A Note From Dr. Fields
Below is a description of our most common conditions causing spine pain and rib pain. While I hope this info helps to provide some insight, it is not a substitute for a doctor’s visit. There are some other very serious reasons behind pain that may require immediate medical attention, so please don’t take the risk of self-diagnosing. Please see a physician like a Chiropractor who can differentiate between a musculoskeletal cause of your pain, and other more serious conditions.
Feel free to give us a call at our Tulsa location if you have questions or request a free consult on this website.
Rib Pain
Rib pain can either be one of the easiest problems to fix for a Chiropractor or one of the hardest. Sometimes an injury or awkward movement (like a sneeze while hunching over) can throw a rib right out of place. A little muscle work and the correct adjustment may be all you need. This is the old “one and done” situation. Other times, postural problems or scapular dysfunction can cause issues with the muscles in the back that create more chronic (long term) rib pathology. In this case, the underlying dysfunction will need to be addressed. Otherwise, the rib problem will likely return or possibly never really resolve. Let’s take a look at the area that most often causes a rib problem.
There are many layers of muscles across the back, all of which can be relevant to rib pain. The ribs connect to the spine in the back. The levator costae muscles, attach to the ribs. Their job is to help elevate those ribs during breathing and other motions. If there is dysfunction or misalignment in the spine, then these muscles will have to work overtime, spasm, and can become tight and tender. When this occurs, the constant tension can pull that rib head out of alignment. This leads to stress, inflammation, and further spasm & tenderness of the surrounding musculature. Now every time you take a breath, especially a deep one, the pain is intense and can even travel in the rib cage around to the side or front. Labored and painful breathing is a sign of rib pain, but can also mean something more serious.
Treatment for chronic rib dysfunction will usually include correcting misalignments of the spine, manipulation of the soft tissue, therapies targeting muscle spasms and pain, correcting postural abnormalities, correcting scapular dysfunction, and of course… manipulation of the rib itself.
Once in a while, a patient may also present with dysfunction in the sternum and costal cartilages. This is a problem with the front of the chest. In this area, there aren’t technically any ribs, but rib cartilage. The ribs stop being bone in the front part of the chest and instead become cartilaginous before they connect to the sternum. When a patient has irritation in the front of the chest, the diagnosis is typically costochondritis. This literally means inflammation of the rib cartilage. A person who experiences these problems often has forward rolled shoulders and forward head carriage. This is really a completely different presentation than rib pain in the back, though the two can be related. This is covered in more detail in the section below.
Chest pain of any sort can indicate a very serious problem. So, if you are experiencing sudden chest pain, it is not a good idea to wait. The issue may warrant emergency procedures, especially if you have any difficulty breathing, impending sense of doom, a feeling of significant pressure in your chest, sweating, fever, vomiting, cough, recent cold, or rapid pulse. A trip to the emergency room may be life-saving. However, if this is localized pain without any accompanying symptoms, and it has been going on for several weeks or more, it is not likely an emergency situation.
If it is not an emergency situation, or if a medical physician has already cleared you of any life-threatening conditions, your next call should be to a Chiropractic Physician.
Costochondritis
Costochondritis is the inflammation and irritation of the ribs as they insert into the sternum causing rib pain. In this front region of the chest, the ribs aren’t actually bone. The ribs here are cartilage as they connect to the sternum bone. This is where the term costochondritis comes from: Costo- indicating ribs, Chondro- meaning cartilage, and -itis signifying inflammation. These joints are solid and fibrous and have little room for motion. Hence any misalignment is not well tolerated.
The problem usually occurs on one side of the sternum more than the other, but can occur on both sides. You may notice increased rib pain with movement like bending forward or backwards or turning the body. You may have more pain associated with your breath like deep inhalation or coughing or sneezing. It is also common to note more pain while laying down as this puts pressure on your ribs stressing the connection at the sternum. There may also be accompanying spine pain in the region between the shoulder blades.
It is not officially established how or why this inflammation occurs, but it is a musculoskeletal issue so it likely boils down to position and movement. In my clinical experience, it is usually associated with misalignment of the thoracic spine and rib cage. The ribs attach to the vertebra in the back, wrap around the body becoming cartilaginous in front, and insert into the sternum forming what we refer to as the rib cage. The ribs themselves are fairly mobile in the back where they attach to the spine to accommodate for bending and rotation that occurs in the thoracic spine. The ribs must also have mobility to allow for respiration. They have a bucket-handle-like movement upwards when inhaling. As you can imagine, with all of the motion that occurs in the spine and ribs, you would need the connection in front to also be fairly mobile. This is why the front of the ribs consist of flexible interlinking cartilage. The softer cartilage allows for the mobility of the ribs for movement and respiration. But, the insertion of the ribs to the sternum is solid and relatively immobile.
A problem can occur when the rib cage changes shape or mobility due to postural changes or injury. The movement of the ribs must still occur, but in it’s dysfunctional state begins to overload the fibrous connection at the sternum. Instead of mobility occurring where it should at the spine, between the ribs, and at the cartilage, now more movement occurs at the front in those fibrous connections to the sternum. This often results in misalignment and stress at this connection causing pain and inflammation.
The first course of treatment is rest, ice and anti-inflammatory medications. However, it is very common for these conservative measures to fail because the underlying mechanics are still a problem. In these cases, it is necessary for a Chiropractor to evaluate the thoracic spine and rib cage to set things right again. By correcting posture, realigning the thoracic spine, and manipulating the individual ribs, the problem can usually be remedied. It is common for the problem to return though. For this reason we may have to consider rehab to retrain the muscles in order to retain the proper position and movement of the thoracic spine and rib cage. Interestingly enough, I find that it is usually best to leave alone the painful area at the sternum. This is because this area is irritated from too much movement and additional movement typically only makes things worse. It is much better to approach the problem in the thoracic spine and other parts of the ribs to allow the fibrous connections in front to heal. In certain circumstances, the ribs do need to be manipulated in front at the sternum. This can be quite uncomfortable, so these maneuvers are reserved for when other methods fail.
Rib Pain
Rib pain can either be one of the easiest problems to fix for a Chiropractor or one of the hardest. Sometimes an injury or awkward movement (like a sneeze while hunching over) can throw a rib right out of place. A little muscle work and the correct adjustment may be all you need. This is the old “one and done” situation. Other times, postural problems or scapular dysfunction can cause issues with the muscles in the back that create more chronic (long term) rib pathology. In this case, the underlying dysfunction will need to be addressed. Otherwise, the rib problem will likely return or possibly never really resolve. Let’s take a look at the area that most often causes a rib problem.
There are many layers of muscles across the back, all of which can be relevant to rib pain. The ribs connect to the spine in the back. The levator costae muscles, attach to the ribs. Their job is to help elevate those ribs during breathing and other motions. If there is dysfunction or misalignment in the spine, then these muscles will have to work overtime, spasm, and can become tight and tender. When this occurs, the constant tension can pull that rib head out of alignment. This leads to stress, inflammation, and further spasm & tenderness of the surrounding musculature. Now every time you take a breath, especially a deep one, the pain is intense and can even travel in the rib cage around to the side or front. Labored and painful breathing is a sign of rib pain, but can also mean something more serious.
Treatment for chronic rib dysfunction will usually include correcting misalignments of the spine, manipulation of the soft tissue, therapies targeting muscle spasms and pain, correcting postural abnormalities, correcting scapular dysfunction, and of course… manipulation of the rib itself.
Once in a while, a patient may also present with dysfunction in the sternum and costal cartilages. This is a problem with the front of the chest. In this area, there aren’t technically any ribs, but rib cartilage. The ribs stop being bone in the front part of the chest and instead become cartilaginous before they connect to the sternum. When a patient has irritation in the front of the chest, the diagnosis is typically costochondritis. This literally means inflammation of the rib cartilage. A person who experiences these problems often has forward rolled shoulders and forward head carriage. This is really a completely different presentation than rib pain in the back, though the two can be related. This is covered in more detail in the section below.
Chest pain of any sort can indicate a very serious problem. So, if you are experiencing sudden chest pain, it is not a good idea to wait. The issue may warrant emergency procedures, especially if you have any difficulty breathing, impending sense of doom, a feeling of significant pressure in your chest, sweating, fever, vomiting, cough, recent cold, or rapid pulse. A trip to the emergency room may be life-saving. However, if this is localized pain without any accompanying symptoms, and it has been going on for several weeks or more, it is not likely an emergency situation.
If it is not an emergency situation, or if a medical physician has already cleared you of any life-threatening conditions, your next call should be to a Chiropractic Physician.
Costochondritis
Costochondritis is the inflammation and irritation of the ribs as they insert into the sternum causing rib pain. In this front region of the chest, the ribs aren’t actually bone. The ribs here are cartilage as they connect to the sternum bone. This is where the term costochondritis comes from: Costo- indicating ribs, Chondro- meaning cartilage, and -itis signifying inflammation. These joints are solid and fibrous and have little room for motion. Hence any misalignment is not well tolerated.
The problem usually occurs on one side of the sternum more than the other, but can occur on both sides. You may notice increased rib pain with movement like bending forward or backwards or turning the body. You may have more pain associated with your breath like deep inhalation or coughing or sneezing. It is also common to note more pain while laying down as this puts pressure on your ribs stressing the connection at the sternum. There may also be accompanying spine pain in the region between the shoulder blades.
It is not officially established how or why this inflammation occurs, but it is a musculoskeletal issue so it likely boils down to position and movement. In my clinical experience, it is usually associated with misalignment of the thoracic spine and rib cage. The ribs attach to the vertebra in the back, wrap around the body becoming cartilaginous in front, and insert into the sternum forming what we refer to as the rib cage. The ribs themselves are fairly mobile in the back where they attach to the spine to accommodate for bending and rotation that occurs in the thoracic spine. The ribs must also have mobility to allow for respiration. They have a bucket-handle-like movement upwards when inhaling. As you can imagine, with all of the motion that occurs in the spine and ribs, you would need the connection in front to also be fairly mobile. This is why the front of the ribs consist of flexible interlinking cartilage. The softer cartilage allows for the mobility of the ribs for movement and respiration. But, the insertion of the ribs to the sternum is solid and relatively immobile.
A problem can occur when the rib cage changes shape or mobility due to postural changes or injury. The movement of the ribs must still occur, but in it’s dysfunctional state begins to overload the fibrous connection at the sternum. Instead of mobility occurring where it should at the spine, between the ribs, and at the cartilage, now more movement occurs at the front in those fibrous connections to the sternum. This often results in misalignment and stress at this connection causing pain and inflammation.
The first course of treatment is rest, ice and anti-inflammatory medications. However, it is very common for these conservative measures to fail because the underlying mechanics are still a problem. In these cases, it is necessary for a Chiropractor to evaluate the thoracic spine and rib cage to set things right again. By correcting posture, realigning the thoracic spine, and manipulating the individual ribs, the problem can usually be remedied. It is common for the problem to return though. For this reason we may have to consider rehab to retrain the muscles in order to retain the proper position and movement of the thoracic spine and rib cage. Interestingly enough, I find that it is usually best to leave alone the painful area at the sternum. This is because this area is irritated from too much movement and additional movement typically only makes things worse. It is much better to approach the problem in the thoracic spine and other parts of the ribs to allow the fibrous connections in front to heal. In certain circumstances, the ribs do need to be manipulated in front at the sternum. This can be quite uncomfortable, so these maneuvers are reserved for when other methods fail.
Low Back Pain
Many patients present to our clinic every week with low back pain. In fact, this is the most common reason to visit our Tulsa Chiropractor. Although Chiropractic Physicians treat more than just back pain, many patients initially visit chiropractors looking for relief from this pervasive condition. In fact, 31 million Americans experience low-back pain at any given time.
Facts About Back Pain
- Low back pain is the single leading cause of disability worldwide, according to the Global Burden of Disease 2010.
- Back pain is one of the most common reasons for missed work. In fact, back pain is the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.
- One-half of all working Americans admit to having back pain symptoms each year.
- Experts estimate that as much as 80% of the population will experience a back problem at some time in their lives.
- Most cases of back pain are mechanical or non-organic—meaning they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.
- Americans spend at least $50 billion each year on back pain—and that’s just for the more easily identified costs.
What Causes Back Pain?
The back is a complicated structure of bones, joints, discs, ligaments and muscles. You can sprain ligaments, strain muscles, rupture disks, and irritate joints, all of which can lead to back pain. While sports injuries or auto accidents can cause back pain, sometimes the simplest of movements (like picking up a pencil from the floor) can have painful results when there is an underlying issue. In addition, arthritis, poor posture, obesity, and psychological stress can cause or complicate back pain. Back pain can also directly result from disease of the internal organs, such as kidney stones, kidney infections, blood clots, or bone loss.
Common Causes of Low Back Pain
The cause of most back pain is biomechanical in nature. In other words, it is a dysfunction in position and movement. The dysfunction leads to excessive stress on the structures of the spine and can cause increasingly severe damage over time. We call this degeneration (Degenerative Disc Disease & Degenerative Joint Disease). As the joints wear out, the muscles tighten & spasm, the discs are damaged, the ligaments calcify creating bone spurs, arthritis sets in, and nerves start to be compressed. It is a process that occurs little by little. It weakens the spine making it vulnerable to acute injury such as disc herniations. If left unchecked, the bones themselves change shape and a condition called stenosis can occur. This is when the spaces that the nerves pass through become narrowed producing pressure on these nerves and can result in all kinds of nasty neurological symptoms.
Common Diagnoses Include:
- Disc Pathology (bulge/herniation)
- Facet Irritation
- Sacroiliac Joint Dysfunction
- Arthritis & Degeneration (Spondylosis)
- Sciatica
- Stenosis
Spinal Manipulation as a Treatment for Back Problems
With today’s growing emphasis on quality care, clinical outcomes and cost effectiveness, spinal manipulation is receiving increased attention. Spinal manipulation is a safe and effective spine pain treatment. It reduces pain (decreasing the need for medication in some cases), rapidly advances physical therapy, and requires very few passive forms of treatment, such as bed rest. In fact, after an extensive study of all available care for low back problems, the federal Agency for Health Care Policy and Research (Under the US Dept. of Health and Human Services) recommended that low back pain sufferers choose the most conservative care first. And it recommended spinal manipulation as the only safe and effective, drugless form of initial professional treatment for acute low back problems in adults!
A well respected review of the evidence in the Annals of Internal Medicine pointed to Chiropractic care as one of the major nonpharmacologic therapies considered effective for acute and chronic low back pain. More recently, research has shown that there is strong evidence that spinal manipulation for back pain is just as effective as a combination of medical care and exercise. An article published in the Journal of the American Medical Association in 2013 also suggested chiropractic care as an option for people suffering from low back pain and noted that surgery is usually not needed and should only be tried if other therapies fail.
The Opioid Epidemic
The epidemic of prescription opioid overuse and abuse has also led many health groups to reconsider the value of a conservative approach to common conditions such as low-back pain. The American College of Physicians (ACP), the largest medical-specialty society in the world, updated its low-back pain treatment guidelines in 2017 to support a conservative approach to care. Published in the Annals of Internal Medicine and based on a review of randomized controlled trials and observational studies, the ACP guidelines cite heat therapy, massage, acupuncture and spinal manipulation (a centerpiece of chiropractic care) as possible options for non-invasive, non-drug therapies for low-back pain. The guidelines state that only when such treatments provide little or no relief should patients move on to medicines such as ibuprofen or muscle relaxants, which research indicates have limited pain-relief effectiveness and carry risk of negative side-effects. According to the ACP, prescription opioids should be a last resort for those suffering from low back pain, as the risk of addiction and overdose may outweigh the benefits.
Tips to Prevent Back Pain
- Get checked by a Chiropractic Physician even in the absence of back pain.
- Maintain a healthy diet and weight.
- Remain active—under the supervision of your Chiropractic Physician.
- Avoid prolonged inactivity or bed rest.
- Warm up then stretch before exercising or physical activities, such as gardening.
- Maintain proper posture and form.
- Wear comfortable, low-heeled shoes.
- Sleep on a mattress of medium firmness to minimize any curve in your spine.
- Lift with your knees, keep the object close to your body, and do not twist when lifting.
- Quit smoking: which results in oxygen, and nutrient deprivation to spinal tissues.
- Work with your Chiropractor to ensure that your workstation is ergonomically correct.
Disc Problems/Herniated Disc
The most common reason to visit our Tulsa Chiropractor is spine pain, and the most common reason for spinal pain is related to problems with the disc. I would like to take some time to explain the basics about these intervertebral discs. Be sure to look at the pictures above for reference.
There is a disc between each vertebral bone in the spine. The disc is basically a shock absorber. It is very much like one of those gel inserts you put in your shoe. The outside consists of rings of rubbery material (the annulus) and the inside is a gelatinous liquid (the nucleus). The design provides for mobility and shock absorption that reduces stress to the spine. However, if enough stress occurs to the disc, it can start to cause damage usually resulting in a tear in the annulus.
There are several patterns of disc tears. Tears can occur through the annulus or between the fibers of the annulus. If the tear is bad enough, the nucleus can begin to migrate from the center position into the tear which causes an abnormal shape of the disc. This abnormal shape interferes with the movement of the spine. You may notice painful restricted motion. You may notice spasm or a shifting/leaning of your spine. When the shape of the disc is distorted, but the nucleus has not yet migrated outside of the confines of the disc, we call it a Disc Bulge.
This Problem can continue to worsen. At the point where the nucleus travels past the outermost layer of the disc, it becomes a Herniation. There are a variety of other terms used to describe differing shapes and phenomenon that can occur with herniations including: protrusions, prolapses, and sequestrations, but we won’t get into those here. So, the take home point is that damage to the disc over time will create these disc bulges and herniations that result in a change in shape and position of the disc material. This in and of itself is painful enough, but there is an even more significant problem that can occur. It can lead to compression of the nerves in the spine!
The spinal cord goes from the brain down through the center of the vertebra and exits the spine right next to the disc in branches called nerve roots. From the spine, these nerves travel to different parts of the body to control sensation, muscle function, and some other things. This system allows your brain to communicate with your body. For example, the nerves that control your legs begin in the brain, travel down your spine, exit out of your low back, then go to your legs. If a disc herniation is compressing these nerves, it interferes with the signal. This can create pain, numbness, tingling, spasm or weakness in your legs: Boom…sciatica!
Disc herniations can compress nerves of the spine in two main ways: nerve root compression, and central cord compression. The herniation can poke out to the side contacting the nerve root, or it can herniate centrally putting pressure on the cord. Pressure on the cord is by far the worst scenario. This can even be life threatening if it occurs in the right place. It could also cause paralysis, loss of bowl or bladder control, and a variety of other terrible issues. This can sometimes be surgical emergency. Thankfully, this is not the most common form. What we usually see is that the disc material herniates out to the side and contacts the nerve root rather than the cord. This can happen in the neck causing pain to shoot out into the shoulder, arms, or hands along with weakness and numbness or spasm of the muscles. It can happen in the low back as well causing the same sort of thing to happen in the buttocks and legs. This is actually the cause of most cases of sciatica.
As the process of disc injury continues, the disc begins to whither and desiccate causing loss of disc space. This creates another situation that we call degenerative disc disease (DDD), which can also lead to narrowing of the space that the nerve needs to exit the spine. If this space is narrowed to the point that it compresses the nerve, we call this stenosis, and it can cause the same sort of nerve problems that a herniation can create.
So, what can a Chiropractor do to help you with your disc issue? A Chiropractor’s job-first and foremost- is to identify which type of disc issue is occurring, and determine whether physical medicine is safe or if you will need surgery. If it’s safe, then we can correct the position of your spine with a variety of different treatments. This will take the stress off of the disc and stop the process of the disc herniation from continuing.
Once the position is corrected, the disc can have a chance to heal especially with the right nutrition. A Chiropractor will usually perform spinal manipulation to correct the position and movement in your spine. This typically brings a lot of relief. I like to use electro-muscle stimulation to calm down the muscles and reduce pain either locally or down the affected limb. Additionally, traction or decompression can be used to take the pressure off of the disc and centralize the nucleus to reduce the herniation. Once the pain is under control, I use progressive rehab techniques to train the muscles of the body to hold the spine in the correct position. This step is important to stabilize the joint so the problem doesn’t just come back the next time you bend over to pick up a pencil.
Sciatica
Signs & Symptoms
If you have experienced low back pain with shooting pain down your the back or side of your leg, then it just might be sciatica. Other symptoms include numbness, tingling, altered sensation, and weakness. Usually one leg is affected, but it is possible to have both legs involved. If both legs are involved this can be a more serious sign (cauda equina syndrome), especially if there is loss of bowel/bladder/sexual function or loss of sensation of the inside of the thighs. Sciatica is not really a specific diagnosis and can have a variety of causes. You might also call sciatica a “pinched nerve”. Where the nerve is being pinched and what is doing the pinching is more complicated. As you might know, the different nerves in your low back go to different places in your legs. The affected area of the leg depends on which nerves are being damaged. The middle nerves of the lumbar spine tend to affect the front of the leg, lower nerves of the lumbar spine tend to affect the side of the leg, while nerves of the upper sacral spine tend to affect the back of the legs. Another sign of sciatica is that symptoms travel below the knee. This indicates a truly neurologic pathology that has a high risk of chronicity. I want to mention here that the term sciatica is derived from the sciatic nerve, but sciatica is often used simply to refer to spine pain or leg pain. This can sometimes cause confusion. For the sake of this article, I will include several conditions which can present with these symptoms, but are not actually sciatica.
Disc Pathology
Vertebral discs can change shape or even herniate. A disc bulge is a change in the shape of the disc. A herniation is when the gel-like center of the disc protrudes out of the normal confines of the disc. These changes in the disc can end up putting pressure on the nerves of the spine. The disc can herniate left, right, or center. Down in the lumbar region a central disc herniation can lead to a condition called Cauda Equina Syndrome that is serious and requires immediate surgery in order to prevent permanent loss of bowel/bladder/sexual dysfunction. A herniation to the left or right will likely put pressure on the nerve root. The symptoms depend on the amount of irritation/ pressure and the level of the disc. Disc pathology is the most common reason for sciatica and is considered the cause in the classic definition of true sciatica.
Spondylosis and Spinal Stenosis
Degenerative joint disease, degenerative disc disease, and osteoarthritis together are lumped into the term spondylosis when they occur in the spine. Spinal Stenosis is the term used to indicate narrowing of the passageway of the nerves. Spondylosis can lead to spinal stenosis. The loss of disc space narrows the diameter of these nerve passageways from top to bottom, and bone spurs can narrow the passage ways from front to back or side to side. Disc and bone changes can also narrow the diameter of the spinal canal (where the cord and several nerve roots exist) causing Cauda Equina-like symptoms. Additionally, people are sometimes born with already narrow nerve passage ways and this puts them at even greater risk of developing sciatica and other related neuropathies. Of course, anything that changes the shape, alignment in the spine can lead to stenosis such as pregnancy, Scheuermann’s disease, or scoliosis.
Other Space-Occupying Lesions and Pathology
Some more serious reasons for sciatica are tumors, fractures and infections. These situations warrant immediate medical intervention. A tumor grows and occupies space that can put pressure on nerves. Fractures may lead to bone fragments putting pressure on nerves and/or cause instability of the spine that results in nerve compression. An infection can also create changes and inflammation in the spine that can lead to these sorts of neuropathies. These pathologies are the first things that should be ruled out during an initial examination.
Piriformis Syndrome
There is a particular muscle in the buttocks called the piriformis. The sciatic nerve runs right under this muscle. A tightening or contracture or over development of this muscle (usually compensation for gluteal weakness) can put pressure on the sciatic nerve. In a small portion of the population, the sciatic nerve travels either partially or entirely through the piriformis muscle. If the piriformis is chronically contracted, then it can strangle the nerve producing sciatica. However, piriformis syndrome is traditionally not considered true sciatica.
Femoral Neuropathy
While true sciatica tends to occur from pressure of the nerves in the lower lumbar spine, nerves can also be irritated in the same way in the upper part of the lumbar spine. When this occurs, the fibers of the femoral nerves can be involved instead of the sciatic nerves. In these cases, pain is typically felt in the front of the thigh instead of the back/side of thigh. The underlying causes are pretty much the same as sciatica, just in a different place affecting a different group of nerves.
Meralgia Paresthetica
This is a condition where the lateral femoral cutaneous nerve (a nerve that runs down the outer thigh) can be compressed or injured. This has been nicknamed the “skinny pants syndrome” because tight fitting pants or belt is the underlying cause (one of the reasons I recommend elastic/stretchy material). The nerve becomes entrapped around the front of the hip and groin region as the nerve passes from the pelvic area to the outer thigh. Motor vehicle accidents can also cause lesions of this nerve from contact of the seat belt. There are several other less common causes for compression and injury to this nerve. This condition is also not included in the classic definition of sciatica.
Iliotibial Band Syndrome and Trochanteric Bursitis
This is another biomechanical issue that can cause pain running down the leg with occasional neurological implications and can be associated with back pain. See the section on Hip Pain for more detail. There is a muscle called the tensor fascia latae (TFL). Tightening of the TFL can create excessive tension of a band of fibrous connective tissue that runs down the outside of the leg called the iliotibial band (ITB). This tension puts pressure against the trochanteric bursa which is located around the hip bone. This whole complex of problems is referred to as ITB syndrome and trochanteric bursitis and they usually occur altogether. Pain often starts in the hip and travels down the outer thigh to the knee. Muscle spasm, swelling, and general tension can lead to nerve compression occasionally. This makes the problem look like sciatica, but again, this is not true sciatica.
Herpes Zoster
Ever had chicken pox? This is caused by the varicella zoster virus. Like all other herpes viruses, it actually lives in your nerves imbedding itself into the DNA of the nerve cells. It is there forever. It is usually dormant but can become active again leading to herpes outbreaks. When chicken pox reactivates, it is called herpes zoster or commonly “shingles”. This typically happens to older adults but can happen in younger people too. Before the full rash appears, a person can have neurological symptoms including pain and numbness. If the affected nerve is in the low back and leg, then this virus can present just like sciatica, and so I’ve included this condition in this section.
General Kinetic Chain Dysfunction
In some cases, pain can appear to shoot down the leg with back pain not because of a pinched nerve, but because of a problem in the kinetic chain. A kinetic chain is the link between several consecutive joints and the muscles and other soft tissue involved in that linkage. It is a head-bone-is-connected-to-the-foot-bone situation. Here is an example: A patient has a “flat foot” that rolls inwards. When that foot rolls inwards, it causes the knee to also travel inwards. This drops the pelvis on that side. This causes the lumbar vertebra to tilt. Many muscles and ligaments are stressed because of these postural changes. The result is a chain of overstressed tissues usually producing a series of trigger points or tender points down the chain. This leads to pain in the back and the leg. Voilà!!! Kinetic chain dysfunction… not sciatica.
Further Considerations
As you can see, sciatica is pretty complicated. I haven’t listed all of the conditions that can cause low back pain with leg pain, but I’m guessing your head is already spinning. These different problems can look like true sciatica, but only a trained physician can correctly diagnose the real issue. Sometimes it is a serious problem that requires immediate medical attention. Sometimes it requires surgery. Sometimes surgical intervention will not fix anything. To compound the problem, studies have shown that MRIs are not as reliable as we once thought. Things like degenerative changes and disc herniations appear all the time in completely asymptomatic patients. The older we are, the more likely we are to have these findings on imaging, but that likelihood has very little association with the symptoms that we experience: it is simply a coincidental finding. Likewise, there are many people who experience what appears to be true sciatica upon clinical examination but have no findings on MRI or X-ray! For those of you who are interested in a reference, I can point you towards Rehabilitation of the Spine: A Practitioner’s Manual: Chapter 14 (this is considered the rehab bible by many physical medicine practitioners).
Treatment
Despite all of the confusion and all of the controversy, there are established guidelines for treatment of sciatica. This is my synopsis:
- Treating sciatica with medicine like muscle relaxers, anti-inflammatories, and pain killers is an appropriate intervention on a preferably temporary basis, but it should be understood that medicine does not address the underlying biomechanical dysfunction. Though, it can help to ease the symptoms while the body heals. I myself sometimes refer patients to medical doctors when symptoms are severe enough. Medicines that calm pain and muscle spasm actually help me to do my work as it decreases guarding allowing me to more easily manipulate and rehab my patients. I like to communicate with my patient’s primary care physician anyways, so we can be on the same page. Cooperation is important.
- Sciatica that does not self-resolve in a few weeks should first be treated conservatively. This includes things like manipulation, physiotherapies, rehab, massage, and manual therapies. I also perform a few injections with naturopathic/homeopathic medicines here in the office as I am certified and licensed to do so.
- If conservative therapy has absolutely no effect by two weeks, then I either change the plan, or possibly seek advanced imaging like X-ray or MRI. I do not allow patients to remain without progress in the clinic. If I really can’t get results, I refer out to a different specialist.
- If conservative treatment is initially effective, but we reach a plateau after a time, then advanced imaging is warranted if not previously obtained along with a possible referral for surgical consult. Though sometimes it is necessary for insurance purposes to first refer back to the patient’s primary care physician. This is another reason it is good to be in communication with the patient’s PCP.
- If I do refer out for surgery, the doctors usually only perform surgery after it is established that steroid injections or other less invasive medical intervention also fails.
- I prefer that patients and their surgeons consider less invasive surgeries that do not involve the use of hardware in the spine. Long term outcomes tend to be poor for these more invasive surgeries (though sometimes there is no other option). The addition of hardware means that the involved sections of the spine are immobilized resulting in stress of the vertebra above and below, and often lead to further surgery of those sections down the road.
- If surgery fails, then patients are typically referred to pain management clinics.
The healthcare community is well-aware of the opioid epidemic and nobody wants the final outcome to be simply mitigating symptoms with pain killers and other medications. The point is that conservative therapy should come first. If this fails, then more aggressive medical measures should be taken.
If you think you might have sciatica, please make an appointment with our chiropractor in Tulsa today.
Scoliosis
Definition
When looking at the spine from the front or back, it should appear straight up and down. While looking from the side, there should be a slight curve forwards in two places: the neck and the low back. This is the normal shape of the spine. Scoliosis is an abnormal curvature of the spine from side to side, and is often accompanied by a rotational or twisting component. The curvature can be a C-shape or an S-shape. A scoliosis is described by the direction it points and its rotational component. For example, a dextrorotary lumbar scoliosis indicates a curvature to the right with rotation in the lumbar spine.
Signs & Symptoms
It is typically a parent, teacher, coach, or even class mate that first notices the signs of scoliosis. It may be noted that one shoulder appears lower than the other or protrude further than the other. The back may appear to twist or lean. The head may appear to be displaced to one side. One hip may appear to be cocked forward or to the side. The rib cage may appear to stick out on one side. One leg may appear to be longer. These general asymmetries are usually the first signs. In addition, the person may have symptoms and complain of pain or spasm in the back, neck, shoulders, or hips. Note that some scoliosis patients do not have spine pain or rib pain at all, only visual asymmetries.
Causes
Nobody knows exactly what causes scoliosis in the wide majority of cases. Hence most scolioses are idiopathic in nature. If the scoliosis is due to some other process, then it is called a secondary scoliosis. Most cases of secondary scoliosis are due to pathology of the nerves, muscles, connective tissue, or some irregularity in the vertebral bones or discs. Other pathologies like tumors or infections or degenerative changes that warp the shape of the vertebra or cause a person to lean away from the side of pain can also cause a scoliosis. If a scoliosis is due to a permanent and fixed abnormality in the shape of the vertebra, this is termed a structural scoliosis. On the other hand, if the scoliosis is not permanent and the spine can actually straighten with certain positions, then it is a functional scoliosis. A functional scoliosis can be due to a short leg or muscle spasm or muscle imbalance. A simple test called Adam’s Test can determine the difference between a structural and functional scoliosis. Names are also given depending on when the scoliosis begins. If a person is born with an abnormality such as a misshapen vertebra, then the term congenital scoliosis is used. If it is discovered from birth to 3 years old, we use the term infantile. From 3-10 years old the term juvenile is used, from 10-18 we use the term adolescent, and in adults we logically use the term adult onset scoliosis.
Risk Factors
Most scoliosis develops between the ages of 10-20 and females are often more affected than males. There is a genetic component as the risk of developing a scoliosis is higher in those individuals who have one parent with scoliosis and much higher in those with two parents. But, as with almost all diseases, environmental factors play a role as well. The earlier the onset of scoliosis, the worse the prognosis. Scoliosis tends to worsen over time and the curvature is at risk of increasing as the spine grows.
Treatment
Treatment of scoliosis is tricky. First off, a side to side curvature in the spine has to be over 10 degrees before it is considered a true scoliosis. This is because almost everybody has some amount of curvature in the thoracic spine to accommodate the space for the heart. If the curvature is over 10 degrees and especially if the patient is younger than 18, then the curvature needs to be monitored over time by X-ray: typically every 3-6 months depending on age. Scoliosis can be treated with manipulation, massage, stretches, and exercises: all in an attempt to straighten the spine, or at least stop the curvature from increasing. Scoliosis can also be due to a problem with anatomical or functional leg length causing the pelvis and spine to tilt, therefore an assessment of the lower extremity must be performed. If the problem is due to abnormal biomechanics of the lower extremity, then the use of orthotics, lifts, or functional rehab to correct the dysfunction should be employed. Braces can be used in more severe curves. If the curve becomes very severe measuring 50 degrees or more, a surgical consult is warranted because at this stage the heart and lungs can begin to be affected.
Prognosis
Generally, the prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are larger curves carry a higher risk of progression than smaller curves, thoracic curves carry a higher risk of progression than lumbar or thoracolumbar curves, and double curves carry a higher risk of progression than single curves. In addition, patients not having yet reached skeletal maturity have a higher likelihood of progression. If you think you have scoliosis, please visit our Tulsa Chiropractor today.
Neck Pain
The neck (cervical spine) runs from the base of the skull down to the top of the shoulders. There are numerous muscles and soft tissues that support the neck. This is necessary in order to carry the weight of the head which is surprisingly heavy: about the weight of a bowling ball. The individual vertebra allow for quite a bit of mobility in this region and must have strong support from muscles and the shock absorbing discs between each vertebra. Because of the weight of the head, the neck is vulnerable to injury. This can happen during a motor vehicle accident and cause whiplash. It can happen during a sports injury when then neck our shoulder is jarred or impacted strongly. It can even happen slowly over time without you realizing it while using devices such as cell phones.
Neck pain can be caused by a variety of different conditions that require correct diagnosis and distinct treatment. Most causes of neck pain are musculoskeletal in nature and are not life-threatening. Causes of neck pain that are serious include: cardiovascular pathology, cancer/tumor, infection, stenosis, auto immune disease, fracture, and dislocation. These causes of neck pain require medical intervention and could involve surgery. Luckily, most of the time neck pain is a biomechanical problem that can be treated conservatively within our clinic. More common conditions include: vertebral disc issues, facet joint arthritis, muscle problems, ligament damage, and postural abnormalities. Let’s talk about a few common problems we see at the clinic.
Postural Syndrome
Also referred to now as text neck, this is typical of people who use electronic devices like a tablet, computer, or cellphone constantly throughout the day. As we sit and look at our screens, our heads tend to lean forward or down creating a change in the shape of our spines and putting stress on the muscles in the neck and upper back area. This tends to become worse over time. The further forward you bring your head, the heavier your head becomes relatively and the harder the muscles have to work. With time, this can produce stress not only in the muscles, but in the discs and ligaments as well. This makes you more prone to arthritis, muscle knots, and spinal misalignment.
Degeneration
Degenerative disc/joint disease is the general term used for deterioration of the discs and joints in the neck. Some may call it arthritis or arthrosis. The facet joints and the discs are warn out over time, usually because of misalignment and bad mechanics…like driving a car with a crooked wheel. The structures are stressed and damaged the more you use it in the misaligned position. Eventually this leads to bone spurs, disc space narrowing, herniations, and possibly pinched nerves.
Whiplash
a combination of strain of the muscles, sprain of the ligaments, and damage to the discs of the cervical spine that occurs during a car wreck. It is typically due to the action of the head bouncing back and force rapidly on impact. The problem can be minor and involve mostly muscle tears, or it could be more serious with ruptured discs and neurological symptoms.
Any one of these pathologies can result in pain, spasm, stiffness, weakness, and even numbness or shooting pain into the arms/hands. You will want to seek out a physician, like a Chiropractor, who can correctly examine and diagnose your neck pain to make sure that you get the right care.
Mid Back Pain
While there are many reasons for mid-back pain (thoracic pain), the more common reasons tend to be musculoskeletal in nature. Patients suffering from mid-back pain typically have dysfunction in the thoracic vertebra and ribs. The most common complaint I hear is pain between the shoulder blades. There are some other more serious causes of mid back pain. For instance, gallbladder and kidney pathology can refer to this area. Infection or cancer can manifest itself as midback pain, but this is very rare. It’s important to let a physician like a Chiropractor properly diagnose your issue to make sure you receive the proper care. Below are some common problems.
Postural Syndrome:
Problems in the midback are typically related to bad posture. Rounding the upper back, carrying the head forward, and rolling the shoulders forward as we sit and work or use of our electronic devices can cause stress to our bodies that adds up over time. The typical result is spasm from overuse of the muscles. If you experience a constant soreness, tightness, and achiness, then this is probably happening to you.
Intercostal Pain:
If you feel pain when taking a breath that shoots through your chest or wraps around your side, then you may have some rib dysfunction. The muscles and/or nerves between the ribs can be irritated from a misalignment of the ribs in relation to each other or as they attach to the thoracic spine. This is the classic “Rib Out” scenario. It’s usually a fairly easy fix, but in some cases , it can be stubborn or return frequently. These cases require more treatment and rehab to retain the corrected position.
Facet Syndrome
An irritation of the joints of the back of the spine. Because of the shape of the spine in the mid back, the joints tend to be stretched rather than compressed and so the irritation is typically in the capsules/ligaments surrounding the joints instead of the surface where the bones meet. This pain tends to be sharp and local and maybe about the size of a marble or golf ball.
Disc Pathology
It is rare to have disc pathology in the midback (thoracic spine) because of the support from the ribs, but it does occur. Scheuermann’s disease is a good example. This is an issue with rounding of the midback and typically involves compression of the discs at the front of the spine. It can be very painful. Other causes exist such as acute trauma like a fall from substantial height or auto accident or sports injury.
Of course, it takes a physician to properly diagnose your problem and get you the correct treatment, so please call today if these symptoms sound familiar.
Rib Pain
Rib pain can either be one of the easiest problems to fix for a Chiropractor or one of the hardest. Sometimes an injury or awkward movement (like a sneeze while hunching over) can throw a rib right out of place. A little muscle work and the correct adjustment may be all you need. This is the old “one and done” situation. Other times, postural problems or scapular dysfunction can cause issues with the muscles in the back that create more chronic (long term) rib pathology. In this case, the underlying dysfunction will need to be addressed. Otherwise, the rib problem will likely return or possibly never really resolve. Let’s take a look at the area that most often causes a rib problem.
There are many layers of muscles across the back, all of which can be relevant to rib pain. The ribs connect to the spine in the back. The levator costae muscles, attach to the ribs. Their job is to help elevate those ribs during breathing and other motions. If there is dysfunction or misalignment in the spine, then these muscles will have to work overtime, spasm, and can become tight and tender. When this occurs, the constant tension can pull that rib head out of alignment. This leads to stress, inflammation, and further spasm & tenderness of the surrounding musculature. Now every time you take a breath, especially a deep one, the pain is intense and can even travel in the rib cage around to the side or front. Labored and painful breathing is a sign of rib pain, but can also mean something more serious.
Treatment for chronic rib dysfunction will usually include correcting misalignments of the spine, manipulation of the soft tissue, therapies targeting muscle spasms and pain, correcting postural abnormalities, correcting scapular dysfunction, and of course… manipulation of the rib itself.
Once in a while, a patient may also present with dysfunction in the sternum and costal cartilages. This is a problem with the front of the chest. In this area, there aren’t technically any ribs, but rib cartilage. The ribs stop being bone in the front part of the chest and instead become cartilaginous before they connect to the sternum. When a patient has irritation in the front of the chest, the diagnosis is typically costochondritis. This literally means inflammation of the rib cartilage. A person who experiences these problems often has forward rolled shoulders and forward head carriage. This is really a completely different presentation than rib pain in the back, though the two can be related. This is covered in more detail in the section below.
Chest pain of any sort can indicate a very serious problem. So, if you are experiencing sudden chest pain, it is not a good idea to wait. The issue may warrant emergency procedures, especially if you have any difficulty breathing, impending sense of doom, a feeling of significant pressure in your chest, sweating, fever, vomiting, cough, recent cold, or rapid pulse. A trip to the emergency room may be life-saving. However, if this is localized pain without any accompanying symptoms, and it has been going on for several weeks or more, it is not likely an emergency situation.
If it is not an emergency situation, or if a medical physician has already cleared you of any life-threatening conditions, your next call should be to a Chiropractic Physician.
Costochondritis
Costochondritis is the inflammation and irritation of the ribs as they insert into the sternum causing rib pain. In this front region of the chest, the ribs aren’t actually bone. The ribs here are cartilage as they connect to the sternum bone. This is where the term costochondritis comes from: Costo- indicating ribs, Chondro- meaning cartilage, and -itis signifying inflammation. These joints are solid and fibrous and have little room for motion. Hence any misalignment is not well tolerated.
The problem usually occurs on one side of the sternum more than the other, but can occur on both sides. You may notice increased rib pain with movement like bending forward or backwards or turning the body. You may have more pain associated with your breath like deep inhalation or coughing or sneezing. It is also common to note more pain while laying down as this puts pressure on your ribs stressing the connection at the sternum. There may also be accompanying spine pain in the region between the shoulder blades.
It is not officially established how or why this inflammation occurs, but it is a musculoskeletal issue so it likely boils down to position and movement. In my clinical experience, it is usually associated with misalignment of the thoracic spine and rib cage. The ribs attach to the vertebra in the back, wrap around the body becoming cartilaginous in front, and insert into the sternum forming what we refer to as the rib cage. The ribs themselves are fairly mobile in the back where they attach to the spine to accommodate for bending and rotation that occurs in the thoracic spine. The ribs must also have mobility to allow for respiration. They have a bucket-handle-like movement upwards when inhaling. As you can imagine, with all of the motion that occurs in the spine and ribs, you would need the connection in front to also be fairly mobile. This is why the front of the ribs consist of flexible interlinking cartilage. The softer cartilage allows for the mobility of the ribs for movement and respiration. But, the insertion of the ribs to the sternum is solid and relatively immobile.
A problem can occur when the rib cage changes shape or mobility due to postural changes or injury. The movement of the ribs must still occur, but in it’s dysfunctional state begins to overload the fibrous connection at the sternum. Instead of mobility occurring where it should at the spine, between the ribs, and at the cartilage, now more movement occurs at the front in those fibrous connections to the sternum. This often results in misalignment and stress at this connection causing pain and inflammation.
The first course of treatment is rest, ice and anti-inflammatory medications. However, it is very common for these conservative measures to fail because the underlying mechanics are still a problem. In these cases, it is necessary for a Chiropractor to evaluate the thoracic spine and rib cage to set things right again. By correcting posture, realigning the thoracic spine, and manipulating the individual ribs, the problem can usually be remedied. It is common for the problem to return though. For this reason we may have to consider rehab to retrain the muscles in order to retain the proper position and movement of the thoracic spine and rib cage. Interestingly enough, I find that it is usually best to leave alone the painful area at the sternum. This is because this area is irritated from too much movement and additional movement typically only makes things worse. It is much better to approach the problem in the thoracic spine and other parts of the ribs to allow the fibrous connections in front to heal. In certain circumstances, the ribs do need to be manipulated in front at the sternum. This can be quite uncomfortable, so these maneuvers are reserved for when other methods fail.
Low Back Pain
Many patients present to our clinic every week with low back pain. In fact, this is the most common reason to visit our Tulsa Chiropractor. Although Chiropractic Physicians treat more than just back pain, many patients initially visit chiropractors looking for relief from this pervasive condition. In fact, 31 million Americans experience low-back pain at any given time.
Facts About Back Pain
- Low back pain is the single leading cause of disability worldwide, according to the Global Burden of Disease 2010.
- Back pain is one of the most common reasons for missed work. In fact, back pain is the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.
- One-half of all working Americans admit to having back pain symptoms each year.
- Experts estimate that as much as 80% of the population will experience a back problem at some time in their lives.
- Most cases of back pain are mechanical or non-organic—meaning they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.
- Americans spend at least $50 billion each year on back pain—and that’s just for the more easily identified costs.
What Causes Back Pain?
The back is a complicated structure of bones, joints, discs, ligaments and muscles. You can sprain ligaments, strain muscles, rupture disks, and irritate joints, all of which can lead to back pain. While sports injuries or auto accidents can cause back pain, sometimes the simplest of movements (like picking up a pencil from the floor) can have painful results when there is an underlying issue. In addition, arthritis, poor posture, obesity, and psychological stress can cause or complicate back pain. Back pain can also directly result from disease of the internal organs, such as kidney stones, kidney infections, blood clots, or bone loss.
Common Causes of Low Back Pain
The cause of most back pain is biomechanical in nature. In other words, it is a dysfunction in position and movement. The dysfunction leads to excessive stress on the structures of the spine and can cause increasingly severe damage over time. We call this degeneration (Degenerative Disc Disease & Degenerative Joint Disease). As the joints wear out, the muscles tighten & spasm, the discs are damaged, the ligaments calcify creating bone spurs, arthritis sets in, and nerves start to be compressed. It is a process that occurs little by little. It weakens the spine making it vulnerable to acute injury such as disc herniations. If left unchecked, the bones themselves change shape and a condition called stenosis can occur. This is when the spaces that the nerves pass through become narrowed producing pressure on these nerves and can result in all kinds of nasty neurological symptoms.
Common Diagnoses Include:
- Disc Pathology (bulge/herniation)
- Facet Irritation
- Sacroiliac Joint Dysfunction
- Arthritis & Degeneration (Spondylosis)
- Sciatica
- Stenosis
Spinal Manipulation as a Treatment for Back Problems
With today’s growing emphasis on quality care, clinical outcomes and cost effectiveness, spinal manipulation is receiving increased attention. Spinal manipulation is a safe and effective spine pain treatment. It reduces pain (decreasing the need for medication in some cases), rapidly advances physical therapy, and requires very few passive forms of treatment, such as bed rest. In fact, after an extensive study of all available care for low back problems, the federal Agency for Health Care Policy and Research (Under the US Dept. of Health and Human Services) recommended that low back pain sufferers choose the most conservative care first. And it recommended spinal manipulation as the only safe and effective, drugless form of initial professional treatment for acute low back problems in adults!
A well respected review of the evidence in the Annals of Internal Medicine pointed to Chiropractic care as one of the major nonpharmacologic therapies considered effective for acute and chronic low back pain. More recently, research has shown that there is strong evidence that spinal manipulation for back pain is just as effective as a combination of medical care and exercise. An article published in the Journal of the American Medical Association in 2013 also suggested chiropractic care as an option for people suffering from low back pain and noted that surgery is usually not needed and should only be tried if other therapies fail.
The Opioid Epidemic
The epidemic of prescription opioid overuse and abuse has also led many health groups to reconsider the value of a conservative approach to common conditions such as low-back pain. The American College of Physicians (ACP), the largest medical-specialty society in the world, updated its low-back pain treatment guidelines in 2017 to support a conservative approach to care. Published in the Annals of Internal Medicine and based on a review of randomized controlled trials and observational studies, the ACP guidelines cite heat therapy, massage, acupuncture and spinal manipulation (a centerpiece of chiropractic care) as possible options for non-invasive, non-drug therapies for low-back pain. The guidelines state that only when such treatments provide little or no relief should patients move on to medicines such as ibuprofen or muscle relaxants, which research indicates have limited pain-relief effectiveness and carry risk of negative side-effects. According to the ACP, prescription opioids should be a last resort for those suffering from low back pain, as the risk of addiction and overdose may outweigh the benefits.
Tips to Prevent Back Pain
- Get checked by a Chiropractic Physician even in the absence of back pain.
- Maintain a healthy diet and weight.
- Remain active—under the supervision of your Chiropractic Physician.
- Avoid prolonged inactivity or bed rest.
- Warm up then stretch before exercising or physical activities, such as gardening.
- Maintain proper posture and form.
- Wear comfortable, low-heeled shoes.
- Sleep on a mattress of medium firmness to minimize any curve in your spine.
- Lift with your knees, keep the object close to your body, and do not twist when lifting.
- Quit smoking: which results in oxygen, and nutrient deprivation to spinal tissues.
- Work with your Chiropractor to ensure that your workstation is ergonomically correct.
Disc Problems/Herniated Disc
The most common reason to visit our Tulsa Chiropractor is spine pain, and the most common reason for spinal pain is related to problems with the disc. I would like to take some time to explain the basics about these intervertebral discs. Be sure to look at the pictures above for reference.
There is a disc between each vertebral bone in the spine. The disc is basically a shock absorber. It is very much like one of those gel inserts you put in your shoe. The outside consists of rings of rubbery material (the annulus) and the inside is a gelatinous liquid (the nucleus). The design provides for mobility and shock absorption that reduces stress to the spine. However, if enough stress occurs to the disc, it can start to cause damage usually resulting in a tear in the annulus.
There are several patterns of disc tears. Tears can occur through the annulus or between the fibers of the annulus. If the tear is bad enough, the nucleus can begin to migrate from the center position into the tear which causes an abnormal shape of the disc. This abnormal shape interferes with the movement of the spine. You may notice painful restricted motion. You may notice spasm or a shifting/leaning of your spine. When the shape of the disc is distorted, but the nucleus has not yet migrated outside of the confines of the disc, we call it a Disc Bulge.
This Problem can continue to worsen. At the point where the nucleus travels past the outermost layer of the disc, it becomes a Herniation. There are a variety of other terms used to describe differing shapes and phenomenon that can occur with herniations including: protrusions, prolapses, and sequestrations, but we won’t get into those here. So, the take home point is that damage to the disc over time will create these disc bulges and herniations that result in a change in shape and position of the disc material. This in and of itself is painful enough, but there is an even more significant problem that can occur. It can lead to compression of the nerves in the spine!
The spinal cord goes from the brain down through the center of the vertebra and exits the spine right next to the disc in branches called nerve roots. From the spine, these nerves travel to different parts of the body to control sensation, muscle function, and some other things. This system allows your brain to communicate with your body. For example, the nerves that control your legs begin in the brain, travel down your spine, exit out of your low back, then go to your legs. If a disc herniation is compressing these nerves, it interferes with the signal. This can create pain, numbness, tingling, spasm or weakness in your legs: Boom…sciatica!
Disc herniations can compress nerves of the spine in two main ways: nerve root compression, and central cord compression. The herniation can poke out to the side contacting the nerve root, or it can herniate centrally putting pressure on the cord. Pressure on the cord is by far the worst scenario. This can even be life threatening if it occurs in the right place. It could also cause paralysis, loss of bowl or bladder control, and a variety of other terrible issues. This can sometimes be surgical emergency. Thankfully, this is not the most common form. What we usually see is that the disc material herniates out to the side and contacts the nerve root rather than the cord. This can happen in the neck causing pain to shoot out into the shoulder, arms, or hands along with weakness and numbness or spasm of the muscles. It can happen in the low back as well causing the same sort of thing to happen in the buttocks and legs. This is actually the cause of most cases of sciatica.
As the process of disc injury continues, the disc begins to whither and desiccate causing loss of disc space. This creates another situation that we call degenerative disc disease (DDD), which can also lead to narrowing of the space that the nerve needs to exit the spine. If this space is narrowed to the point that it compresses the nerve, we call this stenosis, and it can cause the same sort of nerve problems that a herniation can create.
So, what can a Chiropractor do to help you with your disc issue? A Chiropractor’s job-first and foremost- is to identify which type of disc issue is occurring, and determine whether physical medicine is safe or if you will need surgery. If it’s safe, then we can correct the position of your spine with a variety of different treatments. This will take the stress off of the disc and stop the process of the disc herniation from continuing.
Once the position is corrected, the disc can have a chance to heal especially with the right nutrition. A Chiropractor will usually perform spinal manipulation to correct the position and movement in your spine. This typically brings a lot of relief. I like to use electro-muscle stimulation to calm down the muscles and reduce pain either locally or down the affected limb. Additionally, traction or decompression can be used to take the pressure off of the disc and centralize the nucleus to reduce the herniation. Once the pain is under control, I use progressive rehab techniques to train the muscles of the body to hold the spine in the correct position. This step is important to stabilize the joint so the problem doesn’t just come back the next time you bend over to pick up a pencil.
Sciatica
Signs & Symptoms
If you have experienced low back pain with shooting pain down your the back or side of your leg, then it just might be sciatica. Other symptoms include numbness, tingling, altered sensation, and weakness. Usually one leg is affected, but it is possible to have both legs involved. If both legs are involved this can be a more serious sign (cauda equina syndrome), especially if there is loss of bowel/bladder/sexual function or loss of sensation of the inside of the thighs. Sciatica is not really a specific diagnosis and can have a variety of causes. You might also call sciatica a “pinched nerve”. Where the nerve is being pinched and what is doing the pinching is more complicated. As you might know, the different nerves in your low back go to different places in your legs. The affected area of the leg depends on which nerves are being damaged. The middle nerves of the lumbar spine tend to affect the front of the leg, lower nerves of the lumbar spine tend to affect the side of the leg, while nerves of the upper sacral spine tend to affect the back of the legs. Another sign of sciatica is that symptoms travel below the knee. This indicates a truly neurologic pathology that has a high risk of chronicity. I want to mention here that the term sciatica is derived from the sciatic nerve, but sciatica is often used simply to refer to spine pain or leg pain. This can sometimes cause confusion. For the sake of this article, I will include several conditions which can present with these symptoms, but are not actually sciatica.
Disc Pathology
Vertebral discs can change shape or even herniate. A disc bulge is a change in the shape of the disc. A herniation is when the gel-like center of the disc protrudes out of the normal confines of the disc. These changes in the disc can end up putting pressure on the nerves of the spine. The disc can herniate left, right, or center. Down in the lumbar region a central disc herniation can lead to a condition called Cauda Equina Syndrome that is serious and requires immediate surgery in order to prevent permanent loss of bowel/bladder/sexual dysfunction. A herniation to the left or right will likely put pressure on the nerve root. The symptoms depend on the amount of irritation/ pressure and the level of the disc. Disc pathology is the most common reason for sciatica and is considered the cause in the classic definition of true sciatica.
Spondylosis and Spinal Stenosis
Degenerative joint disease, degenerative disc disease, and osteoarthritis together are lumped into the term spondylosis when they occur in the spine. Spinal Stenosis is the term used to indicate narrowing of the passageway of the nerves. Spondylosis can lead to spinal stenosis. The loss of disc space narrows the diameter of these nerve passageways from top to bottom, and bone spurs can narrow the passage ways from front to back or side to side. Disc and bone changes can also narrow the diameter of the spinal canal (where the cord and several nerve roots exist) causing Cauda Equina-like symptoms. Additionally, people are sometimes born with already narrow nerve passage ways and this puts them at even greater risk of developing sciatica and other related neuropathies. Of course, anything that changes the shape, alignment in the spine can lead to stenosis such as pregnancy, Scheuermann’s disease, or scoliosis.
Other Space-Occupying Lesions and Pathology
Some more serious reasons for sciatica are tumors, fractures and infections. These situations warrant immediate medical intervention. A tumor grows and occupies space that can put pressure on nerves. Fractures may lead to bone fragments putting pressure on nerves and/or cause instability of the spine that results in nerve compression. An infection can also create changes and inflammation in the spine that can lead to these sorts of neuropathies. These pathologies are the first things that should be ruled out during an initial examination.
Piriformis Syndrome
There is a particular muscle in the buttocks called the piriformis. The sciatic nerve runs right under this muscle. A tightening or contracture or over development of this muscle (usually compensation for gluteal weakness) can put pressure on the sciatic nerve. In a small portion of the population, the sciatic nerve travels either partially or entirely through the piriformis muscle. If the piriformis is chronically contracted, then it can strangle the nerve producing sciatica. However, piriformis syndrome is traditionally not considered true sciatica.
Femoral Neuropathy
While true sciatica tends to occur from pressure of the nerves in the lower lumbar spine, nerves can also be irritated in the same way in the upper part of the lumbar spine. When this occurs, the fibers of the femoral nerves can be involved instead of the sciatic nerves. In these cases, pain is typically felt in the front of the thigh instead of the back/side of thigh. The underlying causes are pretty much the same as sciatica, just in a different place affecting a different group of nerves.
Meralgia Paresthetica
This is a condition where the lateral femoral cutaneous nerve (a nerve that runs down the outer thigh) can be compressed or injured. This has been nicknamed the “skinny pants syndrome” because tight fitting pants or belt is the underlying cause (one of the reasons I recommend elastic/stretchy material). The nerve becomes entrapped around the front of the hip and groin region as the nerve passes from the pelvic area to the outer thigh. Motor vehicle accidents can also cause lesions of this nerve from contact of the seat belt. There are several other less common causes for compression and injury to this nerve. This condition is also not included in the classic definition of sciatica.
Iliotibial Band Syndrome and Trochanteric Bursitis
This is another biomechanical issue that can cause pain running down the leg with occasional neurological implications and can be associated with back pain. See the section on Hip Pain for more detail. There is a muscle called the tensor fascia latae (TFL). Tightening of the TFL can create excessive tension of a band of fibrous connective tissue that runs down the outside of the leg called the iliotibial band (ITB). This tension puts pressure against the trochanteric bursa which is located around the hip bone. This whole complex of problems is referred to as ITB syndrome and trochanteric bursitis and they usually occur altogether. Pain often starts in the hip and travels down the outer thigh to the knee. Muscle spasm, swelling, and general tension can lead to nerve compression occasionally. This makes the problem look like sciatica, but again, this is not true sciatica.
Herpes Zoster
Ever had chicken pox? This is caused by the varicella zoster virus. Like all other herpes viruses, it actually lives in your nerves imbedding itself into the DNA of the nerve cells. It is there forever. It is usually dormant but can become active again leading to herpes outbreaks. When chicken pox reactivates, it is called herpes zoster or commonly “shingles”. This typically happens to older adults but can happen in younger people too. Before the full rash appears, a person can have neurological symptoms including pain and numbness. If the affected nerve is in the low back and leg, then this virus can present just like sciatica, and so I’ve included this condition in this section.
General Kinetic Chain Dysfunction
In some cases, pain can appear to shoot down the leg with back pain not because of a pinched nerve, but because of a problem in the kinetic chain. A kinetic chain is the link between several consecutive joints and the muscles and other soft tissue involved in that linkage. It is a head-bone-is-connected-to-the-foot-bone situation. Here is an example: A patient has a “flat foot” that rolls inwards. When that foot rolls inwards, it causes the knee to also travel inwards. This drops the pelvis on that side. This causes the lumbar vertebra to tilt. Many muscles and ligaments are stressed because of these postural changes. The result is a chain of overstressed tissues usually producing a series of trigger points or tender points down the chain. This leads to pain in the back and the leg. Voilà!!! Kinetic chain dysfunction… not sciatica.
Further Considerations
As you can see, sciatica is pretty complicated. I haven’t listed all of the conditions that can cause low back pain with leg pain, but I’m guessing your head is already spinning. These different problems can look like true sciatica, but only a trained physician can correctly diagnose the real issue. Sometimes it is a serious problem that requires immediate medical attention. Sometimes it requires surgery. Sometimes surgical intervention will not fix anything. To compound the problem, studies have shown that MRIs are not as reliable as we once thought. Things like degenerative changes and disc herniations appear all the time in completely asymptomatic patients. The older we are, the more likely we are to have these findings on imaging, but that likelihood has very little association with the symptoms that we experience: it is simply a coincidental finding. Likewise, there are many people who experience what appears to be true sciatica upon clinical examination but have no findings on MRI or X-ray! For those of you who are interested in a reference, I can point you towards Rehabilitation of the Spine: A Practitioner’s Manual: Chapter 14 (this is considered the rehab bible by many physical medicine practitioners).
Treatment
Despite all of the confusion and all of the controversy, there are established guidelines for treatment of sciatica. This is my synopsis:
- Treating sciatica with medicine like muscle relaxers, anti-inflammatories, and pain killers is an appropriate intervention on a preferably temporary basis, but it should be understood that medicine does not address the underlying biomechanical dysfunction. Though, it can help to ease the symptoms while the body heals. I myself sometimes refer patients to medical doctors when symptoms are severe enough. Medicines that calm pain and muscle spasm actually help me to do my work as it decreases guarding allowing me to more easily manipulate and rehab my patients. I like to communicate with my patient’s primary care physician anyways, so we can be on the same page. Cooperation is important.
- Sciatica that does not self-resolve in a few weeks should first be treated conservatively. This includes things like manipulation, physiotherapies, rehab, massage, and manual therapies. I also perform a few injections with naturopathic/homeopathic medicines here in the office as I am certified and licensed to do so.
- If conservative therapy has absolutely no effect by two weeks, then I either change the plan, or possibly seek advanced imaging like X-ray or MRI. I do not allow patients to remain without progress in the clinic. If I really can’t get results, I refer out to a different specialist.
- If conservative treatment is initially effective, but we reach a plateau after a time, then advanced imaging is warranted if not previously obtained along with a possible referral for surgical consult. Though sometimes it is necessary for insurance purposes to first refer back to the patient’s primary care physician. This is another reason it is good to be in communication with the patient’s PCP.
- If I do refer out for surgery, the doctors usually only perform surgery after it is established that steroid injections or other less invasive medical intervention also fails.
- I prefer that patients and their surgeons consider less invasive surgeries that do not involve the use of hardware in the spine. Long term outcomes tend to be poor for these more invasive surgeries (though sometimes there is no other option). The addition of hardware means that the involved sections of the spine are immobilized resulting in stress of the vertebra above and below, and often lead to further surgery of those sections down the road.
- If surgery fails, then patients are typically referred to pain management clinics.
The healthcare community is well-aware of the opioid epidemic and nobody wants the final outcome to be simply mitigating symptoms with pain killers and other medications. The point is that conservative therapy should come first. If this fails, then more aggressive medical measures should be taken.
If you think you might have sciatica, please make an appointment with our chiropractor in Tulsa today.
Scoliosis
Definition
When looking at the spine from the front or back, it should appear straight up and down. While looking from the side, there should be a slight curve forwards in two places: the neck and the low back. This is the normal shape of the spine. Scoliosis is an abnormal curvature of the spine from side to side, and is often accompanied by a rotational or twisting component. The curvature can be a C-shape or an S-shape. A scoliosis is described by the direction it points and its rotational component. For example, a dextrorotary lumbar scoliosis indicates a curvature to the right with rotation in the lumbar spine.
Signs & Symptoms
It is typically a parent, teacher, coach, or even class mate that first notices the signs of scoliosis. It may be noted that one shoulder appears lower than the other or protrude further than the other. The back may appear to twist or lean. The head may appear to be displaced to one side. One hip may appear to be cocked forward or to the side. The rib cage may appear to stick out on one side. One leg may appear to be longer. These general asymmetries are usually the first signs. In addition, the person may have symptoms and complain of pain or spasm in the back, neck, shoulders, or hips. Note that some scoliosis patients do not have spine pain or rib pain at all, only visual asymmetries.
Causes
Nobody knows exactly what causes scoliosis in the wide majority of cases. Hence most scolioses are idiopathic in nature. If the scoliosis is due to some other process, then it is called a secondary scoliosis. Most cases of secondary scoliosis are due to pathology of the nerves, muscles, connective tissue, or some irregularity in the vertebral bones or discs. Other pathologies like tumors or infections or degenerative changes that warp the shape of the vertebra or cause a person to lean away from the side of pain can also cause a scoliosis. If a scoliosis is due to a permanent and fixed abnormality in the shape of the vertebra, this is termed a structural scoliosis. On the other hand, if the scoliosis is not permanent and the spine can actually straighten with certain positions, then it is a functional scoliosis. A functional scoliosis can be due to a short leg or muscle spasm or muscle imbalance. A simple test called Adam’s Test can determine the difference between a structural and functional scoliosis. Names are also given depending on when the scoliosis begins. If a person is born with an abnormality such as a misshapen vertebra, then the term congenital scoliosis is used. If it is discovered from birth to 3 years old, we use the term infantile. From 3-10 years old the term juvenile is used, from 10-18 we use the term adolescent, and in adults we logically use the term adult onset scoliosis.
Risk Factors
Most scoliosis develops between the ages of 10-20 and females are often more affected than males. There is a genetic component as the risk of developing a scoliosis is higher in those individuals who have one parent with scoliosis and much higher in those with two parents. But, as with almost all diseases, environmental factors play a role as well. The earlier the onset of scoliosis, the worse the prognosis. Scoliosis tends to worsen over time and the curvature is at risk of increasing as the spine grows.
Treatment
Treatment of scoliosis is tricky. First off, a side to side curvature in the spine has to be over 10 degrees before it is considered a true scoliosis. This is because almost everybody has some amount of curvature in the thoracic spine to accommodate the space for the heart. If the curvature is over 10 degrees and especially if the patient is younger than 18, then the curvature needs to be monitored over time by X-ray: typically every 3-6 months depending on age. Scoliosis can be treated with manipulation, massage, stretches, and exercises: all in an attempt to straighten the spine, or at least stop the curvature from increasing. Scoliosis can also be due to a problem with anatomical or functional leg length causing the pelvis and spine to tilt, therefore an assessment of the lower extremity must be performed. If the problem is due to abnormal biomechanics of the lower extremity, then the use of orthotics, lifts, or functional rehab to correct the dysfunction should be employed. Braces can be used in more severe curves. If the curve becomes very severe measuring 50 degrees or more, a surgical consult is warranted because at this stage the heart and lungs can begin to be affected.
Prognosis
Generally, the prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are larger curves carry a higher risk of progression than smaller curves, thoracic curves carry a higher risk of progression than lumbar or thoracolumbar curves, and double curves carry a higher risk of progression than single curves. In addition, patients not having yet reached skeletal maturity have a higher likelihood of progression. If you think you have scoliosis, please visit our Tulsa Chiropractor today.
Neck Pain
The neck (cervical spine) runs from the base of the skull down to the top of the shoulders. There are numerous muscles and soft tissues that support the neck. This is necessary in order to carry the weight of the head which is surprisingly heavy: about the weight of a bowling ball. The individual vertebra allow for quite a bit of mobility in this region and must have strong support from muscles and the shock absorbing discs between each vertebra. Because of the weight of the head, the neck is vulnerable to injury. This can happen during a motor vehicle accident and cause whiplash. It can happen during a sports injury when then neck our shoulder is jarred or impacted strongly. It can even happen slowly over time without you realizing it while using devices such as cell phones.
Neck pain can be caused by a variety of different conditions that require correct diagnosis and distinct treatment. Most causes of neck pain are musculoskeletal in nature and are not life-threatening. Causes of neck pain that are serious include: cardiovascular pathology, cancer/tumor, infection, stenosis, auto immune disease, fracture, and dislocation. These causes of neck pain require medical intervention and could involve surgery. Luckily, most of the time neck pain is a biomechanical problem that can be treated conservatively within our clinic. More common conditions include: vertebral disc issues, facet joint arthritis, muscle problems, ligament damage, and postural abnormalities. Let’s talk about a few common problems we see at the clinic.
Postural Syndrome
Also referred to now as text neck, this is typical of people who use electronic devices like a tablet, computer, or cellphone constantly throughout the day. As we sit and look at our screens, our heads tend to lean forward or down creating a change in the shape of our spines and putting stress on the muscles in the neck and upper back area. This tends to become worse over time. The further forward you bring your head, the heavier your head becomes relatively and the harder the muscles have to work. With time, this can produce stress not only in the muscles, but in the discs and ligaments as well. This makes you more prone to arthritis, muscle knots, and spinal misalignment.
Degeneration
Degenerative disc/joint disease is the general term used for deterioration of the discs and joints in the neck. Some may call it arthritis or arthrosis. The facet joints and the discs are warn out over time, usually because of misalignment and bad mechanics…like driving a car with a crooked wheel. The structures are stressed and damaged the more you use it in the misaligned position. Eventually this leads to bone spurs, disc space narrowing, herniations, and possibly pinched nerves.
Whiplash
a combination of strain of the muscles, sprain of the ligaments, and damage to the discs of the cervical spine that occurs during a car wreck. It is typically due to the action of the head bouncing back and force rapidly on impact. The problem can be minor and involve mostly muscle tears, or it could be more serious with ruptured discs and neurological symptoms.
Any one of these pathologies can result in pain, spasm, stiffness, weakness, and even numbness or shooting pain into the arms/hands. You will want to seek out a physician, like a Chiropractor, who can correctly examine and diagnose your neck pain to make sure that you get the right care.
Mid Back Pain
While there are many reasons for mid-back pain (thoracic pain), the more common reasons tend to be musculoskeletal in nature. Patients suffering from mid-back pain typically have dysfunction in the thoracic vertebra and ribs. The most common complaint I hear is pain between the shoulder blades. There are some other more serious causes of mid back pain. For instance, gallbladder and kidney pathology can refer to this area. Infection or cancer can manifest itself as midback pain, but this is very rare. It’s important to let a physician like a Chiropractor properly diagnose your issue to make sure you receive the proper care. Below are some common problems.
Postural Syndrome:
Problems in the midback are typically related to bad posture. Rounding the upper back, carrying the head forward, and rolling the shoulders forward as we sit and work or use of our electronic devices can cause stress to our bodies that adds up over time. The typical result is spasm from overuse of the muscles. If you experience a constant soreness, tightness, and achiness, then this is probably happening to you.
Intercostal Pain:
If you feel pain when taking a breath that shoots through your chest or wraps around your side, then you may have some rib dysfunction. The muscles and/or nerves between the ribs can be irritated from a misalignment of the ribs in relation to each other or as they attach to the thoracic spine. This is the classic “Rib Out” scenario. It’s usually a fairly easy fix, but in some cases , it can be stubborn or return frequently. These cases require more treatment and rehab to retain the corrected position.
Facet Syndrome
An irritation of the joints of the back of the spine. Because of the shape of the spine in the mid back, the joints tend to be stretched rather than compressed and so the irritation is typically in the capsules/ligaments surrounding the joints instead of the surface where the bones meet. This pain tends to be sharp and local and maybe about the size of a marble or golf ball.
Disc Pathology
It is rare to have disc pathology in the midback (thoracic spine) because of the support from the ribs, but it does occur. Scheuermann’s disease is a good example. This is an issue with rounding of the midback and typically involves compression of the discs at the front of the spine. It can be very painful. Other causes exist such as acute trauma like a fall from substantial height or auto accident or sports injury.
Of course, it takes a physician to properly diagnose your problem and get you the correct treatment, so please call today if these symptoms sound familiar.
Rib Pain
Rib pain can either be one of the easiest problems to fix for a Chiropractor or one of the hardest. Sometimes an injury or awkward movement (like a sneeze while hunching over) can throw a rib right out of place. A little muscle work and the correct adjustment may be all you need. This is the old “one and done” situation. Other times, postural problems or scapular dysfunction can cause issues with the muscles in the back that create more chronic (long term) rib pathology. In this case, the underlying dysfunction will need to be addressed. Otherwise, the rib problem will likely return or possibly never really resolve. Let’s take a look at the area that most often causes a rib problem.
There are many layers of muscles across the back, all of which can be relevant to rib pain. The ribs connect to the spine in the back. The levator costae muscles, attach to the ribs. Their job is to help elevate those ribs during breathing and other motions. If there is dysfunction or misalignment in the spine, then these muscles will have to work overtime, spasm, and can become tight and tender. When this occurs, the constant tension can pull that rib head out of alignment. This leads to stress, inflammation, and further spasm & tenderness of the surrounding musculature. Now every time you take a breath, especially a deep one, the pain is intense and can even travel in the rib cage around to the side or front. Labored and painful breathing is a sign of rib pain, but can also mean something more serious.
Treatment for chronic rib dysfunction will usually include correcting misalignments of the spine, manipulation of the soft tissue, therapies targeting muscle spasms and pain, correcting postural abnormalities, correcting scapular dysfunction, and of course… manipulation of the rib itself.
Once in a while, a patient may also present with dysfunction in the sternum and costal cartilages. This is a problem with the front of the chest. In this area, there aren’t technically any ribs, but rib cartilage. The ribs stop being bone in the front part of the chest and instead become cartilaginous before they connect to the sternum. When a patient has irritation in the front of the chest, the diagnosis is typically costochondritis. This literally means inflammation of the rib cartilage. A person who experiences these problems often has forward rolled shoulders and forward head carriage. This is really a completely different presentation than rib pain in the back, though the two can be related. This is covered in more detail in the section below.
Chest pain of any sort can indicate a very serious problem. So, if you are experiencing sudden chest pain, it is not a good idea to wait. The issue may warrant emergency procedures, especially if you have any difficulty breathing, impending sense of doom, a feeling of significant pressure in your chest, sweating, fever, vomiting, cough, recent cold, or rapid pulse. A trip to the emergency room may be life-saving. However, if this is localized pain without any accompanying symptoms, and it has been going on for several weeks or more, it is not likely an emergency situation.
If it is not an emergency situation, or if a medical physician has already cleared you of any life-threatening conditions, your next call should be to a Chiropractic Physician.
Costochondritis
Costochondritis is the inflammation and irritation of the ribs as they insert into the sternum causing rib pain. In this front region of the chest, the ribs aren’t actually bone. The ribs here are cartilage as they connect to the sternum bone. This is where the term costochondritis comes from: Costo- indicating ribs, Chondro- meaning cartilage, and -itis signifying inflammation. These joints are solid and fibrous and have little room for motion. Hence any misalignment is not well tolerated.
The problem usually occurs on one side of the sternum more than the other, but can occur on both sides. You may notice increased rib pain with movement like bending forward or backwards or turning the body. You may have more pain associated with your breath like deep inhalation or coughing or sneezing. It is also common to note more pain while laying down as this puts pressure on your ribs stressing the connection at the sternum. There may also be accompanying spine pain in the region between the shoulder blades.
It is not officially established how or why this inflammation occurs, but it is a musculoskeletal issue so it likely boils down to position and movement. In my clinical experience, it is usually associated with misalignment of the thoracic spine and rib cage. The ribs attach to the vertebra in the back, wrap around the body becoming cartilaginous in front, and insert into the sternum forming what we refer to as the rib cage. The ribs themselves are fairly mobile in the back where they attach to the spine to accommodate for bending and rotation that occurs in the thoracic spine. The ribs must also have mobility to allow for respiration. They have a bucket-handle-like movement upwards when inhaling. As you can imagine, with all of the motion that occurs in the spine and ribs, you would need the connection in front to also be fairly mobile. This is why the front of the ribs consist of flexible interlinking cartilage. The softer cartilage allows for the mobility of the ribs for movement and respiration. But, the insertion of the ribs to the sternum is solid and relatively immobile.
A problem can occur when the rib cage changes shape or mobility due to postural changes or injury. The movement of the ribs must still occur, but in it’s dysfunctional state begins to overload the fibrous connection at the sternum. Instead of mobility occurring where it should at the spine, between the ribs, and at the cartilage, now more movement occurs at the front in those fibrous connections to the sternum. This often results in misalignment and stress at this connection causing pain and inflammation.
The first course of treatment is rest, ice and anti-inflammatory medications. However, it is very common for these conservative measures to fail because the underlying mechanics are still a problem. In these cases, it is necessary for a Chiropractor to evaluate the thoracic spine and rib cage to set things right again. By correcting posture, realigning the thoracic spine, and manipulating the individual ribs, the problem can usually be remedied. It is common for the problem to return though. For this reason we may have to consider rehab to retrain the muscles in order to retain the proper position and movement of the thoracic spine and rib cage. Interestingly enough, I find that it is usually best to leave alone the painful area at the sternum. This is because this area is irritated from too much movement and additional movement typically only makes things worse. It is much better to approach the problem in the thoracic spine and other parts of the ribs to allow the fibrous connections in front to heal. In certain circumstances, the ribs do need to be manipulated in front at the sternum. This can be quite uncomfortable, so these maneuvers are reserved for when other methods fail.
Low Back Pain
Many patients present to our clinic every week with low back pain. In fact, this is the most common reason to visit our Tulsa Chiropractor. Although Chiropractic Physicians treat more than just back pain, many patients initially visit chiropractors looking for relief from this pervasive condition. In fact, 31 million Americans experience low-back pain at any given time.
Facts About Back Pain
- Low back pain is the single leading cause of disability worldwide, according to the Global Burden of Disease 2010.
- Back pain is one of the most common reasons for missed work. In fact, back pain is the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.
- One-half of all working Americans admit to having back pain symptoms each year.
- Experts estimate that as much as 80% of the population will experience a back problem at some time in their lives.
- Most cases of back pain are mechanical or non-organic—meaning they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.
- Americans spend at least $50 billion each year on back pain—and that’s just for the more easily identified costs.
What Causes Back Pain?
The back is a complicated structure of bones, joints, discs, ligaments and muscles. You can sprain ligaments, strain muscles, rupture disks, and irritate joints, all of which can lead to back pain. While sports injuries or auto accidents can cause back pain, sometimes the simplest of movements (like picking up a pencil from the floor) can have painful results when there is an underlying issue. In addition, arthritis, poor posture, obesity, and psychological stress can cause or complicate back pain. Back pain can also directly result from disease of the internal organs, such as kidney stones, kidney infections, blood clots, or bone loss.
Common Causes of Low Back Pain
The cause of most back pain is biomechanical in nature. In other words, it is a dysfunction in position and movement. The dysfunction leads to excessive stress on the structures of the spine and can cause increasingly severe damage over time. We call this degeneration (Degenerative Disc Disease & Degenerative Joint Disease). As the joints wear out, the muscles tighten & spasm, the discs are damaged, the ligaments calcify creating bone spurs, arthritis sets in, and nerves start to be compressed. It is a process that occurs little by little. It weakens the spine making it vulnerable to acute injury such as disc herniations. If left unchecked, the bones themselves change shape and a condition called stenosis can occur. This is when the spaces that the nerves pass through become narrowed producing pressure on these nerves and can result in all kinds of nasty neurological symptoms.
Common Diagnoses Include:
- Disc Pathology (bulge/herniation)
- Facet Irritation
- Sacroiliac Joint Dysfunction
- Arthritis & Degeneration (Spondylosis)
- Sciatica
- Stenosis
Spinal Manipulation as a Treatment for Back Problems
With today’s growing emphasis on quality care, clinical outcomes and cost effectiveness, spinal manipulation is receiving increased attention. Spinal manipulation is a safe and effective spine pain treatment. It reduces pain (decreasing the need for medication in some cases), rapidly advances physical therapy, and requires very few passive forms of treatment, such as bed rest. In fact, after an extensive study of all available care for low back problems, the federal Agency for Health Care Policy and Research (Under the US Dept. of Health and Human Services) recommended that low back pain sufferers choose the most conservative care first. And it recommended spinal manipulation as the only safe and effective, drugless form of initial professional treatment for acute low back problems in adults!
A well respected review of the evidence in the Annals of Internal Medicine pointed to Chiropractic care as one of the major nonpharmacologic therapies considered effective for acute and chronic low back pain. More recently, research has shown that there is strong evidence that spinal manipulation for back pain is just as effective as a combination of medical care and exercise. An article published in the Journal of the American Medical Association in 2013 also suggested chiropractic care as an option for people suffering from low back pain and noted that surgery is usually not needed and should only be tried if other therapies fail.
The Opioid Epidemic
The epidemic of prescription opioid overuse and abuse has also led many health groups to reconsider the value of a conservative approach to common conditions such as low-back pain. The American College of Physicians (ACP), the largest medical-specialty society in the world, updated its low-back pain treatment guidelines in 2017 to support a conservative approach to care. Published in the Annals of Internal Medicine and based on a review of randomized controlled trials and observational studies, the ACP guidelines cite heat therapy, massage, acupuncture and spinal manipulation (a centerpiece of chiropractic care) as possible options for non-invasive, non-drug therapies for low-back pain. The guidelines state that only when such treatments provide little or no relief should patients move on to medicines such as ibuprofen or muscle relaxants, which research indicates have limited pain-relief effectiveness and carry risk of negative side-effects. According to the ACP, prescription opioids should be a last resort for those suffering from low back pain, as the risk of addiction and overdose may outweigh the benefits.
Tips to Prevent Back Pain
- Get checked by a Chiropractic Physician even in the absence of back pain.
- Maintain a healthy diet and weight.
- Remain active—under the supervision of your Chiropractic Physician.
- Avoid prolonged inactivity or bed rest.
- Warm up then stretch before exercising or physical activities, such as gardening.
- Maintain proper posture and form.
- Wear comfortable, low-heeled shoes.
- Sleep on a mattress of medium firmness to minimize any curve in your spine.
- Lift with your knees, keep the object close to your body, and do not twist when lifting.
- Quit smoking: which results in oxygen, and nutrient deprivation to spinal tissues.
- Work with your Chiropractor to ensure that your workstation is ergonomically correct.
Disc Problems/Herniated Disc
The most common reason to visit our Tulsa Chiropractor is spine pain, and the most common reason for spinal pain is related to problems with the disc. I would like to take some time to explain the basics about these intervertebral discs. Be sure to look at the pictures above for reference.
There is a disc between each vertebral bone in the spine. The disc is basically a shock absorber. It is very much like one of those gel inserts you put in your shoe. The outside consists of rings of rubbery material (the annulus) and the inside is a gelatinous liquid (the nucleus). The design provides for mobility and shock absorption that reduces stress to the spine. However, if enough stress occurs to the disc, it can start to cause damage usually resulting in a tear in the annulus.
There are several patterns of disc tears. Tears can occur through the annulus or between the fibers of the annulus. If the tear is bad enough, the nucleus can begin to migrate from the center position into the tear which causes an abnormal shape of the disc. This abnormal shape interferes with the movement of the spine. You may notice painful restricted motion. You may notice spasm or a shifting/leaning of your spine. When the shape of the disc is distorted, but the nucleus has not yet migrated outside of the confines of the disc, we call it a Disc Bulge.
This Problem can continue to worsen. At the point where the nucleus travels past the outermost layer of the disc, it becomes a Herniation. There are a variety of other terms used to describe differing shapes and phenomenon that can occur with herniations including: protrusions, prolapses, and sequestrations, but we won’t get into those here. So, the take home point is that damage to the disc over time will create these disc bulges and herniations that result in a change in shape and position of the disc material. This in and of itself is painful enough, but there is an even more significant problem that can occur. It can lead to compression of the nerves in the spine!
The spinal cord goes from the brain down through the center of the vertebra and exits the spine right next to the disc in branches called nerve roots. From the spine, these nerves travel to different parts of the body to control sensation, muscle function, and some other things. This system allows your brain to communicate with your body. For example, the nerves that control your legs begin in the brain, travel down your spine, exit out of your low back, then go to your legs. If a disc herniation is compressing these nerves, it interferes with the signal. This can create pain, numbness, tingling, spasm or weakness in your legs: Boom…sciatica!
Disc herniations can compress nerves of the spine in two main ways: nerve root compression, and central cord compression. The herniation can poke out to the side contacting the nerve root, or it can herniate centrally putting pressure on the cord. Pressure on the cord is by far the worst scenario. This can even be life threatening if it occurs in the right place. It could also cause paralysis, loss of bowl or bladder control, and a variety of other terrible issues. This can sometimes be surgical emergency. Thankfully, this is not the most common form. What we usually see is that the disc material herniates out to the side and contacts the nerve root rather than the cord. This can happen in the neck causing pain to shoot out into the shoulder, arms, or hands along with weakness and numbness or spasm of the muscles. It can happen in the low back as well causing the same sort of thing to happen in the buttocks and legs. This is actually the cause of most cases of sciatica.
As the process of disc injury continues, the disc begins to whither and desiccate causing loss of disc space. This creates another situation that we call degenerative disc disease (DDD), which can also lead to narrowing of the space that the nerve needs to exit the spine. If this space is narrowed to the point that it compresses the nerve, we call this stenosis, and it can cause the same sort of nerve problems that a herniation can create.
So, what can a Chiropractor do to help you with your disc issue? A Chiropractor’s job-first and foremost- is to identify which type of disc issue is occurring, and determine whether physical medicine is safe or if you will need surgery. If it’s safe, then we can correct the position of your spine with a variety of different treatments. This will take the stress off of the disc and stop the process of the disc herniation from continuing.
Once the position is corrected, the disc can have a chance to heal especially with the right nutrition. A Chiropractor will usually perform spinal manipulation to correct the position and movement in your spine. This typically brings a lot of relief. I like to use electro-muscle stimulation to calm down the muscles and reduce pain either locally or down the affected limb. Additionally, traction or decompression can be used to take the pressure off of the disc and centralize the nucleus to reduce the herniation. Once the pain is under control, I use progressive rehab techniques to train the muscles of the body to hold the spine in the correct position. This step is important to stabilize the joint so the problem doesn’t just come back the next time you bend over to pick up a pencil.
Sciatica
Signs & Symptoms
If you have experienced low back pain with shooting pain down your the back or side of your leg, then it just might be sciatica. Other symptoms include numbness, tingling, altered sensation, and weakness. Usually one leg is affected, but it is possible to have both legs involved. If both legs are involved this can be a more serious sign (cauda equina syndrome), especially if there is loss of bowel/bladder/sexual function or loss of sensation of the inside of the thighs. Sciatica is not really a specific diagnosis and can have a variety of causes. You might also call sciatica a “pinched nerve”. Where the nerve is being pinched and what is doing the pinching is more complicated. As you might know, the different nerves in your low back go to different places in your legs. The affected area of the leg depends on which nerves are being damaged. The middle nerves of the lumbar spine tend to affect the front of the leg, lower nerves of the lumbar spine tend to affect the side of the leg, while nerves of the upper sacral spine tend to affect the back of the legs. Another sign of sciatica is that symptoms travel below the knee. This indicates a truly neurologic pathology that has a high risk of chronicity. I want to mention here that the term sciatica is derived from the sciatic nerve, but sciatica is often used simply to refer to spine pain or leg pain. This can sometimes cause confusion. For the sake of this article, I will include several conditions which can present with these symptoms, but are not actually sciatica.
Disc Pathology
Vertebral discs can change shape or even herniate. A disc bulge is a change in the shape of the disc. A herniation is when the gel-like center of the disc protrudes out of the normal confines of the disc. These changes in the disc can end up putting pressure on the nerves of the spine. The disc can herniate left, right, or center. Down in the lumbar region a central disc herniation can lead to a condition called Cauda Equina Syndrome that is serious and requires immediate surgery in order to prevent permanent loss of bowel/bladder/sexual dysfunction. A herniation to the left or right will likely put pressure on the nerve root. The symptoms depend on the amount of irritation/ pressure and the level of the disc. Disc pathology is the most common reason for sciatica and is considered the cause in the classic definition of true sciatica.
Spondylosis and Spinal Stenosis
Degenerative joint disease, degenerative disc disease, and osteoarthritis together are lumped into the term spondylosis when they occur in the spine. Spinal Stenosis is the term used to indicate narrowing of the passageway of the nerves. Spondylosis can lead to spinal stenosis. The loss of disc space narrows the diameter of these nerve passageways from top to bottom, and bone spurs can narrow the passage ways from front to back or side to side. Disc and bone changes can also narrow the diameter of the spinal canal (where the cord and several nerve roots exist) causing Cauda Equina-like symptoms. Additionally, people are sometimes born with already narrow nerve passage ways and this puts them at even greater risk of developing sciatica and other related neuropathies. Of course, anything that changes the shape, alignment in the spine can lead to stenosis such as pregnancy, Scheuermann’s disease, or scoliosis.
Other Space-Occupying Lesions and Pathology
Some more serious reasons for sciatica are tumors, fractures and infections. These situations warrant immediate medical intervention. A tumor grows and occupies space that can put pressure on nerves. Fractures may lead to bone fragments putting pressure on nerves and/or cause instability of the spine that results in nerve compression. An infection can also create changes and inflammation in the spine that can lead to these sorts of neuropathies. These pathologies are the first things that should be ruled out during an initial examination.
Piriformis Syndrome
There is a particular muscle in the buttocks called the piriformis. The sciatic nerve runs right under this muscle. A tightening or contracture or over development of this muscle (usually compensation for gluteal weakness) can put pressure on the sciatic nerve. In a small portion of the population, the sciatic nerve travels either partially or entirely through the piriformis muscle. If the piriformis is chronically contracted, then it can strangle the nerve producing sciatica. However, piriformis syndrome is traditionally not considered true sciatica.
Femoral Neuropathy
While true sciatica tends to occur from pressure of the nerves in the lower lumbar spine, nerves can also be irritated in the same way in the upper part of the lumbar spine. When this occurs, the fibers of the femoral nerves can be involved instead of the sciatic nerves. In these cases, pain is typically felt in the front of the thigh instead of the back/side of thigh. The underlying causes are pretty much the same as sciatica, just in a different place affecting a different group of nerves.
Meralgia Paresthetica
This is a condition where the lateral femoral cutaneous nerve (a nerve that runs down the outer thigh) can be compressed or injured. This has been nicknamed the “skinny pants syndrome” because tight fitting pants or belt is the underlying cause (one of the reasons I recommend elastic/stretchy material). The nerve becomes entrapped around the front of the hip and groin region as the nerve passes from the pelvic area to the outer thigh. Motor vehicle accidents can also cause lesions of this nerve from contact of the seat belt. There are several other less common causes for compression and injury to this nerve. This condition is also not included in the classic definition of sciatica.
Iliotibial Band Syndrome and Trochanteric Bursitis
This is another biomechanical issue that can cause pain running down the leg with occasional neurological implications and can be associated with back pain. See the section on Hip Pain for more detail. There is a muscle called the tensor fascia latae (TFL). Tightening of the TFL can create excessive tension of a band of fibrous connective tissue that runs down the outside of the leg called the iliotibial band (ITB). This tension puts pressure against the trochanteric bursa which is located around the hip bone. This whole complex of problems is referred to as ITB syndrome and trochanteric bursitis and they usually occur altogether. Pain often starts in the hip and travels down the outer thigh to the knee. Muscle spasm, swelling, and general tension can lead to nerve compression occasionally. This makes the problem look like sciatica, but again, this is not true sciatica.
Herpes Zoster
Ever had chicken pox? This is caused by the varicella zoster virus. Like all other herpes viruses, it actually lives in your nerves imbedding itself into the DNA of the nerve cells. It is there forever. It is usually dormant but can become active again leading to herpes outbreaks. When chicken pox reactivates, it is called herpes zoster or commonly “shingles”. This typically happens to older adults but can happen in younger people too. Before the full rash appears, a person can have neurological symptoms including pain and numbness. If the affected nerve is in the low back and leg, then this virus can present just like sciatica, and so I’ve included this condition in this section.
General Kinetic Chain Dysfunction
In some cases, pain can appear to shoot down the leg with back pain not because of a pinched nerve, but because of a problem in the kinetic chain. A kinetic chain is the link between several consecutive joints and the muscles and other soft tissue involved in that linkage. It is a head-bone-is-connected-to-the-foot-bone situation. Here is an example: A patient has a “flat foot” that rolls inwards. When that foot rolls inwards, it causes the knee to also travel inwards. This drops the pelvis on that side. This causes the lumbar vertebra to tilt. Many muscles and ligaments are stressed because of these postural changes. The result is a chain of overstressed tissues usually producing a series of trigger points or tender points down the chain. This leads to pain in the back and the leg. Voilà!!! Kinetic chain dysfunction… not sciatica.
Further Considerations
As you can see, sciatica is pretty complicated. I haven’t listed all of the conditions that can cause low back pain with leg pain, but I’m guessing your head is already spinning. These different problems can look like true sciatica, but only a trained physician can correctly diagnose the real issue. Sometimes it is a serious problem that requires immediate medical attention. Sometimes it requires surgery. Sometimes surgical intervention will not fix anything. To compound the problem, studies have shown that MRIs are not as reliable as we once thought. Things like degenerative changes and disc herniations appear all the time in completely asymptomatic patients. The older we are, the more likely we are to have these findings on imaging, but that likelihood has very little association with the symptoms that we experience: it is simply a coincidental finding. Likewise, there are many people who experience what appears to be true sciatica upon clinical examination but have no findings on MRI or X-ray! For those of you who are interested in a reference, I can point you towards Rehabilitation of the Spine: A Practitioner’s Manual: Chapter 14 (this is considered the rehab bible by many physical medicine practitioners).
Treatment
Despite all of the confusion and all of the controversy, there are established guidelines for treatment of sciatica. This is my synopsis:
- Treating sciatica with medicine like muscle relaxers, anti-inflammatories, and pain killers is an appropriate intervention on a preferably temporary basis, but it should be understood that medicine does not address the underlying biomechanical dysfunction. Though, it can help to ease the symptoms while the body heals. I myself sometimes refer patients to medical doctors when symptoms are severe enough. Medicines that calm pain and muscle spasm actually help me to do my work as it decreases guarding allowing me to more easily manipulate and rehab my patients. I like to communicate with my patient’s primary care physician anyways, so we can be on the same page. Cooperation is important.
- Sciatica that does not self-resolve in a few weeks should first be treated conservatively. This includes things like manipulation, physiotherapies, rehab, massage, and manual therapies. I also perform a few injections with naturopathic/homeopathic medicines here in the office as I am certified and licensed to do so.
- If conservative therapy has absolutely no effect by two weeks, then I either change the plan, or possibly seek advanced imaging like X-ray or MRI. I do not allow patients to remain without progress in the clinic. If I really can’t get results, I refer out to a different specialist.
- If conservative treatment is initially effective, but we reach a plateau after a time, then advanced imaging is warranted if not previously obtained along with a possible referral for surgical consult. Though sometimes it is necessary for insurance purposes to first refer back to the patient’s primary care physician. This is another reason it is good to be in communication with the patient’s PCP.
- If I do refer out for surgery, the doctors usually only perform surgery after it is established that steroid injections or other less invasive medical intervention also fails.
- I prefer that patients and their surgeons consider less invasive surgeries that do not involve the use of hardware in the spine. Long term outcomes tend to be poor for these more invasive surgeries (though sometimes there is no other option). The addition of hardware means that the involved sections of the spine are immobilized resulting in stress of the vertebra above and below, and often lead to further surgery of those sections down the road.
- If surgery fails, then patients are typically referred to pain management clinics.
The healthcare community is well-aware of the opioid epidemic and nobody wants the final outcome to be simply mitigating symptoms with pain killers and other medications. The point is that conservative therapy should come first. If this fails, then more aggressive medical measures should be taken.
If you think you might have sciatica, please make an appointment with our chiropractor in Tulsa today.
Scoliosis
Definition
When looking at the spine from the front or back, it should appear straight up and down. While looking from the side, there should be a slight curve forwards in two places: the neck and the low back. This is the normal shape of the spine. Scoliosis is an abnormal curvature of the spine from side to side, and is often accompanied by a rotational or twisting component. The curvature can be a C-shape or an S-shape. A scoliosis is described by the direction it points and its rotational component. For example, a dextrorotary lumbar scoliosis indicates a curvature to the right with rotation in the lumbar spine.
Signs & Symptoms
It is typically a parent, teacher, coach, or even class mate that first notices the signs of scoliosis. It may be noted that one shoulder appears lower than the other or protrude further than the other. The back may appear to twist or lean. The head may appear to be displaced to one side. One hip may appear to be cocked forward or to the side. The rib cage may appear to stick out on one side. One leg may appear to be longer. These general asymmetries are usually the first signs. In addition, the person may have symptoms and complain of pain or spasm in the back, neck, shoulders, or hips. Note that some scoliosis patients do not have spine pain or rib pain at all, only visual asymmetries.
Causes
Nobody knows exactly what causes scoliosis in the wide majority of cases. Hence most scolioses are idiopathic in nature. If the scoliosis is due to some other process, then it is called a secondary scoliosis. Most cases of secondary scoliosis are due to pathology of the nerves, muscles, connective tissue, or some irregularity in the vertebral bones or discs. Other pathologies like tumors or infections or degenerative changes that warp the shape of the vertebra or cause a person to lean away from the side of pain can also cause a scoliosis. If a scoliosis is due to a permanent and fixed abnormality in the shape of the vertebra, this is termed a structural scoliosis. On the other hand, if the scoliosis is not permanent and the spine can actually straighten with certain positions, then it is a functional scoliosis. A functional scoliosis can be due to a short leg or muscle spasm or muscle imbalance. A simple test called Adam’s Test can determine the difference between a structural and functional scoliosis. Names are also given depending on when the scoliosis begins. If a person is born with an abnormality such as a misshapen vertebra, then the term congenital scoliosis is used. If it is discovered from birth to 3 years old, we use the term infantile. From 3-10 years old the term juvenile is used, from 10-18 we use the term adolescent, and in adults we logically use the term adult onset scoliosis.
Risk Factors
Most scoliosis develops between the ages of 10-20 and females are often more affected than males. There is a genetic component as the risk of developing a scoliosis is higher in those individuals who have one parent with scoliosis and much higher in those with two parents. But, as with almost all diseases, environmental factors play a role as well. The earlier the onset of scoliosis, the worse the prognosis. Scoliosis tends to worsen over time and the curvature is at risk of increasing as the spine grows.
Treatment
Treatment of scoliosis is tricky. First off, a side to side curvature in the spine has to be over 10 degrees before it is considered a true scoliosis. This is because almost everybody has some amount of curvature in the thoracic spine to accommodate the space for the heart. If the curvature is over 10 degrees and especially if the patient is younger than 18, then the curvature needs to be monitored over time by X-ray: typically every 3-6 months depending on age. Scoliosis can be treated with manipulation, massage, stretches, and exercises: all in an attempt to straighten the spine, or at least stop the curvature from increasing. Scoliosis can also be due to a problem with anatomical or functional leg length causing the pelvis and spine to tilt, therefore an assessment of the lower extremity must be performed. If the problem is due to abnormal biomechanics of the lower extremity, then the use of orthotics, lifts, or functional rehab to correct the dysfunction should be employed. Braces can be used in more severe curves. If the curve becomes very severe measuring 50 degrees or more, a surgical consult is warranted because at this stage the heart and lungs can begin to be affected.
Prognosis
Generally, the prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are larger curves carry a higher risk of progression than smaller curves, thoracic curves carry a higher risk of progression than lumbar or thoracolumbar curves, and double curves carry a higher risk of progression than single curves. In addition, patients not having yet reached skeletal maturity have a higher likelihood of progression. If you think you have scoliosis, please visit our Tulsa Chiropractor today.
Neck Pain
The neck (cervical spine) runs from the base of the skull down to the top of the shoulders. There are numerous muscles and soft tissues that support the neck. This is necessary in order to carry the weight of the head which is surprisingly heavy: about the weight of a bowling ball. The individual vertebra allow for quite a bit of mobility in this region and must have strong support from muscles and the shock absorbing discs between each vertebra. Because of the weight of the head, the neck is vulnerable to injury. This can happen during a motor vehicle accident and cause whiplash. It can happen during a sports injury when then neck our shoulder is jarred or impacted strongly. It can even happen slowly over time without you realizing it while using devices such as cell phones.
Neck pain can be caused by a variety of different conditions that require correct diagnosis and distinct treatment. Most causes of neck pain are musculoskeletal in nature and are not life-threatening. Causes of neck pain that are serious include: cardiovascular pathology, cancer/tumor, infection, stenosis, auto immune disease, fracture, and dislocation. These causes of neck pain require medical intervention and could involve surgery. Luckily, most of the time neck pain is a biomechanical problem that can be treated conservatively within our clinic. More common conditions include: vertebral disc issues, facet joint arthritis, muscle problems, ligament damage, and postural abnormalities. Let’s talk about a few common problems we see at the clinic.
Postural Syndrome
Also referred to now as text neck, this is typical of people who use electronic devices like a tablet, computer, or cellphone constantly throughout the day. As we sit and look at our screens, our heads tend to lean forward or down creating a change in the shape of our spines and putting stress on the muscles in the neck and upper back area. This tends to become worse over time. The further forward you bring your head, the heavier your head becomes relatively and the harder the muscles have to work. With time, this can produce stress not only in the muscles, but in the discs and ligaments as well. This makes you more prone to arthritis, muscle knots, and spinal misalignment.
Degeneration
Degenerative disc/joint disease is the general term used for deterioration of the discs and joints in the neck. Some may call it arthritis or arthrosis. The facet joints and the discs are warn out over time, usually because of misalignment and bad mechanics…like driving a car with a crooked wheel. The structures are stressed and damaged the more you use it in the misaligned position. Eventually this leads to bone spurs, disc space narrowing, herniations, and possibly pinched nerves.
Whiplash
a combination of strain of the muscles, sprain of the ligaments, and damage to the discs of the cervical spine that occurs during a car wreck. It is typically due to the action of the head bouncing back and force rapidly on impact. The problem can be minor and involve mostly muscle tears, or it could be more serious with ruptured discs and neurological symptoms.
Any one of these pathologies can result in pain, spasm, stiffness, weakness, and even numbness or shooting pain into the arms/hands. You will want to seek out a physician, like a Chiropractor, who can correctly examine and diagnose your neck pain to make sure that you get the right care.
Mid Back Pain
While there are many reasons for mid-back pain (thoracic pain), the more common reasons tend to be musculoskeletal in nature. Patients suffering from mid-back pain typically have dysfunction in the thoracic vertebra and ribs. The most common complaint I hear is pain between the shoulder blades. There are some other more serious causes of mid back pain. For instance, gallbladder and kidney pathology can refer to this area. Infection or cancer can manifest itself as midback pain, but this is very rare. It’s important to let a physician like a Chiropractor properly diagnose your issue to make sure you receive the proper care. Below are some common problems.
Postural Syndrome:
Problems in the midback are typically related to bad posture. Rounding the upper back, carrying the head forward, and rolling the shoulders forward as we sit and work or use of our electronic devices can cause stress to our bodies that adds up over time. The typical result is spasm from overuse of the muscles. If you experience a constant soreness, tightness, and achiness, then this is probably happening to you.
Intercostal Pain:
If you feel pain when taking a breath that shoots through your chest or wraps around your side, then you may have some rib dysfunction. The muscles and/or nerves between the ribs can be irritated from a misalignment of the ribs in relation to each other or as they attach to the thoracic spine. This is the classic “Rib Out” scenario. It’s usually a fairly easy fix, but in some cases , it can be stubborn or return frequently. These cases require more treatment and rehab to retain the corrected position.
Facet Syndrome
An irritation of the joints of the back of the spine. Because of the shape of the spine in the mid back, the joints tend to be stretched rather than compressed and so the irritation is typically in the capsules/ligaments surrounding the joints instead of the surface where the bones meet. This pain tends to be sharp and local and maybe about the size of a marble or golf ball.
Disc Pathology
It is rare to have disc pathology in the midback (thoracic spine) because of the support from the ribs, but it does occur. Scheuermann’s disease is a good example. This is an issue with rounding of the midback and typically involves compression of the discs at the front of the spine. It can be very painful. Other causes exist such as acute trauma like a fall from substantial height or auto accident or sports injury.
Of course, it takes a physician to properly diagnose your problem and get you the correct treatment, so please call today if these symptoms sound familiar.
Rib Pain
Rib pain can either be one of the easiest problems to fix for a Chiropractor or one of the hardest. Sometimes an injury or awkward movement (like a sneeze while hunching over) can throw a rib right out of place. A little muscle work and the correct adjustment may be all you need. This is the old “one and done” situation. Other times, postural problems or scapular dysfunction can cause issues with the muscles in the back that create more chronic (long term) rib pathology. In this case, the underlying dysfunction will need to be addressed. Otherwise, the rib problem will likely return or possibly never really resolve. Let’s take a look at the area that most often causes a rib problem.
There are many layers of muscles across the back, all of which can be relevant to rib pain. The ribs connect to the spine in the back. The levator costae muscles, attach to the ribs. Their job is to help elevate those ribs during breathing and other motions. If there is dysfunction or misalignment in the spine, then these muscles will have to work overtime, spasm, and can become tight and tender. When this occurs, the constant tension can pull that rib head out of alignment. This leads to stress, inflammation, and further spasm & tenderness of the surrounding musculature. Now every time you take a breath, especially a deep one, the pain is intense and can even travel in the rib cage around to the side or front. Labored and painful breathing is a sign of rib pain, but can also mean something more serious.
Treatment for chronic rib dysfunction will usually include correcting misalignments of the spine, manipulation of the soft tissue, therapies targeting muscle spasms and pain, correcting postural abnormalities, correcting scapular dysfunction, and of course… manipulation of the rib itself.
Once in a while, a patient may also present with dysfunction in the sternum and costal cartilages. This is a problem with the front of the chest. In this area, there aren’t technically any ribs, but rib cartilage. The ribs stop being bone in the front part of the chest and instead become cartilaginous before they connect to the sternum. When a patient has irritation in the front of the chest, the diagnosis is typically costochondritis. This literally means inflammation of the rib cartilage. A person who experiences these problems often has forward rolled shoulders and forward head carriage. This is really a completely different presentation than rib pain in the back, though the two can be related. This is covered in more detail in the section below.
Chest pain of any sort can indicate a very serious problem. So, if you are experiencing sudden chest pain, it is not a good idea to wait. The issue may warrant emergency procedures, especially if you have any difficulty breathing, impending sense of doom, a feeling of significant pressure in your chest, sweating, fever, vomiting, cough, recent cold, or rapid pulse. A trip to the emergency room may be life-saving. However, if this is localized pain without any accompanying symptoms, and it has been going on for several weeks or more, it is not likely an emergency situation.
If it is not an emergency situation, or if a medical physician has already cleared you of any life-threatening conditions, your next call should be to a Chiropractic Physician.
Costochondritis
Costochondritis is the inflammation and irritation of the ribs as they insert into the sternum causing rib pain. In this front region of the chest, the ribs aren’t actually bone. The ribs here are cartilage as they connect to the sternum bone. This is where the term costochondritis comes from: Costo- indicating ribs, Chondro- meaning cartilage, and -itis signifying inflammation. These joints are solid and fibrous and have little room for motion. Hence any misalignment is not well tolerated.
The problem usually occurs on one side of the sternum more than the other, but can occur on both sides. You may notice increased rib pain with movement like bending forward or backwards or turning the body. You may have more pain associated with your breath like deep inhalation or coughing or sneezing. It is also common to note more pain while laying down as this puts pressure on your ribs stressing the connection at the sternum. There may also be accompanying spine pain in the region between the shoulder blades.
It is not officially established how or why this inflammation occurs, but it is a musculoskeletal issue so it likely boils down to position and movement. In my clinical experience, it is usually associated with misalignment of the thoracic spine and rib cage. The ribs attach to the vertebra in the back, wrap around the body becoming cartilaginous in front, and insert into the sternum forming what we refer to as the rib cage. The ribs themselves are fairly mobile in the back where they attach to the spine to accommodate for bending and rotation that occurs in the thoracic spine. The ribs must also have mobility to allow for respiration. They have a bucket-handle-like movement upwards when inhaling. As you can imagine, with all of the motion that occurs in the spine and ribs, you would need the connection in front to also be fairly mobile. This is why the front of the ribs consist of flexible interlinking cartilage. The softer cartilage allows for the mobility of the ribs for movement and respiration. But, the insertion of the ribs to the sternum is solid and relatively immobile.
A problem can occur when the rib cage changes shape or mobility due to postural changes or injury. The movement of the ribs must still occur, but in it’s dysfunctional state begins to overload the fibrous connection at the sternum. Instead of mobility occurring where it should at the spine, between the ribs, and at the cartilage, now more movement occurs at the front in those fibrous connections to the sternum. This often results in misalignment and stress at this connection causing pain and inflammation.
The first course of treatment is rest, ice and anti-inflammatory medications. However, it is very common for these conservative measures to fail because the underlying mechanics are still a problem. In these cases, it is necessary for a Chiropractor to evaluate the thoracic spine and rib cage to set things right again. By correcting posture, realigning the thoracic spine, and manipulating the individual ribs, the problem can usually be remedied. It is common for the problem to return though. For this reason we may have to consider rehab to retrain the muscles in order to retain the proper position and movement of the thoracic spine and rib cage. Interestingly enough, I find that it is usually best to leave alone the painful area at the sternum. This is because this area is irritated from too much movement and additional movement typically only makes things worse. It is much better to approach the problem in the thoracic spine and other parts of the ribs to allow the fibrous connections in front to heal. In certain circumstances, the ribs do need to be manipulated in front at the sternum. This can be quite uncomfortable, so these maneuvers are reserved for when other methods fail.