The Case Of The Mystery Leg Pain
Janine arrived in my clinic complaining that the lift was a pre-war monstrosity and terrifying - she howled that she had contemplated using another osteopathic clinic because of the lift. Given that we were only on the first floor, involving precisely 10 steps, and she was 20 something, I was surprised at the extent of her irritation. Only someone in a great deal of pain reacts in that way, so I had an idea of what I was in for.
Janine perched on the edge of the chair holding her leg with an agonised look on her face. I sat down, waiting for the story of perhaps a disc injury, or back operation etc. It didn’t come. Her medical history was clear. No history of car crashes, no disc bulge, no falls, no operations... She was fit as a fiddle, regularly attended the gym, cycled every weekend if she could, great diet, very health aware... and raging 9 out of 10 leg pain. On and off for 2 years, temporarily relieved by sports massage.
The pain ran down the back of her leg, which we call ‘Sciatica’ – meaning something is irritating the sciatic nerve. All tests that the GP had run were completely clear and he could find no cause for her leg pain – always my favourite cases! Given her crystal clear medical history I had put my Sherlock hat on and had to dig deeper into her story.
“So Janine, lets go over this all again in more detail. You regularly attend the gym. How many times a week?”
“14” Janine replied
My eyebrows raised. (Had I worn glasses I would have looked like Miss Marple, peering over my half moon glasses at her)
“Twice a day?”
“Yes. 2 hours each time.”
“Talk me through your regime.”
“45 minutes on the stepper, 45 minutes on the bike, then weight lifting – leg toning, arm toning...”
“Any stretching after your gym sessions?”
I put my case notes down. I had my diagnosis right there without even assessing her.
Piriformis syndrome. The cause of pain.
The movements that Janine was repeatedly carrying out (bike, stepper, glut presses) were all taking the leg into extension, and specifically tightening the gluteal muscles and the piriformis muscles – all found in the bum cheeks. The sciatic nerve runs between, around and sometimes even right through the piriformis muscle. If the gluts and piriformis tighten enough they can place pressure on the sciatic nerve, even pinch it directly if the nerve passes through the sciatic muscle, and cause extreme leg pain.
People who attend the gym a lot typically forget to stretch, or perhaps don’t realise the importance of stretching after intensive strengthening. Many musculoskeletal pain conditions arise as a result of over using certain muscles in the gym, or in a hobby or work activity where the same activity is carried out repeatedly over time.
Janine’s leg pain was one of the simplest I’ve ever had to treat. Simply reducing the tension in her gluts and piriformis muscles with osteopathy, a specific stretching yoga program and a complete re-education about her gym regime was all it took. If you attend the gym a lot, try to ensure a balance between strengthening and stretching if you want to avoid unnecessary aches and pains in your body.
The Man Who Hadn’t Sat Down For 20 Years
Somewhere between bathroom mirrors and indoor plants in Ikea, Irfan and I discovered chairs. (Irfan was a DJ in Manchester with a penchant for interior design). After much heated discussion, dime bar cakes and free Ikea ‘family card’ coffee, we decided on the black garden chairs with the arm rests - partly because they fitted in with Irfan’s ‘vision’ for the décor in my waiting room (it was my very first clinic - very exciting), but mainly because they had ergonomically designed backs and bottoms that would provide my patients with enough pain relief to keep them from shouting at my poor receptionist Shirley, who spent her life fending off grumpy patients in pain.
After all this effort, imagine my dismay when I opened my treatment room door the following week to find my next patient standing, not sitting in THE CHAIRS.
‘Hector’ (why not?!) came into my treatment room, and refused my offer of a chair. It was too much to take.
“Is there something wrong with the chairs?” I asked (genuinely concerned that perhaps the chairs were not comfortable!, trying not to appear like a paranoid woman ridiculously attached to her great chair choice).
“No not at all” he replied. “they are lovely chairs Coby. I just haven’t sat down for 20 years”.
After choking on my Starbucks Latte and wondering if I should throw the crazed man out right there, he continued with his genuine and heart rending story of his 20 year battle with unexplained, un-diagnosed lower back pain. He described a life of having to eat his dinner on an inflatable exercise ball, and eat in under 15 minutes so he could stand up before the pain got too bad.
It was his wife who really pulled at my heart strings - she had dragged him into my office because whilst she was happy to accept that fact that for 20 years their restaurant choices had been based on the softness of the chairs rather than the food options, they had recently decided to purchase a new car and were having to decide based on the chairs, not the engine size, fuel efficiency… all the usual reasons for choosing a car. It was all too much for her and she decided, as a last resort, to turn to an osteopath.
I was just happy that there was nothing wrong with my chairs. After that it was all plain sailing for me. Nothing could be worse than my patients not liking the black chairs, so as his wife lounged comfortably everything was good. On assessment I found an extreme muscle imbalance through his core and movement muscles, resulting in concrete-resembling muscles in his low back and gluteals (bum cheeks).
I often find that the most extreme cases of back pain are the simplest to resolve, and those that have been around the longest respond the quickest. It’s all about rebalancing muscles in the back that are doing the wrong jobs. Hector had been a JCB driver, (before taking early retirement due to no longer being able to sit in the JCB cab). He was signed off, and put through the usual process of scans and blood tests etc... to no avail.
My diagnosis was that it seems the vibration of the cab had slowly tightened his back and bottom muscles to the point where he was just in complete agony with... tight muscles. A few treatments of elbowing the muscles into submission and a yoga program to rebalance his back muscles and maintain the results and Hector was pain free and eating dinner on a normal chair. I regularly remember this case to motivate me to keep writing and keep putting out yoga programs, because so many people are suffering unnecessarily.
After falling head first from the top of his camper van ‘Hercules’* managed to catch hold of the roof rack that he had been busy tying his 25 year old boat to. (It really should have been in a museum, but try telling Hercules that). Swinging in the sun from one arm, feet dangling 4 foot from the ground, Hercules wondered to himself whether he might have damaged anything. He had.
In true male form, Hercules waited until he could not raise his arm above his chest, had lost power and grip to the point where he could no longer open a jam jar and was living with 8/10 arm and hand pain before seeking my help. I referred him for a scan which found a tendon in his shoulder to be hanging on like a silk thread...
One successful operation later, Hercules disappeared back into his camper van for his travels to the Greek islands... without allowing me to assess him post-operatively.
”It’s all better now…see you at Christmas”... was the email I received. I shrugged my shoulders and thought “He’ll be back”.
Piece of advice people... when an osteopath says to you “it’s not better yet... your treatment plan is not complete”... believe them!
Sure enough Hercules returned to my clinic 10 months later. Given the all clear from the surgeon and signed off from physio with a fully functioning, full range of motion, power and strength, shoulder. Good as new... Except Hercules now had the same arm and hand pain, plus headaches and neck pain on top. He had also lost 50% of the mobility in his neck and was now experiencing regular headaches. He had been advised nothing further could be done and he now had to live with the pain in his arm and hand, as the shoulder was now fixed and fully functioning. Had Hercules not been an avid wind surfer and rock climber he may have accepted his fate, but since he was home for Christmas he popped in to see me to ask if any of his pain could be treated.
What to do?
On assessment I too found he showed full power, grip and range of motion in his shoulder and hand – his nerves were fine – so why was he still in pain?
Further prodding and poking revealed that the muscles in Hercules’ neck, arm and hand had tightened up like concrete. They were so tight that they were literally pinching the nerves in the upper arm and forearm and referring pain into his arm & hand. The tension in his neck muscles had literally stopped him being able to move his head and neck.
The body is extraordinary. When you have a situation like a tendon in the shoulder rip off the bone, the surrounding muscles in the arm, neck and shoulder all kick into action to compensate and allow you to perform the same actions with your arm. You can actually function fairly normally for some time in this way, which is why it took so ling for Hercules to seek help. Sometimes however, they forget to relax, leaving you with more pain than you started with.
Explanation of Hercules post-operative pain
After a tendon is corrected and re-attached to the bone, the patient experiences a lot of pain at the incision and operation sight, from inflammation and tissue healing. To avoid placing pressure through the operation site, the patient will tighten the neck, shoulder and arm muscles around the operation site, so that the muscles do all the work, rather than the tendon. This is normal procedure for healing.
Unfortunately, sometimes, once the tendon is completely healed, the patient has now developed different compensatory patterns of movement, and continues to move in a way that avoids using the tendon. As a result the neck, and arm muscles become over-used, and also used in ways that they were not really designed for. If muscles are over used, or used in ways they were not designed, they tighten and shorten, and eventually fatigue, causing pain, headaches, and restriction in movement.
After giving Hercules immediate basic osteopathic treatment to reduce the tension in the muscles of his arm and neck, I gave him an exercise program to re-balance the muscles in the neck so that they transitioned from being tight, painful muscles, to being strong and balanced. The program also developed core stability in his neck and released and mobilized his upper back – taking the strain off the shoulder. Had his upper back and neck been left as restricted as they were, this would place a lot of strain through the shoulder, and would possibly result in a re-occurrence of the original tendon injury.
Hercules is now pain free, headache free, and has full neck and head mobility. He does however, practice his muscle balancing exercise program regularly, and attend osteopathic ‘MOT’s‘ twice a year.
Never give up!
The Case Of The Unusual Headache
Men prefer to get lost rather than ask for instructions right? Transfer that attitude to an osteopath’s clinic, and you discover that men don’t seek help for pain until they are in so much pain they can hardly walk straight.
One such man zig zagged into my clinic one day complaining of stabbing head pains, hardly able to see though his half opened eyes. The difference here was that he had actually sought the advice of a Doctor, over a 2 year period - MRI scans, CAT scans, and a whole list of investigations later resulted in him landing on my treatment couch without a diagnosis. He was unresponsive to all headache and migraine medication and his pain was getting worse. Great. Welcome to the life of an osteopath!
A familiar experience for an osteopath is that people in extreme pain rock up to us as their last choice of treatment - ask any osteopath and they will tell you that this is the case. This makes our life very easy, because with zero expectation, anything that osteopathy achieves is seen as a bonus. What I don’t understand though, is why after repeated, consistent, effective resolution of pain conditions, it remains the last choice of treatment.
I actually like ‘hopeless’ cases like this, because there is absolutely no expectation of me whatsoever. I am literally allowed to say “Ok – I’ll have a look, poke around and see if I can do anything to help”…and if I achieve nothing, nobody minds. Happy days. Also, it is in these ‘hopeless’ undiagnosed cases that osteopathy and exercise prescription tend to excel because the cause is very often musculoskeletal which is why the patient fails all tests. I often say to my patients that turn up with a story of extensive investigation and no resultant diagnosis that this is the very best diagnosis in itself - because you have ruled out all ‘serious’ causes of pain, leaving you with mechanical, which is resolvable.
What I love about osteopathy is that we treat what we find. We don’t assume a particular pain is being caused by a particular structure – because it rarely is what you expect. You have to assume the role of detective, and approach the problem with no expectations or assumptions of what is causing the pain. You just assess body, assess past history, assess current occupation and lifestyle, and piece all the information together like a jigsaw.
This particular patient - I’ll call him John - loved his job - he was a camera man with ITV down the road. He was 42 years old with an active outdoor pursuits lifestyle - so he was fit, relaxed, and happy. Not the usual picture for headaches. Getting random stabbing agonizing head pains was starting to affect his ability to do his job. After a complete osteopathic assessment, with a completely clear medical history (no operations, no falls, no whiplash, no hits to the head, no anxiety) - I could find only one thing that warranted treatment - tight neck muscles. When I say tight though, I mean ‘bounce-your-basketball-off-them’ tight. There were little balls of muscle tension along his neck muscles (we call these trigger points) that would actually re-create the stabbing head pains when I touched them. The muscle tension was double on the side that he held his camera.
Surely it couldn’t be this simple - it was too simple to be true. Migraine level head pains being caused by tight neck muscles? We are trained to only treat that which needs treating - if it ‘ain’t broke, don’t touch it. And in this case, even though John was in so much pain, his body was fit and healthy. So I reluctantly, feeling a little embarrassed, told him that the only thing I could find ‘wrong’ was this elevation of tension in his neck muscles.
I released his neck muscles with osteopathic techniques, and gave him a program of yoga exercise to stretch out his neck muscles, strengthen his neck muscles, and re-establish core stability in his neck.
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