Foot Drop and Back Pain

ankle foot orthosis for foot dropAlthough the most common symptoms from a compressed nerve in the back is pain radiating down into the legs – as in sciatica – sometimes the nerve compression can result in weakness of  the muscles in the leg. One of the most common areas of weakness is weakness of the foot, resulting in the inability to lift the foot upwards off the ground. This is known as a ‘foot drop’ and can result in compression of either of the lower nerves exciting the spine – generally ‘L4 ‘or ‘L5′. The foot drop can cause distress to sufferer and also makes walking very difficult as the dropped foot will drag on the ground due to weakness of the muscle that normally lifts the foot – called tibialis anterior. This results what doctors call a ‘high stepping gait’ as the suffered must lift the knee high with every step to avoid the foot dragging.

It is important to be aware that there are a variety of different causes of foot drop. The most common is not compression of the nerves in the bag, but compression of the nerve to the foot muscles at the level it passes around the outside of the leg just below the knee – the common peroneal nerve. Weakness caused by compression like this can result just from awkward kneeling causing a temporary weakness, or it can result from soft tissue compression in the same area.

Possible causes of foot drop:

  • Direct compression of common peroneal nerve e.g. below knee
  • Degenerative (wear-and-tear) of lower spine causing nerve compression or spinal stenosis
  • Advanced diabetes, Vitamin deficiency e.g. vitamin B12
  • Rarer nerve muscle diseases (e.g. multiple sclerosis, motor neurone disease, muscular dystrophy, Charcot-Marie-Tooth disease)
  • Stroke
  • Cerebral Palsy

How common is foot drop with back pain?

One recent study by Liu et. al. 2013  found that up to 8% of patients admitted to hospital for surgery with degenerate, wear and tear, changes in the lower back had an associated foot drop. These patients were admitted for surgery for sciatica causing pain, numbness or muscle weakness. The most common nerve affected causing foot drop was the fifth lumbar nerve, L5. The extent of the foot drop in this group of patients varied from no muscle power at all, to some milder weakness. The number of 8%  vastly exaggerates the number of patients with back pain who will have a foot drop. Most people with back pain do not have sciatica and most people with sciatica only have pain or numbness in the legs. Of those with advanced sciatica not improving without surgery, however, this paper shows that up to 8% will also have a foot drop.

How will the cause of my foot drop by diagnosed?

A new foot drop requires urgent investigation. As listed earlier there are a wide range of possible causes. Unless the cause is clear – e.g. history of recent direct injury in area of common peroneal nerve below the knee – your doctor will have to perform blood tests and almost certainly a MRI (magnetic resonance) scan to determine the cause. They are likely to send an urgent referral to a specialist spinal surgeon, neurologist or spinal orthopaedic surgeon for detailed investigation. Further tests might involve muscle activation tests  (EMG) and nerve conduction studies.

What is the initial management / treatment?

The key is prompt investigation and referral to the appropriate specialist. You doctor will prescribe a so called ankle foot orthosis (AFO) as shown in the picture above to keep the foot in a neutral position when walking to stop it dropping when walking and causing difficulty walking or tripping. This also keeps the calf muscles from over tightening with the foot in the dropped position. They may also send a referral to a physiotherapist to instruct on exercises and stretches.

Will my foot drop improve without surgery?

This depends greatly on the cause. A simple pressure on the common peroneal nerve will improve with removal of the pressure, whether it was one off trauma or from a soft tissue compression / stretch. Causes like advanced diabetes, stroke or rarer nerve muscle conditions will be less reversible but some improvement may still be seen.

In the case of compression of the nerve in the lower back – surgery is generally required, although some specialists may still allow a short period of observation as some improvement can be seen, it is likely that surgery will be discussed at an early stage.

In the study by Liu et. al. 2013 – muscle weakness causing the foot drop improved in the majority of people after surgery but was dependant on a range of factors. Firstly the diagnosis must be definite and the nerve in the back causing the problem clearly identified from a MRI scan. After this, the most important determining factors for a good outcome: time from foot drop to surgery, younger patients, and more strength in the muscles to start with. This highlights the important of a prompt diagnosis and referral to a specialist back surgeon where the cause is the nerve compression in the back. Muscle strength, however, still improved in 83% of patients. The average time from onset of the foot drop to surgery in these patients was long being around 180 days, showing that improvement can be seen even with prolonged duration of symptoms but earlier nerve decompression is best.

All always, the most important message from this article is that it is essential to seek an immediate review by a qualified doctor if you develop a foot drop or any other concerning symptoms.

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Reference:
Liu K, Zhu W, Shi J, Jia L, Shi G, et al. (2013) Foot Drop Caused by Lumbar Degenerative Disease: Clinical Features, Prognostic Factors of Surgical Outcome and Clinical Stage. PLoS ONE 8(11): e80375. doi:10.1371/journal.pone.0080375

Pregnancy Back Pain

Back pain and particularly lower back pain is extremely common in pregnancy with up to three out of every four pregnant women being affected at some point. It occurs more commonly as the pregnancy develops and can take many different forms – from simple back ache to severe pregnancy back pain and sciatica.

It is important to see a doctor about the back pain as soon as you can to ensure you get early treatment but it is rare for the back pain to affect the pregnancy or your labour directly.

Causes of pregnancy back pain

There are many factors that can lead to back pain developing when you are pregnant and they include direct physical factors and even hormonal changes.

Posture: Poor posture can put a strain on the muscles and ligaments of the back, leading them to become damaged and painful. Often pregnancy makes it increasingly difficult to maintain a good posture but it is important to focus on this as much as possible, especially early in the pregnancy, to avoid the pain starting. Once pregnancy back pain starts to develop it can be more difficult to fix.

  • Fluid retention: All pregnant women develop a small amount of swelling of the soft tissues in the body. This not only adds to the weight being carried by the back but can also lead to pressure on nerves in the back that were not affected before the pregnancy. This can be the cause of sciatica and this will generally get better after your delivery but developing these symptoms may suggest you are prone to developing sciatica back pain later in life.
  • Hormones: As you will almost certainly know, pregnancy is associated with significant hormonal changes. Some of these lead to changes in the flexibility of the joints and ligaments of the pelvis, particularly towards the end of your pregnancy and before delivery. As a result of these changes, pain may develop from the new stresses being placed on the structures of the pelvis, causing pelvic pain or a condition called symphysis pubis dysfunction.

What can I do to prevent and treat pregnancy back pain?

The suggestions below should be considered by all pregnant women whether they have developed back pain in pregnancy or not. A good routine for exercising and stretching the back and pelvic muscles can only be of benefit to your pregnancy and labour.

  • Pelvic floor exercises: There are many pelvic floor exercises available on the internet and no doubt you will be familiar with some of them. A similar exercise of squeezing your pelvic floor muscles for up to 10 seconds and repeating this several times is a good starter exercise that can be done anywhere.
  • Exercise: Try some simple back exercises or other activities such as swimming – which is ideal in both pregnancy and all those suffering back pain. A good way to exercise and also to improve your posture is to use an exercise ball – even as a replacement for an office chair!
  • Warmth and massage: A warm bath followed by some back stretches or a massage can work wonders for back pain in pregnancy.

Try the above measures but in any case you should be seeking a review from your doctor with your pregnancy back pain so they are aware of the situation and can advise you further if things do not seem to be improving.

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Stress back pain

Stress-related back pain is a relatively modern diagnosis although the concept of muscular pain caused by tension is not a new one. Stress of both the physical and psychological sort can make the painful symptoms of any injury worse but ‘stress back pain’ is a term used for pain caused by stress above all other factors.

For many the idea of thoughts and feelings causing a physical problem seems unlikely, but this is well established in medicine. Stress causes many changes in the body and predisposes to conditions such as gastritis, high blood pressure and heart disease. In addition, it causes a build up of tension throughout the body.

Stress-related back pain is thought to relate to this tension and can be caused by muscle spasm in the back. This spasm is worsened by tension in the muscles and is a target for interventions such as stretches to the back.

Stress could trigger pain in the back by creating tension and spasm in the back muscles but then can also be a part of a vicious cycle of worsening back pain. Individual suffering from daily stress are more likely to avoid gentle exercise and relaxation therapies. As the back pain manifests itself, some people will choose to withdraw from exercise altogether or work longer and harder as the pain limits productivity.

The key to beating back pain is identifying the vicious cycle and taking action to break it. Key to this is reducing stress levels but also increasing light activity, stretching and other exercises. For many people, stress starts at work. When trying to make a change at work thinking beyond just the workload and the obvious psychological stress, ensure you also consider the physical stress of the ‘day job’. If you work at a desk – ensure you’ve on a good ergonomic chair, perhaps you need a footrest, perhaps your computer screen is too high or too small?

Make lots of small changes to you work and lifestyle and you’ll be on your way to beating back pain. Almost call pain is made worse by stress and back pain in particular can respond to a concerted effort to beat the vicious cycle.

Back Pain Chiropractic Therapy – What it involves and when it helps

A chiropractic is a professional who specialises in the treatment of musculoskeletal conditions and especially those that affect the back. A back pain chiropractic is skilled in managing mid and lower back pain, headaches, sciatica, muscle spasms, neck pain and other joint pains.

The mainstay of their therapy is based around stretches and manipulation. A good chiropractor makes an assessment of each individual patient and then aims to tailor their personal treatment. Their therapy aims to relieve pain and restore mobility to affected joints including those of the back.

Although chiropractors are very rarely doctors their therapy is now accepted by the medical profession and often recommended as an early treatment to try.

Key chiropractic interventions

  • Manipulation and mobilisation
  • Ergonomics
  • Pelvic alignment and stability - eg. heal lifts if required
  • Exercises
  • Ultrasound and electical stimulation

Chiropractic therapy is now mainstream and recommended by many physicians as an early therapy to try. Up to 10% of people will visit a chiropractor every year for a range of reasons from headaches to back pain to knee pain. Many patients referred to back surgeons to be considered for back surgery are referred on to try chiropractic therapy and as a result avoid back surgery altogether!

As the therapy has become more and more established, more and more clinics have appeared. Inevitably, some of these are more reputable than others, so how do you identify the best chiropractor?

Choosing a back pain chiropractic

A good place to start if your family doctor or general practitioner. Your GP has almost certainly had experiences of patients going to many local chiropractors and will have had feedback from these patients when it has worked or not worked. They may also know which is good value, and which ‘over-sell’ expensive therapies or devices.

Next, try family and friends – most people will have experienced back pain at some point and many will have sought help from a chiropractor – collect as much advice and feedback as you can.

Aim to have one or two chiropractic clinics on the list at this stage and then go and see them. You should put together a list of questions and then formulate your own opinions on the chiropractor you see. The decision is ultimately yours and don’t forget everyone is an individual! What worked for your neighbour or anyone else with back pain, may not work for you.

Some questions to ask a chiropractor:

  • What techniques do you use and why?
  • Do you use high intensity or low intensity manipulation and when/why?
  • What experience do you have of treating my condition?
  • What are the realistic expectations for the treatment you offer?

Some chiropractors are known to offer cures for more than musculoskeletal problems eg. diabetes, asthma - these are best left to doctors and a chiropractor offering a ‘cure’ is probably one to avoid. Be careful not to be swung by claims on new treatments or orthotic devices that are said to only be offered at one clinic – if they’re new, they’re probably very expensive and also unproven. Finally, chiropractic therapy tends to either work or not – beware the therapist preparing a 6 month or 12 month or longer plan for your treatment.

Sciatica Pain

Sciatica pain occurs along with a range of other symptoms that are caused by compression or irritation of nerve roots in the back that make up the large sciatic nerve in the legs. As a term, it is often used to describe any leg pains thought to originate from the back. Sciatica is commonly associated with back pain and is a condition that is not uncommonly treated by back surgery although many other treatment options exist.

Sciatica symptoms can be quite variable and often vary significantly by the time of day or the day of the week. They range from mild be extremely severe and can be made worse or improved by certain movements and positions.

Sciatica Symptoms:

  • Burning or Tingling pain in the leg – often in a specific, consistent area
  • Sharp shooting pain down the leg
  • Pain worse on sitting or bending down (especially when for long periods of time)
  • Weakness of leg, foot or toe muscles
  • Numbness of skin of legs
  • Pain particularly on one side of the lower back or one leg

Is it permanent? What is the risk of sciatic nerve damage?

Although the symptoms of sciatica originate from irritation of the sciatic nerve, it is uncommon for any permanent damage to the nerve to occur – in other word, a delayed diagnosis or delay to treatment is unlikely to affect final outcome. Nevertheless, it makes sense to start treatment early and it is certainly important to seek a review by a qualified back doctor at the first possible opportunity.

What is the sciatic nerve?

The sciatic nerve is the largest nerve in the body. There is one on the left and one on the right and they runs from the vertebrae of the lower back, down the back of each leg and supply many of the big muscles of the leg and also the overlying skin.

The nerves starts from a smaller nerve ‘root’ at the level of the back known as lumbar 4 (L4) and from further nerve roots down to the sacral region, sacral 3 (S3). Compression can be worst at L4, L5, S1, S2 or S3. Each of these levels supplies a particular area of the skin or muscle and a qualified back doctor will be able to determine which level is most likely affected by examining you.

For example, an L5 level compression of the sciatic nerve tends to result in difficulty in lifting the big toe or ankle and there may be numbness of the top of the foot.

Nerve compression is generally due to a protruding vertebral disc but rarely it can be a result of a condition call piriformis syndrome.

What is the prognosis?

Sciatica is common and most people will find their symptoms improve with simple treatment measures within a few weeks to months. A few people will have severe symptoms that fail to fully respond and, for some, back surgery may be considered as a last resort.

Is sciatica ever an emergency?

If you develop numbness around the buttocks and groin, or difficulty in passing urine or stool, or weakness of the legs, then you must seek medical attention immediately as you may have developed ‘cauda equina syndrome’. This must be treated quickly to avoid lasting damage to the spinal cord and is considered an emergency.

Early surgery is also considered if your sciatica symptoms get continuously worse, particularly if this happens over a short period of time, as in this case nerve damage is a possibility.

Treatment options for sciatica?

Some  helpful measures, as for almost all back pain, include back exercises, back stretches, or other alternatives to back surgery.

You may also be interested in a video on back surgery and sciatica.

There are many other treatment options for sciatica and these will be the topics of future posts on this blog.

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Back Pain Yoga

Back pain yoga is becoming more and more popular and with good reason. It combines three key aspects of the treatment of back pain: back stretches, back exercise and good posture. All three of these are targeted by yoga and although classes that specialize on the treatment of back pain are quite uncommon, most basic yoga classes are useful.

There is evidence that yoga for back pain is more effective than the standard treatments often suggested for the early management of back pain, including simple painkillers, exercise classes, manipulation of the spine and also alternative treatments such as acupuncture.

This evidence comes from a study published last year in the Annals of Internal Medicine by a group from the University of Manchester and University of York – their study involved over 300 patients and compared conventional management of back pain to weekly yoga sessions. Outcome was measured on the basis of a disability questionnaire and found to be slightly better in the yoga group at three, six and twelve months from the start of the study.

There is evidence, also, that yoga is particularly effective for those with lower back pain – the most common form of back pain that most of the population will suffer from at some point in their lives. A study published in the journal Spine in 2009 demonstrated yoga was effective in helping those suffering from chronic lower back pain (symptoms lasting more than 3 months). These findings agreed with a previous study published in the journal Pain in 2005 – again targeting those with chronic lower back pain.

So you know the evidence that yoga helps but where do you start? The first thing to decide is whether to try yoga at home or attend classes. It may be wise to start with classes before continuing what you learn at home. When performing yoga or any other exercises you must stop if your back pain gets worse. If attempting yoga at home make sure you put a soft yoga mat down first or you could end up damaging your back muscles further!

There are many different yoga routines available and some are better than others when you are suffering from back pain. I recommend the following video as a very good beginners yoga routine for lower back pain but there are also some good yoga books available which include routines prepared for those suffering from back pain. I will be posting more good routines in the future so be sure to subscribe via Twitter or RSS.

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Spinal Stenosis

Spinal stenosis is the term given to a narrowing of the spinal canal – the space in the back in which the spinal cord runs. This occurs to some extent in most people as part of the aging process and is a common cause of back pain. Spinal stenosis can also cause numbness of areas of skin – especially of the legs. It can also cause weakness of the legs or other muscles. Spinal stenosis most commonly affects the lower, lumbar spine and often causes lower back pain for this reason.

The condition occurs in both men and women although women require treatment more often then men. It develops progessively with age but generally presents over the age of 50-60 years.

Causes of spinal stenosis

Spinal stenosis occurs to some extent in everyone during aging. A narrowing in the spinal canal may develop due to overgrowth of the soft tissues or bone in the spine, or due to some protrusion from the vertebral discs. Most commonly it is a combination of factors that leads to the narrowing causing symptoms. Arthritis is found to be the main cause most frequently.

Often, one causal factor can end up worsening another. For example, as the vertebral discs become less supportive, more pressure is put on the facet joints of the spine which in turn can lead to worsening arthritis and overgrowths of bone. The loss of height in the vertebral discs and any protrusion from the discs can also cause a reduction in the space available within in spinal canal.

Symptoms

The common symptoms of spinal stenosis are listed below.

  • Back pain – often worse when standing up straight and better when bending forwards. May also be made worse by walking
  • Sciatica - particularly shooting or burning pains in legs
  • Weakness of the legs

It is important with any new medical problem or symptoms to seek medical attention from a qualified doctor at the first opportunity. This is particularly true if your back pain meets any of the criteria discuss in our article on the red flags of back pain cancer.

Diagnosis

Your doctor will take a history of your symptoms from you and will also request further tests to confirm the diagnosis if they feel it is necessary. These tests may include an x-ray or a magnetic resonance imaging (MRI) scan. These tests are often only requested by a specialist back doctor and after simple treatment measures have failed – this is because in the majority of cases, back pain improves and gets better.

Treatment Options

Treatment of spinal stenosis is generally not surgical to start with although back surgery may be required later.

Early treatment options:

  • Simple painkillers – e.g. paracetamol or anti-inflammatory drugs (discuss with your doctor before taking these regularly, especially if you have a history of asthma or stomach problems such as ulcers).
  • Physiotherapy – very effective for almost all types of back pain and an excellent first treatment
  • A Back Pain Chiropractic – Associated with some excellent results and now a recommended treatment option for back pain but always consult your doctor first
  • Injections – A back doctor may advise trying a steroid injection into an area of the spine to see if this relieves your symptoms. The injections can either be to the space around the spinal cord or to the facet joints. They are often only a temporary measure and can only be repeated a limited number of times.

Back surgery

There are several types of back surgery which can be helpful in spinal stenosis. There have been recent advances in spinal surgery for this condition and the main one of these is listed below. The most common procedures performed, however, are the laminectomy or the spinal fusion.

  • Laminectomy: Involves removal of part of the bone and ligaments of the vertebrae in the spine at the level of the spinal stenosis. This creates more space in the spinal canal and is often very effective.
  • Spinal fusion: Involves using a variety of different techniques to eliminate movement at a level of the spine to prevent any narrowing of the spinal canal with movements of the back.
  • Interspinous process implants: These are devices which are implanted between the spinous processes of the spine – the spikes of bone attached to the the back of each vertebrae. The implanted device expants the space between these spinous processes and as a result can create more space in the spinal canal. The implants mimic the position the spine is in when bending forwards – the position where more people suffering from spinal stenosis find their symptoms ease.

There as risks involved with all surgery and back surgery is certainly no exception. The risks should be discussed extensively with your back doctor and understanding the recovery from back surgery is also important. In general, however, four out of five patients undergoing back surgery for spinal stenosis have a good outcome and regain good function and a good lifestyle.

Related articles:

We will be posting further articles on back surgery – the types, alternatives, risks and recovery process. Don’t forget to follow us on Twitter or RSS to ensure you don’t miss out!

Tailbone Pain (coccydynia)

Coccydynia is the term given to tailbone pain. The tailbone (coccyx) is a set of bones at the very base of the spine. Because of the position of the tailbone, the pain may be worse when sitting down.

Symptoms

The primary symptom is tailbone pain – that is pain at the base of the spine. The pain is very variable between people suffering from the condition but is often made worse by sitting, lifting objects and standing up. There are many other symptoms that you may have which occur with variable frequency.

  • Tailbone pain
  • Back pain
  • Pain on passing stools
  • Pain during sex
  • Pain during periods
  • Pain in buttocks/hips

Causes

Coccydynia is a fairly rare cause of back pain and can be provoked by a variety of factors including:

Direct trauma: This is very common and may cause the tailbone to be bruised or even broken. The most common causes are falls onto the tailbone or buttocks, or a direct kick or other impact to this area of the back.

  • Child birth: Tailbone pain is more common in women partly due to childbirth and partly due to the tailbone being more exposed in women. The tailbone is more flexible towards the end of the your pregnancy and if the soft tissues around the pelvis stretches too much then then tailbone pain is often the result.
  • Poor posture or repetitive strain injury: Tailbone pain is particularly associated with certain sports such as cycling. These sports involve a lot of bending of the spine under pressure and may stretch the soft tissues around the tailbone and cause pain. Many people will also have experienced tailbone pain after a prolonged period of sitting or driving. This is generally relieved by getting up or changing position.
  • Infections: Very rarely, a collection of infection at the base of the spine or pelvis can cause pain in this area. For this reason it is especially important you see a doctor quickly if you have other symptoms besides the tailbone pain – such as feeling unwell or having fevers. X-rays or a scan may be required for diagnosis.

Tailbone pain is more common and often worse if you are overweight or obese. This is because the coccyx has a function in carrying the weight of the body and therefore when it is injured it may be more painful for this reason. Paradoxically, being too slim can also be a problem due to the lack of fat padding around the coccyx leaving it vulnerable to injury or irritation. Often, however, tailbone pain can develop and no cause can be found for it.

Treatment

  • Painkillers: In most case the treatment is to manage the symptoms of the tailbone pain because generally this will improve on its own. Painkillers are generally required and your doctor may prescribe some strong painkillers when the pain is at its most severe.
  • Special Cushions: Most people with tailbone pain will find it difficult to sit down and the best way to improve this is a with a doughnut cushion or coccyx cushion – these redistribute your weight away from the tailbone when you are sitting down. You may also find sitting on a hard surface is better than a soft one as on a hard surface your weight tends to go on your pelvis more than the tailbone.
  • Manipulation: Some people benefit from some degree on back manipulation either by a physiotherapist or a chiropractor. These is little evidence of the effectiveness of this approach for tailbone pain – in comparison to lower back pain where there is a growing body of good evidence. This fact may, however, be due to the comparative rarity of the condition.
  • Injections: Steroid and anaesthetic injections may be tried if your pain is severe and lasting longer than expected. These can be very effective but may only have an effect for a few weeks. Nerve blocks are another option – this is another type of injection that aims to block the nerves transmitting the painful signals from your tailbone.
  • Surgery: Back surgery is rarely required and is always a last resort. Part of the coccyx may be removed in a surgical procedure aimed at relieving the pain. After the operation, infections of the area are a common complication although up to ninety in every one hundred people operated on have a significant resolution of their symptoms.

Prognosis

Most people with coccyx pain will improve within a matter of weeks. A fracture of coccyx can take 6-8 weeks to heal but pain will normally reduce gradually throughout this time. Regular painkillers perhaps combined with the some physiotherapy or stretches is generally all that is required. A very small proportion of people can develop chronic tailbone pain and some will require back surgery to remove some of the coccyx.

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