♪ Bob and Brad ♪
♪ The two most famous ♪
♪ Physical therapists on the internet ♪
- Hi folks.
I'm Bob Schrupp, physical therapist.
- Brad Heineck, physical therapist.
- Together we are the most famous physical therapists
on the internet.
- In our opinion, of course, Bob.
- Brad, today you wanted to talk about low back pain
and hip pain, is it nerve?
Is it joint?
Is it muscle?
These are important questions
because how you treat your pain
is going to be dependent upon what you find out.
- Exactly.
We have a lot of people commenting exact same question
so we're gonna help our viewers
and we're gonna help ourselves out.
- We'll see if we can narrow it down.
- Exactly.
- We'll show you some things, how we think about things
and how we think about what's going on
and what may be going on.
- Right, exactly.
- Oh, hi.
Some new people out there Brad.
- Oh, Bob.
- In case you are new to us, please take a second
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- Right, it's somewhere.
- Yeah.
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- Thank you, Bob.
Okay.
- Moving on.
- So, we're talking about back pain, hip pain.
You got pain going down the leg.
- Maybe down the leg.
- Right.
So let's talk about a few sources.
Joint pain, where are the joints
the pain could be coming from?
- There's a lot of them.
- Right.
This is one that a lot of people aren't aware of,
facet joints, or facet joints,
however you wanna pronounce it,
what part of the world you're from.
But they're in the spin and they're actually two of them
at each vertebra level from here all the way up to the neck.
Obviously we're talking about the ones in the low back.
- There's 10 in the low back alone.
- Can we get a little close up of this?
- I think, yeah, right.
- There.
So right here's a facet joint, here's a facet joint,
and if you look you can see they open up a little bit
and together, not a lot but there's definitely motion there
and there's definitely nerve endings there
that can produce and sense pain.
- [Bob] It can wear out just like a knee joint
or a shoulder joint arthritis can wear it out,
so that can give you pain.
- Right, and the other joint is the sacroiliac.
Here's the sacrum, here's the ilium.
- [Bob] Ilium, ilium, and right in here,
this is a bigger joint.
- This is known as the SI joint.
- [Bob] Right.
If you see that or hear it,
that's the joint they're talking about.
- [Bob] Not a lot of motion there.
- Very little, it's kinda controversial, actually.
Of course the hip joint,
we'll get into that a little bit too.
Of course there's muscles around all this area.
- [Bob] Muscles and ligaments that hold it together.
- And naturally we got these right here,
the spinal nerve that come out and these actually are not
cut off like this.
They run down.
- All the way down.
- Right.
These are the tissues and structures that can cause
pain and irritation.
- You start to see why it's so complicated in trying to
diagnose or assess back pain and leg pain
because there's so many sources where it can come from.
- Exactly.
So let's talk about nerve pain first.
Is it a pinched nerve?
Well, one of the things I do is I just talk to the person.
I'm not gonna do any tests at all and the information
they give me gives me a lot of indication of that.
For example, if the person says, I got pain here
and then down in here it hurts and is kinda tingly
and then down here it's actually numb and down into my toes
it tingles and sometimes it feels like
cold water running down there.
These are all symptoms that are consistent
with a pinched nerve.
- Like you said, the fact that it goes all the way down
to the foot, right away you're pretty much thinking
that's a pinched nerve somehow.
- Exactly.
- The second thing is when they get strange sensations,
like you said, Brad.
The weird ones that might even change from minute to minute
or hour to hour.
- Right.
- That tends to be more nerve.
It can be bad, too.
- Sure.
Sometimes it's down in the ankle around the foot
and then it moves to up here.
Unusual things oftentimes is a nerve.
- Yeah, that always makes me think more nerve.
- And again, you mentioned if it's below the knee
down into the foot and ankle,
most of the time it's gonna be a nerve.
- Difficult for other things to send pain that far.
- Right, unless you got some real bad circulation
which could be a situation as well.
And also with that, when that happens we shouldn't jump
to conclusions but oftentimes that's gonna be from a disk
or a piriformis muscle that's irritating the nerve,
usually up in this area, usually it's not below that area.
- So yeah, either the disk is pushing on the nerve
and sending pain down or there's a piriformis muscle
which is in your butt and it crosses over the sciatic nerve
and it can tighten down over it.
Sometimes the nerve crosses in through the muscle
- Right, yeah.
- But it can cross over that nerve
and send pain down the leg.
Quite often what you might see in that instance
is you might see that they have pain going down the leg
but none in the back.
- Sure.
- That would be piriformis.
- That's a good possibility.
- There's tests that we can do with a piriformis test too
but that is probably in another video
if you wanna try and narrow it down more.
- Yeah, actually let's do a couple tests that are specific
to if it is a nerve.
We got the straight leg raise test
and this is one of those.
- The gold standard.
- Right, exactly.
Been going on for years and every doctor, therapist
and every one else in the world knows about this.
- You could do it sitting.
- Sure, that would be the slump test, right?
- Right, you could do this and then slump down.
Basically you bring your leg up
and bring your toe towards you.
Now you're gonna feel stretching pain but if starts feeling
pain all the way up into your back.
- Right.
And then if you bring your head down and it gets even worse
there's a good sign that that might be a nerve issue.
Someone can help you do this, too.
- When I test someone, Bob will do this too,
we don't just bring the head down but we actually have them
slump forward and the head down, bring the leg up
and at this point if they pull the foot up like this
and they feel pain up in through here other than just
in the calf muscle, that's a positive sign.
- Right, which means it's a good chance that there is
a pinched nerve or a herniated disk.
- Right, one way or another.
- Coming from the back.
- The nerve is a culprit.
Should we go through the straight leg raise quickly?
- Sure.
- Why don't you lay down, Bob.
- It's called the straight leg raise
because you do it with a straight leg.
So laying comfortably on the plinth or on the floor
or on the bed at home.
Now Bob is going to lay completely flat
and he's gonna bring this leg up.
What I'll do is I'll do it
on the leg that doesn't hut at all first.
This one doesn't go up and I'll say, at this point
do you feel a stretch there, Bob?
- Right, right.
- Keep the knee straight.
- I usually back down a little bit
and then give it a stretch.
- Yeah, be careful of that
because it can be a little uncomfortable.
We know what the good leg feels like,
and let's say we do this leg
and we get about this far.
- Ow, ow, ow, ow.
- Then if you have them pull their toe up
it makes it worse.
I've had people, when they pull their toe up,
they feel it back here.
- Right, in the back.
- Very clear it's a nerve problem.
- Right.
Sometimes I'll say, lift your head up.
- It'll make it worse.
- Worse, yeah.
Because that whole nerves system connects right up
to the base of your skull.
It's one of those things, everything's connected,
it's rather interesting.
Okay, joint pain.
- Again, if you think about the joints.
When you go like this the joins are spreading apart.
- The facet joints.
- When you go back like this they're jamming together.
That's why one of the tests that we do, one we can do,
is just we have the person go back and maybe to the side
and push down through.
Or back this way and to the side
and push through and if that jams those joints together
and they feel some localized pain here,
that's a good sign that
that might be some facet joints going on.
- Now if you did that same thing
and the pain went down the leg, it's not facet.
- No.
- We're thinking disk.
- Yeah.
Facet, again, generally looking
for a little bit more pinpoint pain.
A little more localized pain.
I often see, like with that again, this doesn't say
that it's a facet but let's say the pain's on this side
and you lean away from it and they're opening the facets
on that side, it feels better.
That's a sign that it might be a joints too.
- There's a lot of combinations, so you have to take this
with a little bit experience and practice.
- A lot of times I just go right on the back even
and push and all though that could be a lot of things,
still, the facet starts leaning towards that.
- How about that SI joint, Bob?
We talked about that sacroiliac joint.
Oftentimes what they say the history is,
if someone walked off a curb and they hit the ground
really hard and after that they felt pain in here,
SI joint typically does not refer past the knee
but it can refer to the knee
and it's typically not the numbness tingling,
it's just a pain feeling to the knee.
- The other very common thing with SI is that people have
leg length discrepancies which, can you see how that would
throw off the pelvis?
- Right.
- We can show you just a couple tests for that, Brad.
- Yeah, let's do it.
- One is the figure four test, very simple.
You just go like this and then you put a little pressure
there and a little pressure here.
- Here and here.
- Push down.
- You're not gonna be very aggressive,
this is pretty gentle.
You could hurt someone.
- It's gonna be generally one sided
and this is gonna make it worse in the area.
- Right.
This is one that you may not even have to press,
just going in this position.
- Just in this position might bring it on.
The lady I just had, that's exactly.
I got her in that position.
Another real simple test, Brad,
is they call it the point test.
Basically you take your finger and you point to where the
pain is and you might even put a piece of tape
where you point and then you come back
and then a little bit later you come back again
and if you point to right the exact same spot again
and it's pinpoint, believe it or not that's a test for SI.
It's a real pinpoint test.
- So SI is specific, that specific pain back in there
can refer down the leg.
I think the part, is it muscle or not?
- Right.
Brad and I tend to think that muscle is less often
a culprit than usual, would you say that?
- A muscle strain is less likely of the problem,
usually a disk, SI problem, but if it is a muscle
it's usually gonna be more localized.
- Yes.
- It's not gonna refer down the leg or down in the foot,
none of those symptoms.
- If you simply push on the muscle
you'll find tenderness.
- Why don't you lay down, this is best assessed, I think,
in prone position.
It's hard to assess yourself
because you can't reach back very well.
Bob is relaxed, I'm gonna go right down in the muscle,
not down the spin.
- Yeah, on the outside.
- Yeah, I'll just work down.
If it's a facet joint you might feel it there.
I've worked this where I've pushed somewhere
and all of a sudden just like that pain or symptoms
will go down the leg
and then then I know it's not the muscle, it's the nerve.
But if it's just one spot, it's tender, might even be
a little warm there, that may be a sign that it's a muscle.
- I'll often even just rub back and forth across the
muscle, Brad.
- Back this way?
- Yeah, like that because that tends to get
more of the muscle and not so much the facet then.
- You can feel those knots in the muscle that way, too.
- I can tell you, I had an episode of pain recently
and it was muscle.
I Was like, is that coming from a facet or disk?
I took the Thera Cane and rubbed on it, oh my God,
that felt so good.
- Took care of it?
- Relieved it right away.
In the case of the muscle,
heat and ice are gonna feel good and such.
- Exactly.
- I know this again, this wasn't totally comprehensive
but maybe it gives you somewhat of an idea
what to look at and what to think about.
- Back pain is not easy.
You work with it and that's why we practice this
over a number of years and we get better with it.
So good luck with it and take care.
We can fix just about anything, Bob.
- Except for a broken heart.
- But we got some videos, we're getting close to it.
- Gosh darn, we're trying.
- You bet, we're not stopping.
(laughs)