Back Clinic Conditions Treated. Chronic Pain, Auto Accident Care, Back Pain, Low Back Pain, Back Injuries, Sciatica, Neck Pain, Work Injuries, Personal Injuries, Sports Injuries, Migraine Headaches, Scoliosis, Complex Herniated Discs, Fibromyalgia, Wellness & Nutrition, Stress Management, and Complex Injuries.
At El Paso’s Chiropractic Rehabilitation Clinic & Integrated Medicine Center, we are focused on treating patients after debilitating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility, and agility programs tailored for all age groups and disabilities.
If Dr. Alex Jimenez feels you need other treatment, then you will be referred to a clinic or Physician that is best suited for you. Dr. Jimenez has teamed with the top surgeons, clinical specialists, medical researchers, and premiere rehabilitation providers to bring El Paso the top clinical treatments to our community. Providing the top non-invasive protocols is our priority. Clinical insight is what our patients demand in order to give them the appropriate care required. For answers to any questions you may have please call Dr. Jimenez at 915-850-0900
Ankylosing spondylitis/AS is a common type of arthritis that can cause damage to spinal structures, body parts, and organs. Ankylosing spondylitis causes inflammation in the spine’s ligaments and joints which can cause affected vertebrae to fuse, but other symptoms/complications are skin disorders. Ankylosing spondylitis flare-ups can present with skin disorders like rashes and the possible development of skin diseases like psoriasis.
The inflammation causes back stiffness and pain that causes the spine to become inflexible and rigid. The vertebrae can fuse in extreme cases.
It is typically seen in the early adult population as back pain and hip pain.
Symptoms are more common in individuals between 17 and 45.
Men are more likely to be affected than women.
Genetics can play a role in this condition.
Doctors utilize multiple approaches to relieve symptoms and manage the condition through combined exercise, chiropractic, physical therapy, diet, and stress management to help improve quality of life.
A flare-up can present as a skin rash but can also affect the skin in other ways that include:
Rashes brought on by medication treatments.
Trouble healing from incisions after surgery.
Psoriasis presents as red skin patches appearing anywhere on the body.
The most common areas are the scalp, palms, elbows, and knees.
The affected skin can itch, become tender, and can also sting and burn.
Some psoriasis outbreaks result in lesions or blisters.
Ankylosing Spondylitis vs. Psoriatic Arthritis
Ankylosing spondylitis and psoriatic arthritis are related and come under spondyloarthritis/SpA rheumatic disease.
Ankylosing spondylitis is typically localized to the spine, whereas psoriatic arthritis can affect almost any joint in the body and presents with tendinopathy.
Some individuals with AS can begin to develop psoriasis.
Muscle tension happens when the muscles stay contracted after working, sports, exercise, and stress, presenting with stiffness and achiness that progresses to chronic myofascial pain. Myofascial is used to describe the connective tissues throughout the body. Myo refers to the muscles, and fascia refers to the body tissues. Myofascial pain syndrome describes muscle pain in various forms. Most individuals have experienced chronic muscle tension in muscle pain or tension headaches. Myofascial pain can vary, ranging from mild to severe. Chiropractic can provide treatment and post-prevention plans to eliminate the pain and strengthen the body.
Myofascial pain syndrome is a complex condition that could be repetitive stress injuries on the muscles or nervous system malfunction and is often characterized by symptoms like:
Each symptom is not a sign of the condition, but it could be myofascial pain syndrome when combined and does not resolve with some time. This chronic pain disorder is associated with referred pain that appears in one part of the body but the root cause in another region.
Chiropractic medicine will get to the root of the problem with a thorough diagnosis. This will be done through physical examination, medical history, and symptom review. The chiropractor will perform a detailed exam of the affected muscles, including a range of motion test, strength test, and palpations of suspected trigger points to see how the muscles respond, twitch, and/or cause pain in a specific pattern or region. Sometimes blood tests are ordered to look for other causes, like vitamin D deficiency or hypothyroidism. Chiropractic can combine treatment therapies that include:
Therapeutic massage will loosen the tight, knotted muscles and relieve cramping and/or spasms.
Includes stretching, postural, and strengthening exercises.
Pain medications are directly injected into the trigger points.
Chiropractic physicians work on the whole body and not just the hurting areas. Chiropractors are trained to incorporate treatment with primary care and specialists. Patients receive education in exercise programs, corrective exercises, nutritional recommendations, and health coaching.
Lavelle, Elizabeth Demers, et al. “Myofascial trigger points.” Anesthesiology clinics vol. 25,4 (2007): 841-51, vii-iii. doi:10.1016/j.anclin.2007.07.003
Stults-Kolehmainen, Matthew A et al. “Chronic psychological stress impairs recovery of muscular function and somatic sensations over a 96-hour period.” Journal of strength and conditioning research vol. 28,7 (2014): 2007-17. doi:10.1519/JSC.0000000000000335
Tantanatip A, Chang KV. Myofascial Pain Syndrome. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK499882/
Vernon, Howard, and Michael Schneider. “Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature.” Journal of manipulative and physiological therapeutics vol. 32,1 (2009): 14-24. doi:10.1016/j.jmpt.2008.06.012
Ear problems like blockages or congestion can cause irritation and pain, as well as symptoms such as dizziness, ear discomfort, headaches, and sinus pain that can lead to infection. This condition can happen to anyone but is prevalent in children, individuals that live in high altitudes, and individuals who suffer from allergies. Spinal misalignments can cause interference to the nervous system that can create problems elsewhere in the body, like the ears.
If there is neck misalignment along with pinched, tangled nerve/s signal transmissions can misfire or cut off messages disrupting the process of draining the Eustachian tube. This creates a buildup of bacteria and fluid, which can cause pain and pressure. Chiropractic decompression treatment uses gentle manipulation of the cervical spine to release the pressure affecting the ear.
Bacteria or viruses cause ear infections in the middle ear. Infection often results from another illness like cold, sore throat, flu, respiratory disease, or allergies that causes congestion and swelling of the nasal passages, throat, and eustachian tubes.
The tubes functions include:
Regulating air pressure in the middle ear
Resupply fresh air in the ear
Drain the middle ear
The eustachian tubes are two canals that connect the middle ear to the throat and nasal cavity, known as the nasopharynx. (The eustachian tubes are more narrow in children, which makes them difficult to drain and more likely to get clogged.)When the lining of these canals comes under stress, they can become inflamed/swollen, blocking or filling with fluid causing excessive pressure and pain. This fluid can become infected and cause ear infection symptoms.
If the ear problem is connected to a misalignment of the cervical spine, the following symptoms may be experienced:
Fluid/effusion stays in the middle ear for an extended time.
It can build up over and over, despite no infection.
It can also affect hearing.
Misalignment in the upper cervical spine can cause muscles to flex awkwardly/irregularly, disrupting the opening and closing of the eustachian tubes and their positioning. This often causes inflammation along the eustachian canal, upper throat, and nasal cavity. If left untreated, the inflammation can develop into an infection, causing swelling and/or fluid buildup in the inner and middle ear. Common symptoms of middle ear infections in adults include:
Pain in one or both ears
Hearing is muffled
Fluid drainage from the ear
Treatments are helpful for individuals who want to reduce taking antibiotics, which can minimize immunity by destroying the healthy bacteria in the gut. Chiropractic is a simple and effective way to treat ear problems. Realigning the vertebrae relieves tissue inflammation/swelling around the Eustachian tube to allow drainage, relieve pressure, and restore health.
Spinal Decompression Chiropractor
Collins, Rachael, et al. “Paralysis from an ear infection: a severe case of otitis externa leading to acute complete cervical cord syndrome.” BMJ case reports vol. 14,12 e245594. 1 Dec. 2021, doi:10.1136/bcr-2021-245594
Harmes, Kathryn M et al. “Otitis media: diagnosis and treatment.” American family physician vol. 88,7 (2013): 435-40.
Laulajainen Hongisto, Anu et al. “Severe Acute Otitis Media and Acute Mastoiditis in Adults.” The journal of international advanced otology vol. 12,3 (2016): 224-230. doi:10.5152/iao.2016.2620
Murphy, D R. “Chiropractic rehabilitation of the cervical spine.” Journal of manipulative and physiological therapeutics vol. 23,6 (2000): 404-8. doi:10.1067/mmt.2000.108143
Polkinghorn, B S. “Treatment of cervical disc protrusions via instrumental chiropractic adjustment.” Journal of manipulative and physiological therapeutics vol. 21,2 (1998): 114-21.
Even though it is not officially summer, the heat says otherwise. Individuals with neuropathy can experience flare-ups when out in the heat for extended periods. Avoiding discomfort and having fun with family and friends can be stressful. This could be graduations, park festivals, family gatherings, weddings, etc. Here are some neuropathy summer tips/recommendations to maintain a healthy, fun, and pain-free season.
Neuropathy results from damaged or destroyed nerve cells and is often a side effect associated with diabetes, autoimmune diseases, infections, tumors, and/or hereditary conditions. Also known as peripheral neuropathy, symptoms range from tingling sensations, burning pain, muscle spasms, difficulty moving the arms or legs, feelings of light headiness, and sometimes atrophy. The symptoms depend on the damaged nerves, ranging from autonomic, motor, and sensory nerves. As neuropathy progresses, individuals may begin to feel a loss of balance.
Neuropathy Summer Tips
Research and Prepare
Preparation and planning are highly recommended to prevent a flare-up. For long outdoor ceremonies:
Stay fully hydrated
Dress in cool clothes
Make sure footwear has proper arch/sole support and breathing room.
Wear a hat and sunglasses
Stand periodically to ensure proper circulation if sitting for a while.
Shift weight back and forth during the event to pump circulation throughout the body.
Bring snacks like fruits, veggies, or gluten-free bars.
Know where cool resting areas are located.
If cooling down accommodations are not available, get there early to find a place in the shade, or in the case of bleachers, bring a more comfortable chair, umbrella, and misting fan.
Listen to the body
Listen to the body when engaged in activities, don’t try to push through where you don’t feel comfortable.
The goal is to ensure comfort during the activity, as being uncomfortable can exacerbate symptoms.
The body needs thorough rest after a long day in the sun. It is recommended to ice any areas where pain presents to decrease inflammation and neuroplasticity and help with any symptoms of itching, pressure, numbness, or pins and needles.
Start with icing for three minutes, take the ice off and see how it feels.
If the area feels better, continue icing for a full ten minutes.
Remove the ice if irritation occurs or do not feel a difference.
Watching what you eat can be difficult at summer events. Specific foods like bread, gluten, and high-sugar products can cause symptoms.
If it causes an upset stomach or swelling, it is recommended to avoid it.
Go with fresh seasonal fruits and vegetables.
A little planning can ensure you eat the food that’s best for you.
Call ahead to let friends/family know of any food sensitivities.
Gluten apps allow the ability to scan an item to see if it contains gluten.
Consult a nutritionist to set up an enjoyable diet.
Chiropractic Care and Prevention
Chiropractic care for neuropathy focuses on the underlying conditions causing nerve pain and inflammation.
Treating the inflammation alleviates the pain in the joints and extremities.
Each treatment plan is personalized to meet the needs of every patient.
Treatment will focus on massage, adjustments, decompression, exercises, therapies, and nutrition that expedite healing throughout the body.
Spinal Decompression Non-Surgical
Campbell, James N, and Richard A Meyer. “Mechanisms of neuropathic pain.” Neuron vol. 52,1 (2006): 77-92. doi:10.1016/j.neuron.2006.09.021
Athletes and fitness enthusiasts work hard to stay in shape, but they are also at an increased risk for a lumbar hyperextension injury. Lumbar hyperextension injuries happen when the low back is bent backward repeatedly or overarches repeatedly. The repetitive stress can lead to severe complications and damage the nerves, vertebrae, and backbones. Motorized decompression therapy could be a treatment option.
Lumbar Hyperextension Injury
Injuries can be caused by overuse, improper mechanics and technique, lack of proper conditioning, insufficient stretching, or trauma. When looking for symptoms of lumbar hyperextension injuries, the first is low back pain that is severe and lasts at least a few days while becoming more intense with time. The lower back pain that worsens when extending, or arching the back, in addition to stiffness, muscle spasms, radiating buttock and thigh pain, tight hamstrings, and difficulty standing or walking, can be indicators of a lumbar hyperextension injury. However, this could be difficult to distinguish from other injuries like muscle strain, disc herniation, and stenosis; this is why a proper examination by a medical professional is recommended.
Initial treatment consists of resting, sitting out from the sport, and other activities that could aggravate the back.
A doctor may recommend over-the-counter non-steroidal anti-inflammatory medications.
Heat and ice can also be used to increase circulation and relieve pain.
If hyperextension of the back continues even after rest, it could signify a stress fracture in the vertebrae. This condition is referred to as spondylolysis.Spondylolysis is an overuse injury. It occurs in individuals who participate in sports like gymnastics, diving, volleyball, football, and weight lifting. Spondylolysis and spondylolisthesis are common in adolescent athletes experiencing lower back pain.
A doctor may assign a back brace to prevent movement, allowing the bone to heal back together.
A doctor could also recommend physical therapy for 6-12 weeks after the diagnosis and once the bones have had time to heal.
Rehabilitation exercises focus on improving back flexibility and strength.
Athletes can be cleared to return to their sport within 3-6 months.
Surgery is rarely necessary and only looked into if the individual continues to have persistent pain after 6-12 months of treatment.
This changes the spine’s position, takes the pressure off the nerves and discs, and restores the cushioning.
As the machine pulls the body, a vacuum effect fills the discs with oxygen and nutrients to stimulate healing.
Computer technology controls treatment duration, angle, intensity, and relaxation.
Athletes and fitness enthusiasts are recommended to seek professional help to retrain how they perform repetitive and excessive high-impact activities. Specifically, those involving hyperextension movements like kicking, jumping, running, and back bending help minimize the risk of developing a back injury. They are also recommended to maintain body conditioning, back and hamstring flexibility, core muscle strength and endurance, cardiovascular fitness, and properly warming up and stretching before and after the physical activities.
DOC Decompression Table
Ball, J.R., Harris, C.B., Lee, J. et al. Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations. Sports Med – Open 5, 26 (2019). doi.org/10.1186/s40798-019-0199-7
Carter, D R, and V H Frankel. “Biomechanics of hyperextension injuries to the cervical spine in football.” The American journal of sports medicine vol. 8,5 (1980): 302-9. doi:10.1177/036354658000800502
Goetzinger, Sara, et al. “Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management.” Journal of sports medicine (Hindawi Publishing Corporation) vol. 2020 9235958. 21 Jan. 2020, doi:10.1155/2020/9235958
Lawrence, Kevin J et al. “Lumbar spondylolysis in the adolescent athlete.” Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine vol. 20 (2016): 56-60. doi:10.1016/j.ptsp.2016.04.003
Disc bulge and disc herniation are some of the most common conditions affecting the spine of both young and middle-aged patients. It is estimated that approximately 2.6% of the US population annually visits a clinician to treat spinal disorders. Roughly $ 7.1 billion alone is lost due to the time away from work.
Disc herniation is when the whole or part of the nucleus pulposus is protruded through the torn or weakened outer annulus fibrosus of the intervertebral disc. This is also known as the slipped disc and frequently occurs in the lower back, sometimes also affecting the cervical region. Herniation of the intervertebral disc is defined as a localized displacement of disc material with 25% or less of the disc circumference on an MRI scan, according to the North American Spine Society 2014. The herniation may consist of nucleus pulposus, annulus fibrosus, apophyseal bone or osteophytes, and the vertebral endplate cartilage in contrast to disc bulge.
There are also mainly two types of disc herniation. Disc protrusion is when a focal or symmetrical extension of the disc comes out of its confines in the intervertebral space. It is situated at the intervertebral disc level, and its outer annular fibers are intact. A disc extrusion is when the intervertebral disc extends above or below the adjacent vertebrae or endplates with a complete annular tear. In this type of disc extrusion, a neck or base is narrower than the dome or the herniation.
A disc bulge is when the outer fibers of the annulus fibrosus are displaced from the margins of the adjacent vertebral bodies. Here, the displacement is more than 25% of the circumference of the intervertebral disc. It also does not extend below or above the margins of the disc because the annulus fibrosus attachment limits it. It differs from disc herniation because it involves less than 25% of the disc’s circumference. Usually, the disc bulge is a gradual process and is broad. The disc bulge can be divided into two types. In a circumferential bulge, the whole disc circumference is involved. More than 90 degrees of the rim is involved asymmetrically in asymmetrical bulging.
Normal Intervertebral Disc Anatomy
Before going into detail about the definition of disc herniation and disc bulge, we need to look at the standard intervertebral disc. According to spine guidelines in 2014, a standard disc is something that has a classic shape without any evidence of degenerative disc changes. Intervertebral discs are responsible for one-third to one-fourth of the height of the spinal column.
One intervertebral disc is about 7 -10 mm thick and measures 4 cm in anterior-posterior diameter in the lumbar region of the spine. These spinal discs are located between two adjacent vertebral bodies. However, no discs can be found between the atlas and axis and the coccyx. About 23 discs are found in the spine, with six in the cervical spine, 12 in the thoracic spine, and only five in the lumbar spine.
Intervertebral discs are made of fibro cartilages, forming a fibrocartilaginous joint. The outer ring of the intervertebral disc is known as the annulus fibrosus, while the inner gel-like structure in the center is known as the nucleus pulposus. The cartilage endplates sandwich the nucleus pulposus superiorly and inferiorly. The annulus fibrosus comprises concentric collagen fiber sheets arranged in a radial tire-like structure into lamellae. The fibers are attached to the vertebral endplates and oriented at different angles. With their cartilaginous part, the endplates anchor the discs in their proper place.
The nucleus pulposus is composed of water, collagen, and proteoglycans. Proteoglycans attract and retain moisture, giving the nucleus pulposus a hydrated gel-like consistency. Interestingly, throughout the day, the amount of water found in the nucleus pulposus varies according to the person’s level of activity. This feature in the intervertebral disc serves as a cushion or a spinal shock-absorbing system to protect the adjacent vertebra, spinal nerves, spinal cord, brain, and other structures against various forces. Although the individual movement of the intervertebral discs is limited, some form of vertebral motion like flexion and extension is still possible due to the features of the intervertebral disc.
Effect of Intervertebral Disc Morphology on Structure and Function
The type of components present in the intervertebral disc and how it is arranged determine the morphology of the intervertebral disc. This is important in how effectively the disc does its function. As the disc is the most important element which bears the load and allows movement in the otherwise rigid spine, the constituents it is made up of have a significant bearing.
The complexity of the lamellae increases with advancing age as a result of the synthetic response of the intervertebral disc cells to the variations in the mechanical load. These changes in lamellae with more bifurcations, interdigitation and irregular size and number of lamellar bands will lead to the altered bearing of weight. This in turn establishes a self-perpetuated disruption cycle leading to the destruction of the intervertebral discs. Once this process is started it is irreversible. As there is an increased number of cells, the amount of nutrition the disc requires is also increasingly changing the normal concentration gradient of both metabolites and nutrients. Due to this increased demand, the cells may also die increasingly by necrosis or apoptosis.
Human intervertebral discs are avascular and hence the nutrients are diffused from the nearby blood vessels in the margin of the disc. The main nutrients; oxygen and glucose reach the cells in the disc through diffusion according to the gradient determined by the rate of transport to the cells through the tissues and the rate of demand. Cells also increasingly produce lactic acid as a metabolic end product. This is also removed via the capillaries and venules back to the circulation.
Since diffusion depends on the distance, the cells lying far from the blood capillaries can have a reduced concentration of nutrients because of the reduced supply. With disease processes, the normally avascular intervertebral disc can become vascular and innervated in degeneration and in disease processes. Although this may increase the oxygen and nutrient supply to the cells in the disc, this can also give rise to many other types of cells that are normally not found in the disc with the introduction of cytokines and growth factors.
The morphology of the intervertebral disc in different parts of the spine also varies although many clinicians base the clinical theories based on the assumption that both cervical and lumbar intervertebral discs have the same structure. The height of the disc was the minimum in the T4-5 level of the thoracic column probably due to the fact that thoracic intervertebral discs are less wedge-shaped than those of cervical and lumbar spinal regions.
From the cranial to caudal direction, the cross-sectional area of the spine increased. Therefore, by the L5-S1 level, the nucleus pulposus was occupying a higher proportion of the intervertebral disc area. The cervical discs have an elliptical shape on cross-section while the thoracic discs had a more circular shape. The lumbar discs also have an elliptical shape though it is more flattened or re-entrant posteriorly.
What is a Disc Bulge?
The bulging disc is when the disc simply bulges outside the intervertebral disc space it normally occupies without the rupture of the outer annulus fibrosus. The bulging area is quite large when compared to a herniated disc. Moreover, in a herniated disc, the annulus fibrosus ruptures or cracks. Although disc bulging is more common than disc herniation, it causes little or no pain to the patient. In contrast, the herniated disc causes a lot of pain.
Causes for Disc Bulging
A bulging disc can be due to several causes. It can occur due to normal age-related changes such as those seen in degenerative disc disease. The aging process can lead to structural and biochemical changes in the intervertebral discs and lead to reduced water content in the nucleus pulposus. These changes can make the patient vulnerable to disc bulges with only minor trauma. Some unhealthy lifestyle habits such as a sedentary lifestyle and smoking can potentiate this process and give rise to more severe changes with the weakening of the disc.
General wear and tear due to repeated microtrauma can also weaken the disc and give rise to disc bulging. This is because when the discs are strained, the normal distribution of weight loading changes. Accumulated micro-trauma over a long period of time can occur in bad posture. Bad posture when sitting, standing, sleeping, and working can increase the pressure in the intervertebral discs.
When a person maintains a forward bending posture, it can lead to overstretching and eventually weakness of the posterior part of the annulus fibrosus. Over time, the intervertebral disc can bulge posteriorly. In occupations that require frequent and repetitive lifting, standing, driving, or bending, the bulging disc may be an occupational hazard. Improper lifting up of items, and improper carrying of heavy objects can also increase the pressure on the spine and lead to disc bulges eventually.
The bulging intervertebral discs usually occur over a long period of time. However, the discs can bulge due to acute trauma too. The unexpected sudden mechanical load can damage the disc resulting in micro-tears. After an accident, the disc can become weakened causing long-term microdamage ultimately leading to bulging of the disc. There may also be a genetic component to the disc bulging. The individual may have a reduced density of elastin in the annulus fibrosus with increased susceptibility to disc diseases. Other environmental facts may also play a part in this disease process.
Symptoms of Disc Bulging
As mentioned previously, bulging discs do not cause pain and even if they do the severity is mild. In the cervical region, the disease will cause pain running down the neck, deep pain in the shoulder region, pain radiating along the upper arm, and forearm up to the fingers.
This may give rise to a diagnostic dilemma as to whether the patient is suffering from a myocardial infarction as the site of referred pain and the radiation is similar. Tingling feeling on the neck may also occur due to the bulging disc.
In the thoracic region, there may be pain in the upper back that radiates to the chest or the upper abdominal region. This may also suggest upper gastrointestinal, lung, or cardiac pathology and hence need to be careful when analyzing these symptoms.
The bulging discs of the lumbar region may present as lower back pain and tingling feeling in the lower back region of the spine. This is the most common site for disc bulges since this area holds the weight of the upper body. The pain or the discomfort can spread through the gluteal area, thighs, and to the feet. There may also be muscle weakness, numbness or tingling sensation. When the disc presses on the spinal cord, the reflexes of both legs can increase leading to spasticity.
Some patients may even have paralysis from the waist down. When the bulging disc compresses on the cauda equine, the bladder and bowel functions can also change. The bulging disc can press on the sciatic nerve leading to sciatica where the pain radiates in one leg from the back down to the feet.
The pain from the bulging disc can get worse during some activities as the bulge can then compress on some of the nerves. Depending on what nerve is affected, the clinical features can also vary.
Diagnosis of Disc Bulging
The diagnosis may not be apparent from clinical history due to similar presentations in more serious problems. But the chronic nature of the disease may give some clues. Complete history and a physical examination need to be done to rule out myocardial infarction, gastritis, gastro-oesophageal reflux disease, and chronic lung pathology.
MRI of Disc Bulge
Investigations are necessary for the diagnosis. X-ray spine is performed to look for gross pathology although it may not show the bulging disc directly. There may be indirect findings of disk degeneration such as osteophytes in the endplates, gas in the disc due to the vacuum phenomenon, and the loss of height of the intervertebral disc. In the case of moderate bulges, it may sometimes appear as non-focal intervertebral disc material that is protruded beyond the borders of the vertebra which is broad-based, circumferential, and symmetrical.
Magnetic resonance imaging or MRI can exquisitely define the anatomy of the intervertebral discs especially the nucleus pulposus and its relationships. The early findings seen on MRI in disc bulging include the loss of normal concavity of the posterior disc. The bulges can be seen as broad-based, circumferential, and symmetrical areas. In moderate bulging, the disc material will protrude beyond the borders of the vertebrae in a non-focal manner. Ct myelogram may also give detailed disc anatomy and may be useful in the diagnosis.
Treatment of Disc Bulging
The treatment for the bulging disc can be conservative, but sometimes surgery is required.
When the disc bulging is asymptomatic, the patient does not need any treatment since it does not pose an increased risk. However, if the patient is symptomatic, the management can be directed at relieving the symptoms. The pain is usually resolved with time. Till then, potent pain killers such as non-steroidal anti-inflammatory drugs like ibuprofen should be prescribed. In unresolved pain, steroid injections can also be given to the affected area and if it still does not work, the lumbar sympathetic block can be tried in most severe cases.
The patient can also be given the option of choosing alternative therapies such as professional massage, physical therapy, ice packs, and heating pads which may alleviate symptoms. Maintaining correct posture, tapes, or braces to support the spine are used with the aid of a physiotherapist. This may fasten the recovery process by avoiding further damage and keeping the damaged or torn fibers in the intervertebral disc without leakage of the fluid portion of the disc. This helps maintain the normal structure of the annulus and may increase the recovery rate. Usually, the painful symptoms which present initially get resolved over time and lead to no pain. However, if the symptoms get worse steadily, the patient may need surgery
If the symptoms are resolved, physiotherapy can be used to strengthen the muscles of the back with the use of exercises. Gradual exercises can be used for the return of function and for preventing recurrences.
When conservative therapy does not work with a few months of treatment, surgical treatment can be considered. Most would prefer minimally invasive surgery which uses advanced technology to correct the intervertebral disc without having to grossly dissect the back. These procedures such as microdiscectomy have a lower recovery period and reduced risk of scar formation, major blood loss, and trauma to adjacent structures when compared to open surgery.
Previously, laminectomy and discectomy have been a mainstay of treatment. However, due to the invasiveness of the procedure and due to increased damage to the nerves these procedures are currently abandoned by many clinicians for disc bulging.
Disc bulging in the thoracic spine is being treated surgically with costotransversectomy where a section of the transverse process is resected to allow access to the intervertebral disc. The spinal cord and spinal nerves are decompressed by using thoracic decompression by removing a part of the vertebral body and making a small opening. The patient may also need a spinal fusion later on if the removed spinal body was significant.
Video-assisted thoracoscopic surgery can also be used where only a small incision is made and the surgeon can perform the surgery with the assistance of the camera. If the surgical procedure involved removing a large portion of the spinal bone and disc material, it may lead to spinal instability. This may need bone grafting to replace the lost portion with plates and screws to hold them in place.
What is a Disc Herniation?
As mentioned in the first section of this article, disc herniation occurs when there is disc material displaces beyond the limits of the intervertebral disc focally. The disc space consists of endplates of the vertebral bodies superiorly and inferiorly while the outer edges of the vertebral apophyses consist of the peripheral margin. The osteophytes are not considered a disc margin. There may be irritation or compression of the nerve roots and dural sac due to the volume of the herniated material leading to pain. When this occurs in the lumbar region, this is classically known as sciatica. This condition has been mentioned since ancient times although a connection between disc herniation and sciatica was made only in the 20th century. Disc herniation is one of the commonest diagnoses seen in the spine due to degenerative changes and is the commonest cause of spinal surgery.
Classifications of Disc Herniation
There are many classifications regarding intervertebral disc herniation. In focal disc herniation, there is a localized displacement of the disc material in the horizontal or axial plane. In this type, only less than 25% of the circumference of the disc is involved. In broad-based disc herniation, about 25 – 50 % of the disc circumference is herniated. The disc bulge is when 50 – 100 % of the disc material is extended beyond the normal confines of the intervertebral space. This is not considered a form of disc herniation. Furthermore, the intervertebral disc deformities associated with severe cases of scoliosis and spondylolisthesis are not classified as a herniation but rather adaptive changes of the contour of the disc due to the adjacent deformity.
Depending on the contour of the displaced material, the herniated discs can be further classified as protrusions and extrusions. In disc protrusion, the distance measured in any plane involving the edges of the disc material beyond intervertebral disc space (the highest measure is taken) is lower than the distance measured in the same plane between the edges of the base.
Imaging can show the disc displacement as a protrusion on the horizontal section and as an extrusion on the sagittal section due to the fact that the posterior longitudinal ligament contains the disc material that is displaced posteriorly. Then the herniation should be considered an extrusion. Sometimes the intervertebral disc herniation can occur in the craniocaudal or vertical direction through a defect in the vertebral body endplates. This type of herniation is known as intravertebral herniation.
The disc protrusion can also be divided into two focal protrusion and broad-based protrusion. In focal protrusion, the herniation is less than 25% of the circumference of the disc whereas, in broad-based protrusion, the herniated disc consists of 25 – 50 % of the circumference of the disc.
In disc extrusion, it is diagnosed if any of the two following criteria are satisfied. The first one is; that the distance measured between the edges of the disc material that is beyond the intervertebral disc space is greater than the distance measured in the same plane between the edges of the base. The second one is; that the material in the intervertebral disc space and material beyond the intervertebral disc space is having a lack continuity.
This can be further characterized as sequestrated which is a subtype of the extruded disc. It is called disc migration when disk material is pushed away from the site of extrusion without considering whether there is continuity of disc or not. This term is useful in interpreting imaging modalities as it is often difficult to show continuity in imaging.
The intervertebral disc herniation can be further classified as contained discs and discs that are unconfined. The term contained disc is used to refer to the integrity of the peripheral annulus fibrosus which is covering the intervertebral disc herniation. When fluid is injected into the intervertebral disc, the fluid does not leak into the vertebral canal in herniations that are contained.
Sometimes there are displaced disc fragments that are characterized as free. However, there should be no continuity between disc material and the fragment and the original intervertebral disc for it to be called a free fragment or a sequestered one. In a migrated disc and in a migrated fragment, there is an extrusion of disc material through the opening in the annulus fibrosus with a displacement of the disc material away from the annulus.
Even though some fragments that are migrated can be sequestered the term migrated means just to the position and it is not referred to the continuity of the disc. The displaced intervertebral disc material can be further described with regard to the posterior longitudinal ligament as submembranous, subcapsular, subligamentous, extra ligamentous, transligamentous, subcapsular, and perforated.
The spinal canal can also get affected by an intervertebral disc herniation. This compromise of the canal can also be classified as mild, moderate, and severe depending on the area that is compromised. If the canal at that section is compromised only less than one third, it is called mild whereas if it is only compromised less than two-thirds and more than one third it is considered moderate. In a severe compromise, more than two-thirds of the spinal canal is affected. For the foraminal involvement, this same grading system can be applied.
The displaced material can be named according to the position that they are in the axial plane from the center to the right lateral region. They are termed as central, right central, right subarticular, right foraminal, and right extraforaminal. The displaced intervertebral disc material’s composition can be further classified as gaseous, liquefied, desiccated, scarred, calcified, ossified, bony, nuclear, and cartilaginous.
Before going into detail on how to diagnose and treat intervertebral disc herniation, let us differentiate how cervical disc herniation differs from lumbar herniation since they are the most common regions to undergo herniation.
Cervical Disc Herniation vs. Thoracic Disc Herniation vs Lumbar Disc Herniation
Lumbar disc herniation is the most commonest type of herniation found in the spine which is approximately 90% of the total. However, cervical disc herniation can also occur in about one-tenth of patients. This difference is mainly due to the fact that the lumbar spine has more pressure due to the increased load. Moreover, it has comparatively large intervertebral disc material. The most common sites of intervertebral disc herniation in the lumbar region are L 5 – 6, in the Cervical region between C7, and in the thoracic region T12.
Cervical disc herniation can occur relatively commonly because the cervical spine acts as a pivoting point for the head and it is a vulnerable area for trauma and therefore prone to damage in the disc. Thoracic disc herniation occurs more infrequently than any of the two. This is due to the fact that thoracic vertebrae are attached to the ribs and the thoracic cage which limits the range of movement in the thoracic spine when compared to the cervical and lumbar spinal discs. However, thoracic intervertebral disc herniation can still occur.
Cervical disc herniation gives rise to neck pain, shoulder pain, pain radiating from the neck to the arm, tingling, etc. Lumbar disc herniation can similarly cause lower back pain as well as pain, tingling, numbness, and muscle weakness seen in the lower limbs. Thoracic disc herniation can give rise to pain in the upper back radiating to the torso.
Although disc herniation can occur in all age groups, it predominantly occurs between the fourth and fifth decade of life with the mean age of 37 years. There have been reports that estimate the prevalence of intervertebral disc herniation to be 2 – 3 % of the general population. It is more commonly seen in men over 35 years with a prevalence of 4.8% and while in women this figure is around 2.5%. Due to its high prevalence, it is considered a worldwide problem as it is also associated with significant disability.
In most instances, a herniated disc occurs due to the natural aging process in the intervertebral disc. Due to the disc degeneration, the amount of water that was previously seen in the intervertebral disc gets dried out leading to the shrinking of the disc with the narrowing of the intervertebral space. These changes are markedly seen in degenerative disc disease. In addition to these gradual changes due to normal wear and tear, other factors may also contribute to increasing the risk of intervertebral disc herniation.
Being overweight can increase the load on the spine and increase the risk of herniation. A sedentary life can also increase the risk and therefore an active lifestyle is recommended in preventing this condition. Improper posture with prolonged standing, sitting, and especially driving can put a strain on the intervertebral discs due to the additional vibration from the vehicle engine leading to microtrauma and cracks in the disc. The occupations which require constant bending, twisting, pulling and lifting can put a strain on the back. Improper weight lifting techniques are one of the major reasons.
When back muscles are used in lifting heavy objects instead of lifting with the legs and twisting while lifting can make the lumbar discs more vulnerable to herniation. Therefore patients should always be advised to lift weights with their legs and not the back. Smoking has been thought to increase disc herniation by reducing the blood supply to the intervertebral disc leading to degenerative changes of the disc.
Although the above factors are frequently assumed to be the causes for disc herniation, some studies have shown that the difference in risk is very small when this particular population was compared with the control groups of the normal population.
There have been several types of research done on genetic predisposition and intervertebral disc herniation. Some of the genes that are implicated in this disease include vitamin D receptor (VDR) which is a gene that codes for the polypeptides of important collagen called collagen IX (COL9A2).
Another gene called the human aggrecan gene (AGC) is also implicated as it codes for proteoglycans which is the most important structural protein found in the cartilage. It supports the biochemical and mechanical function of the cartilage tissue and hence when this gene is defective, it can predispose an individual to intervertebral disc herniation.
Apart from these, there are many other genes that are being researched due to the association between disc herniation such as matrix metalloproteinase (MMP) cartilage intermediate layer protein, thrombospondin (THBS2), collagen 11A1, carbohydrate sulfotransferase, and asporin (ASPN). They may also be regarded as potential gene markers for lumbar disc disease.
Pathogenesis of Sciatica and Disc Herniation
The sciatic pain originated from the extruded nucleus pulposus inducing various phenomena. It can directly compress the nerve roots leading to ischemia or without it, mechanically stimulate the nerve endings of the outer portion of the fibrous ring and release inflammatory substances suggesting its multifactorial origin. When the disc herniation causes mechanical compression of the nerve roots, the nerve membrane is sensitized to pain and other stimuli due to ischemia. It has been shown that in sensitized and compromised nerve roots, the threshold for neuronal sensitization is around half of that of a normal and non-compromised nerve root.
The inflammatory cell infiltration is different in extruded discs and non-extruded discs. Usually, in non-extruded discs, the inflammation is less. The extruded disc herniation causes the posterior longitudinal ligament to rupture which exposes the herniated part to the vascular bed of the epidural space. It is believed that inflammatory cells are originating from these blood vessels situated in the outermost part of the intervertebral disc.
These cells may help secrete substances that cause inflammation and irritation of the nerve roots causing sciatic pain. Therefore, extruded herniations are more likely to cause pain and clinical impairment than those that are contained. In contained herniations, the mechanical effect is predominant while in the unconfined or the extruded discs the inflammatory effect is predominant.
Clinical Disc Herniation and What to Look for in the History
The symptoms of the disc herniation can vary a great deal depending on the location of the pain, the type of herniation, and the individual. Therefore, history should focus on the analysis of the main complaint among the many other symptoms.
The chief complaint can be neck pain in cervical disc herniation and there can be referred pain in the arms, shoulders, neck, head, face, and even the lower back region. However, it is most commonly referred to as the interscapular region. The radiation of pain can occur according to the level at the herniation is taking place. When the nerve roots of the cervical region are affected and compressed, there can be sensory, and motor changes with changes in the reflexes.
The pain that occurs due to nerve root compression is called radicular pain and it can be described as deep, aching, burning, dull, achy, and electric depending on whether there is mainly motor dysfunction or sensory dysfunction. In the upper limb, the radicular pain can follow a dermatomal or myotomal pattern. Radiculopathy usually does not accompany neck pain. There can be unilateral as well as bilateral symptoms. These symptoms can be aggravated by activities that increase the pressure inside the intervertebral discs such as the Valsalva maneuver and lifting.
Driving can also exacerbate pain due to disc herniation due to stress because of vibration. Some studies have shown that shock loading and stress from vibration can cause a mechanical force to exacerbate small herniations but flexed posture had no influence. Similarly, activities that decrease intradiscal pressure can reduce the symptoms such as lying down.
The main complaint in lumbar disc herniation is lower back pain. Other associated symptoms can be a pain in the thigh, buttocks, and anogenital region which can radiate to the foot and toe. The main nerve affected in this region is the sciatic nerve causing sciatica and its associated symptoms such as intense pain in the buttocks, leg pain, muscle weakness, numbness, impairment of sensation, hot and burning or tingling sensation in the legs, dysfunction of gait, impairment of reflexes, edema, dysesthesia or paresthesia in the lower limbs. However, sciatica can be caused by causes other than herniation such as tumors, infection, or instability which need to be ruled out before arriving at a diagnosis.
The herniated disc can also compress on the femoral nerve and can give rise to symptoms such as numbness, tingling sensation in one or both legs, and a burning sensation in the legs and hips. Usually, the nerve roots that are affected in herniation in the lumbar region are the ones exiting below the intervertebral disc. It is thought that the level of the nerve root irritation determines the distribution of leg pain. In herniations at the third and fourth lumbar vertebral levels, the pain may radiate to the anterior thigh or the groin. In radiculopathy at the level of the fifth lumbar vertebra, the pain may occur in the lateral and anterior thigh region. In herniations at the level of the first sacrum, the pain may occur in the bottom of the foot and the calf. There can also be numbness and tingling sensation occurring in the same area of distribution. The weakness in the muscles may not be able to be recognized if the pain is very severe.
When changing positions the patient is often relieved from pain. Maintaining a supine position with the legs raised can improve the pain. Short pain relief can be brought by having short walks while long walks, standing for prolonged periods, and sitting for extended periods of time such as in driving can worsen the pain.
The lateral disc herniation is seen in foraminal and extraforaminal herniations and they have different clinical features to that of medial disc herniation seen in subarticular and central herniations. The lateral intervertebral disc herniations can when compared to medial herniations more directly irritate and mechanically compress the nerve roots that are exiting and the dorsal root ganglions situated inside the narrowed spinal canal.
Therefore, lateral herniation is seen more frequently in older age with more radicular pain and neurological deficits. There is also more radiating leg pain and intervertebral disc herniations in multiple levels in the lateral groups when compared to medial disc herniations.
The herniated disc in the thoracic region may not present with back pain at all. Instead, there are predominant symptoms due to referred pain in the thorax due to irritation of nerves. There can also be predominant pain in the body that travels to the legs, tingling sensation and numbness in one or both legs, muscle weakness, and spasticity of one or both legs due to exaggerated reflexes.
The clinician should look out for atypical presentations as there could be other differential diagnoses. The onset of symptoms should be inquired about to determine whether the disease is acute, sub-acute, or chronic in onset. Past medical history has to be inquired about in detail to exclude red flag symptoms such as pain that occurs at night without activity which can be seen in pelvic vein compression, and non-mechanical pain which may be seen in tumors or infections.
If there is a progressive neurological deficit, with bowel and bladder involvement is there, it is considered a neurological emergency and urgently investigated because cauda equine syndrome may occur which if untreated, can lead to permanent neurological deficit.
Getting a detailed history is important including the occupation of the patient as some activities in the job may be exacerbating the patient’s symptoms. The patient should be assessed regarding which activities he can and cannot do.
Degenerative disc disease
Myofascial pain leading to sensory disturbances and local or referred pain
Cyst leading to occasional motor deficits and sensory disturbances
Spondylosis or spondylolisthesis
Discitis or osteomyelitis
Malignancy, neurinoma or mass lesion causing atrophy of thigh muscles, glutei
Spinal stenosis is seen mainly in the lumbar region with mild low back pain, motor deficits, and pain in one or both legs.
An epidural abscess can cause symptoms similar to radicular pain involving spinal disc herniation
Aortic aneurysm which can cause low back pain and leg pain due to compression can also rupture and lead to hemorrhagic shock.
Hodgkin’s lymphoma in advanced stages can lead to space-occupying lesions in the spinal column leading to symptoms like that of intervertebral disc herniation
Lumbar nerve root schwannoma
Herpes zoster infection results in inflammation along with the sciatic or lumbosacral nerve roots
Examination in Disc Herniation
Complete physical examination is necessary to diagnose intervertebral disc herniation and exclude other important differential diagnoses. The range of motion has to be tested but may have a poor correlation with disc herniation as it is mainly reduced in elderly patients with a degenerative disease and due to disease of the joints.
A complete neurological examination is often necessary. This should test muscle weakness and sensory weakness. In order to detect muscle weakness in small toe muscles, the patient can be asked to walk on tiptoe. The strength of muscle can also be tested by comparing the strength to that of the clinician. There may be dermatomal sensory loss suggesting the respective nerve root involvement. The reflexes may be exaggerated or sometimes maybe even absent.
There are many neurologic examination maneuvers described in relation to intervertebral disc herniation such as the Braggart sign, flip the sign, Lasegue rebound sign, Lasegue differential sign, Mendel Bechterew sign, Deyerle sign both legs or Milgram test, and well leg or Fajersztajin test. However, all these are based on testing the sciatic nerve root tension by using the same principles in the straight leg raising test. These tests are used for specific situations to detect subtle differences.
Nearly almost all of them depend on the pain radiating down the leg and if it occurs above the knee it is assumed to be due to a neuronal compressive lesion and if the pain goes below the knee, it is considered to be due to the compression of the sciatic nerve root. For lumbar disc herniation detection, the most sensitive test is considered to be radiating pain occurring down the leg due to provocation.
In the straight leg raising test also called the Lasegue’s sign, the patient stays on his or her back and keeps the legs straight. The clinician then lifts the legs by flexing the hip while keeping the knee straight. The angle at which the patient feels pain going down the leg below the knee is noted. In a normal healthy individual, the patient can flex the hip to 80- 90? without having any pain or difficulty.
However, if the angle is just 30 -70? degrees, it is suggestive of lumbar intervertebral disc herniation at the L4 to S1 nerve root levels. If the angle of hip flexion without pain is less than 30 degrees, it usually indicates some other causes such as tumor of the gluteal region, gluteal abscess, spondylolisthesis, disc extrusion, and protrusion, malingering patient, and acute inflammation of the dura mater. If pain with hip flexion occurs at more than 70 degrees, it may be due to tightness of the muscles such as gluteus maximus and hamstrings, tightness of the capsule of the hip joint, or pathology of sacroiliac or hip joints.
The reverse straight leg raising test or hip extension test can be used to test higher lumbar lesions by stretching the nerve roots of the femoral nerve which is similar to the straight leg raising test. In the cervical spine, in order to detect stenosis of the foramina, the Spurling test is done and is not specific to cervical intervertebral disc herniation or tension of the nerve roots. The Kemp test is the analogous test in the lumbar region to detect foraminal stenosis. Complications due to the disc herniation include careful examination of the hip region, digital rectal examination, and urogenital examination is needed.
Investigation of Disc Herniation
For the diagnosis of intervertebral disc herniation, diagnostic tests such as Magnetic resonance imaging (MRI), Computed tomography (CT), myelography, and plain radiography can be used either alone or in combination with other imaging modalities. Objective detection of disc herniation is important because only after such a finding the surgical intervention is even considered. Serum biochemical tests such as prostate-specific antigen (PSA) level, Alkaline phosphatize value, erythrocyte sedimentation rate (ESR), urine analysis for Bence Jones protein, serum glucose level, and serum protein electrophoresis may also be needed in specific circumstances guided by history.
Magnetic Resonance Imaging (MRI)
MRI is considered the best imaging modality in patients with history and physical examination findings suggestive of lumbar disc herniation associated with radiculopathy according to North American Spinal Society guidelines in 2014. The anatomy of the herniated nucleus pulposus and its associated relationships with soft tissue in the adjacent areas can be delineated exquisitely by MRI in cervical, thoracic, and lumbosacral areas. Beyond the confines of the annulus, the herniated nucleus can be seen as a focal, asymmetric disc material protrusion on MRI.
On sagittal T2 weighted images, the posterior annulus is usually seen as a high signal intensity area due to radial annular tear associated with the herniation of the disc although the herniated nucleus is itself hypointense. The relationship between the herniated nucleus and degenerated facets with the nerve roots which are exiting through the neural foramina are well-demarcated on sagittal images of MRI. Free fragments of the intervertebral disc can also be distinguished from MRI images.
There may be associated signs of intervertebral disc herniation on MRI such as radial tears on the annulus fibrosus which is also a sign of degenerative disc disease. There may be other telling signs such as loss of disc height, bulging annulus, and changes in the endplates. Atypical signs may also be seen with MRI such as abnormal disc locations, and lesions located completely outside the intervertebral disc space.
MRI can detect abnormalities in the intervertebral discs superiorly to other modalities although its bone imaging is a little less inferior. However, there are limitations with MRI in patients with metal implant devices such as pacemakers because the electromagnetic field can lead to abnormal functioning of the pacemakers. In patients with claustrophobia, it may become a problem to go to the narrow canal to be scanned by the MRI machine. Although some units contain open MRI, it has less magnetic power and hence delineates less superior quality imaging.
This is also a problem in children and anxious patients undergoing MRI because good image quality depends on the patient staying still. They may require sedation. The contrast used in MRI which is gadolinium can induce nephrogenic systemic fibrosis in patients who had pre-existing renal disease. MRI is also generally avoided in pregnancy especially during the first 12 weeks although it has not been clinically proven to be hazardous to the fetus. MRI is not very useful when a tumor contains calcium and in distinguishing edema fluid from tumor tissue.
Computed Tomography (CT)
CT scanning is also considered another good method to assess spinal disc herniation when MRI is not available. It is also recommended as a first-line investigation in unstable patients with severe bleeding. CT scanning is superior to myelography although when the two are combined, it is superior both of them. CT scans can show calcification more clearly and sometimes even gas in images. In order to achieve a superior imaging quality, the imaging should be focused on the site of pathology and thin sections taken to better determine the extent of the herniation.
However, a CT scan is difficult to be used in patients who have already undergone laminectomy surgical procedures because the presence of scar tissue and fibrosis causes the identification of the structures difficult although bony changes and deformity in nerve sheath are helpful in making a diagnosis.
The herniated intervertebral discs in the cervical disc can be identified by studying the uncinate process. It is usually projected posteriorly and laterally to the intervertebral discs and superiorly to the vertebral bodies. The uncinate process undergoes sclerosis, and hypertrophy when there is an abnormal relationship between the uncinate process and adjacent structures as seen in degenerative disc disease, intervertebral disc space narrowing, and general wear and tear.
Myelopathy can occur when the spinal canal is affected due to disc disease. Similarly, when neural foramina are involved, radiculopathy occurs. Even small herniated discs and protrusions can cause impingement of the dural sac because the cervical epidural space is narrowed naturally. The intervertebral discs have attenuation a little bit greater than the sac characterized in the CT scan.
In the thoracic region, a CT scan can diagnose an intervertebral disc herniation with ease due to the fact that there is an increased amount of calcium found in the thoracic discs. Lateral to the dural sac, the herniated disc material can be seen on CT as a clearly defined mass that is surrounded by epidural fat. When there is a lack of epidural fat, the disc appears as a higher attenuated mass compared to the surrounding.
Plain radiography is not needed in diagnosing herniation of the intervertebral discs, because plain radiographs cannot detect the disc and therefore are used to exclude other conditions such as tumors, infections, and fractures.
In myelography, there may be deformity or displacement of the extradural contrast-filled thecal sac seen in herniation of the disc. There may also be features in the affected nerve such as edema, elevation, deviation, and amputation of the nerve root seen in the myelography image.
In this imaging modality, the contrast medium is injected into the disc in order to assess the disc morphology. If pain occurs following injection that is similar to the discogenic pain, it suggests that that disc is the source of the pain. When a CT scan is also performed immediately after discography, it is helpful to differentiate the anatomy and pathological changes. However, since it is an invasive procedure, it is indicated only in special circumstances when MRI and CT have failed to reveal the etiology of back pain. It has several side effects such as headache, meningitis, damage to the disc, discitis, intrathecal hemorrhage, and increased pain.
Treatment of Herniated Disc
The treatment should be individualized according to the patient-guided through history, physical examination, and diagnostic investigation findings. In most cases, the patient gradually improves without needing further intervention in about 3 – 4 months. Therefore, the patient only needs conservative therapy during this time period. Because of this reason, there are many ineffective therapies that have emerged by attributing the natural resolution of symptoms to that therapy. Therefore, conservative therapy needs to be evidence-based.
Since the herniation of the disc has a benign course, the aim of treatment is to stimulate the recovery of neurological function, reduce pain, and facilitate early return to work and activities of daily living. The most benefits of the conservative treatment are for younger patients with hernias that are sequestered and in patients with mild neurological deficits due to small disc hernias.
Bed rest has long been considered a treatment option in herniation of the disc. However, it has been shown that bed rest has no effect beyond the first 1 or 2 days. The bed rest is regarded as counterproductive after this period of time.
In order to reduce the pain, oral non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen can be used. This can relieve the pain by reducing inflammation associated with the inflamed nerve. Analgesics such as acetaminophen can also be used although they lack the anti-inflammatory effect seen in NSAIDs. The doses and the drugs should be appropriate for the age and severity of the pain in the patient. If pain is not controlled by the current medication, the clinician has to go one step up on the WHO analgesics ladder. However, the long-term use of NSAIDs and analgesics can lead to gastric ulcers, liver, and kidney problems.
In order to reduce the inflammation, other alternative methods such as applying ice in the initial period and then switching to using heat, gels, and rubs may help with the pain as well as muscle spasms. Oral muscle relaxants can also be used in relieving muscle spasms. Some of the drugs include methocarbamol, carisoprodol, and cyclobenzaprine.
However, they act centrally and cause drowsiness and sedation in patients and it does not act directly to reduce muscle spasm. A short course of oral steroids such as prednisolone for a period of 5 days in a tapering regime can be given to reduce the swelling and inflammation in the nerves. It can provide immediate pain relief within a period of 24 hours.
When the pain is not resolved adequately with maximum effective doses, the patient can be considered for giving steroid injections into the epidural space. The major indication for the steroid injection into periradicular space is discal compression causing radicular pain that is resistant to conventional medical treatment. A careful evaluation with CT or MRI scanning is required to carefully exclude extra discal causes for pain. The contraindications for this therapy include patients with diabetes, pregnancy, and gastric ulcers. Epidural puncture is contraindicated in patients with coagulation disorders and therefore the foraminal approach is used carefully if needed.
This procedure is performed under the guidance of fluoroscopy and involves injecting steroids and an analgesic into the epidural space adjacent to the affected intervertebral disc to reduce the swelling and inflammation of the nerves directly in an outpatient setting. As much as 50% of the patients experience relief after the injection although it is temporary and they might need repeat injections at 2 weekly intervals to achieve the best results. If this treatment modality becomes successful, up to 3 epidural steroidal injections can be given per year.
Physical therapy can help the patient return to his previous life easily although it does not improve the herniated disc. The physical therapist can instruct the patient on how to maintain the correct posture, walking, and lifting techniques depending on the patient’s ability to work, mobility, and flexibility.
Stretching exercises can improve the flexibility of the spine while strengthening exercises can increase the strength of the back muscles. The activities which can aggravate the condition of the herniated disc are instructed to be avoided. Physical therapy makes the transition from intervertebral disc herniation to an active lifestyle smooth. The exercise regimes can be maintained for life to improve general well-being.
The most effective conservative treatment option that is evidence-based is observation and epidural steroid injection for the relief of pain in the short-term duration. However, if the patients so desire they can use holistic therapies of their choice with acupuncture, acupressure, nutritional supplements, and biofeedback although they are not evidence-based. There is also no evidence to justify the use of trans electrical nerve stimulation (TENS) as a pain relief method.
If there is no improvement in the pain after a few months, surgery can be contemplated and the patient must be selected carefully for the best possible outcome.
The aim of surgical therapy is to decompress the nerve roots and relieve the tension. There are several indications for surgical treatment which are as follows.
Absolute indications include cauda equina syndrome or significant paresis. Other relative indications include motor deficits that are greater than grade 3, sciatica that is not responding to at least six months of conservative treatment, sciatica for more than six weeks, or nerve root pain due to foraminal bone stenosis.
There have been many discussions over the past few years regarding whether to treat herniation of intervertebral disc disease with prolonged conservative treatment or early surgical treatment. Much research has been conducted in this regard and most of them show that the final clinical outcome after 2 years is the same although the recovery is faster with early surgery. Therefore, it is suggested that early surgery may be appropriate as it enables the patient to return to work early and thereby is economically feasible.
Some surgeons may still use traditional discectomy although many are using minimally invasive surgical techniques over recent years. Microdiscectomy is considered to be the halfway between the two ends. There are two surgical approaches that are being used. Minimally invasive surgery and percutaneous procedures are the ones that are being used due to their relative advantage. There is no place for the traditional surgical procedure known as a laminectomy.
However, there are some studies suggesting microdiscectomy is more favorable because of its both short-term and long-term advantages. In the short term, there is a reduced length of operation, reduced bleeding, relief of symptoms, and reduced complication rate. This technique has been effective even after 10 years of follow-up and therefore is the most preferred technique even now. The studies that have been performed to compare the minimally invasive technique and microdiscectomy have resulted in different results. Some have failed to establish a significant difference while one randomized control study was able to determine that microdiscectomy was more favorable.
In microdiscectomy, only a small incision is made aided by an operating microscope and the part of the herniated intervertebral disc fragment which is impinging on the nerve is removed by hemilaminectomy. Some part of the bone is also removed to facilitate access to the nerve root and the intervertebral disc. The duration of the hospital stay is minimal with only an overnight stay and observation because the patient can be discharged with minimal soreness and complete relief of the symptoms.
However, some unstable patients may need more prolonged admission and sometimes they may need fusion and arthroplasty. It is estimated that about 80 – 85 % of the patients who undergo microdiscectomy recover successfully and many of them are able to return to their normal occupation in about 6 weeks.
There is a discussion on whether to remove a large portion of the disc fragment and curetting the disc space or to remove only the herniated fragment with minimal invasion of the intervertebral disc space. Many studies have suggested that the aggressive removal of large chunks of the disc could lead to more pain than when conservative therapy is used with 28% versus 11.5 %. It may lead to degenerative disc disease in the long term. However, with conservative therapy, there is a greater risk of recurrence of around 7 % in herniation of the disc. This may require additional surgery such as arthrodesis and arthroplasty to be performed in the future leading to significant distress and economic burden.
In the minimally invasive surgery, the surgeon usually makes a tiny incision in the back to put the dilators with increasing diameter to enlarge the tunnel until it reaches the vertebra. This technique causes lesser trauma to the muscles than when seen in traditional microdiscectomy. Only a small portion of the disc is removed in order to expose the nerve root and the intervertebral disc. Then the surgeon can remove the herniated disc by the use of an endoscope or a microscope.
These minimally invasive surgical techniques have a higher advantage of lower surgical site infections and shorter hospital stays. The disc is centrally decompressed either chemically or enzymatically with the use of chymopapain, laser, or plasma (ionized gas) ablation and vaporization. It can also be decompressed mechanically by using percutaneous lateral decompression or by aspirating and sucking with a shaver such as a nucleosome. Chemopapin was shown to have adverse effects and was eventually withdrawn. Most of the above techniques have shown to be less effective than a placebo. Directed segmentectomy is the one that has shown some promise in being effective similar to microdiscectomy.
In the cervical spine, the herniated intervertebral discs are treated anteriorly. This is because the herniation occurs anteriorly and the manipulation of the cervical cord is not tolerated by the patient. The disc herniation that is due to foraminal stenosis and that is confined to the foramen are the only instances where a posterior approach is contemplated.
The minimal disc excision is an alternative to the anterior cervical spine approach. However, the intervertebral disc stability after the procedure is dependent on the residual disc. The neck pain can be significantly reduced following the procedure due to the removal of neuronal compression although significant impairment can occur with residual axial neck pain. Another intervention for cervical disc herniation includes anterior cervical interbody fusion. It is more suitable for patients with severe myelopathy with degenerative disc disease.
Complications of the Surgery
Although the risk of surgery is very low, complications can still occur. Post-operative infection is one of the commonest complications and therefore needs more vigorous infection control procedures in the theatre and in the ward. During the surgery, due to poor surgical technique, nerve damage can occur. A dural leak may occur when an opening in the lining of the nerve root causes leakage of cerebrospinal fluid which is bathing the nerve roots. The lining can be repaired during the surgery. However, headache can occur due to loss of cerebrospinal fluid but it usually improves with time without any residual damage. If blood around the nerve roots clots after the surgery, that blood clot may lead to compression of the nerve root leading to radicular pain which was experienced by the patient previously. Recurrent herniation of the intervertebral disc due to herniation of disc material at the same site is a devastating complication that can occur long term. This can be managed conservatively but surgery may be necessary ultimately.
Outcomes of the Surgery
There has been extensive research done regarding the outcome of lumbar disc herniation surgery. Generally, the results from the microdiscectomy surgery are good. There is more improvement of leg pain than back pain and therefore this surgery is not recommended for those who have only back pain. Many patients improve clinically over the first week but they may improve over the following several months. Typically, the pain disappears in the initial recovery period and it is followed by an improvement in the strength of the leg. Finally, the improvement of the sensation occurs. However, patients may complain of feeling numbness although there is no pain. The normal activities and work can be resumed over a few weeks after the surgery.
Although conservative therapy is the most appropriate therapy in treating patients, the current standard of care does not address the underlying pathology of herniation of the intervertebral discs. There are various pathways that are involved in the pathogenesis such as inflammatory, immune-mediated, and proteolytic pathways.
The role of inflammatory mediators is currently under research and it has led to the development of new therapies that are directed at these inflammatory mediators causing damage to the nerve roots. The cytokines such as TNF ? are mainly involved in regulating these processes. The pain sensitivity is mediated by serotonin receptor antagonists and ?2 adrenergic receptor antagonists.
Therefore, pharmacological therapies that target these receptors and mediators may influence the disease process and lead to a reduction in symptoms. Currently, cytokine antagonists against TNF ? and IL 1? have been tested. Neuronal receptor blockers such as sarpogrelate hydrochloride etc have been tested in both animal models and in clinical studies for the treatment of sciatica. Cell cycle modifiers that target the microglia that are thought to initiate the inflammatory cascade have been tested with the neuroprotective antibiotic minocycline.
There is also research on inhibiting the NF- kB or protein kinase pathway recently. In the future, the treatment of herniation of the intervertebral disc will be much more improved thanks to the ongoing research. (Haro, Hirotaka)
Dr. Alex Jimenez DC, MSACP, RN, CCST
A disc bulge and/or a herniated disc is a health issue that affects the intervertebral discs found in between each vertebra of the spine. Although these can occur as a natural part of degeneration with age, trauma or injury as well as repetitive overuse can also cause a disc bulge or a herniated disc. According to healthcare professionals, a disc bulge and/or a herniated disc is one of the most common health issues affecting the spine. A disc bulge is when the outer fibers of the annulus fibrosus are displaced from the margins of the adjacent vertebral bodies. A herniated disc is when a part of or the whole nucleus pulposus is protruded through the torn or weakened outer annulus fibrosus of the intervertebral disc. Treatment of these health issues focuses on reducing symptoms. Alternative treatment options, such as chiropractic care and/or physical therapy, can help relieve symptoms. Surgery may be utilized in cases of severe symptoms. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
Curated by Dr. Alex Jimenez D.C., C.C.S.T.
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Delayed Onset Muscle Soreness – DOMS is when muscle pain or stiffness develops a day or two after playing sports, weight lifting, exercise, or work that involves concentrated physical activity like lifting and carrying objects. DOMS is considered a normal response to extended exertion and is part of the adaptation process that the recovering muscles experience as they undergo hypertrophy or an increase in muscle size. It is common in individuals who have just started exercising, increased the duration or intensity of their workouts, or just beginning a physically demanding job.
When muscle contracts as it lengthens is known as eccentric muscle contractions, which is most associated with DOMS. It is related to increased stress in muscle fibers as they are exerted excessively. This also happens when engaging in movements the muscles are not used to, like a new exercise or helping a friend move heavy boxes, furniture, etc. Examples include:
It is different for everybody; personal experience will determine which works best for the individual.
Active recovery is a technique that uses low-impact aerobic exercise right after a workout to increase blood flow to the muscles.
The increased blood supply can help relieve the inflammation.
This technique is used for acute injuries but can be applied to delayed onset muscle soreness. It stands for:
A chiropractic massage is for healing sore muscles, tendons, ligaments after an intense game, workout, etc. Chiropractic increases the blood and nerve circulation around the muscles delivering added oxygen and nutrients. This type of massage helps loosen the muscles/connecting tissues allowing the body to recover and heal quicker.
When Muscles Are Not Rested
Not taking time to recover because of overtraining/working can have consequences on the body. Inflammation that is not given the time to heal can lead to:
Weakened immune system.
Muscle mass loss.
Mental health issues.
The body’s immune system cannot function at total capacity during intense physical stress. This causes difficulty when trying to fight off germs and viruses. Studies have found preventing inflammation and injury requires prioritizing rest. Constantly being on the go and under intense physical stress can take a toll not only on the body but the brain as well. This can lead to irritability, frustration, anger, which leads to other health problems generating a vicious cycle.
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Musculoskeletal Nutrition: Musculoskeletal conditions are non-communicable conditions/disorders and are the most common conditions that chiropractors and physiotherapists treat. Unhealthy lifestyle practices like smoking, an unhealthy diet, and little to no exercise or physical activity impact musculoskeletal disorders and remain the most common causes of physical disability and pain. Musculoskeletal conditions include:
Carpal Tunnel Syndrome
Tendonitis – inflammation of the fibrous tissues that connect the muscles to the bones.
A lack of proper nutrients increases the risk for bone, muscle, and joint disease. A proper diet combined with strengthening and stretching will help with injury recovery and help prevent disorders, injury, and pain. For example, inadequate consumption of calcium and vitamin D intake can lead to osteoporosis. Both nutrients are necessary for musculoskeletal health. Calcium helps build bone tissue, and vitamin D promotes calcium absorption.
Even physically active and healthy individuals’ can go through inadequate nutrition intake, increasing the risk of injury from its effect/s on rehabilitation and recovery. There are mechanisms to insufficient nutrient intake that can lead to muscle injury.
Intense training causes skeletal muscle breakdown that can worsen from poor dietary protein intake.
Not hydrating the body can compromise blood flow to working muscles, increasing the risk for injury and other health issues.
Hydration influences the amount and composition of joint fluid and helps maintain articular cartilage.
Deficiencies in nutrients like:
The lack of micronutrients and their role in bone and muscle metabolism increases the risk for injury and the development of musculoskeletal conditions.
Connective tissue holds the body’s bones and muscles together and is essential for joint integrity. Athletes and individuals with physically demanding jobs and lifestyles need to take care of their connective tissues to prevent degradation, injuries, and joint conditions, like arthritis and tendon injuries. It is recommended to have a diet that is:
Achieving optimal health requires all-around healthy lifestyle choices and musculoskeletal nutrition.
Many nutrient-rich foods can be incorporated into an individual’s diet to improve overall well-being.Superfoods are high in antioxidants and contain vast amounts of vitamins and minerals. A superfood is a food rich in compounds that are beneficial to an individual’s health. These compounds include:
Phytochemicals – include antioxidants like polyphenols that provide anti-inflammatory properties.
Omega-3 fatty acids
Superfoods are recognized by national nutrition guidelines as Powerhouse Fruits and Vegetables or PFV. Antioxidants reduce free radicals and prevent and repair damage caused by oxidative stress. Oxidative stress occurs when free radicals accumulate in the body and can lead to chronic and degenerative illnesses like arthritis, cardiovascular disease, and cancer. A diet rich in antioxidants can expedite recovery time from injury, illness, and physical activity/exercise-induced stress.
Anthocyanins are a type of polyphenol that become antioxidants that help reduce the incidence of chronic disease. They are different types of pigments found in plants, giving fruits and vegetables their vibrant colors. These include:
Purple sweet potatoes
A diet rich in anthocyanins can reduce oxidative stress and inflammation, help prevent cardiovascular disease, and control and prevent diabetes.
Craddock, Joel C, et al. “Vegetarian and Omnivorous Nutrition – Comparing Physical Performance.” International journal of sports nutrition and exercise metabolism vol. 26,3 (2016): 212-20. doi:10.1123/ijsnem.2015-0231
Mendonça, Carolina Rodrigues et al. “Effects of Nutritional Interventions in the Control of Musculoskeletal Pain: An Integrative Review.” Nutrients vol. 12,10 3075. 9 Oct. 2020, doi:10.3390/nu12103075
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Slavin, Joanne L, and Beate Lloyd. “Health benefits of fruits and vegetables.” Advances in nutrition (Bethesda, Md.) vol. 3,4 506-16. 1 Jul. 2012, doi:10.3945/an.112.002154
Tucker, K L et al. “Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women.” The American journal of clinical nutrition vol. 69,4 (1999): 727-36. doi:10.1093/ajcn/69.4.727
Musculoskeletal Disorders, or MSDs, are injuries, conditions, and disorders that affect the body’s musculoskeletal system. It includes the muscles, tendons, ligaments, nerves, discs, blood vessels, bones, and joints. MSDs are common, and the risk of developing them increases with age. The severity of an MSD can vary. They cause discomfort, recurrent pain, stiffness, swelling, and aching that interfere with everyday activities. Early diagnosis and treatment can alleviate symptoms and improve long-term health. Common disorders include:
The term musculoskeletal disorder is used as it accurately describes the injury or condition. Other terms used are repetitive motion injury, repetitive stress injury, and overuse injury. When individuals are exposed to MSD risk factors, they begin to fatigue. This can start a musculoskeletal imbalance. With time, fatigue completely overtakes recovery/healing, and the musculoskeletal imbalance continues, a musculoskeletal disorder develops. The risk factors are broken into two categories: work-related/ergonomic risk factors and individual-related risk factors.
High Task Repetition
Many work tasks and cycles are repetitive and are typically controlled by hourly or daily production targets and work processes.
High task repetition combined with other risks factors like high force and/or awkward postures can contribute to the formation of MSD.
A job is considered highly repetitive if the cycle time is 30 seconds or less.
Many job tasks require high force loads on the body.
Muscle effort increases in response to high force requirements. This increases associated fatigue.
Repetitive or Sustained Awkward Postures
Awkward postures place excessive force on joints, overload the muscles and tendons around affected joints.
The joints of the body are most efficient when they operate close to the mid-range motion of the joint.
The risk of MSD is increased when the joints are worked outside of this mid-range repetitively for sustained periods without a proper amount of recovery time.
Unhealthy work practices
Lack of physical activity/fitness
Unhealthy Work Practices
Individuals that engage in poor work practices, body mechanics, and lifting techniques are introducing unnecessary risk factors.
These poor practices create unnecessary stress on the body that increases fatigue and decreases the body’s ability to recover properly.
Poor Health Habits
Individuals who smoke, drink excessively, are obese, or exhibit numerous other poor health habits put themselves at risk for musculoskeletal disorders and other chronic diseases.
Insufficient Rest and Recovery
Individuals that do not get adequate rest and recovery put themselves at higher risk.
MSDs develop when fatigue outruns the individual’s recovery system, causing a musculoskeletal imbalance.
Poor Diet, Fitness, and Hydration
Individuals who eat unhealthily are dehydrated, at a poor level of physical fitness, and do not take care of their bodies are putting themselves at a higher risk of developing musculoskeletal and chronic health problems.
The causes of musculoskeletal disorders are varied. Muscle tissue can be damaged with the wear and tear of daily work, school, and physical activities. Trauma to the body can come from:
Auto accident injuries
Direct trauma to the muscle/s
Poor body mechanics can cause spinal alignment problems and muscle shortening, causing other muscles to be strained, causing problems and pain.
A doctor will recommend a treatment plan based on the diagnosis and severity of the symptoms. They may recommend moderate exercise and over-the-counter medications like ibuprofen or acetaminophen to address occasional discomfort or pain. They often recommend chiropractic and physical therapy rehabilitation to learn how to manage pain and discomfort, maintain strength, range of motion, and adjust everyday activities. Different types of manual therapy, or mobilization, can treat body alignment problems. A doctor may prescribe medications like nonsteroidal anti-inflammatories NSAIDs to reduce inflammation and pain for more severe symptoms. For individuals with musculoskeletal disorders like fibromyalgia, medications to increase the body’s level of serotonin and norepinephrine may be prescribed in low doses to modulate sleep, pain, and immune system function.
Types of Pain
Pain can be grouped into three categories:
Early Warning Pain
This is most recognizable after having just touched a pan, and the hand jerks away before realizing how hot the pan is, also known as the withdrawal reflex.
This is a protective mechanism that helps avoid danger and is vital for survival.
This type of pain happens after an injury or surgery while the body is healing and recovering.
Inflammation prevents the body from performing movements to prevent and avoid re-injury.
This type of pain can happen after the body has healed, but the nervous system has been damaged.
This is often the case with individuals who sustain an injury and inform doctors that the injured area is never the same.
If the rehabilitation does not correctly heal the nervous system, protective pain measures can generate a false alarm causing pain signals to fire off.
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Villa-Forte A. (n.d.). Diagnosis of musculoskeletal disorders. merckmanuals.com/home/bone,-joint,-and-muscle-disorders/diagnosis-of-musculoskeletal-disorders/introduction
As the weather gets colder, individuals may feel like their muscles and joints are frequently stiff and experience more aches and pains. This is even more evident for individuals that work outside in the winter or with specific ailments/conditions. Colder weather can increase the risk of suffering musculoskeletal injuries and intensify the condition.
How Colder Weather Impacts The Muscles
Individuals with arthritic conditions might find that symptoms become exacerbated. This can keep individuals away from regular activities. Conditions like rheumatoid arthritis and osteoarthritis tend not to react well to weather sudden atmospheric changes, worsening symptoms. However, individuals are well aware of how their body feels and moves when colder weather is present with or without existing conditions. Movement slows down, and when trying to move, the muscles can contract involuntarily, causing tension and stiffness. This usually results in soreness and pain. Feeling warm, safe, and comfortable is essential for the body’s overall health. Overuse and overexertion can increase the risk of injury in colder temperatures.
When the weather gets colder, barometric pressure drops. The Body’s tissues like the muscles, tendons, and ligaments expand. This places pressure on nerves near the joints, causing discomfort and pain.
In cold weather, the fluid density in the joints lessens, causing the bones to rub against each other harder because the fluid is not thick enough to allow for proper lubrication.
The cold makes the muscles shiver, contract, and tighten. This can compress the nerves in the joints and increase pain symptoms.
Prevent Stiffness and Musculoskeletal-Related Injuries
Leg spasms and cramps are common conditions where the muscles in the leg suddenly become tight and painful. They present with no warning and can cause excruciating and debilitating pain. They usually occur in the calf muscles but can affect any area of the leg, including the feet and thighs. After the cramping has passed, pain and tenderness can remain in the leg for several hours. Although many leg spasm episodes go away by themselves, they can disrupt normal activities, exercise regimens, and sleep if they continue and are left untreated.
Leg Spasms and Symptoms
A leg spasm is a sudden, sharp contraction or tightening of a muscle in the leg. This can last a few seconds to a few minutes. Muscle cramps anywhere in the body cause sudden contraction of the muscle. This is an involuntary function and can include the following symptoms:
Soreness and discomfort can be mild to extreme.
Hardening of the muscle.
Twitching of the muscle.
Leg spasms are typically brief and go away on their own, but individuals are recommended to seek treatment if they are frequently experienced or last for extended periods.
Dehydration is a common cause of leg spasms and pain.
Lack of fluids can cause the nerve endings to become sensitized, triggering muscle contractions.
When the body sweats, it loses water and electrolytes.
When the body is low on electrolytes
It can affect nerve transduction and lead to muscle spasms.
If the body does not produce sufficient thyroid hormone, this is known as hypothyroidism.
Over time, this deficiency can damage the nerves that send signals from the brain and spine to the legs.
Tingling, numbness, and frequent cramping can result.
Spinal misalignment can compress nerve roots that run down the leg.
This can cause radiating leg pain and spasms, specifically in the back of the thigh.
Muscle and Connective Tissue Injuries
Injuries like tears, strains, and sprains can lead to leg spasms and frequent cramping.
In the second and third trimesters of pregnancy, calcium and magnesium deficiency are common and can lead to leg spasms and cramps.
The proper course of treatment for leg spasms depends on the severity and underlying cause/s. A chiropractor can identify the cause and develop a personalized treatment plan to relieve and eliminate leg cramps.
Misalignments can compress the nerve roots radiating from the spine to the legs.
This can lead to radiating leg pain and/or leg spasms.
Realignment through chiropractic can relieve the pressure on compressed nerve roots, alleviating leg discomfort and pain.
A chiropractor will also recommend exercises and stretches to strengthen the legs and core muscles.
Physical Therapeutic Massage
A physical therapist will use various massage techniques to relax the leg muscles to prevent and reduce the severity of spasms.
Massage therapy will relieve any inflammation that accompanies leg spasms, decreasing pain and swelling in the area.
As a part of the treatment plan, a health coach will evaluate the individual’s diet and suggest changes that will help address any nutritional deficiencies contributing to leg spasms and cramps.
Track Inflammation and Fluid Imbalances From Injury or Surgery
Inflammation can occur with little to no visible symptoms following surgery or injury. Precision measurement of body water can detect water retention and inflammation to aid rehabilitation treatment. InBody effectively distinguishes water in the following compartments that comprise total body water.
Intracellular-ICW-within the tissues.
Extracellular-ECW-within the blood and interstitial fluids.
The Edema Index can be used to detect fluid imbalances resulting from inflammation from injury or recovery after surgery.
Assessing fluid balance in the body and specific segments can help identify inflammation and guide treatment to reduce the risk of re-injury or post-surgery complications. These measurements are provided for the whole body and can determine where fluid imbalances may be occurring for more precise analysis.
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Mekhail, Nagy et al. “Long-term safety and efficacy of closed-loop spinal cord stimulation to treat chronic back and leg pain (Evoke): a double-blind, randomized, controlled trial.” The Lancet. Neurology vol. 19,2 (2020): 123-134. doi:10.1016/S1474-4422(19)30414-4
A Trendelenburg gait is an abnormal walking gait resulting from a defective or weakened hip abductor.The gluteal musculature is the primary musculature that includes the gluteus medius and gluteus minimus muscles. Weakness in these muscles causes sagging/dropping of the pelvis on the opposite side while walking. There will be a noticeable side-to-side motion if the glutes are too weak to support the body’s weight when walking. It can look as though the individual is limping or missing a step. Individuals can minimize the effects with foot orthotics, core strengthening, chiropractic, and physical therapy.
Trendelenburg Gait Causes
This gait often results from straining the hip abductor muscles during physical activity. Exercises specifically for the glutes done improperly are a common cause. When improper exercise form is the cause, the abnormal gait usually goes away as muscle inflammation fades. The gait can also present after total hip replacement surgery, as the procedure requires incisions in the gluteus medius muscle. This can weaken the muscle causing an abnormal gait. Weakness in these muscles can also be caused by:
Nerve damage or dysfunction in the nerves that run through the gluteal minimus and medius muscles.
Osteoarthritis is a type of arthritis that occurs when joint cartilage starts to wear down.
Muscular dystrophy is a condition that causes the muscles and bones to become weak over time.
Poliomyelitisis a condition associated with polio that weakens the muscles.
Stance – The other leg stays still and maintains balance.
The main symptom of Trendelenburg gait can be seen when one leg swings forward and the hip drops down and move outward. This is because the hip abductor of the other leg is too weak to support the weight. Individuals may lean back or to the side slightly when walking to maintain balance, or they may lift the foot higher off the ground with each step to avoid losing balance or tripping as the pelvis shifts unevenly.
Abnormal hip movement during a swing of one or both legs can give a doctor enough evidence to diagnose a Trendelenburg gait. A doctor will observe the individual’s walk in front and behind to get a detailed view. A doctor will also use the Trendelenburg test to diagnose the condition. The doctor will instruct the individual to lift one leg for 30 seconds. If the individual cannot keep the hips parallel with the ground while lifting, it could indicate Trendelenburg gait. X-rays of the hip will be used to identify any causes of weakness in the gluteus minimus or medius.
Treatment options will depend on the severity and cause of the gait.
If the gait is causing pain, over-the-counter nonsteroidal anti-inflammatory NSAIDs, like ibuprofen or acetaminophen, will help ease symptoms.
In severe cases, a doctor may prescribe cortisone injections to help reduce pain.
A doctor could also recommend using a foot orthotic in one or both shoes to compensate the hip abductor muscle weakness.
Chiropractic, Physical Therapy, and Exercise
Chiropractic and physical therapy can help adjust, realign, and strengthen the muscles to regain control of the Trendelenburg gait. The chiropractor or physical therapist will move the legs in various directions to help the joints become more accustomed to moving in certain directions and increase muscle strength and resistance. Exercises that can strengthen the hip abductor muscles include:
Lie on the side and extend the leg straight out.
Lie on the floor and move one leg up, over the other, and back in the opposite direction.
Step sideways and onto an elevated surface, then back down again.
Talk with a doctor or chiropractor before beginning any new exercise routine so they can recommend specific exercises and educate on proper form.
If left untreated, moderate-to-severe cases of Trendelenburg gait can become debilitating, leading to severe complications. These include:
Pain, stiffness, or grinding in the hips.
Loss of range of motion in the hips and gait.
Losing the ability to walk, which could require the use of a walker or wheelchair.
Trendelenburg gait is treatable with special shoes, orthotics, and exercises designed to strengthen the hip abductor muscles. Chiropractic and physical therapy can help limit the condition’s impact on the body’s health, the ability to walk, and reduce the risk of complications.
The bright and tangy fruits are packed with vitamins and unique plant compounds known as polyphenols that can help lower blood pressure naturally.
However, it’s important to note that grapefruit and grapefruit juice could interact with certain prescription medications.
Beans and Lentils
Foods high in magnesium, potassium, and fiber can help maintain healthy blood pressure.
This is where beans and legumes come in, as they are high in fiber, potassium, and magnesium.
Individuals that swapped beans and lentils noticed a lower blood pressure, whether or not they had been diagnosed with hypertension.
These seeds are packed with potassium, magnesium, and arginine.
Arginine is an amino acid used to make nitric oxide, which helps the blood vessels relax and dilate, allowing lower blood pressure.
A study found that postmenopausal women who took 3 grams of pumpkin seed oil daily for six weeks saw a significant decrease in their systolic blood pressure.
Garlic contains nitric oxide, which has been shown to relax blood vessels.
Kyolic garlic, in particular, has been shown to help with arterial stiffness and can improve cholesterol levels.
Feyh, Andrew et al. “Role of Dietary Components in Modulating Hypertension.” Journal of Clinical & experimental cardiology vol. 7,4 (2016): 433. doi:10.4172/2155-9880.1000433
The shoulder is a ball-and-socket joint. The shoulder has several muscles that help it move and allow a wide range of motion. A strain or pulled shoulder muscle can affect the slightest movements, making simple activities difficult and painful. Pulling a muscle in the shoulder can be caused by an injury, overuse, and general wear and tear. Minor shoulder injuries usually heal on their own with rest and self-care. Severe shoulder muscle injuries should be addressed by a medical professional.
Pulled Shoulder Muscle Causes
Pulling a muscle in the shoulder can happen quickly. This could be from falling on the shoulder, an auto accident, or a work accident. It can develop after weeks, months, and years of repetitive motion and overuse. It is common among individuals that play certain sports or jobs that require repetitive activities with the shoulders. They can also happen with no apparent cause. Treatment and recovery depend on the type and severity of the injury.
How to Tell If It’s a Pulled Muscle
It can be hard to tell the cause unless the individual has experienced the specific type of pain before. Otherwise, it is recommended to consult a medical professional like a physical therapist or chiropractor. This is because shoulder pain can be caused by inflammation of the tendons and joints and/or the joint itself.
Pulled Muscle Shoulder Symptoms
A pulled muscle is characterized by:
Dull, sore, or aching pain.
Sometimes it can cause shooting pain between the shoulder blades in the front or back.
Pain when the shoulder is at rest.
Pain when the specific muscle is used.
Swelling of the area.
The shoulder feels fragile.
Movement causes pain.
A bump may develop at the top of the shoulder near the end of the collarbone.
Inability to use the muscle at all.
If the pain is persistent, it could signify that there is something other than a pulled muscle like a pinched nerve or a joint issue.
Treatment and Recovery Options
Treatment and recovery vary and depend on the severity of the pull and the individual’s overall health. Many find that their pain is reduced with self-care in 2 or 3 weeks. Chiropractic treatment for a pulled shoulder muscle can provide relief within 1 or 2 weeks.
Depending on the severity of the pull and how much pain is being experienced, individuals could be recommended to take an NSAID like Ibuprofen to reduce pain and swelling. Self-care can include:
Ice To Reduce Swelling
Applying ice or a cold pack to the area can help reduce swelling.
Place a cloth or towel between the skin and the cold pack.
Apply it for 20 minutes an hour.
The swelling should reduce in a day or two.
It is recommended to rest the shoulder for no more than 2 or 3 days.
This begins the healing process and prevents worsening the injury.
Wrap or Sling
During rest days, it can be hard to keep the shoulder from moving.
To avoid this, use a shoulder wrap or a sling to support the arm.
However, they should not be used for more than 2 or 3 days.
It is essential to get the muscle working again after 2 or 3 days of rest.
Stretches will help the muscle group heal and gain strength.
Not stretching the muscle could prolong recovery and worsen the injury, and possibly cause new injuries.
Stretches For a Pulled Shoulder
Stretching a pulled shoulder muscle after a few days of rest is recommended because not working out the injured muscle can cause more problems. Not using the muscle can cause it to atrophy, which will take longer to heal, and the surrounding muscles become weak.
Slightly bent support the body by placing the unaffected arm on a table or chair.
Let the injured arm hang straight down.
Swing the arm in small circles clockwise as far as the pain or discomfort allows.
Perform for 1 minute.
Go counterclockwise for one minute.
Repeat 4 to 8 times throughout the day.
If self-care is not providing sufficient relief, then chiropractic treatment is recommended. A doctor of chiropractic can advise on the best treatment options and get to the root of the issue. Chiropractors have a treatment arsenal of modalities and approaches to help treat pulled muscles. These include:
A somatotype is the overall shape and composition of the human body. Body types based on physique have three generalized divisions:
However, it is rare for someone to fall entirely into one somatotype. Individuals can have a combination of qualities from two somatotypes, like an ectomorph-endomorph hybrid or an endomorph-ectomorph, for example.
Naturally lean with long limbs, ectomorphs typically possess a slender look no matter what type of diet.
A lot of endurance runners and swimmers are ectomorphs.
Ectomorphs may have a decent amount of muscle but may appear to have less muscle development because of their long limb length.
Body fat also seems to get hidden by the long, slender figure, which means they can get away with a few extra pounds of fat.
However, if ectomorphs do not watch their health, they can become skinny fat.
Mesomorphs have a natural athletic look.
They can achieve a muscular physique without really trying.
The physiology tends to include:
A large frame contributes to a muscular appearance.
Many professional fighters, football, and basketball players are mesomorphs.
Endomorphs have a larger structure with wide hips and shoulders.
Shorter arms and legs.
This type of body shape is excellent for activities that require a lot of strength.
Rugby players, strength athletes, and powerlifters are endomorphs.
This body type is considered to be a contributing performance factor in Ironman athletes.
Blache, Y et al. “Superficial shoulder muscle co-activations during lifting tasks: Influence of lifting height, weight, and phase.” Journal of electromyography and kinesiology: official journal of the International Society of Electrophysiological Kinesiology vol. 25,2 (2015): 355-62. doi:10.1016/j.jelekin.2014.11.004
Brantingham, James W et al. “Manipulative therapy for shoulder pain and disorders: expansion of a systematic review.” Journal of manipulative and physiological therapeutics vol. 34,5 (2011): 314-46. doi:10.1016/j.jmpt.2011.04.002
Kandel, Michel et al. “Somatotype, training and performance in Ironman athletes.” European journal of sports science vol. 14,4 (2014): 301-8. doi:10.1080/17461391.2013.813971
McFarland, Daniel C et al. “Spatial dependency of shoulder muscle demand during dynamic unimanual and bimanual pushing and pulling.” Applied ergonomics vol. 73 (2018): 199-205. doi:10.1016/j.apergo.2018.07.011
Compartment syndrome is a condition that causes pressure within a group of muscles to build up to dangerous levels. This pressure build-up begins to decrease blood flow, not allowing proper circulation, nutrients, and oxygen from getting to the nerves and muscle cells. The syndrome can be acute or chronic, and surgery can be required. Acute compartment syndrome is considered a medical emergency, usually caused by a severe injury and requires immediate treatment; otherwise, it can lead to permanent muscle damage. Chronic compartment syndrome or exertional compartment syndrome is usually not a medical emergency and is often caused by physical exertion.
The fascia does not stretch or expand because its job is to keep the tissues in place. If compartmental pressure builds up, swelling and bleeding may occur. When the tissues don’t have enough blood to provide the proper amount of oxygen and nutrients, the tissues begin to die, leading to permanent damage. Because the fascia does not stretch if there is swelling or bleeding within a compartment, this increases pressure on the:
Muscles in that compartment.
Blood circulation does not reach the compartment to supply oxygen and nutrients.
Nerve and muscle cells get damaged.
Compartment syndrome most often takes place in the lower leg’s anterior/front calf compartment.
However, it can also develop in other areas like the:
The typical symptom is pain, specifically when the muscle in the compartment is stretched.
The pain is more intense than the injury itself.
Flexing, contracting, or stretching the muscles increases the pain.
Tingling or burning sensations may present.
Muscle tightness or fullness sensation like bloating.
Numbness or paralysis are late symptoms that usually indicate severe to permanent tissue injury.
The acute syndrome develops after a severe injury, like an automobile accident or from a broken bone. Injuries and conditions that can cause acute compartment syndrome include:
Muscle contusion/bruise that goes beyond just a bump. Two examples include a motorcycle falling on the rider’s leg or a football player getting hit in the leg intensely.
Constricting bandages – Casts and bandages that are too tight can cause the blockage of blood. If symptoms develop, remove or loosen any constricting bandages. If it is from a cast, contact the doctor immediately.
When sleeping, a blood vessel can get blocked. Lying for a long time in a position that causes a limb to go to sleep, then shifting, moving, or getting up can contribute to the condition. This type of development can happen in individuals with neurological damage or who do not realize what is occurring. This can happen after intense intoxication with alcohol and/or drugs.
Surgical repair of a damaged blood vessel that was blocked can result in compartment swelling.
Permanent disability and tissue death can result unless the pressure is relieved.
Chronic Physical Exertion
The pain and swelling from the chronic condition are caused by vigorous physical activity/exercise. It most often occurs in the leg. Individuals that participate in activities with repetitive motions have an increased risk. Physical activities/sports include:
This is usually not dangerous and is often relieved by discontinuing the specific exercise/s or physical activity for a while. Symptoms include:
Pain during exercise.
Cramping during exercise.
Moving the foot is difficult.
Muscle bulge can be seen.
Leg pain should not be ignored for long as the problems could escalate into severe/dangerous territory. Chiropractic treatment is highly effective in the detection and treatment of leg pain. Chiropractors are experts in the neuromusculoskeletal system. Their expertise in promoting physical function applies to the whole body’s systems, including the:
They are trained to diagnose and treat developing and chronic musculoskeletal problems and know when to seek specialized medical care when necessary.
Can’t Individuals Just Exercise More and Eat Whatever They Want?
No individuals cannot just exercise/move more and eat whatever they want if they are serious about losing excess weight. A healthy diet and exercise are essential parts of the formula for effective weight loss. One study shows that being aware of diet in quality and quantity overtakes just exercising when achieving and maintaining healthy body composition changes as a vital part of maintaining a healthy lifestyle. Evaluating the effects of diet, exercise, or a combination of both revealed that long-term success was most significant in the mix of diet and exercise. Individuals can exercise vigorously, but losing weight can be very difficult if they have unhealthy eating habits or cannot stick to a healthy diet. The individual can develop other health problems from an unhealthy diet.
Braver, Richard T. “Chronic Exertional Compartment Syndrome.” Clinics in podiatric medicine and surgery vol. 33,2 (2016): 219-33. doi:10.1016/j.cpm.2015.12.002
Joubert, Sonia V, and Manuel A Duarte. “Chronic Exertional Compartment Syndrome in a Healthy Young Man.” Journal of chiropractic medicine vol. 15,2 (2016): 139-44. doi:10.1016/j.jcm.2016.04.007
Schmidt, Andrew H. “Acute compartment syndrome.” Injury vol. 48 Suppl 1 (2017): S22-S25. doi:10.1016/j.injury.2017.04.024
Vajapey, Sravya, and Timothy L Miller. “Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature.” The Physician and sportsmedicine vol. 45,4 (2017): 391-398. doi:10.1080/00913847.2017.1384289
The Gluteus Maximus Muscle is the largest and the outermost of the gluteal muscles. It stretches from the sacrum and coccyx, parts of the spinal column, down to the femur. The other gluteal muscles include the gluteus minimus and medius. They each have a role in the normal function of the hips and legs. They are prone to tightness resulting in soreness, aches, and pain around the hips and in and around the buttocks.
The Gluteal/Rear End Muscles
There are three rear-end muscles:
The Gluteus Maximus extends the hip and rotates the thigh outwards, straightens the legs when moving, and provides strength.
The minimus and medius are underneath the Maximus and stabilize the hip when:
Other physical activities
There is another group of diagonal muscles under the gluteus minimus that attaches to the femur. The uppermost is the piriformis that is attached to the sacrum. The sciatic nerve and major arteries run below it.
Tightness and Irritation
The primary function of the muscles is to open the hips and push the legs out. Sitting for long periods shortens the gluteal muscles causing them to become tight, limiting normal hip function. The gluteal muscles are susceptible to tightness brought on from overuse and lack of development/strength. This can develop into tender/tight muscle bands that interfere with the normal function of the muscles. To get an example of what is happening imagine flexing and contracting one of the bicep muscles 6-10 hours a day. It would be extremely sore, tight, and tender.
Sports and Physically Active
Athletes and individuals that are physically active can also have tight gluteal muscles. This can cause post-game/exercise muscle soreness. Intense activities force the gluteal muscles to work overtime to support the back and knees. Sports that require a lot of leg muscle activation include:
Awkward Walking Gait
Individuals that move with an unusual gait are vulnerable to straining the muscles. What happens is the muscles become stiff from the awkward positions/postures. This places additional strain on the back and hip muscles and worsens their overall posture. The hip muscles are also attached to the pelvis, and when the muscles begin to tighten they can pull on the gluteal muscles. Irritation of the sacroiliac joint can also place pressure on the piriformis, causing spasms that affect the gluteal muscles. Piriformis muscle spasms can also place pressure on the sciatic nerve, causing sciatica.
Diagnosis and Treatment
An examination will be necessary to diagnose whether the soreness or pain is due to muscle inflammation or other cause. Sciatica symptoms and problems at the hip level that involves the gluteus minimus and medius can be felt in the leg. The examination includes seeing and feeling muscle reactions, responses, contractions through a series of motion exercises and movements that involve different muscles. Common treatment includes:
Range of motion exercises
Strengthening exercises like bridging and resistance bands
Deep tissue massages
Heat and cold packs
Electric muscle stimulation
Tightness in the glutes can be managed with chiropractic treatment. This includes:
Soft tissue work
Spinal joint manipulation
Simple exercises can help engage and strengthen the muscles. These include:
Individuals that sit for long periods of time, don’t get enough physical activity, and have an unhealthy diet can experience insulin resistance. This happens when insulin is not able to transport excess blood sugar out of the blood and into the muscles. A study found that women who sat for eight hours a day had an increased chance of developing diabetes. Diabetics can be inclined to have more fat within the body, specifically visceral fat. This further encourages insulin resistance. Diabetics also experience rapid loss of muscle mass as they age, intensifying symptoms and further affecting body composition.
Cochrane, Darryl J et al. “Does short-term gluteal activation enhance muscle performance?.” Research in sports medicine (Print) vol. 25,2 (2017): 156-165. doi:10.1080/15438627.2017.1282358
Coratella, Giuseppe et al. “The Activation of Gluteal, Thigh, and Lower Back Muscles in Different Squat Variations Performed by Competitive Bodybuilders: Implications for Resistance Training.” International journal of environmental research and public health vol. 18,2 772. 18 Jan. 2021, doi:10.3390/ijerph18020772
Distefano, Lindsay J et al. “Gluteal muscle activation during common therapeutic exercises.” The Journal of orthopedic and sports physical therapy vol. 39,7 (2009): 532-40. doi:10.2519/jospt.2009.2796
Kalyani, Rita Rastogi et al. “Age-related and disease-related muscle loss: the effect of diabetes, obesity, and other diseases.” The lancet. Diabetes & endocrinology vol. 2,10 (2014): 819-29. doi:10.1016/S2213-8587(14)70034-8
Selkowitz, David M et al. “Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes.” The Journal of orthopedic and sports physical therapy vol. 43,2 (2013): 54-64. doi:10.2519/jospt.2013.4116
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