Look at the Entire Chain for Low Back Pain

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[00:01:41] Welcome back now to old Physio Stories. We're back with another A synchronous episode. This time I'm talking about a recent Lumbar case this is a patient I've seen on and off for about two to four visits at a time over the course of the last two years.

[00:01:57] He's had chronic back pain for probably over 15 years. Mostly radiates down to the leg. He works a couple of part-time jobs as family owns local chicken barbecue place so he's always delivering or standing around grilling quite a bit or cooking huge vats of salt potatoes.

[00:02:19] If you guys know what those are deadly for the waistline, crazy amount of salt. And also he delivers newspaper so a lot of time is spent sitting. When he gets up and walks around

[00:02:33] he has left side to low back pain, rating all the way down into his leg. He's gotten a couple of injections into his spine and none of them have helped and he's actually gotten more

[00:02:47] than two or three even though none of them helped and the last one he actually got worse afterward. So upon initially evaluating him a couple years ago, he looked laterally shifted to the right

[00:03:00] away from the pain. He was helped significantly but not wasn't a ballast completely with a lot of side glides, frequent changes in position. I think he had to also do some posterior change strengthening. So we returned to me this year after being mostly compliance with a lot of

[00:03:24] his stuff, he'd also put on weight, stopped working out so I tried to get him back to just general workouts. But anyway, coming back this year, similar presentation not really resolved. I thought

[00:03:36] it had resolved after three or four visits because he just stopped coming and told me he was better but it turns out that the TWS only may be about 70-80% better. So he still gets

[00:03:45] a lot of pair of pair of stations his calf and a ton of foot pain. So he was complaining more about the foot pain in general this time and I had thought that he was really talking about radiating pain,

[00:03:59] but he tells me he mentioned this last time but I went back and checked into records, he did not. It turns out he has significant metatarsalgia. So this metatarsalgia either is standard metatarsalgia or an aroma. He wasn't quite positive for like an aroma

[00:04:18] squeeze test, I don't even know if that's really indicative of having an aroma but he definitely had a lot of point tenderness between his second and third metatarsals on the planter aspect

[00:04:28] of the same foot, the side that he has entouchicate and a difficulty loading. So I told him about the spacers or I'm sorry not the spacers. He actually tried to spacers and they didn't work

[00:04:45] completely, they did relieve some pain but they kept on falling out. So I told him about the solution that I ended up using that helped my severe metatarsalgia to the point where I was able

[00:04:57] to start running again. My metatarsalgia was so bad that if I saw someone walking on stones I was definitely centrally sensitized, I would get nauseous. If I saw my kids walking around barefoot around the pool I would get nauseous. So I found these little gel inserts that went

[00:05:15] around your toe and I started wearing those in my socks. The problem is the little loop that would irritate that was like a ring that was attached to the disc it would go around your

[00:05:27] your second toe. That would actually irritate the skin of my toe and it would often break. So I found the better solution that are kind of so did to like these mini, they're not really

[00:05:37] socks but they're kind of rings that go around all of your like the door salastpect and the plantar aspect. It's a cloth that actually has that gel pad sewn in and you could just wear those

[00:05:49] all day underneath your socks so that they stay put. So I told him about those after wearing those for about maybe three to four months. I was pretty much 100% better but I was kind of scared to take them off

[00:06:00] for several years. So he tried those ordered them from my store and his gate was significantly improved and I think that was really the key to making the side glides and improvements in

[00:06:15] a posterior chain and lateral chain stick. That it didn't really matter how many side glides he did is if every time he was walking he had to significant and tell you get the significant pain

[00:06:26] in his meta-tarsals or his is in the aroma. So after kind of cushioning that he was able to walk without unloading and reversing all those side glides he was doing and that was the again the key

[00:06:38] to having him empty his cup faster than you can fill it up. What do you think about that Andrew? Hey, Erson. Well another interesting case as usual you do definitely seem to get

[00:06:48] more interesting ones than I do or at least remember them better than I do. But I think I don't know if you've told your story about your meta-tarsalgia. You probably have but I don't remember

[00:06:58] you're going into the details like you did mentioning and passing in this episode with your sort of own central sensitization with feelings sort of nauseous seeing like your kids even walk barefoot on the pool or seeing people walk on stones. That's really interesting.

[00:07:15] It's a look you look back in the archives and see if you've discussed that and if not we should definitely get into that. But to the patient at hand, it's certainly really interesting with the lack of progress with side glides and the sort of the coincidental nature

[00:07:34] of having meta-tarsalgia on that side and I think it speaks to a larger issue as well. That clinicians can apply to all of our patients that what are habits, behaviors, lifestyle factors would have you posture movements that your patient is doing when they're not

[00:07:58] with us. That could be potentially contributing to their either their sort of repetitive stress condition, keeping a situation irritated or not allowing our interventions to be maybe as successful as they might be. And sometimes that's going to take some investigations and questioning

[00:08:20] certainly observing things when they're with us but it's hard because if you only see your patients one two hours a week maybe that's 160-six hours in the week that they're not with us and so they

[00:08:34] might be doing things even if we've discussed it with them. The idea of for example like someone with a gluteal tonnopathy trying to especially if they have a habitual pattern of one

[00:08:44] to sit with their lace cross for example like many women want to that can be some a position that tends to maybe keep that tissue irritated or has the potential to a greater potential to

[00:08:58] keep things irritated so it's hard when there's such a habitual thing and then you don't get immediate feedback from a symptom standpoint so you have to come up with certain strategies potentially to help mitigate that. This was an example like said if it hadn't been hurting

[00:09:16] in his foot but he had still been doing some sort of accommodation compensating in some way how much longer might that have gone on for the fact that it's started to become painful

[00:09:27] in and of itself end up being a good thing is it needs something that could be addressed that certainly may have had an effect higher up the chain into the Lombar spine from that repetitive antallegiate that was sort of abnormal loading sensitive tissue. So doing a relatively

[00:09:43] simple intervention with sort of the meditarsal with with a toaster-based or cushion thing made a huge difference in the success of the Cyclehead intervention which otherwise would have been probably more successful. So get it really interesting so when somebody consider and

[00:10:03] looking at these different things as some of the members just takes asking patients questions in terms of it's hard because you don't want to get into all your patients aches and pains because they can get very drawn out and sometimes not connected but at some point sometimes it

[00:10:18] may be related especially if you're not having the results that you would expect of an intervention that you're doing. Alright thanks again for another great case, Erson and hopefully we'll talk in person soon. Thanks for commenting, Andrew. Always insightful as well. And I don't know

[00:10:34] if I have better memory about my cases maybe yours are like dreams maybe you actually are having a really interesting patients but you can't remember them the next day. Anyway if you guys liked this

[00:10:47] episode please make sure to comment on social media rate untold physio stories five stars especially on Spotify and iTunes or Apple podcasts hit that subscribe button and please share untold physio stories with your friends and colleagues. And as always you guys have a great day

[00:11:05] and a wonderful Christmas season.