A PAIN IN THE BUTT

For my first newsletter, I wanted to write an article about low back pain (LBP) and the benefits of getting into physical therapy (PT) as early as possible in order to have a greater chance of alleviating the pain completely. In addition, patients will learn how to take care of their back and exercises to get stronger in order to prevent a reoccurrence. LBP, or sciatica, is the number one reason why people seek out medical attention.¹ These symptoms can represent a multitude of diagnoses which the MD will ferret out, based on the physical exam and testing procedures. PTs will do a complete evaluation to fine-tune the causes of patient symptoms in order to determine the appropriate PT treatment. The evaluation, coupled with the subjective information from the patient, will lead to the appropriate treatment regimen. The PT will ask discerning questions such as, “what hurts more, sitting or standing? Lying on your back or side?” Does your back hurt when you sneeze or cough?” These questions help determine what may be causing symptoms, whether it be one or more of the diagnoses described in the tables below.

As I wrestled with starting the article and looking for research to back up the claim that LBP is the most common medical complaint, I happened to be at my son’s cross-country meet. I began talking with another boy’s father, who was a runner like me, and like me has not been able to run because of an injury. He said that he has been having severe hamstring pain and some LBP. He is currently seeing a chiropractor and receiving electrical stimulation and ASTYM, but has not had much improvement. He felt the chiropractor was not getting to the “root” of the problem. He didn’t know if his pain was coming from his back or just a severe hamstring strain.

After this conversation, I decided to shift my article slightly to describe the most common back diagnosis (dx) I see and compare it to hamstring strain/proximal hamstring tendonopathy. The following tables list the most common symptoms associated with each diagnosis and some immediate recommendations to follow before receiving medical attention. There is quite a bit of overlap. There are other diagnoses that might have some of these same symptoms as well, such as a spinal tumor, degenerative disc disease, osteoporosis, but I did not address these diagnoses in this article. Further testing will be recommended by the MD, or the PT will send the patient back to the MD if other more serious diagnoses are suspected.

DX: Herniated Lumbar Disc

Symptoms	Do’s & Don’ts
Stiffness, viselike LBP	Dos: Avoid painful positions Brace self when sneeze/coughLie on side with pillow between legsLie on back with pillow under knees Use heat or ice on back, whichever feels better Walk, if does not increase pain Walk in pool, if does not increase pain Roll on side to get out of bed
Pain in sitting
Pain w/sneeze or cough
Numbness/tingling/pain down back of legs, which can go to big toe
Lying on 1 side worse than other side
Bowel or bladder changes
LBP upon waking in morning
Decreased light touch sensitivity in leg
Weakness anywhere in leg
Trip over toes	Don’t: Bend overLift heavy objectsStretch hamstrings
Pain when bending over
Decreased leg reflexes
No LBP, but back of leg symptoms as described above

DX: SI Joint Dysfunction (SI=sacroiliac)

Symptoms	Do’s & Don’ts
Pain at SI joint	Do’s: Avoid painful positionsLie on side with pillow between legsLie on back with pillow under kneesUse heat or ice on back whichever feels better Walk if does not increase pain Walk in pool if does not increase pain Roll on side to get out of bed
“My back feels like it needs to be cracked”
Pain climbing stairs
Pain lying on back
Pain in butt/piriformis muscle
Pain/numbness/tingling down back of leg
Headache
Recent fall onto butt
Recently hit head	Don’ts: Do activities that spread legs apart such as getting out of car one leg at a timeStretch hamstringsLift heavy objectsLimit stair climbing
Past fall on butt or hit to head

DX: Lumbar Spinal Stenosis

Symptoms	Do’s & Don’ts
LBP	Do’s: Avoid painful positionsLie on side with pillow between legsLie on back with pillow under kneesUse heat or ice on back whichever feels better Walk if does not increase pain Walk in pool if does not increase pain Roll on side to get out of bed
Pain in front of thighs
Pain/numbness/tingling down front or back of thighs
LBP when wake in the morning
Pain decreases as day goes on
Long walks increase leg symptoms
Weakness in leg/s
Decreased leg reflexes
Trip over toes
Feels better sitting	Don’ts: Bend backwardsStretch hamstringsLift heavy objects

DX: Strained Hamstring or Proximal Hamstring Tendonopathy

Symptoms	Do’s & Don’ts
Hurts at toe off during walk/run	Do’s: Exercises that don’t increase pain, e.g., spin, swim, weight-lifting, etc.Ice tender areasKinesiotape hamstringHip flexor and IT band stretches
Pain in sitting
Pain bending over
Pain at bottom of butt at sits bone (ischial tuberosity)
Hamstring weakness
Tenderness at hamstring attachment on sits bone
No sensory issues
Sleeping is usually fine in any position	Don’ts: Stretch hamstringsDo activities that increase pain
Reflexes are fine

In general, the PT treatment for each of these issues is the same, manual therapy and therapeutic exercise. However, while some exercises are appropriate for one diagnosis, those same exercises may aggravate other diagnoses. There is no one size fits all when it comes to an exercise program for sciatica, low back pain, or proximal hamstring tendonopathy. The manual therapy techniques are also specific to each diagnosis, but there is greater overlap. For instance, I find everyone needs work on their SI joints regardless of their primary diagnosis. The SI joints are part of the pelvis, the base of the spine. Like the floor of a house, if it’s not level than everything above it will be thrown off. Then once the pelvis position is balanced, the manual therapy then becomes more symptom-specific.

Research shows that PT can be very successful much of the time for each of these diagnoses.² PT is even more successful if a patient gets into the PT’s office sooner than later. If you suspect you have any of the above issues, make an appointment with your MD as soon as possible and request physical therapy.

1. Hanney WL, Morey JK, Beekhuizen KS. Implications for physical activity in the population with low back pain. Am J Lifestyle Med. 2009;3(1):63-70.

2. Balthazard P, de Goumoens GR, Rivier G, et al. Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain. BMC Musculoskelet Disord. 2012;13(162).