Ruling Out the Lumbar Spine

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[00:01:12] Welcome to Untold Physio Stories Podcast. Your perfect commute resource with

[00:01:26] physiofaliers, successes, interest in cases and more from the physio and rehab world.

[00:01:34] With your host Dr Andrew Rothschild and Urson Rallyhiosome.

[00:01:39] Welcome back to Untold Physio Stories Podcast. I'm

[00:01:43] when you're host Dr. Rhee with my Domain therapy edge mobility system and be

[00:01:46] sure to check out my private network, the Eclactic approach. You can try that

[00:01:50] out at members.eclacticapproach.com.

[00:01:53] Andrew Rothschild is not with me today but I have his very special guest Dr. Ashley Mack.

[00:01:57] How's it going today Ashley? It's going great Dr. He's good to see you.

[00:02:01] Yeah I was just on his podcast. If you can check that out I fix your sciatica.com right?

[00:02:07] Yeah the fix your sciatica podcast actually.

[00:02:13] That is quite a niche and I'm sure you help a ton of people with your background.

[00:02:17] Why don't you give people a little intro?

[00:02:20] Even though I said your step, you can give people a little intro,

[00:02:23] a little background and then tell us your story.

[00:02:26] Absolutely. I've been a practicing physical therapist since 2012

[00:02:29] and my biggest approach has been focusing on really listening to the patient

[00:02:34] and one of the biggest things and one of the reasons why I got

[00:02:37] we outlinked up is that I've been following you ever since 2014-2015.

[00:02:42] So I've been following you for a while.

[00:02:43] Been a huge fan and I mean my big focus has been sciatica pain.

[00:02:48] That's the niche that I've focused on specifically in the past couple years but

[00:02:53] I mean like many other physical therapists have been able to address a lot

[00:02:56] of other orcative pedic issues as well.

[00:02:58] But I found particularly great success in people who are dealing with sciatica pain issues

[00:03:04] and low back pain as many of you other physical therapists have been.

[00:03:07] And the story, do you like for me to go into the story about some people?

[00:03:13] Yeah, go right into it.

[00:03:14] All right so...

[00:03:15] Leave me hanging.

[00:03:16] It's trying to tell me the story earlier and I'm like I don't want to hear it.

[00:03:18] I want to be surprised.

[00:03:20] You know I'm going to promise with the fact that if I saw this case 10 years ago,

[00:03:25] it probably would have taken me 10 to 12 visits to actually even just come to this conclusion.

[00:03:30] And so let's start backwards and then we'll go through.

[00:03:34] But anyway, ultimately it turns out that the patient that I was working with ended up

[00:03:39] with some SI joint instability and the reason why it took me so...

[00:03:45] would usually take me so long was because I remember in my schooling the focus was one to clear the

[00:03:51] spine first before you moved down the chain.

[00:03:53] And I remember when I was coming out of school, I said I'm going to look at only the spine first.

[00:03:59] Let me go ahead and address the spine for the next 12 sessions before I move on to the next item.

[00:04:04] Now, fast forward to 10 to 12 years.

[00:04:07] The great news is the fact that after seeing the many countless patterns that have come across

[00:04:12] and combining the teachings that you have brought up, Dr. E.

[00:04:15] I was actually able to figure out that we were in fact dealing with some sort of SI joint

[00:04:20] stability. So let's go into the patient case itself. So here we have a 58-year-old female.

[00:04:25] She was listening to my podcast and heard about me and said actually I've been dealing with some

[00:04:29] sciatica pain issues and I need some of your help. And so whenever I deal with a consult like that,

[00:04:36] a lot of fact as many of you listeners have been probably doing what's a lot of misinformation

[00:04:41] on what sciatica pain is or what irritation is, sciatica pain.

[00:04:45] Because oftentimes people say well I have sciatica so that means that I paid on my butt

[00:04:50] and in my hamstring. What's really interesting is that the sciatica nerve doesn't

[00:04:53] innovate the glute, doesn't innovate the butt right? And so what that means is a couple of

[00:04:58] different things. Obviously the nerve roots that innovate the butt can also come from the same

[00:05:03] nerve roots that actually innovate the sciatica nerve. And so the typical physical therapists and as

[00:05:08] they were telling me about this, they were dealing with butt pain, hamstring pain and calf pain

[00:05:14] also a little bit of weakness in their leg. And one of the really interesting things was by the time

[00:05:19] they spoke with me, they actually were going to physical therapy. They were given the McKenzie

[00:05:25] press ups which you know that's an entirely different discussion from there. But one of the

[00:05:29] interesting things is whenever I go on a consult and someone says I'm having muscle weakness,

[00:05:32] the first thing I would actually recommend that they do because you have muscle weakness my off these

[00:05:37] perhaps, I would say okay go get them right. Let's just make sure that nothing is

[00:05:42] scary or nothing is out of the scope of our ability to help. So I told them to push and speak

[00:05:48] with their physician and ortho and they actually were able to get their MRI report.

[00:05:53] Go ahead, Arson. I have a quick question. You're not in a

[00:05:56] laboratory but when you say I'm kind of surprised at that. When you say muscle weakness,

[00:06:00] you mean significant myotomy weakness like more than like an inhibition due to pain that wouldn't

[00:06:08] cause you to say like oh I'm going to do a recommend a scan first rather than me,

[00:06:12] proceed with an evaluation. Great question. Well the thing was was I mean let's premise with the

[00:06:19] fact that it wasn't weakness because of the pain she just said wow this like I just couldn't

[00:06:25] push through this leg that much more and it was kind of a sudden onset and I found it to be

[00:06:31] intriguing that when I asked the patient hey did they other PT like check your strength to see

[00:06:38] if there's a difference they said no and I'm a big proponent of I want to make sure that I'm not

[00:06:43] wasting anyone's time so that's one of the things and especially like they're going through their

[00:06:48] insurance and so they were able to actually get the MRI pretty quickly. So that was just one of

[00:06:53] the things I just wanted to realize were red flags before we do anything else like that and so

[00:06:58] and especially because she was a cyclist too so it was just it was an interesting thought and I just

[00:07:04] because the fact that she said it's so weak you know there's a difference between someone says like

[00:07:09] oh I experienced a little bit of weakness versus oh man this is so weak and so when someone says that

[00:07:13] that kind of brings up a couple different flags and I mean luckily the great news is the fact that

[00:07:17] she and a scanner MRI like pretty much the following week and actually turned out to be nothing

[00:07:21] and so I said and this is and this all happened before we actually even met and I actually saw

[00:07:27] as a patient I said let's get this cleared first and so from there I see them and what was really

[00:07:33] interesting they've been dealing with this for probably for I'll say two or three months they

[00:07:38] went to a previous PT they were given bridges prone press ups and some stretching and I asked

[00:07:46] them well how does it feel like how did this feel as a result and they said it doesn't really

[00:07:52] feel like much and I'm a big proponent of when you're you are in an active state of pain

[00:07:59] every action we do should be actually just reducing the degree of that pain in the first

[00:08:04] way so really really looking at pain as really more like a sliding skull versus like do you have pain

[00:08:08] versus not so even if you know if they're doing these activities and it really has no effect no

[00:08:14] improvement in range motion you don't prevent and strengthen or improve in a pain I'm thinking well

[00:08:18] what is missing in the first place and I like to go on a step by step back so as I was saying

[00:08:23] back in the day you know would take me 12 visits to actually like figure out to clear this fine

[00:08:28] what's great is the fact that I was able to clear the spine within the first visit and so the

[00:08:31] way that we clear the spine is like one this patient actually had symptoms kind of just

[00:08:36] literally the pain would kind of like come and go and like I would talk with the patient patient

[00:08:40] standing right there talking to me she was like all I'm not experiencing pain right now but the

[00:08:44] limb will do 30 seconds later as she standing she's like the pain is on the pain is off and from there

[00:08:50] clear in the spine flexion with over pressure produce no change nothing happens with spinal flexion

[00:08:59] a spinal extension with over pressure no change in that spinal lateral flexion or side gliding

[00:09:06] no change no effect symmetrical and full as well as rotation again no change and so from there

[00:09:12] I said all right well she's here seeing me and she's in an active state of pain what can we do to

[00:09:19] reduce so I said let's go ahead and move down the chain move down to the SI joints just press a

[00:09:24] little bit and I was looking at some gapping compression and it turned out that the symptomatic side

[00:09:30] which was the left side the moment that I pressed on the ASIS the entire left side that helped

[00:09:38] us rotate it compared to the right side and so I was trying to figure out was there actual movement

[00:09:43] at the SI joint or was it the fact that there's a difference in muscle bulk like what was going on

[00:09:49] so I reclested I was like I'm gonna go ahead and block the other SI J let me see if there's any

[00:09:53] sword drill play there's a lot of joint play that was actually happening at the left SI joint especially

[00:09:58] into posterior rotation so from there I said okay what do we do next right it's like okay there's

[00:10:06] some sort of instability we know that and also what's interesting is I looked at hip range of motion

[00:10:11] I looked at the difference between a hip internal and external rotation at 90 degrees

[00:10:16] hip internal or internal and external rotation at 0 degrees they were pretty much symmetrical

[00:10:22] and so I was thinking well what do we need to do to actually allow this and I said let's see

[00:10:28] what happens right which oftentimes you know we come across it's like okay here are these pieces

[00:10:33] here are these bread crumbs that are leading us to some sort of clinical decision okay we're dealing

[00:10:38] with some sort of SI going stability why is this dealing first place okay so from there I asked

[00:10:44] hey do you happen to have one of those booty bands right you know I'm talking about like a booty

[00:10:49] band is like it's like a really small loop band that you put around your knees and you know all the

[00:10:53] insular miles put around their knees it's like do butt workouts well she had like the cloth

[00:10:57] version and I said let's go ahead and experiment if we put this around your hips really at the top

[00:11:02] with a lay a crest with a little bit of compression how does that feel so once you did that right

[00:11:07] which when you do that it's kind of like akin to an SI joint belt right like not everyone has an

[00:11:12] SI joint belt but they might have a booty band they might have a cams belt you know there's

[00:11:15] opportunities from there apply a little compression put it on she started walking did pain went away

[00:11:21] pain went away her strength actually improved as well and she was like oh my gosh this is extremely

[00:11:26] better and so from there I was like well I can't just give you this band and then leave like we

[00:11:30] have to find other ways to actually stabilize and it turned out that this patient naturally has

[00:11:34] a tendency to hyper extend or asymptomatic leg which ends up resulting in the fact that her hips

[00:11:39] come out to the side and also the way that she ends up standing actually causes a lot of issues

[00:11:44] a lot of just like overall posture rotation now I will say I wasn't like an ultimate big believer

[00:11:51] in regards to like looking at the SI joint and see how it actually influences but interestingly

[00:11:55] enough I actually had an interview doc like year probably two or three years ago with Dr. Ryan

[00:12:01] Walton which you may have come across on I know from LinkedIn yeah yeah so he had a big focus

[00:12:08] I think he's always talking about the SI and I'm always like I'm always like

[00:12:13] not even like like a jerk but I'm like oh you know like I think I usually say that like

[00:12:18] less than 1% of my love bar cases are real SI you know yes exactly and that's

[00:12:24] and that's one of the reasons why I mean you know a couple years ago it literally would take me like

[00:12:29] 12 visits or like a couple weeks to say like is this really the issue right and so I think what's

[00:12:35] important has a clinician to be able to say like all right well the patient's presenting with

[00:12:39] like these symptoms but like let me go ahead and go through my like usual checklist of of things

[00:12:45] and if they don't fit that profile like what's the other option I'd much rather do that than say like

[00:12:50] all right let me go ahead and use this visit to kind of let me give you plans let me give you

[00:12:54] precepts like let me give you these things that that I can do it in my anyway right yeah yeah

[00:13:00] and I'm not one to you know wait someone's time or fill it up as well so I was really surprised

[00:13:04] let me ask you a question though I mean what did you do just give her like

[00:13:08] just wear the belt until the SI became stable or you know specifically have her work out

[00:13:15] I wouldn't said like oh she's working out in when she has the belt on at like I'm just trying

[00:13:21] to think like what did he do because you didn't mention oh yeah sorry yeah so anyway

[00:13:24] as I do it um you know booty van and then I actually focused on actually I'm think and

[00:13:30] and I was suspecting right as I joined instability it means that she's probably end up using a lot

[00:13:34] of her extensors to actually do a lot of activity a lot of pulling which also helped me actually

[00:13:40] assess how is our interior core strength or actually not core strength but more so how's our

[00:13:44] interior core sequencing ability right so what I am of giving her was kind of like the I call

[00:13:50] the the partial Turkish get up so it's pretty much a rolling pattern from like supine to prone

[00:13:55] but you're actually just sitting about one album right and so I think they do it all the baby get

[00:14:00] the baby get up exactly so that you did the baby get up and then I'm

[00:14:03] to remember like usually baby get ups like the movement fault is often that the uh the same

[00:14:07] side of light will actually pick up or the contralautos I will actually pick up when you do that

[00:14:11] baby get up and so I said okay go focus on the breathing we're gonna focus on actually addressing

[00:14:16] that so that was number one um also looked like her 80 doctors were a little bit uh

[00:14:22] instant metrical in regards to strengthening so I actually had her focus on some side lying

[00:14:27] 80-duction um which actually was particularly helpful and then I was like open chain or close chain

[00:14:34] open chain oh open chain yeah so we'll say like symptomatic side was actually down so she

[00:14:39] was on the side lying and she were like yeah yeah and then from there um it was I was really using

[00:14:46] these exercises as an opportunity to say hey be more aware of these these uh these muscles because

[00:14:53] I find that and this is just from my experience that patients aren't necessarily like weak or

[00:15:01] inactivated they just like they're not moving efficiently and so really I like to use these small

[00:15:07] corrective exercises as conduits into actually doing stuff like squats, hinging and moving but then

[00:15:12] we also noticed that like because she experienced a lot of pain with sitting I said let's go ahead

[00:15:18] and actually look at how you sit like are you sitting in the the position that is more comfortable for

[00:15:24] you and so what was interesting was the fact that when she was sitting she would often post

[00:15:28] seriously tell sit on really more so her sacrum and I said would you ever consider rocking more

[00:15:33] so on to your sit bones and one of the things that I learned from you um was the fact that like there's

[00:15:38] not one position that's bad it's just the fact that if she's been sick or sitting for literally

[00:15:42] past couple years why not change it up why not make it so that we're we're not filling that cup

[00:15:47] as you usually say right why are we using that like why not give it you an opportunity just to sit in

[00:15:52] a different position for a little bit a lot for a little while and here's an interesting thing

[00:15:56] I messaged her the fall and morning right and I said hey how are you feeling she said well I woke up

[00:16:00] up a little sore but then I had no pain I actually felt fine I was able to go back to bifriting

[00:16:07] so really I think it was really more of like a neural reset more so than anything I didn't

[00:16:12] realign her pelvis I didn't make her pelvis more stable I just said I'm trying to think though I mean

[00:16:19] especially for a 51 year old I mean she fits the demographic of potentially having true

[00:16:24] resides dysfunction but I also would have expected that she probably just didn't tell you or should

[00:16:29] you remember that you would have had like a horrible biking accidents where like the left leg was

[00:16:35] extended and she fell on it and like that's why that side is so locked they mean like you don't

[00:16:41] expect aside to shift significantly when you're doing SI provocation test right you expect

[00:16:47] to provoke pain but I don't expect like like discernible action movement yeah yeah so and that was

[00:16:56] another reason why I was in kind of like not really suspecting but I said why not look at it because

[00:17:01] of the fact that you know I and I get this all the time it's like could it be an SIJ it's like well

[00:17:06] unless you like had some sort of trauma and like probably not and so that and that was like a while

[00:17:12] that was a while of case I said because because of the fact that usually my assessments would go

[00:17:20] one more spine hip and glued and then like lower down the chain like looking at the SI joint is

[00:17:26] actually not something that would often look at I just skip right over it yeah exactly yes that's

[00:17:32] exactly it's not even really a joint you know yeah majority people are just not right there's not

[00:17:37] like a perishable movement right yeah it's just like yeah yeah so so that what would that be

[00:17:43] in said you know it could be and I didn't notice any sort of asymmetries when it came to glute

[00:17:48] bulk but like it could even be just as like lying supine right there was a definitive bulk

[00:17:56] difference between the left and right glute and that's what could have resulted in the joint

[00:17:59] playing the first one so anyway that was I found it'd be so intriguing then when you asked me to

[00:18:04] like share a story that I thought was really interesting I was like wow this is unbelievable um because

[00:18:09] I mean maybe I never would have gotten to that point you know yeah I'm so biased against the SI

[00:18:13] yeah there have been there have been a few times where I think I told him a podcast a long time ago

[00:18:18] I was working with another PT virtually and it didn't seem like SI because it was unilateral but

[00:18:23] she had bilateral like radiating pain and bilateral what seemed like sciatica except for only one

[00:18:29] side it went below the knee in like a derma tumor pattern and so that already made me think oh

[00:18:34] it's not SI and the left side it was like like the right side went below the knee the left side

[00:18:39] it went only to above the knee and she you know she got better with press ups and a lot of like

[00:18:44] extra walks and we're gonna move in everything but it was so it was then completely pained for you

[00:18:48] throughout the day with her work was like a home care PT and then she only felt that at night lying

[00:18:54] on her side then like I don't even know why I suggested I'm like oh you have a gay fountain she's like

[00:18:58] yeah she's like okay I'm like wrap that around your pelvis and like pull it tight and go to bed like

[00:19:02] that and then she like yeah that was it it was it was something about like stabilizing your SI

[00:19:08] at night only it was it surely needed to do it for like a week before she was something for

[00:19:12] she didn't need it anymore but I'm like I wouldn't consider that at all because it's only in lying

[00:19:16] and I belt her in lying because you think of it is like on weight bearing you know kind of standing

[00:19:20] phenomenon where somehow an SI ligament is gonna be irritated you know yeah and and I think

[00:19:27] that's one of the magical things about you know the work that we do is because like we get

[00:19:30] presented with this stuff and we just ask more questions it'd be like well why is this and I think

[00:19:35] that's actually what allows us to get the outcomes that we do have with our patients because of

[00:19:39] the fact that we ask questions right if I was like you know like the previous PT that she had which

[00:19:43] you know that PT is very confident confident but if I just said oh well I don't know what's going on

[00:19:48] so let's go ahead and just do clamps and press ups for now because it doesn't seem to like help or

[00:19:52] not do anything it doesn't help me get a better idea of what's going on either right and so I think

[00:19:57] that was particularly useful and yeah I really said let me go ahead and step out of that bias

[00:20:02] right and see what's happened and actually it's not working out really really well so that's great

[00:20:07] good awesome yeah um hey we're out of time though but why don't you tell people where they could

[00:20:12] find you listen to your podcasts and we'll close out yeah so you can find me on my website iFixerSciadica.com

[00:20:21] and you can also actually find me in some of the work that I do over at Ashley ash sorry ashleyjmack.com

[00:20:27] which is spelled ashlyjmak.com all right is that uh wait what is that is that it's like a blog or

[00:20:37] I forget are you really like a photographer or something or artist no there's just I I work with

[00:20:42] patients virtually in person and then I also do some more work for you independent of your you

[00:20:47] know what i'm sorry I said that there's like another PT who was who I just went on their thing

[00:20:51] and they're like we also happen to be like an amazing photographer oh man like I wouldn't have

[00:20:55] expected that at all so you know all right I wish um all the the other like a like a google

[00:21:02] Ashley Mack and there's one emulation who happens to be a photographer so um you're not you're

[00:21:07] not too far there's a lot of Ashley Mack on Instagram my phone yeah decent yeah most of them not

[00:21:14] dudes most of them not dudes yeah I think they're maybe one more right in Malaysia in Malaysia exactly

[00:21:23] yeah all right yeah hey it was great having you on my podcast we got to swap again sometime absolutely

[00:21:28] it's good seeing you all right yeah good seeing you hey if you enjoyed this podcast you have any

[00:21:32] comments or questions reach out to either one of us on social media make sure you rate my podcast

[00:21:37] and Ashley podcast five stars wherever you listen to podcasts it really helps with our SEO and it's

[00:21:42] always you guys have a great day