Bad back and sciatica

This patient was late 30’s with a desk job but tried his best to keep fit with trips to the gym a couple of times a week. This was hard because of the kids and the increasing demands on his time. He knew that his back was tightening up for several months and simple things like putting his socks on were harder as he just didn’t bend well.

The issue came just after the birth of his second child when bending over the cot to pick out the increasingly heavy and wriggly baby. He felt a sharp twinge in the lower back which momentarily took his breath away. After that moment he was able to straighten up but over the next few hours, he could feel his back stiffen up. It was later that day that there was a noticeable tightness and ache in the back of his left thigh and the stiffness in the back was worsening. He was able to move but it was hard work and bending and twisting just caused pain.

There was no pins and needles or numbness in the thigh or lower leg. Nor was there real sharp pain, just a dull ache. He tried to keep moving, as he has to with a toddler and a newborn, but it was stiff and painful. The next day at work was particularly difficult, especially when trying to get up and moving after being sat for a spell.

This went on for a couple of weeks without any real change. He had several further sharp twinges when overstretching with the kids and whilst he tried a few Dr Google stretches and took some ibuprofen he was not getting better.

We had seen this patient before with a calf muscle strain when playing football a few years before so he knew we would be able to help. After taking the history as described above we found that the lower back was very stiff, a combination of gradual tightening as well as the recent spasm and immobility. Flexion was worse with pain limiting it, but side flexion was not much better and extension was ok.

We tested the neural system and found that there were no specific areas of concern in the way the nerve was moving and it was not ‘trapped’ as such. There was a stiffness in the hamstring which will have contributed to the load on the back when bending over the cot, however.

Palpation of the spine found the base joints to be rigid and tender, especially over the edges where the facet joints are. There was a lot of tightness in the muscles to the side of the back as well as tightness in the gluteal muscles on the left side, which extended to the hamstring.

The diagnosis was of a strain to the facet joints with some muscular strain and irritation of the sciatic nerve. This was not a disc bulge or a pinching of the nerve. It was a strain born of immobility in the hamstrings and spine which overloaded one area of the joint – the facet joints and strained them.

Treatment is two-fold. We have to treat the acute spasm and stiffness in the joints to improve the movement as well as treat the strained tissues to allow them to heal. Secondly, we have to restore the mobility of the lower back to where it was before the stiffness set in so as to stop it happening again.

Treatment consisted of local mobilisation of the soft tissues with hand on techniques, mobilisation of the facet joints to flexion and rotation to restore range of motion and work through the gluteals and hamstring around the sciatic nerve to release this spasm. All of this was hands-on involving some twisting and stretching mobilisation and manipulation, as well as the use of straps to fix the pelvis down so we can ease the back out. We did all this on the first day.

Happily, we were able to restore about 80% of the movement then and there and, whilst there was a bit of treatment soreness, the back felt a lot better. ‘Like a weight has been lifted from it‘ was the quote!

We set 3 different exercises – no more because this man had little time, so we need to make things practical. These were simple seated stretches that could be done at home and work.

When we saw this patient a week later there was a good improvement, about 60%. Sleeping was fine, as was carefully lifting the baby, but there were still times after prolonged sitting that the back stiffened up. The sciatica had near enough gone. Examination showed that whilst the range was better there was still some focussed stiffness in the base joints of the back. The long term stuff.

We treated again with a combination of different hands-on mobilisation and manipulative techniques which restored the movement very nicely. We progressed the exercises to tougher ones to push the last of the range and added in some strength work as time was right to return to the gym. The patient had been interested in joining a yoga class at the gym which we felt was an excellent compliment to the exercises we had set.

In a couple of weeks we met up again and the back was pretty much back to normal. We again mobilised the long term stiff segments at the base of the back and worked with the patient to get the exercises right for him to keep this going.

The yoga was good and he felt it was targetting bits that he had not really stretched for years. Having a dedicated hour a week class was also good for him personally outside of the mayhem at home!

We discharged the patient at this time with the understanding that he could return to get the lower back mobilised out at any time should he feel that it had stiffened up beyond what his exercises and yoga could manage. We now see him about 3 times a year for ‘maintenance’ on the lower back, usually after a tough period at work has meant less time for exercise and more time at the desk. For this patient, it makes sense to keep the lower back moving because he understands that there is an ‘occupational hazard’ at play regardless of good ergonomics.

Mark Buckingham

Ref 1. Low back pain and exercise

Ref 2. NICE state the evidence shows exercise in all its forms are the best treatment

Ref 3. Overview of how low back pain is best treated.