Lower Back Pain and Sciatica

Almost everyone will experience lower back pain at least once in their lifetime, with an estimated 5%-10% of patients with low back pain having sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49% to 70%. The annual prevalence of disc related sciatica in the general population is estimated at 2.2% ("Diagnosis and Treatment of Sciatica", Koes, B W, M W van Tulder, and WC Peul, 2018). These statistics highlight the importance of understanding the reason for lower back pain, and the concerning levels of how chronic the situation can get, particularly if not dealt with.

Most people consider NSAID's (Non-steroidal Anti-Inflammatory Drugs) a sufficient way to deal with the pain as they help relieve the symptoms. However, there is increasing awareness of the over use of pain killers on both the immune system and liver, and unless dealt with physically, it is more likely to return and thus, become chronic. Therefore, this displays the importance of dealing with lower back pain physically by correcting the issue directly, rather than "masking" the issue and hoping NSAIDs work. Here I aim to show ways in which you can do this, by explaining the various causes of lower back pain, and realistic and manageable ways to help relieve the pain properly. It must be noted that moderate use of NSAIDs is acceptable unless your doctor has advised otherwise, with the understanding that NSAIDs simply deal with the pain, and commonly not the cause. NOTE: If you are taking NSAIDs, it is important you DO NOT take any pre-treatment as it increases risk of worsening the situation.

COMMON CAUSES OF LOWER BACK PAIN:

1) Anteriorly (forward) rotated pelvis aka Lordosis

2) Sciatica

3) Breathing Dysfunctions

Questions I ask my clients:

- How curved is your lower back?

- Do you stand and lie down with hyperextended knees?

- When you lie down on your back, how far off the ground is your lumbar spine? And is one SI Joint off the surface more than the other, ie. is there more pressure on one of your glutes?

- In standing, how much pressure do you put down your heels?

- How much pressure do you put down your big toe compared to the outside of your foot? Does the pressure differ between each big toe and foot?

- Are the arches in your feet high, average or collapsed/fallen?

- Can you feel one hip bone on the front (ASIS) more than the other?

- Is more weight down the front of your leg or back of the leg (ie. Quads or Hamstrings)?

- Do you breathe into your gut, chest or shoulders?

A fun exercise to show how the pelvis balances (requires more than one person):

Stand facing each other, and taking it in turns, the first person gently pushes the others shoulders backwards as they stand with feet rotated outwards (laterally rotated). DO NOT push too hard as this is the weaker position, be respectful and appreciate what it is showing. Then the person rotates their feet inwards, and repeat gently pushing the shoulders back.

With the feet laterally rotated, the hip stabilisers are not acting sufficiently as the pressure is being absorbed more by the lateral rotators, therefore, I describe this as the stilletoe heel in sand as the spine receives more pressure. With the feet rotated inward, the hip stabilisers are in a stronger position, allowing for absorption into the whole pelvis, meaning less pressure into the spine, and thus, I describe this as the elephants foot in sand.

1) ANTERIORLY ROTATED PELVIS aka LORDOSIS

In simple terms, the support of the arch in your foot comes from the hip stabilisers which are glute min and mede.

The balance of the pelvis depends on how the feet and knees absorb the pressure, and also superiorly in regards to the balance of the torso. In some cases, the shoulders, head and jaw can be imbalanced due to the lack of support from the feet/a foot which compensates through the leg and hip!

Moving upwards:

Laterally rotated feet means less support for the tibia, placing increased pressure on the outside of the foot and less use of the big toe (noting the big toe, physiologically known as the hallux, is vital for balance), which can create fallen and collapsed arches. This creates imbalanced pressures into the knee, causing it to collapse inward as a result of the lack of tibia support which is physiologically known as a knee valgus. Knee valgus creates strain on the hip as the glute min and mede switch off, meaning increased strained tension in TFL and IT Band, and more pressure on the groin and hip flexor insertion at the top of the medial (inner) femur.

In terms of performance, laterally rotated feet cause the tibia and fibia to twist outwards meaning the outer half of the calf (gastrocnemius and soleus muscles) are worked more, and with the lack of use of the big toe creates more pressure on the plantar plate. Moving upwards, as the tibia and fibia twist outwards, the femur twists outwards and collapses inwards to compensate, meaning the more pressure on the MCL and twisted strain on the LCL, and causing the ACL and PCL to twist and absorb imbalanced pressures in the knee joint. As the femur rotates and collapse, the quads become more like the IT Band, IT Band more like hamstrings, hamstrings more like adductors, and adductors like quads, noting the iliopsoas (hip flexors) insertion is now absorbing more pressure as the balance is placed on the groin. With the tension into the iliopsoas increases, it pulls on the lower back, and consequently tilting the pelvis forward, ie. anteriorly rotated pelvis.

Moving downwards:

From Kyphosis - The more kyphotic in posture, the more pressure created on the anterior chain (front of the body) in terms of balance against gravity. As stated in a previous blog (Stress in the Neck and Shoulders), Julian Baker at the British Fascia Symposium 2016, put forward that the SCM (a neck muscle) is a hip flexor, noting the back and forth movement of the neck in sprinters. In order for the body to maintain an upright posture with increased pressure on the anterior chain, tilting the body forward, the hip flexors are required to absorb the tension from the lower back to legs, via the pelvis. As the hip flexors become more hypertonic, they shorten causing the pelvis to anteriorly tilt!

From sway back posture - With the head behind the hips, it creates increased tension in the back extensors, shortening the gaps between spinal processes in the lumbar area (lower back), and SI Joints absorb abnormal pressures into the pelvis.

Ultimately, it can be recognised with weakened abdnominal muscles, tight back extensors, hip flexors and quads, causing weakness in the antagonistic glutes and hamstrings.

TOP TIP: If you think you are walking pigeon toed (toes in), you are likely to be walking with straight feet. It may feel odd to begin with, but the more you do it, the easier it will become. It is important to do this without looking down as looking down puts more pressure on the anterior chain. Ensure there is the straight line between ear, shoulder, hip, and ankle. Compare the pelvis to a bucket of water, tip too far forward or back and the water will spill.

TOP TIP: Towel scrunches with feet inwards and square pelvis. This will help mobilise the connective chain from big toe to hip in the correct way.

TOP TIP: Glute bridges with feet and knees straight and in line with the hips, and hips in line with the shoulders. Make sure the big toe is engaged throughout, and that you are using the whole pelvus. Gently roll each vertebrae of the ground using the glutes to power the movement, and then gently roll each vertebrae back down, ensuring chain between big toe and hip is balanced and engaged throughout. Note, the knees may try and collapse in or out due to tension, try and maintain straightness, even if it means you cannot move up too far, as it will increase with practice.

TOP TIP: Uphill walking ensuring toes are facing in, using the big toe (curling and pushing down), knees are straight, pelvis is square, shoulders back and down and head retracted. The concept of keeping the bucket of water full analogy is very helpful here, as it puts more pressure on the glutes, including hip stabilisers (ensuring feet are straight and using big toe). This then engages the hamstrings more, and allows the quads and hip flexors to focus more on moving uphill, and less on posture. This links in with slow and fast twitch muscle groupings.

2) SCIATICA

Repeating what was mentioned above, an estimated 5%-10% of patients with low back pain have sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49% to 70%. The annual prevalence of disc related sciatica in the general population is estimated at 2.2%("Diagnosis and Treatment of Sciatica", Koes, B W, M W van Tulder, and WC Peul, 2018). It is evident that many people suffer with sciatica at some point, and the location of pain can vary depending on the cause. In some cases, as above, it can be due to a herniated disc, which is where the spinal disc moves forwards and/or sideways and presses on the sciatic nerve. In this case, a course of physiotherapy, sports massage, and chiropractic or osteopathy treatment is recommended, noting it is important to not take any NSAIDs before treatment to avoid risk of further injury.

If the sciatica is not due to a herniated disc, it is usually due to the piriformis muscle. The sciatic nerve leaves the spinal cord between spinal processes L5 and S1 which is where the lower back meets the pelvis, and travels down through the pelvic cavity to the leg, and down to the foot. In the pelvic cavity, it passes just anterior to the piriformis muscle which is a prime lateral rotator for the hip/leg, meaning the more the hip/leg is laterally rotated, the shorter this muscle becomes. Therefore, the more hypertonic the piriformis becomes, the more likely it will compress the sciatic nerve. This pain can be localised to the glutes, or it can travel down the leg as far as the foot.

TOP TIP: "Running Man" exercises, this is a complicated exercise to explain in writing, so I recommend watching this video from Tim Hill of "You Tonic" (SRMT, Nutritionist PT) who made me aware of this exercise - https://www.dropbox.com/s/i9w3zp9plewdfxz/Running%20Man.mp4?dl=0

TOP TIP: side steps using a resistance band around the knees and/or ankles, focusing on keeping both feet facing slightly inward, and standing upright keeping the "bucket full", shoulders back and down, and head retracted.

TOP TIP: Abduction in standing or sideline, ensuring toes are slightly inward and knees do not collapse in or out, and the pelvis and leg does not rotate.

TOP TIP: Lateral rotator, hamstring (ensuring square pelvis), and adductor stretches. Quad and hip flexor stretches are also helpful. "Banana Stretches" are also good if there is more than one of you. Note- Try keeping the big toe a little curled (initiating an arch in the foot), and facing slightly inward for hamstring stretches, and pushing down into the surface with the big toe on the adductor stretches. For quads and hip flexors, it is a hip flexor stretch if you can see your knee, and if not, it is predominantly a quad stretch, and again noting that the pelvis is square.

3) BREATHING DYSFUNCTIONS