Need help with a diagnosis

Triathlon Forum
1

Ok guys, I am pretty much at my wits end here and was hoping someone might have some insight about what I’ve been dealing with.

The below is mostly a repost from something I posted at roadbikereview in April of this year. I got a lot of helpful advice back then, but my situation has not improved. Initially I thought I had piriformis syndrome but after months of piriformis specific stretching I have not improved.

A little history- I am 40 years old and started riding “seriously” in 1999, first mountain biking for a couple years and then moved to road only after 2002. At my peak I was riding maybe 100-120 miles a week so not a huge load by any means. In 2004 I started doing Sprint Triathlons and did that the next 3 years for a total of about 8-9 races. 2006 was my heaviest year as far as training load and I finished the tri season in Sep 06 with some good results.

In October of 06 I did a half marathon and then took some time off because I was feeling burned out. A planned 2 months off of training became 6 months off. I began some half hearted training for the 2007 season, but my first and last Tri that year was in June. I pretty much stopped most training after that except for the occasional ride every few weeks.

In April of 08 I started having low back pain which has continued now for a year. Its evolved from just simple lumbar pain to the inability to sit for more than 15 mins without serious pain upon standing. The pain is now also in my right hip and shoots down my right leg causing pretty intense pain when I stand or rise from lying down. The worse thing is attempting to extend my right leg straight while sitting.

Medical history- MRI shows mildly bulging discs at L4 and L5 and mild arthritis, Doc says my MRI results are not consistent with the amount of pain I have. Xray of my sacro-iliac joints shows mild arthritis in SI (sacroilitis) but nothing major.

I’ve had a cortizone injection directly into the SI which didn’t help (hurt like a mother though) Blood tests show nothing abnormal, no abnormal inflammation on CRP serum. I’ve tried physical therapy which is focused on balancing my core as the PT said my pelvis is tilted/ higher on right side.

I’ve also tried Acupuncture, yoga and stretching. The only thing that really relieves the pain is standing instead of sitting and anti-inflammatories like Motrin Naproxen which I’ve been on for way too long. I am also taking vicodin now.

Jim

**update for August 09- I’ve now had a 2 more injections. One in the piriformis muscle and one in the lumbar spine region. I got fairly decent relief for about 7 days after the piriformis injection (70% reduction) but it wore off right away. The lumbar spine injection did nothing. I’ve learned to stay consistent with taking anti-inflammatories, but as soon as I hit the 8 hour mark my pain returns. If I stay off them more than a day I am almost in the exact same situation as I was at the start of all of this. I’ve been on these drugs for way too long and am concerned about long term impacts on my liver, not to mention I dont like taking Vicodin at all.

I have another appointment with my doctor tomorrow (I am in an HMO) but frankly it seems that traditional medicine seems clueless in resolving this kind of nerve pain. They can treat the symptoms but not fix the underlying issue.

On the bright side I have began to get some benefits from yoga. I go for 2.5 hrs once a week and feel looser and my lumbar pain is gone at this point. The sciatic and hip pain is the same as always unfortunately. I now have tingling in my right foot and calf now which is new. I also have pain deep in my right buttock.

Getting back to racing tri’s would be great…so any help would be greatly appreciated.

Jim

2

? Piriformis Syndrome - as you alluded to. Seems like there are lots of avenues to target re: PT/hip stretching/strengthening…

Dave

3

I think I’ve tried every piriformis stretch there is…I guess its possible I am not doing them right but dont think so. Also done core strengthening and hamstring stretches very consistently for over 4 months as prescribed by the PT (she’s a triathlete also)

4

Jim,

Not to sound too sadistic, but I like this! Seriously though, I enjoy challenging situations like this…

You mentioned that your physical therapist noticed that one side of your pelvis is higher than the other; did your PT try to correct this? Do you have pain predominantly along the front of your thigh? Did your PT conduct a thorough sacroiliac assessment? Any sacral torsions?

Do you happen to remember what initially caused your pain? did you step off a curb awkwardly? Fall? What’s your occupation? What other special tests did your PT perform? What does your PT think overall?

Sorry for all the questions…I like the challenge and would like to see you get well.

Mark

5

Pain management / treatment can be a very tricky thing, especially if you have been dealing with it for a while. Pain associated with one problem typically leads to another problem with a new pain associated. The fact that you are getting some relief is a good sign. Some pain relief shows that you are treating the right area but maybe not the exact right location. I think that the best way to approach this is to seek enough pain relief to create a window of opportunity for PT and possibly massage.

Regarding the bulging disc’s: Did you every get a Discogram to determine if the disc is a source of the pain? Just because the bulge in the disc is not significant enough to warrant concern doesn’t mean that the disc isn’t a contributing factor.

SI Joint Injection: Si joint pain is not well understood. There are many approaches to treating pain in the SI joint, one of which is an injection into the joing itself. They can also target the nerves at the SI foramen (S1-S4), and many also feel that you need to treat the L5-S1 dorsal rami as part of the overall treatment as well.

Radicular Pain down the leg: This usually indicates nerve involvement from L4, L5 or S1. This could be due to nerve intrapment from a leaky disc, which would lead me back to doing the discogram. This would help diagnose the pain as well as the potential for disc leakage. Discograms can be very painful in that they can recreate your pain but are a very good diagnostic tool.

As I mentioned in the first paragraph try to look at pain managment success in terms of creating enough relief to open a window for rehab / PT. Most people think that if the pain doesn’t totally disappear then the procedure was not a success. I know someone who delt with severe radicular pain from the cervical region. She was able to get enough relief from her injections to start massage therapy and PT. Each time the pain came back it was less severe to the pain now where she has not needed an injection in several years.

I would keep trying to narrow down the diagnosis to find what works. Maybe you need to meet with another pain physician to get another set of eyes on the problem. Let me know where you are located and I might have some names for you. Good Luck

6

Maybe I’m just a freak, but I have labral tears in my hip that cause pain to radiate down my leg and up into my back. They seem to be one of those injuries that cause a variety of symptoms in strange places. Have you had anyone do an MRI with contrast of your hips?

7

Mark, thanks for your reply and your “sadistic” viewpoint. That may be just what I need!

Today I had the appointment with my general practitioner and he did some evaluations and believes that I do not have piriformis syndrome based on what he did. He moved my leg from side to side and had me resist his pulling and I had no pain. However lifting my extended right leg straight up made me yell out and he sent me for an xray to rule out avascular necrosis in my right hip. I didn’t know what that was so I read the wikipedia page on it while I was waiting for the xray. I now understand that it is basically bone death from lack of blood flow. He wants the pros to read my xray but when he saw it he didnt think I showed signs of avascular necrosis. Which is a relief!

In response to your questions: The PT I saw gave me a series of strengthening and stretching exercises which she said would stabilize my pelvis but that it would take months. I’ve followed them religiously for probably 6 months now. I’ve only seen her once, she told me (to my surprise) that she was not big on follow-ups. When I saw her she instantly homed in on the pelvis and focused on that almost exclusively. I contacted her after about 16 weeks and she told me to stay the course with the exercises and that I should improve eventually.

I have no pain in the front of the thigh, its deep inside in the middle, or towards the back but definitely not the front.

The PTA did not do a thorough sacroiliac assessment or any sacral torsions.

I cant pinpoint any specific reason for the pain, there was no one thing that happened where the pain started by any means. I have had bouts of low back pain for about 10 years, usually once a year which would self resolve within a week at most. I did crash hard on my right side during a mountain bike race in 2001. This episode of pain didn’t start until about a 1 1/2 ago however.

My occupation is telecomm engineer, and I spent a lot of time sitting in front of the computer. I now have a very nice ergo chair and sit/stand desk and I alternate as much as possible. I have been in this type of job for 10 years. Thats a lot of sitting.

The PT did not perform any other specials tests, in fact that one appointment is the only time I’ve seen here. It seems that being in the Kaiser system may be limiting the amount of attention my problem needs. So I might need to seek help outside the Kaiser plan on my own dollar. I did see a “somatic” guy once who dug DEEP into my pelvis/hip abductors. He told me that my abductors were inflamed which were pulling on my piriformis, which in turn was pulling on my sciatic. No improvement from that treatment however.

Thanks in advance for any advice you may have. Jim

8

I dealt in the past with similar deep glute pain (and am currently dealing with hamstring injury). Anyway, simply stretching did not make it go away, i had to massage out the area: what helped me was foam rolling the area, and for the glute deep part i used a tennis ball–it does hurt so be prepared to sit on the ball–you can use your hands to push on the ground to reduce your weight, you may need to put the foot of the bad leg across the top of your good leg knee to hit the right spot with the ball.
if it turns out his is all due to nerve impingement up in your spine, then this won’t help unless pain has made you alter your gait etc and you have some muscle/tendon tightness as a result.

good luck
jim

9

In reply to your post climbwalz.

I agree totally about how tricky the treatment can be, it just gets frustrating and after a while I think “why cant they just fix me” I know that is not realistic… And the pain is not consistent, it varies over time and can be hard to characterize at times also.

I have not had a discogram, I remember seeing something about them during my many hours surfing the internet searching for ideas but my doctor has not suggested one yet.

How do they target the nerves at S1-S4, is that also an injection? My epidual spine injection was in the L5 area. I am located in Sacramento,Ca. in case you happen to know anyone out here that is good.

Thank you

Jim

10

I’ll throw out my differential here as well:

My first direction would be repositioning the pelvis. Some PT’s are good at this, some don’t do it at all. What about extension based movements. Beyond stretching, have you done any hip strengthening stuff? I know you said core, but this hips are part of “core” as well. Since you can’t handle sitting, and I’m guessing you’re not in your sixties, what does extension do for you? I’m talking about prone press up type stuff 20x5 second holds or something along that order (not just one back bend). Another consideration would be sports hernia. There are 20 something varieties, but any pain at your pubic symphysis? any problems with pelvic floor issues (leakage front or back) problems starting, stopping, retaining urine, that kind of thing?

I’m assuming you’ve been cleared for bowel/bladder dysfunction, systemic type things?

Phil Gregory, DPT, CSCS, FOS, YMMV, ineedmorelettersattheendofmynametoprovei’mlegit :wink:

11

Phil,

I have not done any hip strengthening. I will look into that. Is this the prone press you mentioned:
http://www.dcdoctor.com/pages/rightpages_wellnesscenter/homeexercises/back/exercises/exer_back_ex_pronepress.html

A while back I used to have pain in the pubic region, I felt it was more in the left testicle area more than anything. Currently I dont have any pain in the pelvis at all. No problems with urinating at all.

I havent been cleared for bowel/bladder dysfunction but my doctor did ask about that at the beginning and told me if I ever have problems with control that its considered an emergency.

Thanks for your reply.

Jim

12

Thanks Jim. I actually have a TP massage ball and have been using it for a while. It hurts like a mother! I think I’m hitting the right spot.

13

No they havent done a MRI of the hip, just the spine. But I will push for one if necessary. Kaiser doesnt do much without a push.

14

I agree with about the press ups. If you have been in a flexed position for a long time i.e. riding and sitting at work, some extension or McKenzie based PT application might be in order. If you can see a PT that will spend more than one visit with you and consistanly re-assess your situation that would be the way to go. Good Luck!!

15

I like the fact that you have several clinicians involved here…

The bottom line: first, shame on the PT for only seeing you once. Maybe this was more of a Kaiser thing but nonetheless, you didn’t benefit from the so called “treatment.” What needs to happen is to have a PT who utilizes manual therapy along with therapeutic exercises evaluate and treat you. So if there is a mis-alignment of your pelvis, they can work towards aligning you AND stabilizing you with various exercises. In my opinion, the resolution is usually a combination of things, all of which have been suggested by the PT’s addressing your problem.

Where do you live? California? Maybe one of us can suggest a knowledgeable PT to go to…

Mark

16

Sounds like a potential l4,l5, s1 nerve root problem-? disc herniation aka protrusion/extrusion ? stenosis or degeneartive (bulge unlikely to cause a problem unless you have other issues/stenosis). If it’s been more than 6 months since your prior MRI and your not getting better, see about getting another MRI and ,maybe a second opinion from a spine doc (neurosurg or ortho). Discograms aren’t all that-not neccessarily as useful as once thought especially for radicular (leg) symptoms. Doesn’t sound like piriformis syndrome. Any suggested PT or exercises may help but I’m skeptical they’ll solve the problem. …as always get real advice from your doctors.

17

Mark,

Yes i live in Sacramento Ca.

And you are absolutely right, the advice I am getting from everyone including yourself is invaluable and I really appreciate everyones input.

As a matter of fact, damons reference to McKenzie method above prompted me to go to the McKenzie website and I see two PTs on the list who are local to me. One of them appears to be with Kaiser, which would be great if I can see her through Kaiser instead of out of pocket.

Still definitely hoping to hear if anyone knows of someone local who is recommended.

Jim

18

Hmmm…“real” advice from doctors? I think it’s a healthcare team approach. Of course I am protective of my profession but I have seen referrals from doctors (specialists) where the diagnosis has been incorrect. Several opinions are important, yes, but there are very knowledgeable PT’s AND physicians.

19

Many opinions here…the important thing is to find a physician and PT that will take the time. Several things need to be ruled out before a clinician can hang their hat on the actual diagnosis. If pelvic alignment is good, then maybe this can be ruled out…then move to the next. A good clinician will implement several diagnostic tests whatever they are. More times than not, it is usually not just one thing, but actually a few.

I think the first step is to find a physician to work with…a specialist is ideal, either ortho spine or neursurgeon. Before you can see a PT in California, you will need a prescription (as you probably know) and then we can make referrals to other PT’s. I know a PT in the Sac area so I will talk to her and maybe she has some ideas for physicians.

Mark

20

Lighten up Frances… You misinterpreted my quote: Should have said YOUR doctors and healthcare team (including PTs, which of course are helpful). I was only telling the OP to largely rely on the advice from HIS healthcare professionals (goes without saying) who have much more information regarding his situation including the benefit of actual personal contact with him and his evaluation/studies. Getting diagnoses or treatments based on forum discussion may be helpful, but may be harmful as well.
By the way, I personally believe surgery is an absolute last result but an ortho or NS 2nd opinion may help in establishing a diagnosis.

Long live PT and core exercises.