Life through a TV Screen PT. 2
***Disclaimer: This next chapter will be part personal experience, part physical therapy education based on existing research literature. It is not necessarily medical advice, and you should contact your doctor for specific medical advice matching your individual needs.**
Fall 2021
“There are many tough days along the way, and even if there is a well-detailed plan laid out, it is normal for the feeling of uncertainty to creep in from time to time.”
Completion of my orthopedic residency in August of 2021 was a double-edged sword for my rehabilitation process. On one hand, I now had significantly more free time to rest, get ample sleep, and take care of my body physically and mentally. On the other hand, I had lost my insurance and needed to get new insurance.
Fortunately, California has a program called Covered California where people living in California can apply for affordable low-cost healthcare. I applied and got approved for Medi-Cal, California’s version of Medi-caid.
The good news: I could seek out care and things would get fully covered.
The bad news: it can take a decent amount of time to get in to see your assigned primary care provider. Although I was covered, the soonest I could see a primary care physician was January 2022. For 4 months, I performed rehabilitation exercises, daily errands within my physical level of function, and waited patiently to see a physician.
Navigating a chronic injury is tough. Progress in rehabilitation is similar to progress with running: it is almost never linear. Some days are better than others. There are many tough days along the way, and even if there is a well-detailed plan laid out, it is normal for the feeling of uncertainty to creep in from time to time.
January 2022
My initial visit with my physician in January went smoothly, and a new plan was established: I was prescribed a non-steroidal anti-inflammatory medication and obtained a referral for physical therapy. Although I am a physical therapist by training, I decided to get a referral for 2 reasons: to get another opinion on my condition, and to have a proper procedural pathway in place in the event that it was deemed medically necessary to obtain imaging or perform other non-PT treatment.
I was referred out to a clinic contracted with the hospital system that I am being treated with, and started to go to PT on a weekly basis.
February 2022
I re-evaluated my current position. I was 4 visits into this new plan of care with the physical therapist, and had yet to see any clinically meaningful changes to my condition. 4 weeks is not a very long time to be going to a PT if one is starting a plan of care from scratch. Chronic injuries especially can take many months to heal even with the right treatment.
However, I feel that my case is a little different given that I am also a PT, have been performing my own PT treatment prior to starting to work with this new PT, and that a personal plan of care has had the time to evolve over the last couple of years. Failure of a patient to demonstrate improvement in 30 days can be a sign of misdiagnosis or warrant further investigation for a potential serious medical condition.(1)
The hospital where I received my MRI
Weighing my overall attempts at rehabilitation over the last couple years, conversations with colleagues, current research evidence on low back pain physical therapy treatment and the trajectory of my PT care, I decided to reach out to my primary care physician to move forward with an MRI.
With regards to management of low back pain with radicular symptoms, imaging can be recommended for patients with progressive neurological changes, or if a provider is trying to make a decision for whether patient is a potential candidate for surgery or epidural steroid injections.(1)
I was blessed in being able to get scheduled to go in for an MRI extremely quickly (visits at the hospital are scheduled out about 3 months but there happened to be an opening due to a cancellation), with results interpreted the same day and sent to my primary care physician. Matching the MRI interpretation with my medical knowledge and clinical presentation, I feel that I am one concrete step closer to figuring out a resolution.
Before I dive into the MRI findings and what they mean, I believe a little bit of relevant low back anatomy is needed in order to orient whoever is reading to have a better understanding of what is most likely going on for me. However, if you are absolutely not interested in the anatomy or education pieces and want to skip to the TLDR portion, you can scroll down below.
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A Brief Overview of Lower Back Anatomy
The low back, or the lumbar spine, consists of a combination of smaller bones called vertebrae, discs between the vertebrae for shock absorption, nerves that leave the spinal cord to supply the lower body’s muscle and sensation functions, blood vessels, and other supporting muscles and ligaments.(2 )
There are 5 lumbar vertebrae with designated names of L1 - L5. Nerves exit the spinal cord through a space called the intervertebral foramina just below the vertebrae that they are named after. For example, if a nerve is exiting the foramina through the space between the L2 and L3 vertebrae, it is named as the L2 nerve. Discs are named for the vertebrae they are located between, so using the same example, the disc would be the L2-3 disc.
The sacrum, located below the lumbar spine, does not have discs but still has corresponding spinal levels and accompanying nerves named S1 – S5 that exit the spine in a slightly different orientation & location compared to the lumbar spinal nerves.
A lumbar spine diagram with vertebrae and disc labeled. Nerves exit the spinal cord through the open white spaces in these diagrams. Image courtesy of Cooper G. (3) (2015)
With the anatomy established, we can introduce my MRI findings:
The first note is the more interesting of the two notes. Although findings on imaging do not always match up with clinical presentation,(1) in my particular case it seems to match up. We’ll expand on that matching in a little bit. For now, the key notes with this are:
- L5-S1 disc protrusion/herniation
- Contact & displacement of the right S1 nerve root that correlates with my symptoms on the right side of my body.
There are a variety of reasons for low back pain to occur, but in my case, we’re most interested in lumbar disc herniations. Lumbar disc herniations can occur through trauma from excessive loading, gradual degenerative change or spontaneous occurrence.(2) Approximately 95% of disc herniations in the lumbar region occur at the L4-L5 disc or the L5-S1 disc.(2)
With a lumbar disc herniation, patients may report that coughing, sneezing or any other activity that increases intra-abdominal pressure reproduces their pain.(2) The clinical presentation of a disc herniation can but does not always include radicular pain, sensory changes, and muscle weakness.(2) For lumbar disc herniations at the level of L5-S1, compression of the S1 nerve root can occur.(2)
In my case, in addition to my low back pain, I also currently experience loss of sensation, numbness and tingling on the bottom of my right foot as well as the back of my right calf. If I try to run or walk for more than 5-10 minutes, the tingling progresses in both intensity and area of effect, only returning to baseline once I have a chance to rest. Below are diagrams color-coded with different nerves that supply the foot and leg and their corresponding spinal levels:
Sensory nerve names, distributions bottom of the foot and their corresponding spinal nerve levels.(4)
Sensory nerve names, distributions in the leg and their corresponding spinal nerve levels.(4)
On the diagrams, each of the nerves named on this diagram receive contribution from 2 or more different spinal levels, hence the multiple numbers
Note the portions of the diagrams that include the S1 nerve root (the portion shown to be displaced on the MRI) and the L5 nerve root (which exits at the level of the disc herniation), and how the distribution covers an overwhelming majority of the bottom of the foot and notable portions of the leg. A list of the nerves with the L5 and S1 levels/ the areas where I experience symptoms is also included below:
· Foot: medial plantar nerve, lateral plantar nerve, sural nerve, tibial nerve
· Leg: Superficial peroneal nerve (yellow space), sural nerve (brown space)
Other clinical tests that I have already done on myself include a positive straight leg raise test and a positive slump test. These two commonly used tests assess neural tissue sensitivity.
Evaluating all the presented information, we can then put together the following likely concluding diagnoses:
- Pathoanatomical diagnosis: chronic R. L5-S1 lumbar radiculopathy secondary to L5-S1 disc herniation.
- World Health Organization’s ICF model for PT impairment-based treatment diagnosis1: chronic low back pain with radiating pain.
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The TLDR version of my condition: My MRI indicates that I have a lumbar spine disc herniation that is partially displacing a nerve root on my right side, which is a likely contributor to my low back pain with concurrent radicular symptoms i.e., the numbness and tingling that I experience in my right leg and foot.
“A retrospective cohort study published in 2021 had 97% of patients within their group of almost 278,000 patients successfully treated non-operatively”
How do I feel about this information? Interestingly enough, it’s given me a sense of peace at mind. The good news with the imaging is that I know that there isn’t anything immediately life threatening (although this is something I’ve kind of already known for a while). While my symptoms have not yet significantly improved, they are also not getting significantly worse.
Lumbar disc herniations also have the potential to be successfully treated without resorting to surgery. A retrospective cohort study published in 2021 had 97% of patients within their group of almost 278,000 patients successfully treated non-operatively.(5) In rehabilitation and in competitive running, it is important to acknowledge not just the challenges but also the positives.
So what’s next? Well, since the first round of medication and PT has yet to pan out in a significantly clinically meaningful manner, the next step recommended by my primary care physician was to be evaluated for use of injections. I met with an interventional spine physiatrist for a consultation regarding a spinal corticosteroid injection, and after discussing the recommendations, weighing my clinical presentation and considering current literature, I have made a decision to proceed with an injection. The hope is that the combination of injection and PT will lead to a breakthrough in getting my overall function and pain to trend positively.
Thanks for making it through the second chapter. Stay tuned for Part 3!
References
1. Delitto, A., George, S. Z., Van Dillen, L., Whitman, J. M., Sowa, G., Shekelle, P., Denninger, T. R., & Godges, J. J. (2012). Low back pain. Journal of Orthopaedic & Sports Physical Therapy, 42(4). https://doi.org/10.2519/jospt.2012.42.4.a1
2. Al Qaraghli MI, De Jesus O. Lumbar Disc Herniation. [Updated 2021 Aug 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560878/
3. Cooper G. (2015) Clinical Anatomy of the Lumbosacral Spine. In: Non-Operative Treatment of the Lumbar Spine. Springer, Cham. https://doi.org/10.1007/978-3-319-21443-6_1
4. Nerve supply of the human leg. Wikipedia. https://en.wikipedia.org/wiki/Nerve_supply_of_the_human_leg. Published April 15, 2020.
5.Lilly DT, Davison MA, Eldridge CM, et al. An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures. Global Spine Journal. 2021;11(7):1054-1063. doi:10.1177/2192568220936217
