Question
QUESTION: Dear sir,

I am 23 and have been weight-lifting for about 3 months.  Exactly two days ago I injured myself doing traditional mixed-grip deadlifts.  On my 4th set and 6th rep, at the top of the movement, I felt a pain on the right side of my inner-lower back.  Immediately after I would feel a very sharp pain any time I would try to put any pressure on my lower back that radiated into my butt by bending.    I lowered the weight, left the gym, and iced the area immediately.  I've been taking Naproxen for the past 2 days (twice a day) and trying to keep off it as much as possible.  Driving is the worst because the pain is aggrevated most when sitting (unless my back is completely straight.)  Now, two days after the injury, the pain is pretty much localized in my butt anytime I bend.  I feel a general tightness in my lower back (which is what I usually feel after deaedlifts) but the real pain is in my buttocks and sometimes radiates down my leg.  I have regained a slight bit of motion back but the pain is almost the same if not a bit more dull and slightly less sharp.  

What would you advise me to do in order to recover and stay healthy?  

Sincerely,
Steve


ANSWER: Dear Steven,

The most common weight lifting injuries are muscle strains and ligament sprains, so I wouldn't get too worried about this yet.  Give it a few more days of rest and light stretching without weight lifting and monitor your pain levels.  

If the pain persists and is not showing signs of improvement, then I would suggest that you go to a chiropractic physician and have them evaluate the lower spine for joint dysfunction in the facet joints (spinal joints), evaluate the disk, and especially the sacroiliac (SI) joint.  It is most likely that you have injured/irritated the SI joint with the pain you have described, however, disk injury and facet joint injury can follow the same pain distribution.

Now that being said, the fact that you are young and healthy is favorable, and you will probably recover from this very well.  When I see acute SI joint injuries in my clinic, they are usually not severe, and respond quickly to adjustments and stability exercises.  So I would not expect that you will need a lot of care, and you should feel much better in 6-8 visits.

Lastly, concerning dead lifts, power clean, and clean and jerk type lifts, I do not recommend them to most people even young healthy ones.  The reason is that the majority of people performing these lifts do so incorrectly and wind up injuring themselves.  These lifts are absolutely great for building strength, mass and explosive power, but they are complicated lifts that require strict form.  If you have only been lifting for three months, then I would suggest that you hire a certified personal trainer or strength and conditioning specialist to train you on technique and monitor it until it is perfect.  This way you will hopefully n o re-injure yourself.  You an find qualified instructors around the country at the National Strength and Conditioning Association website:  www.nsca-lift.org  Good luck.

Respectfully,
Dr. Shawn Leatherman
www.suncoasthealthcare.net

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

QUESTION: Hello again Dr.

It's been two months now and my back has been getting better very slowly everyday but for the past two weeks or so I feel as though I haven't progressed further.  I no longer have any radiating pains (those went away completely after two weeks) but as I stand now I have somewhat sharp pains in various parts of my butt and lower back (different areas at different times) and my lower-back in general feels tight.  

I went to a doctor one week ago, they took 3 x-rays of my lower-back and told me there were no abnormalities and my pain was very likely due to muscle damage.  I asked my doctor about referring me to a chiropractor and she didn't recommend it since "it's muscle damage, there isn't much a chiropractor can do."  She put me on Naproxen and a muscle relaxant and told me to use a heat pack twice a day and do some light stretching.  

What is your advice for me?  How do you feel I am progressing and should I really push for a chiropractor during my next visit?  I'm going back this coming Monday so any advice would be greatly appreciated.  Thank you for your time and advice.

Sincerely,
Steve  

Answer
Dear Steven,

First of all, print this out it is lengthy.   

Okay, you do not need a referral from your medical doctor to see a chiropractic physician.  Most MD's don't know any chiropractors, what chiropractic entails, or when it is appropriate to refer to a chiropractor anyway. The fact that she thinks that muscle pain is the cause but doesn't think chiropractic can help proves her lack of education concerning chiropractic manipulation and associated care procedures...the majority of chiropractors utilize muscle work techniques on their patients.  However, I do agree that you should be utilizing heat and gentle low back stretching.  Some techniques chiropractor utilize to specifically address the muscular system are Graston technique, Active Release Technique (ART), SASTM technique, and others.  You can look all of these up on the internet for detailed explanations.

Chiropractors are considered to be primary care physicians in all 50 states, so you can go on your own.  Not to mention large governmental research studies have found that chiropractors analyze and diagnose spinal conditions with a high degree of sophistication.  . If the x-rays that your doctor took were in the standing position, then take them for the chiropractor to review and that will save you some money.  If they were taken lying down then they are absolutely worthless for biomechanical evaluation.  I would suggest that you look for a chiropractor with a certification inn sports injury or a chiropractor who has advanced training in sport injury or orthopedics.  Check out www.acbsp.com for help in finding a sports certified chiropractor in your area.

If the pain has persisted for this long then I would recommend that you have a chiropractor evaluate it.  The fact that you have continued sharp pain indicates that muscle dysfunction is not the only problem. Muscles heal very well when injured, and 6-8 week is more than enough for the tissue to have healed if this was only muscular.  From what you have described, you probably have sacroiliac joint dysfunction (SI), and this should be analyzed.  This has probably not been done to this point.  Most MD's do not examine the spine functionally with physical testing (orthopedic tests), and even fewer examine the SI joint.  I am going to attach some research for you to appreciate.

The Role of Sacroiliac Joint Dysfunction in the Genesis of Low Back Pain: The obvious is not always right
Archives of Orthopaedic and Trauma Surgery
December 2007 [e-pub]

Natan Weksler, Gad J. Velan, Michael Semionov, Boris Gurevitch, Moti Klein, Vsevolod Rozentsveig and Tzvia Rudich

FROM ABSTRACT:
Background context:  It is a common practice to the link low back pain with protruding disc even when neurological signs are absent. Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, we assumed that the diagnosis of sacroiliac joint dysfunction is frequently overlooked.

Purpose:  To assess the incidence of sacroiliac joint dysfunction in patients with low back pain and positive disc findings on CT scan or MRI, but without claudication or objective neurological deficits.

Methods:  Fifty patients with low back pain and disc herniation, without claudication or neurological abnormalities such as decreased motor strength, sensory alterations or sphincter incontinence and with positive pain provocation tests for sacroiliac joint dysfunction were submitted to fluoroscopic diagnostic sacroiliac joint infiltration.

Results:  The mean baseline VAS pain score was 7.8.  Thirty minutes after infiltration [of the SI joint with anesthesia], the mean VAS score was 1.3. Forty-six patients [out of 50] had a VAS score ranging from 0 to 3, eight weeks after the fluoroscopic guided infiltration.

Conclusions:  Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients.

THESE AUTHORS ALSO NOTE:
揕ow back pain is second only to common cold as a cause of primary care office visits in the USA.?
揂pproximately 90 of adults have experienced back pain at some point of time in their lives.?br>
Low back pain is responsible for direct care expenditures ranging from $5 billion to more than $20 billion annually and as much as $50 billion per year in indirect costs.  Medical residents are not usually taught to consider sacroiliac joint dysfunction as a cause for low back pain.

This study used 200 patients with low back pain who were prior treatment failures from NSAID drugs, physical therapy and intramuscular injections. They were fluoroscopic guided injected with a combination of anesthetic and steroid into their SI joints.

DISCUSSION:
揅hronic persistent low back pain is commonly linked with positive disc findings on CT or MRI imaging. However, these imaging techniques are not always helpful, because they have a poor degree of correlation with clinical signs.? 揑t is not rare to have positive disc findings in asymptomatic patients.?br>
揘early 25 of asymptomatic individuals below the age of 60 years and 33 of older patients have evidence of disc herniation on MRI scans? 揟he diagnosis accuracy of the tissue origin of chronic low back pain and referred lower extremity symptoms based on clinical criteria are about 19?4.?[In medical practice]  Estimated prevalence of SI joints causing low back pain is 13 to 30.

揟he SIJ has a rich nociceptive innervation.?Its anterior portion is innervated by the posterior rami of the L2朣2 roots, and its posterior aspect is innervated by the posterior rami of L4朣3. [IMPORTANT]

The piriformis muscle is located close to the SIJ, originating at the anterior aspect of the sacrum and inserting into the greater trochanter of the femur. SIJ problems can cause piriformis spasm and provoke sciatic irritation, with 損ain radiating to the buttock, the posterior calf, and to the anterior and lateral calf and foot mimicking radiculopathy.?[IMPORTANT]

揟he current gold standard for the diagnosis of the SIJ syndrome is fluoroscopically guided infiltration of local anesthesia leading to at least an 80 reduction in VAS scores.?However, three physical tests showed good correlation with the diagnosis of SIJ dysfunction: SIJ compression test (94
greement), the thigh thrust test (90) agreement, Yeoman抯 test (88) agreement. [IMPORTANT]

Studies have 揷oncluded that manipulations appear to be successful in many patients suffering from SIJ dysfunction?

CONCLUSIONS:
1) The incidence of SIJ dysfunction in patients with low back pain and discopathy on CT or MRI scans and without neurological deficits appears to be higher than previously described.
2) Pain in SIJ dysfunction can radiate towards the calf and foot mimicking radicular pain.
3) 揚hysicians seeing patients with low back pain should have a high index of suspicion for SIJ dysfunction, especially in the absence of neurological deficits.?

KEY POINTS FROM SUNCOAST HEALTHCARE PROFESSIONALS
1) Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, the diagnosis of sacroiliac joint dysfunction is frequently overlooked. However, chiropractic physicians are specifically trained to evaluate SIJ function along with lumbar spine function. [IMPORTANT]
2) 揕ow back pain is second only to common cold as a cause of primary care office visits in the USA.?
3) 揂pproximately 90 of adults have experienced back pain at some point of time in their lives.?br> 4) Medical residents are not usually taught to consider sacroiliac joint dysfunction as a cause for low back pain. [IMPORTANT]
5) 揅hronic persistent low back pain is commonly linked with positive disc findings on CT or MRI imaging. However, these imaging techniques are not always helpful, because they have a poor degree of correlation with clinical signs.?br> 6) 揘early 25 of asymptomatic individuals below the age of 60 years and 33 of older patients have evidence of disc herniation on MRI scans?br> 7) Estimated prevalence of SI joints causing low back pain is 13 to 30.
8) The SI joint has a rich nociceptive innervation by the posterior rami of the L2朣3 roots. [IMPORTANT]
9) The piriformis muscle is located close to the SIJ, originating at the anterior aspect of the sacrum and inserting into the greater trochanter of the femur. SIJ problems can cause piriformis spasm and provoke sciatic irritation, with 損ain radiating to the buttock, the posterior calf, and to the anterior and lateral calf and foot mimicking radiculopathy.?[IMPORTANT]
10) 揟he current gold standard for the diagnosis of the SIJ syndrome is fluoroscopically guided infiltration of local anesthesia leading to at least an 80 reduction in VAS scores.?
11) Three physical tests showed good correlation with the diagnosis of SIJ dysfunction: SIJ compression test (94
greement), the thigh thrust test (90) agreement, Yeoman抯 test (88) agreement. [IMPORTANT]
12) Manipulation is successful in many patients suffering from SIJ dysfunction. [IMPORTANT]
13) The incidence of SIJ dysfunction in patients with low back pain and discopathy on CT or MRI scans and without neurological deficits appears to be higher than previously described.
14) Pain in SIJ dysfunction can radiate towards the calf and foot mimicking radicular pain. [IMPORTANT]
15) 揚hysicians seeing patients with low back pain should have a high index of suspicion for SIJ dysfunction, especially in the absence of neurological deficits.?br> 16) Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients.

Hope this helps Steve...find a good chiropractic physician to address this.  Even if the SI joint is not the main problem, spinal manipulation is the most effective pain reducing treatment for low back pain...this has been shown many times in the medical literature, as well with government funded studies in Canada and the United States.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net