Question
QUESTION: Hello. I am a very active (military) 27 year old male. I have sustained a left hip injury that initially presented with acute pain where the piriformis attaches to the hip joint as well as knots in my glute (that when manipulated produced a tingle sensation down my leg), extremely tight QL's and deep lateral rotators as well as knee pain. As I am currently trying to change roles from pilot to a very arduos, weight-bearing job, an MRI scan was ordered as part of a thorough investigation with the following findings: All discs in the lumbar spine and in the lower thoracic spine are extremely well hydrated and essentially unremarkable except for the disc at the level L5/S1 which shows evidence of mild and early disc degeneration and mild disc bulging.  At the level L5/S1, this mild disc bulging is prominent in the left paracentral location and is causing mild contact to the traversing left S1 nerve root at this level.  There is no evidence of neural deviation or compression of the traversing left S1 nerve root despite the presence of mild and early contact. Questions: Is there any significance to this finding or is it well within the 'normal' range? Should it prohibit me from changing roles? What is the significance of 'mild contact' and 'mild disc bulging'? They are trying to write-me off and stop me from changing roles.... should I fight this or give in? Thank you in advance.

ANSWER: Jamie,

Odds are the L5 disc lesion is driving your symptoms and causing the "protective tensioning" of your QL and buttock muscles.  There is a chance it is not the only etiology.  You could also have adhesion formation around the nerve root or along the portion of the sciatic nerve in the buttock area.   The best treatment would included flexion/distraction (some people do well with this and some don't) and chiropractic joint manipulation, active myofascial release to the buttock area, and neuromobilization in case you have nerve sheath adhesion.   A good dynamic physical examination will help uncover if there is any root irritation or nerve adhesion.  If the doctor has no training in how to detect this, then obviously the diagnosis will be that there is nothing wrong...   You can't find something that you don't know how to find...   There usually is no correlation between MRI findings and physical ability, and without severe degenerative findings or "Modic Signs" then you cannot predict physical disability or impairment.  

'Hope this helps.

Dr. G

---------- FOLLOW-UP ----------

QUESTION: Wow, thank you for such a quick response. Just a few more questions for clarification if you don't mind... the military Docs have already got their teeth into this one and are incredibly risk averse.  They are suggesting that this injury, given the fact that I will need to be very mobile with 80lbs on my back, will degenerate further and cause have serious implications.  Given the very 'mild' nature of the findings would you agree with this? Also, a lot of articles seem to suggest that this isn't a particularly amazing discovery for an active male of my age and could well be present and un-detected in any number of my colleagues. Would you agree? Finally, if this was causing the pain in my hip area, would I not get radiating nerve pain specifically down my S1 pathway and all the way to my extremities (even if the disc is just 'touching' the nerve and not compressing it)? Will it get better or is that me for life now? At the end of the day, it is all down to percieved risk and exposure... There is always risk in the military but am I on a hiding to nothing? Thank you so much for your help with this.. it is causing me a great deal of worry.

Answer
Jamie,

I would ask that your doctors do a prone instability test (PIT) on you. See:  "Hicks, G. et al; Arch Phys Med Rehabil Vol 84, December 2003; Interrater Reliability of Clinical Examination Measures forIdentification of Lumbar Segmental Instability."   If you have a (-)PIT, and you can bend, twist, lift, etc with no pain, then I would call you fit for duty regardless of what the MRI says.  Do you think your peers are without degenerated/bulging discs?  'Jumping out of airplanes with packs?  I'll bet there's lots of disc bulging and degeneration...   Usually S1 nerve irritation will refer into the calf and sometimes into the hip/groin.   If there is no compression or chemical irritation to the nerve, then there will be no radiating symptoms.  The degenerated disc itself can cause a referred pain into the buttock and thigh.  This is called a "sclerotomal" pain pattern.  Functionally, they should evaluate you doing alternating lunges to assess function of your hip/knee/ankle dynamically.  Weak hip rotators will affect your knee, including how much the knee (tibia) rotates inward.  Weak hamstrings will show up as a forward bending torso on lunge, as the hamstring fails to pull you from the ischial tuberosity.  If any of these are at a deficit, then they need to be trained.   If you have a (+)PIT, then you must focus on core stability exercises.  Also, with a (+)PIT, your prognosis for going in the field is less favorable, in my opinion.

'Hope this helps.

Dr. G