Why I Never Diagnose My Patients with Sciatica

I want to write an article about sciatica, because there is a lot, I mean, A LOT of confusion around what this word means in the minds of patients and health practitioners alike.

It’s a word that is often thrown around and is often mistakenly seen as synonymous with low back pain, or buttock pain; so much so that very often patients come to my clinic thinking that they have sciatica. And 100% of the time I diagnose them with something else.

How is that possible? Is it ever sciatica? For me, no. It never is, simply because the word sciatica does not actually describe a specific medical condition…

So what does sciatica actually mean? Historically the term is defined as a lower limb pain with or without neurological symptoms, which stems from the nerve roots of the lumbar and sacral spine.

To understand this, let’s do a bit of anatomy.

Here is a drawing of a portion of the lumbar vertebrae, which form the bottom third of the spine. The yellow lines coming out from the vertebrae represent what we call the nerve roots, which originate from the spinal cord (encased inside the vertebrae). The nerve roots split and combine to form various nerves which travel all the way down our legs, allowing us to a) control our muscles and b) feel sensations in our legs. When a nerve root is irritated, it results in pain felt in the area of the leg served by the nerves which originate from it. In a certain scenarios, it can also alter sensation in those areas of the leg (like numbness or pins and needles), and alter strength and reflexes: These are neurological symptoms.

So sciatica refers to either of these scenarios in the lower limbs. Medically, these symptoms are referred to as radicular pain (when it’s just pain cause by nerve root irritation) and radiculopathy (when there are neurological symptoms as a result of nerve root irritation). So, technically, sciatica means either of those things, which isn’t very helpful. So much so that it is debated in the medical world whether or not the word sciatica should simply be eliminated from medical dictionaries, as the frequent use of the term both in some medical practices and in some research articles cause more confusion than needed. Personally, I’m all for it.

But more importantly, there are many things which can cause these symptoms of which we call “sciatica”, and THAT is what is important to diagnose in order to help it. So if a patient comes to the clinic with sciatica, as defined, the aim is to diagnose the underlying condition. This may be a disk budge, or a disk prolapse (commonly called ‘slipped disk’), vertebral degeneration (like osteoarthritis), or simple pain referral from an irritated joint… the list goes on. Hence the un-usefulness of the term ‘sciatica’.

On top of that, in my experience, 90% of people who believe they have sciatica use this word because they don’t know how else to describe their pain, and in those cases, their low back and leg pain is caused by something OTHER than nerve root irritation, so not sciatica to begin with. This again, will result in a wide variety of more specific diagnoses.

I hope this article has been helpful if you have been given the diagnosis of sciatica, or if you are experiencing low back and leg symptoms. Please share your stories, thoughts, questions and opinions in the comment section below.  

The anatomy of Pain: 3 common types of decompensation patterns

The anatomy of Pain: 3 common types of decompensation patterns

 

If you’ve read our last article, Decompensation Patterns: Or, How Pain In Your Neck Can Come From Your Big Toe; you’ll know that the body works as a unit. And sometimes, when a part of your body stops working as well as it should, it results in a cascade of compensation patterns which can result in pain.

 

Let's have a look at the anatomy of 3 common compensation patterns, how they develop, and how they can result in pain.

 

 

#1 The tricky talus

 

There are 33 joints in the human ankle and foot, the mechanics of which are very important, considering we spend half our time putting all our body weight through them.

 

Together they produce a very sophisticated but subtle twisting-rolling-springing motion which absorbs the shock with each foot step, distributes our weight up our legs and hips, and allows us to enjoy the benefits of good old bipedalism.

 

The talocrural joint is central to the ankle, and is located between the bottom end of the tibia and fibula (the shin bones) and the talus, a tarsal bone sitting on top of all the other bones which make up the foot. The talocrural joint is particularly prone to restrictions because the talus is the only bone in the whole body to not have any muscles attach to it, leaving it essentially floating between the bones that it forms joints with.

 

Restrictions in this joint can occur after a mild trauma, like a sprained ankle, even if it didn’t seem like a major injury at the time. If the talus is locked to one side, or doesn’t move as it normally would, other parts of the body will work differently. The slight natural twisting of the leg which should occur with each step will not be able to travel down the ankle as per usual, and the foot’s ability to act as a spring during walking will be compromised. In this sort of scenario, it is quite common to see knee pain develop on the side of the restriction. This is because the knee is now receiving more of the un-absorbed force from our body weigh due to the decreased ability of the foot and ankle to do so. The same can be said of the hips and lower back as unresolved restrictions and dysfunctions can travel up the body.

 

 

#2 The anonymous AC and SC

 

We don’t often talk about the two little joints on either end of the clavicle (collar bone): the sternoclavicular joint- or SC, connects the clavicle to the breastbone, and the acromioclavicular joint –AC, is found between the collarbone and the shoulder.

 

They aren’t very glamourous compared to the famous ball-and socket joint most people identify as the shoulder, called the glenohumeral joint,

 

but they do contribute a big portion of the movements we can do with our arms. Try reaching above your head without moving your collar bone…

 

 

Convinced? Truth be told, these two little joints are actually as big a part of the shoulder as the glenohumeral joint, and all three should always be considered as a whole.

FUN FACT: The SC is the only joint connecting the arm to the rest of the body. So, there’s a lot of pressure resting on this little guy’s shoulders! (See what I did there?)

If either of these two little joints become restricted (which could result from various reasons such as mild trauma, posture, muscular tightness, etc), the glenohumeral joint and surrounding structures will inevitably become strained from trying to compensate for the lack of movement. This can result in a susceptibility to injury or simply achiness around the glenohumeral joint after what should normally be considered low-level activities involving the shoulder.

 

 

#3 – The CD/OA paradigm

 

This is by far the most common decompensation pattern, and happens when the upper part of the spine becomes stiff and tight. The vertebra there often end up somewhat locked into a forward flexed position, usually because of prolonged periods spent in a slumped posture (which is why it is so common, as a lot of people spend vast amounts of times in front of desks and computers). This happens most noticeably at the cervico-dorsal junction, or CD- the joints between the vertebra of the upper back and the one at the base of the neck.

 

To balance out this forward bend, the neck has to extend backward, to keep our head facing up ahead, so we can keep staring at our computer screens.

 

And the place where most of the compensatory movement happens is at the level of the joint between the top vertebra in your neck and the base of the skull – called the occipitoatlantal joint (often referred to as the OA). This pattern overworks the neck muscles in all sorts of ways (and article of its own), which is often the cause of neck pain, and even headaches.

 

Please share your thoughts and questions with us in the comments' section below.

 

Grey Lynn Osteopathy does not claim ownership over any of the images used in the blog section.

Decompensation patterns:                         Or, how pain in your neck can come from your big toe

Decompensation patterns: Or, how pain in your neck can come from your big toe

The cool thing about being an osteopath (apart from the whole saving-humanity-from-bodily-torments thing) is discovering how the body works as an interconnected structure.

Imagine a tree, where the branches are bare. Now, attach elastic ropes between the branches, some tight, some loose, some short connections, and some longer ones. The body is much like this structure, made up of elastic elements (muscles) and more stiff elements (bones). If you pull on one elastic on our magical tree, you’ll see the whole tree move in a certain way. If you pull on one branch at the top, you may see branches on the other side move as well.

This is what we call tensegrity. The ability of a structure to move in an interconnected way, because it is made up of both elastic and stiff structures which transmit tensile forces across the whole structure.

And this is key.

 

Why?

You may say we are not trees, but when a particular part of our body moves differently, or a muscle is tighter, it does affect everything else, like in the tree metaphor. Try lifting your arms above your head while you are sitting in a slumped position. Now try again when your back is straighter. You should notice quite a big difference in your ability to do so. How? Tensegrity, my friend.

Similarly, if a part of our body, joint or muscle, can’t move as well as it should, the other parts of the body have to work harder to let you continue to be able to do whatever you were doing.

Or not.

Decompensation patterns occur when a particular part of your body cannot cope any longer with the added burden of overworking for the part that stopped pulling its own weight. It’s when you get pain.

This is the type of pain that worsens over period of time, without you recollecting actually injuring that painful part. Or the pain that you get when you do too much of a particular activity. In short, this is the pain you might go to the doctor for. They won’t know the exact cause, so if they doesn’t suspect anything major, they’ll just give you some mild pain killers and ask you to come back in a month or so. If you are reading this, my guess is that you would get that icky feeling that the drugs are just hiding the pain, which, by the way, you still don’t know the real cause of.

The painful area is the result of another part not working well (which you usually don’t notice).

 Even though the idea that neck pain can be caused by your big toe may seem pretty far-fetched, it’s an image to illustrate the not-so-unconceivable fact that we do see people with neck or back problems because of pain or restrictions lower down. This could cause them to walk differently, or maybe twist one hip a little. In this example, this twisting can continue up the spine and may cause pain in the higher spinal joints there which are trying to twist in the opposite way to counter-balance and keep the upper body facing forward.

This is but one example among an array of possible scenarios. Decompensation patterns are so common, and can be the origin of anything from minor tendon irritations, to long term disabilities.

But don’t despair! The good news is that osteopaths can trace back what the cause of the pain is, and treat what caused the problem in the first place. This is the difference between a therapy which provides relief, and a targeted treatment which results in long-lasting resolution of the pain.

 

Please let us know your experience, thoughts, questions and other ideas through the comments' section! Or talk directly to your osteopath, Sam Mallinson, for further discussion on this topic.