Leg Pain - Ask Dr. P - The Pain Doc

The 30 Day Pain Relief Challenge Kick Off

by Pain Doc | Jan 4, 2021 | Foot and Ankle Pain, Hand and Wrist Pain, Hip Pain, Knee Pain, Leg Pain, Low Back Pain, Neck Pain

It’s 2021 and time to kick off the 30 Day Pain Relief Challenge!

But first I want to acknowledge what’s on everyone’s mind.

2020 began with an unexpected crisis, the COVID-19 pandemic. A new corona virus strain emerged; highly contagious and deadly for certain individuals, and for which there was no vaccine. As of this writing, over 85 million people worldwide have contracted the virus, with 1.85 million dying from it. The United States is being hit the hardest, with 20.8 million cases and 352,000 dead. The numbers are expected to spike following the holiday season, thanks to many people choosing to get together in large groups and ignoring the risk. So please, remain extra vigilant the next two weeks because chances are, there are more viruses around you than there were a month ago, ready to find a new host.

As we navigate through COVID-19 in 2021, life must still go on. I know many have been hurt economically, and their number-one priority is to find a way to get back on their feet. It is not an easy thing to do, especially if you lost your job and the life skills you possess are in an industry that has been permanently impacted by the pandemic. If this describes your situation, I sincerely hope you find a way to re-position or re-invent yourself, to get back to earning a living.

While COVID-19 dominates the news and peoples’ attention, we must not lose focus on the many other challenges life presents that also need our attention. How would you rate your health at the start of the new year? How about your energy levels and endurance?

Quarantining and social distancing have a way of discouraging exercising and promoting over-eating, a terrible combination to health. When one is restricted from going outside and going to a gym (although a gym is not necessary for staying fit, but I digress…) and constantly bombarded by news of doom and gloom, the tendency is to stay home, surf the web, and eat, more than you typically do (what else is there to do in such a scenario?). And for many, the choice is high-calorie comfort food. This can lead to unwanted weight gain, muscle atrophy, joint pain, and so on.

If you are not feeling 100%, then I encourage you to open all the emails I’ll be sending over the next 30 days—the 30 Day Pain Relief Challenge is about to kick off, and email is how it will be executed.

And what exactly is the challenge? It’s about challenging yourself to get out of your comfort zone and do all the things I will suggest in the coming days so that you can get out of pain, or significantly knock it down to levels you haven’t experienced in a long time.

The other reward may be that you will lose 10 pounds or more; will have more energy, and will notice that your mind/ thinking is clearer. This is because the methods I’ll go over target your body and all its systems; not just the area of pain. It is wholistic.

But first let me explain how you will be measuring your results. After all, pain is subjective. You need some kind of tool to quantify your improvement, so read on.

Pain, aches, discomfort or whatever you want to call it affects your health. There is mental health and physical health; both important to happiness in different ways. Your physical and mental health are impacted, even just a little and perhaps unnoticeable to you, if you have chronic pain/aches/discomfort. Less-than-optimal physical and mental health impacts quality of life. Quality of life in this sense refers to your ability to physically do what you need or want to do; whether it be your job; recreational activity such as playing golf or swimming; or activities of daily living; i.e. taking care of yourself and your personal needs.

Why You Might Have a Disability if You Have Pain

If you live with chronic pain, you likely have some degree of disability.

“Me disabled?” you might be thinking. “No way!”

The word “disability” is often misconstrued. Disability doesn’t necessarily mean “disabled” and in a wheel chair. It simply means not being able to perform a certain task without some degree of difficulty or impediment; or not being able to do it at all.

Doctors (medical examiners) who issue disability certificates or write medical-legal reports are tasked to determine the degree to which someone is disabled. Their findings determine the patient’s disability compensation from the insurance company or government agency. They use observation, physical exam procedures, diagnostic tests like X-rays and nerve conduction; and instruments to measure strength, pain perception, reflexes, coordination, and range of motion. Any deficiency is expressed as a percent disabled, and there are laws that define levels of disability.

For example, in the insurance industry, the loss of both eyes, or the loss of two limbs equates to “100% disability.” Not being able to maintain a tight grip could be rated as 20% disability if the person’s occupation requires power gripping machinery.

Disability can also be subjectively quantified using Disability questionnaires where the patient rates his/ her ability to perform certain tasks on a scale of zero to some number; and the level of pain. In some questionnaires, the zero rating means you have zero difficulty doing the task (best score), while in others the zero rating means you cannot do the task at all (worst score).

For example, the following is one section of the Oswestry Low Back Pain Disability Questionnaire. Imagine having low back pain and rating yourself (0 to 5) on your ability to lift things:

LIFTING:

0 – I can lift heavy weights without extra pain

1 – I can lift heavy weights but it gives extra pain

2 – Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table

3 – Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned

4 – I can lift very light weights

5 – I cannot lift or carry anything at all

When rating yourself, you must try to be as objective as possible—don’t over rate your ability; nor under rate it. Give each question some thought.

Then, you add up the numbers, divide it by the total number of points and multiply by 100 to get a percentage score.

If the zero rating is assigned to “full ability to do the task” (like the Oswestry above), then the score is interpreted as “percent disabled.” So, an individual with no low back disability whatsoever will score zero out of 50 and his rating will therefore be zero percent disabled; i.e. 100% functional. If his score is 30, then 30/50 x (100) = 60% disabled.

Below is an example of an Oswestry Low Back Pain Disability Questionnaire completely filled out:

oswestry low back pain disability questionnaire

In the above example, the total points out of all ten questions is 19, which is considered a Moderate disability, out of No, Mild, Moderate, Severe and Total Disability. In this case, 19/50 x 100 = 38% disabled due to low back pain. Now this person has a baseline for his condition, and can set goals to lower it each time; perhaps to 20% after a month, then 10% after three months of therapy.

If the zero rating is instead assigned to “no ability to do the task,” the score is interpreted as “percent functional.” This is how the Upper and Lower Extremity Disability questionnaires are designed. So a score of zero in this case means zero percent functional (totally disabled), and 30% means you are 30% functional (you lost 70% function in that limb).

Please note that Disability questionnaires are used as tools to quantify and set baselines for pain and functional capacity; your scores do not officially establish any disability you may have, they simply provide a more tangible interpretation of pain.

Quantifying pain/disability, even if subjective, gives you a sense of how significant it is; i.e. how much it affects your life. Secondly, it can be used as a tool to measure your improvement over time, after doing some therapy and/or rehabilitation (strength and coordination exercises). This lets you know if what you did works for your condition, and therefore, whether to continue or discontinue it.

For example, if your baseline Oswestry score was 60%, and you were prescribed some McKenzie exercises for one week and a follow- up score was 40%, it suggests that those exercises improved your condition and you should continue or progress to the next level. If it was 60% or higher, you should discontinue the exercises and try another approach.

You don’t have to see a doctor to use Disability questionnaires to subjectively assess your disability. They are fairly straightforward to use and you can download the forms from the internet (see below; I’ve done it for you).

Determine Your Pain/Disability Baseline

If you have low back pain, neck pain, shoulder pain, or lower or upper limb pain then I suggest monitoring your condition using the appropriate disability questionnaire. If you are getting therapy, your doctor should be having you fill these forms (or something similar) out each visit and going over the results with you. It’s substandard care if you don’t know if the therapy you are getting or exercises you are doing is helping; these questionnaires will prompt you to think about the change or lack of change in your functional capacity, and will help you assess your care so that you can take appropriate action.

Below you will find forms to assess any musculoskeletal pain you are having. If you wish to participate in the 30 Day Pain Relief Challenge, print out the appropriate disability questionnaire; rate your abilities as objectively as you can and calculate your score; set it aside, and be ready to fill out a new questionnaire after 30 days of diligently doing the things I will cover over the next 30 days.

My goal is for participants to experience at least a 50% improvement in their pain/ disability scores. If you have any friends who might be interested in participating, please refer them to my site, https://PainandInjuryDoctor.com and have them enter their email in the opt in form.

Download the Low Back Pain Disability Questionnaire

Download the Neck Pain Disability Questionnaire

Download the Shoulder Pain and Disability Index Questionnaire

Download the Upper Extremity Disability Questionnaire

Download the Lower Extremity Disability Questionnaire

Spinal Stenosis – What it Is, and What to Do

by Pain Doc | Sep 14, 2013 | Leg Pain, Sciatica

Spinal Stenosis

Recently, Carrie Ann Inaba, one of the judges of the show Dancing With the Stars publicly announced that she has been suffering for quite some time from cervical spinal stenosis– a condition in which the canal that encases the spinal cord in the neck narrows and obstructs nerve tissue. She explained how her condition impacts her life, limiting her from doing the things she loves to do. To Carrie Ann’s dismay, she no longer dances with a partner for fear of getting whiplash and paralysis. That’s quite unfortunate for someone whose entire career revolved around dancing.

Although spinal stenosis is a generalized term for narrowing of the spinal canal by any cause, the most common type, which will be discussed here, is the type caused by osteophytes— growth of bony projections that narrow the openings where nerves pass through. Advanced osteophytic activity is also referred to as spondylosis. When it is severe enough to narrow the spinal canal (foramen) it then creates the condition known as spinal stenosis. For your information, other forms of spinal stenosis are those caused by herniated discs, spondylolisthesis, tumors or any mass that encroaches into the spinal canal.

In her article, Carrie Ann mentioned that spinal stenosis is a form of arthritis and that she is anxious to find a cure for it. Unfortunately spinal stenosis is not one of those conditions that can resolve on its own with rest, exercise and time and other non- invasive measures. And since the inflammation from spinal stenosis is secondary to irritation of nerves, it is technically not a type of arthritis. That is why anti-inflammatory medications have minimal effect on the pain associated with spinal stenosis, which is typically deep, sharp and radiating in nature.

Spinal stenosis occurs when vertebrae, the bones that comprise the spinal column gradually morph in a way that constricts the spinal foramen (canal), or space where the spinal cord resides. When there is less space for the spinal cord to move, it is subject to more abrasion with spinal movement; i.e. bending and turning your neck. The cord (actually, meninges or covering of the cord) rubs against sharp edges of the bony projections into the foramen with movement causing inflammation and injury to the nerve tissue, sometimes causing sclerosis (hardening). In advanced cases, especially cases of lumbar spinal stenosis (due to the more significant weight burden) the narrowing gets so advanced that there is constant pressure on the nerve roots. At this point, it is an emergency situation as renal function and sensation to the legs are affected.

Signs of advanced spinal stenosis include paresthesias, sharp pain with movement, weakness in the extremities, and muscle atrophy in legs and/or arms. Symptoms can be permanent if not treated early.

And what is the treatment for spinal stenosis? First of all, doctors will usually order MRI and x-ray to determine extent of narrowing. If it is caught early, physical therapy and lifestyle modification is recommended. The goal is to slow down or stop the progression of the narrowing.

Surgery is the only option for advanced cases. Since spinal stenosis involves physical structures compressing nerve tissue, there are surgical procedures that can enlarge the spinal canal by scraping off the encroaching bone material and buy the patient more time. Since bone is comprised of live cells, the movement of bony projections (called osteophytes) into the spinal canal is still likely after surgery and many who have had such spinal decompression surgeries develop the same problem several years later.

It’s not quite evident why some people suffer from spinal stenos more than others. But those who have a history of physical trauma to the spine like car accidents, sports injuries and falls are at a higher risk. The theory is that the injury event disrupts the normal alignment of the spinal segments resulting in accelerated wear and tear over time; much like how a loose screw in a machine accelerates mechanical failure. Some orthopedists hypothesize that the appearance of bony projections is the body’s attempt to fuse and stabilize adjacent vertebrae so they can no longer move separately; thus reducing the probability of injury. However, the nerves that share the space with the vertebrae get damaged in the process. If this theory holds true, then it is an inherent design flaw of the body’s self-healing mechanisms.

Also, heavy smoking and obesity, and general poor health can increase your chances of developing spinal stenosis.

I’m sure more than one doctor broke the news to Ms. Inaba that there basically is no “cure” for spinal stenosis once it is in its advanced stages, which appears to be her case based on her own description of her symptoms. It is a mechanical condition that mandates mechanical intervention. No amount of drugs will cure spinal stenosis from advanced osteophyte formatioin. Her only option at this point is spinal decompression surgery to widen the spinal canal and hope that the nerve tissue did not sustain permanent damage.

The best strategy for dealing with spinal stenosis is prevention. If you sustained injury to your spine from a car accident (even a low impact one that did not require medical treatment), a sports injury (including repetitious trauma like that related to gymnastics and football) or slip and fall, realize that “the seed” for spinal stenosis may have been planted in you already. If your injury event was over five years ago, get an x-ray to identify any levels where osteophytes are present; these are the sentinels of potential areas of spinal stenosis as they identify areas of biomechanical weakness. If there are some, the first course of action is to not worsen things. Avoid or reduce activities that regularly place trauma to your spine. Engage in specific exercises that strengthen the neck and lower back to offer more stability. Stretch often (yoga is a great choice) and take care of the insides of your body as well with proper diet, nutrition, hydration and adequate rest.

Lastly, the Cervical and Lumbar Posture Pump is a home rehabilitation device that tractions and separates vertebrae to hydrate the discs and increase nutrient absorption which can slow down the progression of spinal stenosis if done diligently on a regular basis. I have personally used them in my practice, and patients reported positive results.

What Happens When You “Pull” Your Leg Muscle?

by Pain Doc | Sep 1, 2010 | Leg Pain

The Achilles' tendon. PD image from Gray's Ana...

Image via Wikipedia

If there’s one thing that can stop you dead in your tracks, it’s a pulled calf muscle. The word “pulled muscle” usually refers to an involuntary, painful spasm that occurs without a single, forceful impact which characterizes a typical muscle sprain/ strain.

You’ll feel your calf muscle contract by itself, and sometimes oscillate (twitch) reflexively causing you to quickly bend your knee to stop the progressing contraction. A deep, painful sensation is felt at the myofascial junction that eventually forms the Achilles tendon. If you’re lucky, sometimes you can prevent it from spasming if you immediately stop what you are doing at the first sign of the spasm (jerky, involuntary twitching) and focus on relaxing the leg.

Basically, pulled calf muscles occur after prolonged exercise of the legs, such as in long distance running, cycling, swimming, and uphill climbing. Muscle contraction is mediated by a complex biological pathway that involves electrolytes, mainly calcium, phosphorus, and sodium ions. These ions need to be available in order for the actin and myosin fibers to “ratchet” properly during contraction and relaxation. Prolonged leg exertion, without replenishing lost electrolytes can lead to muscle spasms. This is why sports teams use Gatorade to hydrate the athletes, and protect against muscle injuries.

Nocturnal (night) calf muscle spasms are a common occurrence in 2nd and 3rd trimester pregnant women. It it thought to be caused by low electrolytes as a result of the pregnancy. Eating foods rich in calcium and phosphorus can reduce these symptoms.

Lactic acid buildup in the myofascial sheath can also be a contributing factor to pulled muscles. If more lactic acid is created that can be neutralized by the body, it can affect muscle contraction.

TREATMENT:

If the spasm got you before you could stop it, don’t panic. The pain will work itself out in about 30 minutes. If it is still present after an hour, see your doctor.

Drink an athletic sport drink to replenish your electrolytes. If you have multivitamins at home, take 2 tablets with water.

Wrap an icepack around your calf, especially over the end of the muscle belly (that’s the start of the Achilles tendon); hold in place for 20 minutes.

Gradually, extend your knee; if you feel twitching again, stop and return to flexed knee position, ice applied; give it another 10 minutes.

When you can extend the knee fully without pain (all this is done sitting on the floor), gently test the calf muscle by bending your foot upwards toward your knee (called dorsiflexion). Do this very slowly, and hold the stretch for10 seconds; repeat five times.

Next, attempt to walk. That should be the end of your painful episode! In the future, before you engage in arduous exercise involving a lot of legwork, load up on foods rich in electrolytes. Most of those sports snacks include them, like Cliff Bars and others. Try to get the healthy ones.

Sciatica – Ever Had a Pain in the Butt?

by Pain Doc | Aug 25, 2010 | Leg Pain, Sciatica

(Updated 3/29/2021)

No, I don’t mean a really bad boss or acquaintance. I mean literally.

Buttock pain, medically called gluteal pain is a deep pain usually affecting one buttock. The sensation is often described as an electrical-like shock shooting from the bottom area of the buttock down to the back of the same side leg. Numbness and tingling is also often present. When not shooting, it feels like a bruise and is quite bothersome. Sciatica can make prolonged standing difficult, and even light walking. Sitting is very uncomfortable. Walking upstairs can make it hurt even more. Slouching over tends to ameliorate the pain.

The pain is usually described to be in the cheek part (lower) of the buttock a couple of inches to the side and downwards, from the sacrum– the triangular bone at the base of your lower back that is connected to your pelvic bones on either side. In some people, the pain continues down the back of the thigh to the calf, and sometimes the bottom of the foot.

In many cases, the patient cannot explain what caused the pain. This type of problem usually is reported to have a gradual onset, getting progressively worse.

Sciatica, or pain down the sciatic nerve is usually the diagnosis. The sciatic nerve is the largest nerve in the body. It forms from nerve roots that branch from the sides of the lower lumbar spine and sacrum.

However, the term “sciatica” describes a symptom and does not provide much clinical information. Sciatica can be caused by a herniated disc that presses on a nerve root that partially forms the sciatic nerve; spinal stenosis, which is narrowing of the lumbar spinal canal to the point where the cauda equina, the long nerve roots that form at the terminus of the spinal cord, experiences irritation/compression; it can be caused by a pelvic tumor that encroaches upon the sciatic nerve (or in very rare cases, the part of the brain that controls the affected leg), and it can be caused by a condition called piriformis syndrome.

piriformis syndrome compression

Piriformis – Muscles of the Lower Extremity Anatomy Visual Atlas, page 8 (Photo credit: robswatski)[/caption]

The piriformis muscle is one of the small muscles that connect your hip bone (femur head) to the side of the sacrum and is used to externally rotate the leg (turn outwards). The sciatic nerve passes between the piriformis muscle and adjacent muscles before it descends down the leg. If the piriformis muscle is in spasm, it can squeeze the sciatic nerve causing deep gluteal pain; the piriformis muscle itself can generate pain if it is inflamed.

Piriformis muscle spasm can be caused by a hard fall on your seat that puts the muscle in spasm. It can also develop when the pelvis is uneven; i.e. one hip is higher than the other when standing. This can cause uneven pull on the gluteal muscles, causing the hip rotators to spasm.

SELF-TREATMENT FOR SCIATICA

If the pain persists for over a month or is unrelenting, see your doctor so that a herniated disc, spinal stenosis and tumor can be ruled out (you may get an MRI). Once that is ruled out, you can do a couple of things to make the pain go away:

1. Check the level of your iliac crests while standing in front of a mirror. Place your fingertips flat on top of your hip bones; see if one is higher than the other. Sometimes if the unevenness is large, you can see the high side and low side simply by looking in the mirror, and focusing on your belt or skirt/pant top — it will not be parallel to the ground, one side will be higher. If this is the case, try inserting a heel lift in the shoe on the side of the “lower” pelvic bone. This will help even out the pelvis and remove strain to the gluteal muscles. You can purchase an “over the counter” heel lift at most drugstores like Walgreens or CVS. Check out this YouTube video that explains it:

Optionally, you can buy a pair of gel inserts for shoes, and use only one in the shoe on the side of the low iliac crest. Make sure to wear the lifts for at least two weeks to see if they help. Decreased pain or frequency of pain indicates that they are working.

2. Slowly and gently stretch the painful piriformis muscle by lying on your back, raising the leg on the affected side and bending the knee. Grab with both hands behind the knee and pull gently at a 45 degree angle relative to your body; you should feel a stretch in your gluteal muscle. Hold the position for 30 seconds; repeat three times. Watch this Sciatica YouTube video for a demonstration:

3. Apply infrared heat with an IR heat lamp and red light therapy. IR heat penetrates deeper, which is necessary to reach the nerve which is several inches deep, beneath layers of gluteal fat and muscle.

Follow up with a Red Light therapy wrap. Red light invigorates cells and gives them a boost of energy.

red light therapy LED wrap

In summary, sciatica can be caused by several things. Your prognosis is good if it is due to a bulging disc or piriformis syndrome, which can be managed by exercises, stretches and the therapeutic modalities I listed here.

If your sciatica is due to degenerative disc disease, spondylosis (bone spurring) and subsequent central spinal canal stenosis, unfortunately you are likely to have chronic, intermittent sciatica. Some people with this presentation have found success with spinal decompression surgery involving removal of the posterior structures of one or several vertebrae (laminectomy), but it is a very risky procedure and can often cause new, low back pain problems.