteric Pain Syndrome
Lateral hip pain affects 10% to 25% of the general population.43 Greater trochanteric pain syndrome refers to pain over the greater trochanter. Several disorders of the lateral hip can lead to this type of pain, including iliotibial band thickening, bursitis, and tears of the gluteus medius and minimus muscle attachment.43�45 Patients may have mild morning stiffness and may be unable to sleep on the affected side. Gluteus minimus and medius injuries present with pain in the posterior lateral aspect of the hip as a result of partial or full-thickness tearing at the gluteal insertion. Most patients have an atraumatic, insidious onset of symptoms from repetitive use.43,45,46
In conclusion, hip pain is a common complaint which may occur due to a wide variety of health issues. Moreover, the precise location of the patient’s hip pain can provide valuable information to healthcare professionals regarding the underlying cause of the problem. The purpose of the article above was to demonstrate and discuss the evaluation of the patient with hip pain. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Data Sources: We searched articles on hip pathology in American Family Physician, along with their references. We also searched the Agency for Healthcare Research and Quality Evidence Reports, Clinical Evidence, Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force guidelines, the National Guideline Clearinghouse, and UpToDate. We performed a PubMed search using the keywords greater trochanteric pain syndrome, hip pain physical examination, imaging femoral hip stress fractures, imaging hip labral tear, imaging osteomyelitis, ischiofemoral impingement syndrome, meralgia paresthetica review, MRI arthrogram hip labrum, septic arthritis systematic review, and ultrasound hip pain. Search dates: March and April 2011, and August 15, 2013.
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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8.�Deslandes M, Guillin R, Cardinal E, et al. The snapping iliopsoas tendon: new mechanisms using dynamic sonography.�AJR Am J Roentgenol. 2008;190(3):576�581.
9.�Blankenbaker DG, De Smet AA. Hip injuries in athletes.�Radiol Clin North Am. 2010;48(6):1155�1178.
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16.�Beall DP, Sweet CF, Martin HD, et al. Imaging findings of femoroacetabular impingement syndrome.�Skeletal Radiol. 2005;34(11):691�701.
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Sitting at a desk for extended periods of time is not healthy and can lead to a host of health problems. As more and more studies show the detriments of prolonged sitting, some companies are taking action to protect their employees� health by installing upright work stations. These desks take the person from a seated position and move them into one where they are leaning. As a result, most of the workers are enjoying several health benefits.
Health Benefits
It Facilitates Healthy Postural Transitions
Simply put, postural transitions are the body movements made when changing positions. There are large movements like going from sitting to standing, standing to leaning, and standing to sitting, but also small movements like adjusting arm placement or moving a foot.
Ergonomists suggest that a person should be making postural transitions several time an hour. They also recommend that people avoid any static position such as standing, sitting, or leaning for an extended period of time, instead advocating a transition or movement every 20 minutes when possible.
Static positioning has been linked to obesity, heart disease, and other health conditions. When the body is positioned in such a way that facilitates healthy movement, the body moves more often and in a more natural way. This is not likely to happen with static positioning, especially prolonged sitting.
It Improves Spine Health
Sitting or standing for long periods of time is not good for the spine. When a person stands or sits without any healthy postural transitions the spine can begin to compact and the discs become hard. This undermines the spines ability to adequately support the body, leading to loss of mobility, decreased flexibility, and pain.
The spine is made up of small bones, vertebrae, which are cushioned by spongy, fluid filled discs. In a healthy spine, the discs are filled with fluid providing a good cushion for the vertebrae as they move and support the body. However, the discs need movement to encourage blood flow so they can continue working as they should. Working upright facilitates those movements, thus decreasing the likelihood of spinal problems.
It Discourages Painful Posture
Standing and sitting for prolonged periods of time can cause pain and certain mobility problems. While they share some pain points, each brings its own problems. A strained neck and stiff, sore shoulders are often associated with sitting and standing, usually due to improper computer monitor placement. Poor leg circulation, tight hips, and lower back pain are also common problems of people who do a lot of standing or sitting on their jobs.
Using an upright workstation moves the body into a more natural, healthier posture that encourages natural, frequent movement. The spine is properly aligned over the hips, the hips are open, and the feet are adequately supported. It promotes posture that is completely contrary to being hunched over a desk � the typical posture for a sitting workstation.
It Keeps Core Muscles Engaged
When in a seated position, the core muscles are mostly lax and rarely engaged. Over time, these muscles can actually be trained to become weak, or lazy and not engage as they should. This means that they stop supporting the back and body which leads to poor posture, loss of balance, lack of mobility, decrease in flexibility, and pain.
Working upright encourages micro movements that engage the core. It�s not like crunches at the gym, but more like an ongoing mini-workout that keeps the core muscles toned and supportive. The results are a healthier spine, fewer gastrointestinal problems, better posture, and improved circulation.
Other health benefits of working upright include a decreased risk of certain cancers like colon cancer and breast cancer, improved circulation, better brain function, and a decreased risk of health conditions like diabetes, heart disease, and hypertension. Working upright is the most natural position for the body�s best function and health.
Health Benefits: Chiropractic Care Crossfit Rehabilitation
Gale Grijalva suffered from severe back pain as a result of an automobile accident injury. Where it was once very difficult to go about her regular daily tasks, Gale Grijalva is now able to participate in physical activities she wasn’t able to engage in before thanks to Dr. Alex Jimenez, chiropractor in El Paso, TX. Gale Grijalva describes how patient Dr. Jimenez is and she discusses how thoroughly he’s been able to help her, including answering any concerns she may have. Gale Grijalva also experienced results through rehabilitation.
Chiropractic Severe Back Pain Treatment
Severe chronic back pain is a serious, recurring condition which affects a person’s everyday life. Back pain lasting over three months is considered chronic. The spine is an essential component of the body. Severe chronic back pain might be the backbone’s manner of telling the body that there is an issue. The spine is composed of bony vertebrae, soft spinal discs, facet joints, tendons, ligaments and tendons. Within the bony vertebral artery lies the spinal cord, the delicate but effective nerve pathway of the central nervous system.
We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.
As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
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One of my friends recommended me, over and over, and just extended how good he�(Dr. Alex Jimenez, D.C.) was. So I gave it a shot. I had really bad sciatica and it was killing me, I couldn’t walk, but he has been helping me out, I can walk now… I couldn’t walk more than 25 yards, it (sciatica) was really affecting me. I had to get some help. I can’t say enough about Dr. Jimenez, he’s been helping me out, I can walk.
Edgar M. Reyes
According to the American Association of Neurological Surgeons, approximately 75 to 85 percent of individuals in the United States alone will experience some form of back pain throughout their lifetime, where 50 percent will suffer more than one episode within a year. Back pain is one of the most common complaints frequently reported among the general population and it is often a symptom which could indicate the presence of another underlying condition. Back pain can be caused by a variety of factors, some due to bad habits, such as improper posture, and others due to injuries from accidents. Other health issues, such as degenerative disc disease, or DDD, and arthritis can also result in back pain.�While the causes can vary, they share the same symptoms.
Bak pain can include upper back pain, middle back pain and lower back pain, often connected to sciatica, or sciatic nerve pain, a condition characterized by the compression or impingement of the sciatic nerve found in the low back. Back pain and sciatica have been closely associated with several common health issues. Often times, sciatica, or sciatic nerve pain, is caused by an underlying health issue along the lumbar spine. The sciatic nerve is the longest nerve in the human body, which connects to nerve roots in the region of the lower back and runs through the buttocks, down along the hips and into the back of each leg. Further sections of this nerve then branch out from the calf to the foot and into the toes. Sciatica can be identified by the following symptoms.
Low back pain which radiates down one or both legs
Leg and/or foot pain along with tingling and burning sensations
Numbness in the leg, feet and/or toes
Persistent pain and discomfort on one or both sides of the buttocks
Intense painful symptoms in the lower extremities
Having difficulties when sitting and while getting up
It’s essential to understand that back pain and sciatica are not generally considered to be a specific health issue themselves but rather, they are usually only considered to be a collection of several symptoms associated with an underlying injury and/or condition. A proper diagnosis of the root cause of your symptoms is additionally important in order to safely and effectively treat back pain and sciatica. As mentioned above, numerous factors can cause back pain and sciatica symptoms. Below, we will discuss some of the most common spine health issues which can cause back pain and sciatica, including degenerative disc disease, lumbar spinal stenosis, lumbar herniated disc and spondylolisthesis. Approximately 90 percent of sciatica cases are due to disc herniations.
Degenerative Disc Disease
The degeneration of the intervertebral discs, found between each vertebrae of the spine, is a natural process which often occurs with age, while for some individuals, however, it can begin to develop earlier than usual. In a healthy spine, the intervertebral discs function as shock absorbers between the bones of the spine, which ultimately provide height and allow the back to remain flexible while resisting forces. As we begin to get older, these rubbery discs begin to shrink and lose integrity. Almost everyone will demonstrate signs of wear-and-tear along their spinal discs over time, but not everyone will experience degenerative disc disease, or DDD. Although not actually a disease, DDD refers to a condition in which pain with the degeneration of the intervertebral discs.
One or more degenerated discs along the length of the spine may irritate a nerve root and cause sciatica. This condition is commonly characterized when a reduced disc becomes exposed. Bone spurs can also develop with disc degeneration and can lead to sciatica. Symptoms of degenerative disc disease, or DDD, frequently occur along the lower back, however, they can also develop in the neck, depending on the location of the degenerated discs. Common symptoms of DDD include, pain and discomfort, particularly when sitting, bending, lifting or twisting, tingling sensations and/or numbness in the extremities, and lessened symptoms when walking and moving, as in with changing positions or lying down. Weakness in the leg muscles or foot drop may be a sign that there is damage to the nerve root.
Lumbar Spinal Stenosis
Another common cause of back pain and sciatica is lumbar spinal stenosis. The natural degeneration of the spine which occurs with age can cause a variety of changes to the spine. Lumbar spinal stenosis is brought on by a gradual narrowing of the spinal canal that is common in the aging process and it generally affects people over the age of 50. When the space around the spinal cord narrows, it can place unnecessary amounts of pressure on the spinal cord and nerve roots. Additionally, it can be the result of a bulging disk, enlarged aspect joints, or an overgrowth of tissue. Only a small number of individuals are born with spine health issues which can develop into lumbar spinal stenosis. This is known as congenital spinal stenosis and it is frequently diagnosed in men.
Arthritis, or the degeneration of any joint in the body, has been attributed to be the most common cause of spinal stenosis. As the intervertebral discs begin to wear-and-tear naturally begin, they can lose water content and eventually dry out, ultimately losing height and even collapsing. This can place pressure on the facet joints, the joints which provide flexibility and movement to the spine, resulting in arthritis. As a result, the ligaments around the structures of the spine can increase in size, lessening the space for the nerves. Also, the human body may respond by growing new bone, additionally narrowing the space for the nerves to pass through. Symptoms of lumbar spinal stenosis may include, pain, tingling or burning sensations, numbness and weakness, as well as less painful symptoms when leaning forward or sitting.
Lumbar Herniated Disc
A herniated disc is a condition which can occur anywhere along the length of the spine, however, it most commonly affects the lower back or lumbar spine. It may also be referred to as a bulging, protruding or ruptured disc. A lumbar herniated disc is considered to be one of the most common causes of back pain in the lower back, as well as sciatica. An intervertebral disc begins to herniate when the soft, jelly-like nucleus, known as the nucleus pulposus, pushes against its outer ring, known as the annulus fibrosus, due to wear-and-tear or a sudden injury. With persistent pressure, the jelly-like nucleus may push through the disc’s outer ring or it may cause the ring to bulge, putting additional pressure on the spinal chord and its surrounding nerve roots.
Moreover, the intervertebral disc material can release chemicals and/or substances which may ultimately irritate the surrounding structures of the spine, contributing to nerve inflammation. When a nerve root becomes irritated, it can potentially lead to symptoms of pain and discomfort, numbness and weakness in one or both legs, otherwise referred to as sciatica, or sciatic nerve pain. An individual may also develop a herniated disc without ever experiencing any symptoms. A lumbar herniated disc is generally caused by the natural degeneration of the spine and discs, however, trauma and/or injury may also result in lumbar disc herniations. Symptoms of a lumbar herniated disc includes sciatica, tingling sensations, numbness, weakness, and loss of bladder or bowel control in severe cases. This last symptoms will require immediate medical attention.
Spondylolisthesis
Spondylolisthesis is another common cause of back pain and sciatica, particularly in young athletes. Repeated stress on the lower back, or lumbar spine, can create a crack or stress fracture in one of the vertebrae. In these cases, however, the stress fracture can often weaken the bone so much, to the point where it is unable to maintain its proper position in the spine, ultimately causing the vertebra to begin to shift or slip out of place. This condition is what is commonly known as spondylolisthesis. In children and adolescents, spondylolisthesis can occur through periods of rapid growth, by way of instance, during an adolescent growth spurt. This condition frequently occurs as a result of overuse, overstretching, or hyperextension, and even due to genetics.
Many healthcare professionals characterize spondylolisthesis as either low grade or high grade, depending on how much the vertebrae have shifted or slipped out of place. A high grade slip is generally identified when more than 50 percent of the width of the fractured vertebra slips forwards onto the vertebra beneath it. Individuals with high grade cases of spondylolisthesis will commonly describe experiencing significant levels of pain and discomfort as well as nerve injury. In the majority of instances, however, individuals with spondylolisthesis will not experience any obvious symptoms, as a matter of fact, most are unaware of the condition till an x-ray is taken for an unrelated injury and/or condition. Individuals with spondylolisthesis may experience back pain and sciatica, including muscle spasms, back stiffness and tight hamstrings.
Dr. Alex Jimenez’s Insight
Back pain is one of the most common reasons why individuals often miss days from work or go to the doctor, as it has also become one of the leading causes of disability worldwide. As a matter of fact, it has been statistically determined that approximately 80 percent of people will or have experienced back pain at least once throughout their life. Fortunately, a variety of treatments are available which can help ease the symptoms of back pain. It’s essential to understand back pain and sciatica, a collection of symptoms commonly associated with spine health issues along the lower back, in order to seek proper diagnosis and continue with an appropriate treatment plan in order to relieve your symptoms of back pain and sciatica.
Treatment for Back Pain and Sciatica
Chiropractic care is a well-known, alternative treatment option commonly utilized to help diagnose, treat and prevent back pain and sciatica. Since there are many factors which can contribute to symptoms of back pain and sciatic nerve pain, a doctor of chiropractic’s, or chiropractor’s, initial step would be to determine the root cause of the patient’s symptoms. Determining a diagnosis involves a thoughtful review of the patient’s health history, and a physical and neurological examination. Diagnostic testing may involve an x-ray, MRI, CT scan and/or electrodiagnostic tests, such as a nerve conduction speed evaluation or an electromyography. These examinations and tests help determine possible contraindications to treatment.
The aim of chiropractic care is to help promote the human body’s potential to heal itself. It is based on the scientific principle that limited spinal motion results in pain and reduced function and performance. Chiropractic care is non-invasive, or non-surgical, and drug-free. The type of chiropractic treatment provided is dependent upon the cause of the individual’s back pain and sciatica. A treatment program may include many distinct treatments and therapies, like ice/cold therapies, ultrasound, TENS, and spinal adjustments or manual manipulations. If the doctor of chiropractic decides that the patient’s spinal health issue requires treatment by a different kind of physician, then the individual may be referred to another healthcare professional.
Physical therapeutics for these conditions is also effective and generally has two components: active and passive. Passive physical therapeutics consist of ultrasound, electric stimulation, heat and ice packs as well as iontophoresis. Active physical therapeutics modalities include stretching exercises, back exercises and low-impact aerobic conditioning. Manual physical therapeutics, such as spinal adjustments and/or manual manipulations, might be integrated in part by a chiropractor. Physical therapists normally recommend 20 minutes of dynamic lumbar stabilization exercises every day. Core muscle strengthening is also important in treating back pain. Low-impact aerobics are also important and include water therapy, biking, and walking.
Physical therapeutics are an important element of treating spinal health issues. If you meet with a physical therapist, there will be a full assessment. Tests will be performed and an individualized treatment plan will be developed based on the patient’s goals. If you’re experiencing back pain or sciatica, don’t wait any longer for relief. Contact a healthcare professional to establish a one-on-one consultation and complete evaluation. Many chiropractors and physical therapists are certified, experienced and dedicated to helping you feel better. They have helped many others recover from spinal health issues and can help you too. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
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