Chronic Pain

Lumbar Spondylolisthesis

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Your spine is made up of 24 individual vertebrae all stacked on top of each other. The lowest five vertebrae are referred to as your lumbar spine. Each vertebra has two basic components: the “body” and the “arch.” You can envision this as a coffee mug lying on its side. The cup would represent the vertebral body, and the handle would represent the arch. The spinal cord travels through each of

the vertebral arches on its way from your brain to your tailbone. The term “lumbar isthmic spondylolisthesis” describes a condition where your arch has broken free from its anchor on the vertebral body, allowing the vertebral body to slide forward. Lumbar spondylolisthesis typically affects the lowest lumbar vertebra, L5, or occasionally the second lowest, L4.

The condition is sometimes caused by trauma, but more often follows a “stress fracture” involving the arch of the vertebra. This break and slippage is thought to result from repetitive movements, especially hyperextension (arching back) and rotation. The break usually happens during childhood but does not always cause symptoms when it occurs. Many times, the condition will lie dormant until later in life. Lumbar spondylolisthesis is present in six to seven percent of the population and affects males twice as often as females. The problem is more common in those who participate in sports. Some sports predispose children to this “break and slip”. Athletes who participate in gymnastics, rowing, diving, football, wrestling, weight lifting, swimming, tennis, volleyball, and track & field throwing sports (i.e. discus, shot put, etc) are at greatest risk.

The pain usually starts in your back but may radiate into your buttock or thigh. Your pain usually intensifies with standing upright for prolonged periods of time or leaning backwards, especially during heavy activity. Some women report increased symptoms during the later stages of pregnancy. Be sure to tell your doctor if you notice pain, numbness or tingling in your groin, a loss of bowel or bladder function, fever, night sweats, pain extending beyond your knee, or weakness in your legs.

Your doctor will “grade” your spondylolisthesis based on the percent of the vertebral body that has slipped forward. Your doctor will try to determine if your spondylolisthesis is “active”, meaning a recent break or “inactive”, referring to a long-standing problem. If your doctor has determined that your spondylolisthesis is new and has a chance of worsening, you may need to stop certain activities or sports for a period of time until your fracture heals. Sometimes a lumbar brace is used to help you recover more quickly. Patients with a long-standing “inactive” spondylolisthesis may benefit from a combination of treatments including stretching and strengthening. You should limit leaning backwards or sleeping on your stomach. Females should avoid wearing high heels.

Lumbar Spondylo-what?

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Your spine is made up of 24 individual vertebrae, all stacked on top of each other. The lowest five vertebrae are referred to as your lumbar spine. Each vertebra has two basic components- the “body” and the “arch.” You can envision this as a coffee mug lying on its side. The cup would represent the vertebral body, and the handle would represent the arch. The spinal cord travels through each of the vertebral arches on its way from your brain to your tailbone.

The term lumbar spondylysis describes a condition where a part of the arch breaks free from its anchor site on the vertebral body. This condition most commonly occurs during adolescence while bones are hardening. When we are young our bones have taken shape but they have not yet become hardened. Think of this as a clay coffee mug that has not yet been fired in the kiln. During adolescence, our bones transform from this softer clay to a more brittle bone.

The condition is sometimes caused by trauma but more often is a “stress fracture” to the arch of the vertebra. This defect is thought to result from repetitive movements, especially hyperextension and rotation. The condition is more common in people who were born with a small or weak arch- think of a coffee mug handle with a very thin brittle attachment.

Lumbar spondylolysis usually affects the lowest lumbar vertebra- L5, or occasionally L4. Most patients are 10-15 years of age when they are diagnosed with the condition, although sometimes symptoms do not present until adulthood. It is more common in those who participate in sports. Some sports predispose children to this problem. Athletes who participate in diving, wrestling, weight lifting, track, football and gymnastics have the highest incidence of spondylolysis.

The pain usually starts in your back but may radiate into your buttock or thigh. Your pain usually intensifies with standing upright for prolonged periods of time or leaning backwards. You should limit movements that involve hyperextension, like leaning backwards. Females should avoid wearing high heels.

Your doctor likely performed x-rays or an MRI to make the diagnosis of spondylolysis. If your doctor has determined that your spondylolysis is new and has a chance of worsening, you may need to stop certain activities or sports for a period of time until your fracture heals. Sometimes a lumbar brace is used to help you recover more quickly.

What is Lumbar Stenosis? 

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The term stenosis means “narrowing” of a tube or opening. Spinal stenosis means that the tube surrounding your spinal cord and nerve roots has become too small, and your nerves are being compressed. Stenosis can arise in different ways. Sometimes, people are born with a spinal canal that is too small. Other times, the canal may have been narrowed by surgery or conditions like disc bulges. Most commonly, spinal stenosis arises from chronic arthritic changes that narrow the canal. This type of stenosis usually develops slowly over a long period of time, and symptoms show up later in life.

Patients with stenosis often report pain, tingling, numbness or weakness in their legs. Lower back pain may or may not be present, but leg symptoms are usually more bothersome. You may notice increasing symptoms from standing or walking and relief while sitting because the available space in your spinal canal decreases when you stand, walk or lean back and increases when you sit or flex forward. Walking down hill is usually more uncomfortable than walking up hill. You may notice that when you walk with a shopping cart or lawn mower, you are more comfortable, as this promotes slight flexion. Sleeping on your side in a fetal position with a pillow between your knees may be most comfortable.

The natural course of spinal stenosis is variable. Most patients notice their symptoms stay about the same over time, while others are divided into fairly equal groups who either improve or worsen. Be sure to tell your doctor if you notice that your legs become cold, swollen or change color. Likewise, tell us if you notice a fever, unexplained weight loss, flu-like symptoms, excessive thirst or urination, numbness in your groin or loss of bladder control.

While there is no non-surgical cure for stenosis, we offer potent treatments to help ease your symptoms. Treatment is focused on helping improve your mobility so that you can walk and function better. You will be given exercises to help with conditioning. You should avoid activities that increase your pain, including heavy lifting or those that cause you to extend your back, like prolonged standing or overhead activity. When you are forced to stand, you may find relief by slightly elevating one foot on a stool or bar rail. You may find relief while washing dishes if you open your cabinet door and alternately rest one foot on the inside of the cabinet to provide a little bit of flexion. Recumbent cycling is often a more tolerable alternative to walking or running. Some patients report relief by using an inversion table.

Thumb/Wrist pain from De Quervain’s Disease…..

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Tendons are strong, fibrous bands of tissue connecting muscles to bones. Some tendons are covered by a protective, lubricated insulation called a “synovial sheath.” The two tendons on the thumb-side of your wrist that extend and abduct your thumb into a “hitchhiker” position are covered by a sheath. Normally, these tendons move freely within this covering, much like a sword sliding through a sheath.

If these tendons and sheaths are forced to repetitively rub against the bones of your wrist, they can become painfully swollen. This condition is called De Quervain’s tenosynovitis.

The pain of De Quervain’s tenosynovitis may begin abruptly, but more commonly starts gradually and increases over time. The pain is provoked by movements of your thumb or wrist. In more severe cases, you may notice swelling on the outside of your wrist. Some patients complain of “catching” or a slight “squeaking” sound while moving their wrist.

Activities like gardening, knitting, cooking, playing a musical instrument, carpentry, walking a pet on a leash, texting, video gaming and sports like golf, volleyball, fly fishing and racquet sports are known triggers. The condition was once known as “Washer woman’s sprain,” since wringing out wet clothes can trigger the problem. Lifting infants or children by placing your outstretched finger and thumb beneath their armpit has led to the nicknames of “Mommy thumb” or “Baby wrist.”

The condition strikes women much more frequently than men. It typically affects middle-age adults and is more slightly common in African-Americans, patients with diabetes or rheumatoid arthritis may be at higher risk for this problem.

Many patients will experience resolution of their symptoms through conservative care, like the type provided in our office. You should avoid lifting, grasping and pinching movements, especially when your wrist is bent toward either side. You may need to find alternate ways to lift children and perform work, sport and leisure activities. Video game players and those who text should take frequent breaks and try to hold their wrists straighter. Avoid wearing tight wristbands. Applying ice to your wrist for 10 minutes every hour or performing an “ice massage” (freeze a paper cup filled with water, tear off the bottom to expose the ice, massage over the tendons in a figure-eight pattern for 6-10 minutes, taking breaks as needed) can provide relief.

Patients who have severe pain or swelling are less likely to respond to conservative care. These patients may require a cortisone injection to relieve their pain, however, surgery is rarely necessary.

Mobility Myth #4

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Myth: You only need to do mobility work if you’re an athlete or if something hurts.

Truth: “Whether you’re pro athlete, weekend warrior, or parent being active with their kids, the mobility requirement for fundamental movements (running, squatting, etc.) stays the same,” says Ardoin. “We always need adequate mobility in the same key areas, such as the ankles, hips, thoracic spine (upper back), shoulders.” He says everyone should be able to meet the following mobility baselines:

  • Touch your chin to your chest without opening your mouth.

  • Look up toward the ceiling with your face becoming parallel to the floor.

  • Rotate your head to each side until your chin reaches mid collarbone.

  • Touch your toes with straight legs.

  • Lower into a deep squat without your heels coming up or toes rotating out.

“If you don’t have access to the necessary mobility, your body will find a way to get it by compensating elsewhere, which could lead to injuries down the road,” he says.

But the injuries might be in unexpected places: Your first thought might be to deal with the area that hurts—but, often, that’s not the true source of the problem. “Often times the issue causing lower-back pain isn’t the lower back, but an issue with hip mobility,” says Esquer. An elbow issue might actually be due to a lack of wrist mobility, and upper-back pain might be due to tightness in the front of the chest and shoulders.

“A lot of times we don’t notice movement restrictions until we’re in pain,” says Esquer. Maintaining your natural mobility day in and day out (kind of like brushing your teeth to prevent cavities) will help prevent surprise injuries from popping up.

I’m getting old Doc… Getting old….

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Your lumbar spine (low back) is made up of 5 individual vertebrae stacked on top of a bone called the “sacrum”. To allow for flexibility and movement, there is a cushion or “disc” in between each level. As we age, these discs can wear and become thinner over time. This leads to additional changes, including bone spurs and narrowing of the opening where your nerves exit your spine.

This process is called “lumbar spondylosis”, or simply, “arthritis”. This problem most commonly involves the vertebra at the very base of your spine, which bear the highest loads.

Lumbar arthritis is exceptionally common, affecting people as young as 20 and becoming extremely likely by age 70. How quickly you develop low back arthritis is largely a trait you inherited from your parents. Other factors may play a role, including a history of trauma, smoking, operating motorized vehicles, being overweight and/ or performing repetitive movements (i.e. lifting, twisting, bending or sitting). Men seem to be affected slightly more often than women.

Symptoms often begin as back and buttock pain that gradually worsens over time. Stiffness may be present upon arising in the morning. Pain is relieved by rest or light activity and aggravated by strenuous work. Sometimes your nerves can become “pinched” in narrowed openings where they exit your spine. This can cause “sciatica” which results in pain, numbness, or tingling radiating into your leg along the path of the irritated nerve. Be sure to tell your doctor if you notice any weakness or if you have fever, abdominal pain, change in bowel or bladder function, or pain in your groin crease.

Arthritic changes can be seen on x-rays, but interestingly, the amount of wearing does not seem to correlate directly with the severity of your symptoms. People with the same degree of arthritis may have symptoms ranging from none to severe. Most researchers believe that the symptoms of osteoarthritis are not the direct result of the disease, but rather, from the conditions that preceded the disease and those that develop subsequent to it, like joint restrictions and muscle tightness. Fortunately, those conditions are treatable and our office has a variety of tools to help relieve your pain.

In general, you should avoid repeated lifting and twisting and take frequent breaks from prolonged sitting, especially in motorized vehicles. Avoid any position that causes an increase in radiating pain. Low-impact activities, like walking, stationary cycling, water aerobics, and yoga may be helpful.

Radial Tunnel Syndrome

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Your radial nerve begins in your neck and travels past your elbow en route to its final destination in your hand. Just beyond your elbow, this nerve passes through a 2-inch area on the back of your forearm called the “Radial tunnel”. “Radial tunnel syndrome” means that your radial nerve has been compressed or irritated within this space-leading to forearm pain or hand weakness.

Radial tunnel syndrome is thought to result from muscular overuse, especially prolonged or excessive wrist extension or rotation. The most common cause of compression comes from excessive tightness in a muscle called the “Supinator”. Workers whose jobs require heavy or repetitive wrist movements are at an increased risk for this disorder. Occasionally, the radial nerve can become irritated from direct compression by a tight band or brace. The condition may be more common in those who have diabetes or thyroid problems.

Symptoms from irritation of the radial nerve depend upon which specific nerve fibers are irritated. The most common symptoms include pain, numbness, tingling or decreased sensitivity along the top of your forearm radiating toward your hand and thumb. The symptoms often mimic those of “tennis elbow.” When the nerve fibers that control muscle function become compressed, you may experience weakness when trying to extend your fingers, hand or wrist. Seventy percent of radial tunnel patients also have problems in their neck or upper back.

Conservative treatment of radial tunnel syndrome is generally successful. Fixing the problem means limiting excessive or repetitive wrist movements, especially extension and rotation. In severe cases, a splint may be necessary to limit your motion. Try to avoid compression of your forearm, particularly from tight bands or braces. Use of a tennis elbow brace will likely aggravate your symptoms. You may find relief by applying ice or ice massage to the area for 10-15 minutes at a time.

So it FEELS like Carpal Tunnel but it ISN’T Carpal Tunnel?

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Your Median Nerve begins in your neck and travels down your arm on its way to your hand. This nerve is responsible for sensation on the palm side of your first 3 ½ fingers and also controls some of the muscles that flex your fingers. The median nerve can sometimes become entrapped near your elbow as it travels through a muscle called the “pronator teres”. Compression of the median nerve by the pronator muscle is called “Pronator Syndrome.”

Pronator syndrome is often brought on by prolonged or repeated wrist and finger movements, i.e., gripping with the palm down. Carpenters, mechanics, assembly line workers, tennis players, rowers, and weight lifters are predisposed to this problem. The condition is more common in people with excessively developed forearm muscles and is also more common in your dominant arm. Pronator syndrome most often affects adults age 45-60 and females are affected about four times more frequently than males. People who suffer from diabetes, thyroid disease, and alcoholism have an increased risk for developing pronator syndrome.

Pronator syndrome produces symptoms very similar to a more common cause of median nerve compression called “carpal tunnel syndrome”. Symptoms of pronator syndrome include numbness, tingling, or discomfort on the palm side of your thumb, index, middle finger, and half of your ring finger. The discomfort often begins near the elbow and radiates toward your hand. Your symptoms are likely aggravated by gripping activities, especially those that involve rotation of the forearm, like turning a doorknob or a screwdriver. Unlike carpal tunnel syndrome, pronator syndrome symptoms are not generally present at night. You may sometimes feel as though your hands are clumsy. In more severe cases, hand weakness can develop.

To help resolve your condition, you should avoid activities that involve repetitive hand and forearm movements. Perhaps the most important aspect of your treatment plan is to avoid repetitive forceful gripping. You may apply ice packs or ice massage directly over the pronator teres muscle for ten minutes at a time or as directed by our office. In some cases, an elbow splint may be used to limit forearm movements. If left untreated, pronator syndrome can result in permanent nerve damage. Fortunately, our office has several treatment options available to help resolve your symptoms.

Mobility Myth #2

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Myth: You can get rid of knots or scar tissue with foam rolling or massage.

Truth: “You probably hear of ‘breaking up fascia’ and ‘breaking up scar tissue,’ but the reality is that it literally takes 200 tons to deform scar tissue or cause mechanic changes to the fascia,” says Los Angeles–based physical therapist Jen Esquer, D.P.T., creator of the Mobility Method program. So whenever you’ve been told that someone is “massaging out a knot” in your back, or that foam rolling is “realigning your muscle fibers,” it’s a load of B.S. (You’ve probably also heard that foam rolling can get rid of cellulite.)

“Think: If you bump into something super hard, yeah, you might bruise, but you’re not actually breaking something in your body or tearing tissue,” says Esquer. “So why would we think that lying or rolling around on a foam roller for a while would have that extreme effect?”

You might be thinking, “But it totally helps!” You’re not wrong—it does. It just helps for a different reason: “Really, foam rolling and massage work by bombarding the brain with safe, feel-good information, convincing the muscle to relax and let go,” says Ardoin. That calming of the nervous system results in the release of tension and tightness that you feel.

And since it’s all about relaxation, you should never be trying to create pain in the body, says Esquer: “You don’t want to fire anything back up and make it potentially worse. It always comes back to relaxation.”