Sciatica

[ya1]

I have minimal experience with peripheral nerve injuries and would appreciate any opinion on the following case.

I have a patient (40 yo) with sciatica syndrome. Sounds like it’s due to slight overuse (it happened after work-outs, but the guy was not doing anything extreme, prolonged, or super strenuous or unusual). Pain started in back and leg. The back pain resolved withint a few days. He has been having pain, tingling, pulsing, numbness in piriformis area and heel, sometimes in the thigh and calf. Has troubles sleeping on the involved side. He has been taking 3 pain pills a day to be able to go through the day at work. Gets tired fast and pain increases with weight bearing activities and sitting. Pain gets better with rest in supine or prone.

I have been treating him for more than a month now: stretching, activities within comfortable limits to avoid more irritation, soft tissue mobs, tried some join mobs at L spine… he has been doing all that by himself daily as well. Pain has been getting better SLOWLY. He could bearly walk at first, now he can walk but still gets tired and is still on 3 pain pills/day (tried to cut on the pills, but was too uncomfortable). The patient is healthy otherwise.

So my question is, is there anything else I can do for him??? I feel like by now he knows what to do on his own and I am wasting his insurance. What would you guys do in this situation?

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[noyceguy]

You need to refer back to PCP so this guy can get some imaging done. Maybe give him the option to do therapy another month and then DC.

 

[ya1]

Thanks noyceguy. What would the imaging be for?

 

[noyceguy]

You need to refer back to PCP so this guy can get some imaging done. Maybe give him the option to do therapy another month and then DC.

The PCP would either order MRI or send to orthopedics for exam/eval and they would work up the differential.

 

[truthseeker]

several Qs, how is hip internal rotation motion? are his legs of equal length? does he have any neurological signs? or just symptoms? does he have neural tension signs? (hamstring plus dorsiflexion causes "the zing") Can he abolish or at least centralize his symptoms with directional preference type movements (prone on elbow, or double knee to chest)?

 

[jesspt]

I have minimal experience with peripheral nerve injuries and would appreciate any opinion on the following case.

I have a patient (40 yo) with sciatica syndrome. Sounds like it’s due to slight overuse (it happened after work-outs, but the guy was not doing anything extreme, prolonged, or super strenuous or unusual). Pain started in back and leg. The back pain resolved withint a few days. He has been having pain, tingling, pulsing, numbness in piriformis area and heel, sometimes in the thigh and calf. Has troubles sleeping on the involved side. He has been taking 3 pain pills a day to be able to go through the day at work. Gets tired fast and pain increases with weight bearing activities and sitting. Pain gets better with rest in supine or prone.

I have been treating him for more than a month now: stretching, activities within comfortable limits to avoid more irritation, soft tissue mobs, tried some join mobs at L spine… he has been doing all that by himself daily as well. Pain has been getting better SLOWLY. He could bearly walk at first, now he can walk but still gets tired and is still on 3 pain pills/day (tried to cut on the pills, but was too uncomfortable). The patient is healthy otherwise.

So my question is, is there anything else I can do for him??? I feel like by now he knows what to do on his own and I am wasting his insurance. What would you guys do in this situation?

Questions:
1. Does the patient demonstrate directional preference and can his symptoms be centralized (or abolished) with repeated trunk movements?
2. Does he have leg weakness? If so, is it getting more pronounced? Any other neuro signs like reduced reflexes?
3. Does he have a positive straight leg raise?
4. When you say pain meds, do you mean NSAIDs or opioids, or antiepileptics?

If he has directional preference, you need to match his home program with that direction. If he has a positive straight leg raise, and you're having him stretch his hamstrings, stop that. Like yesterday.
If he is having progressive motor weakness, he needs to get referred for imaging.
If he is still taking opioid medication three times per day, you need to discuss this with his referring physician.

 

[ya1]

Leg length is pretty equal.

Hip ROM is WNL now (was > limited due to pain at first).

Neuro tensioning test was not really positive: SLR test: Gets worse w/ DF, but does not change w/ neck flx.

Couldn’t centralize symptoms w/ movement.

Feels better after piriformis stretches (temporarily), when in prone, or in supine w/ hip ER and relaxed.

Has leg weakness, but it has been getting better (can WB > now during the day but he is still on NSAIDs, 4 a day (I think you are not supposed to take more than 2 a day? but he is a big guy)

No reflex reduction.

Thanks guys for your input!

 

[SnowyDPT]

Have you tried dry needling the piriformis?

 

[ya1]

Have you tried dry needling the piriformis?

nope. have no idea how to do that lol. PTs are not allowed to do dry needling in this state I believe. Do you think he may benefit from acupuncture? He's been getting better, it is just soooooooo SLOW. I think I have used everything I have been trained for, so any ideas where he should be refereed to/tools that may help him would be appreciated.

 

[truthseeker]

If symptoms get worse with hamstring plus DF, those are peripheral neural tension signs. Have the patient get them selves into position so that they have no symptoms with the hamstring stretch and the ankle plantar flexed, then can dorsiflex to just barely touch the "zing". Osscilate just barely into and out of the "Zing" for 30 seconds twice per day. If they do it too aggressively, their symptoms will get worse, if they do it right, they will go higher before they get the "zing". Neural desensitization.

 

[mimmerma]

ugh this thread is depressing lol
Accupuncture will be no better than placebo. Neither will dry needling. We need to have solid clinical reasoning based in science and the research instead of just blindly "trying stuff" and hoping it sticks.
Sounds like you may be dealing with a HNP at L5 S1
Usually the natural history for this stuff is favorable with majority of patients getting better at 6-8 weeks.
I echo everything Jesspt said....
If I were in your situation, I would do my best to educate the patient about the diagnosis and prognosis. If I feel that he has maximized his therapeutic benefit from seeing me I would suggest to taper down his visits and eventually DC. Some patients may require more invasive interventions such as injection or even surgery. It is part of our job to recognize when we can be of no more benefit and not string patients along.

 

[mimmerma]

I have minimal experience with peripheral nerve injuries and would appreciate any opinion on the following case.

I have a patient (40 yo) with sciatica syndrome. Sounds like it’s due to slight overuse (it happened after work-outs, but the guy was not doing anything extreme, prolonged, or super strenuous or unusual). Pain started in back and leg. The back pain resolved withint a few days. He has been having pain, tingling, pulsing, numbness in piriformis area and heel, sometimes in the thigh and calf. Has troubles sleeping on the involved side. He has been taking 3 pain pills a day to be able to go through the day at work. Gets tired fast and pain increases with weight bearing activities and sitting. Pain gets better with rest in supine or prone.

I have been treating him for more than a month now: stretching, activities within comfortable limits to avoid more irritation, soft tissue mobs, tried some join mobs at L spine… he has been doing all that by himself daily as well. Pain has been getting better SLOWLY. He could bearly walk at first, now he can walk but still gets tired and is still on 3 pain pills/day (tried to cut on the pills, but was too uncomfortable). The patient is healthy otherwise.

So my question is, is there anything else I can do for him??? I feel like by now he knows what to do on his own and I am wasting his insurance. What would you guys do in this situation?

what does he do for work? lumbar roll for his chair / car may be of help. Sounds like he doesnt respond well to load (worse with standing and sitting, better with supine or prone)

What happens with active lumbar movements?

 

[ya1]

what does he do for work? lumbar roll for his chair / car may be of help. Sounds like he doesnt respond well to load (worse with standing and sitting, better with supine or prone)

What happens with active lumbar movements?

He can sits or walk at work... not sedentary but nothing strenuous beyond walking around...
No change w/ lumbar movements. Only feeling of slight stretch w/ lumbar flx.

Thanks guys SO MUCH for all your input! I no longer feel like a complete useless idiot since I have been doing most of the stuff you would have done so far. THANKS A LOT!!!

 

[mimmerma]

Ya1, its not about "doing stuff" its about using clinical reasoning to arrive at the best plan of care which is based on science and the available evidence. we dont "do stuff" to patients. every single intervention we apply has to have a solid rational behind it.

i suggest reading this article: Therapist as operator or interactor? Moving beyond the technique

 

[Fiveoboy11]

interesting

maybe consider traction, involved side foraminal gapping positioning, re visit if there's a directional preference and design exercise program based upon it, educate him about what exercises maybe to avoid (i'd say no deadlifts or similar exercises, or exercises that have profound increase in intra-abdominal pressure -- i.e. anything with maximal lifting)