Hey everyone. Welcome to the first post
of my rehab, wellness, and fitness blog. On this blog, I'm going to
hopefully post one anatomy fun fact per week. In addition, I will try
to publicly answer some questions I get regarding injury, anatomy,
exercise, form, whatever. If it has to do with the human body moving,
I love talking about it. I'm well versed in the world of strength
training, powerlifting, grappling, running, and sport in general.
Because of the overlap between my education and my interests, I've
learned to mesh the two to advance my performance in both fields. I
welcome questions in and outside my field of interests so if you want
to ask about dance, occupational, or clown-fighting injuries, I'm
more than happy to help any way I can. This blog is likely to be
fairly basic, but I'll include pictures, videos, research, and
others' articles to keep you interested. Now put your thinking caps on, keep an open mind, and *gasp* LEARN :)
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5 comments:
I am a 52 yr old male with disc L5/S1 go from a small herniation over ten years ago, had a discectomy with some relief. After about three years it got really bad, got an MRI which revealed loss of disc space - surgeon said the disc was practically flattened out. Got a minimally invasive fusion in early 2007. Of course I had to go through all the usual non-invasive treatments like PT, aqua PT, epidurals along with a few visits to chiropractors. All MRI's I've had through this ~10 year period note a bulged disc at L4/L5 but no one ever seemed concered.
Much better after the fusion but still had pain, mainly in lower back. Too much activity, especially anything involving bending over brought on temporary nerve pain in left leg, which for the most part went away if I took it easy and kept up with my daily lower back stretches and walking. It would start out as sharp pain radiating into the buttocks, sometimes in the back of my knee. Last year I had another epiduarl with no good results. Had aqua therapy, and the therapist said that my said I had sacroiliac dysfunction at one point, but it did loosen up by the end of my sessions. The sensitivity to activity remained so he felt it wasn't an issue I suppose.
Fast forward to this year, I had to reluctantly go back to machine shop work after unsuccesfully trying to break into computer repair. My employer knows my limitations and doesn't give me the really big stuff, but still I occasionally have to get stuck manipulating moderately heavy pieces of steel (35-50 lbs or more). I developed left leg pain around my knee extending up and down my leg, only this time it didn't go away.
My question is this: if I damaged something in my back where a nerve is aggrevated or impinged, would bending my knee be able to make it worse? In other words, if I grab my ankle and pull my leg tight against the back of my thigh, it seriously escalates my pain. What I'm trying to sort out whether the pain is from leg damage possibly on a muscular level or from nerve aggrevation in my back.
I need to make a decision whether to try to get out of this job, which I love. I hate to admit it but my gut feeling is I did additional permanent damage in my back, in light of the previously mentioned nerve pain behind my knee. The pain now is different, not that sharp, acute pain. I had an MRI last year which my pain management doctor said revealed the usual problems associated with my injury and some of which are what happens in the body after surgery. Any thoughts would be much appreciated. Thank you!
Hey stargazr,
I'm sorry to hear about your extensive back issues. I forgot to put a disclosure on the blog initially, but I have to let you know that the advice I give is not a professional assessment as I have not and cannot examine and diagnose over the internet. I maintain no liability for any actions you may take as a result of my opinion. Please take that into mind when you read the following post.
Firstly, let me explain dermatomes to you (it's related to your back). Dermatomes are the areas of skin innervated by a specific spinal nerve root. This means that if the L3 nerve root is affected (by a disc, nerve entrapment, tumor, etc), it will affect the respective L3 dermatome. Each nerve root has a respective area of skin, roughly following the pattern in the image below.
Dermatome Map
A disc protrusion at L4-L5 should result in impingement of the L5 nerve root. If you look at the dermatome map, that would be on the outside of your knee down the front/outside of your shin. If you were having neural symptoms at the level of your knee, it would likely consist of some numbness and/or tingling, in addition to pain (at the knee or in the low back or both). Do you have numbness and tingling? Can you describe in more detail or (much preferred) can you find a picture on google of a lower extremity and color in the area where you feel pain? People use the term "leg" for the whole lower extremity, but there's the leg which is the lower segment including the shin while the thigh is the part between your hip and your knee. It's a little tricky to understand where you're talking about.
There are tools we use that are called neurodynamic tension tests. This may sound like a funny question, but when you bend your knee and get your pain, does the pain change when you bend your neck forward? How about back (looking up)? That might help give me a little bit more information.
I fully understand your disclosure. I read the thread about whether a disc can heal by itself, and gained a great deal of respect for not just your grasp of spinal problems, but also your professionalism and open mind, and also the limitaions of PT in certain cases.
I am interested in your thoughts, understanding the limitations of not being able to examine me in person, and that you are not a spine surgeon.
I am familiar with dermatomes and have an excellent older software program called Dynamic Spine. My pain is centered around the area in the this photo: http://imageshack.us/photo/my-images/577/94686877kneepain.jpg/ where the woman's hand is on her leg, specifically around her index and middle finger. It appears to be around the line between the L5 and S1 on the dermatome map, hard to tell but definitely on the side and back of leg as opposed to the front, a few inches below the knee cap. It is aggravated if I stand up and pull my knee into the back of my thigh, if I kneel down, but not if I'm sitting. I occasionally experience tingling in the entire area between my knee and ankle, hard to tell specifically front or back. Also want to point out the joint dysfunction previously mentioned was on my right side, opposite my current knee area pain.
Edit: My pain is not aggrevated when sitting if I pull my knee towards my upper body.
I appreciate your feedback about the disc thread on ATHF. I think that's definitely something I'll transcribe into an article here at some point in time. It's good stuff.
Does the pain on the back of your knee sometimes progress to numbness, tingling, ants-crawling-on-your-skin sensation? If not, is the numbness and tingling you get in the same location specifically? Or is it more diffuse?
If you have L5-S1 dysfunction, it would make sense that you could get symptoms there. Everybody's personal dermatome map is a little different. The thing that needs to be considered is what's actually causing the pain - the knee or the low back? I asked the above questions to get a bit more info about your low back.
The way you describe your aggravating factors (bringing thigh back) doesn't typically fit with disc pathology. If you have tight hip flexors (particularly rectus femoris), pulling you knee back while standing can put your spine into extension. Typically, that's an ok position for people with disc pathology, unless it's more severe. However, it's a bad position for people who have nerve entrapment due to neural foraminal narrowing (narrowing of the hole your spinal nerve root goes through). That can be caused by bone spur formation (common with lumbar disc degeneration), poor spinal mechanics/flexibility (which is something PT can help), or poor baseline position (posture, locked vertebral segment, etc). Actually, all of these can interact to cause symptoms. PT cannot treat things like bone spurs, but joint mobilization, stretches, and exercise can relieve significant back pain.
Lastly, you could also have some knee involvement. Posterior (back of the) knee pain can be caused by poor peripheral nerve movement (sciatic nerve, which makes up the tibial nerve and common fibular nerve), muscle strain (popliteus, hamstring), meniscus damage, ligament sprain, etc.
See, its a little difficult to start ruling in and ruling out problems because I can't actually evaluate you. Your back plays a factor in all likelihood and may very well be the sole cause of the pain. However, I'm not sure enough that I can tell you not to worry about your knee. In the best case scenario, I'd try to see a good physical therapist (maybe look for the OCS certification after the PTs name - stands for orthopedic clinical specialist) and get it looked at. I know that's not always an option with insurance issues and such (and considering it requires a medical doctor's diagnosis), but that would be ideal if it's affecting your work and quality of life.
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