Expert: Scott F. Gillman, DC, DACBSP - 5/25/2009

Question
Hi, I just wanted to respond and thank-you for your help with an earlier correspondence; I will attach below.  You were right on with disc pain though people I was seeing disagreed... I finally figured that the "SI Joint Pain" I was having could be really low on the spine.  I finally had an MRI and it showed a protruding disc L5-S1 (9mm).  

I was hoping you could help interpret what the radiologist wrote in the last sentence and chiropractic treatment options and expected time for recovery?
"At L5-S1 there is a mild broad posterior disc protrusion with a large posterior right paracentral focal disc protrusion.  Maximum AP caliber of this focal disc protrusion component is about 9mm.  This has mass effect and displaces the traversing right S1 nerve root.  There is moderate osteophytic narrowing of the bilateral neural foramina."

Old Correspondence Reference
On Mon, Apr 20, 2009 at 7:08 PM, AllExperts <> wrote:


Subject: SI Joint

Volunteer Expert: Scott F. Gillman, DC, DACBSP

Question:
Three months ago I began suffering lower back pain and could not bend forward more than 4-6 inches without experiencing lower back pain originating around my SI Joint carrying down my leg. The pain was worse in the morning but was always better later in the day so I continued to perform lifts at the gym (Squats, deadlifts, running) with extra warm-up sessions. I had an MRI on the SI region and X-Ray which apparently did not show anything.

The pain became worse about 4 weeks ago after some extended sitting during travelling so I stopped running, deadlifts, and squats to try to allow my body to recover.

I have visited a few well recognized chiropractors/sports injury experts the past two months who found my Psoas (Psoas Minor especially tender)and QL muscles to be very tight. They believe that is pulling on my ilium causing my SI Joint to be out and pinch my sciatic nerve. I've been getting active release, acupuncture, and chiropractic adjustments 2-3 times per week for almost three weeks now and have had little to no improvement. (I was told the problem would disappear in 2-3 weeks...)

The latest diagnosis was the problem could be foot related so I've been doing straight leg tensor band resistant exercises for over 1 week with no improvements. I also have been wearing orthodics in my shoes/boots.
The pain is always worse first thing in the morning and I can barely get my right sock on. The pain lessens through-out the day with some stretching and walking/light activity but always returns come morning. This condition is frustrating as it seems the muscle are tight because the joint is out and the joint is out cause the muscles are tight. (which came first the chick or the egg?)

How do I break this cycle & get my life and workouts back on track?
Any suggestions?

Any help is greatly appreciated
Frustrated Athlete

Answer:
Ian,

This really sounds like a lumbar disc problem.   Was that MRI of the lumbar spine?  An irritated disc will cause all the symptoms you describe.  The disc doesn't have to be protruded or extruded to cause leg symptoms.  It can simply be irritated and chemically irritate the nerves.  Discs will hydrate and pressurize overnight as you sleep, making for a lot of stiffness first thing in the morning, with symptoms subsiding as you move around. The same can be said for any degenerated joints.   I highly doubt your feet are the cause of your back problem.   I'd have another look at that MRI.  Ask your chiropractor to do disc-related tests and nerve tensioning tests to see if I'm correct or not.  Also, there could be one exercise that is provoking your disc pain, and out of the short list you provided, I'd try avoiding squats for at least 5 days and see if that changes anything.  If not, eliminate deadlifts for 5 days.   You will not decondition over 5 days (some argue that 7 days is okay).  If you are doing any unsupported seated cable rows or machine leg presses, try avoiding these as well.  Ask your DC to do a prone instability test to see if you have an unstable segment (see: Arch Phys Med Rehabil Vol 84, December 2003; Hicks et.al.).   If you have a (+) instability test, then your first option is to do core stability exercises (see: McGill, et.al, Arch Phys Med Rehabil Vol 90, January 2009).

Good Luck!

Dr. G  

Answer
Ian,

So much for those "experts" that couldn't diagnose something that is text-book obvious...     You need to try the McKenzie approach to attempt to "offload" the disc.   This means finding trunk positions that alleviate the pain and take it out of your leg and thigh.  Usually it involves postures that extend your trunk, and if so, then you want to focus all your exercises towards trunk extension.  You should also find a chiro with a Cox table or Lloyd flexion-distraction table and try a short course of flexion-distraction to the spine.   Add to this a Stuart McGill style of core exercises and you're in business.   If these fail, then you are looking at interventional pain management: epidural steroid injection.   If your condition worsens and you develop neurologic signs, e.g. loss of achilles reflex, inability to do a calf raise, then you're looking potentially as microdiscectomy.   I'd focus on the conservative treatments first.   You can google the above terms or email me off-list for some references.

'Good luck,

Dr. G
www.drgillman.com