Bilateral leg pain case study: look upstream, then train the hips

This is number 25 of the Performance Place Sports Care Podcast. Let's do it. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, this is Dr. Sebastian Gonzales again with Performance Place Sports Care Podcast. Today, we're going to do one all by myself, and this is a case presentation. It is someone who actually did come into my office here, and it was a little bit of a troubling case, which is why I think it would be useful for everybody to learn from.

Obviously, I am keeping their actual identity a secret because it's not proper to share people's personal information, obviously. So, but yeah, this was a really interesting case. It was with not really of low back pain, but it was of leg pain, but of both sides, kind of intermittently. And the reason why I wanted to bring it up is because there was a little bit of a lack of communication here. And I don't know if it was on my part or not, but I was pretty sure that I mentioned it a few times. And I want to make sure that this type of communication or this understanding happens with everybody out there with this similar type of condition.

Now, what you have to consider with a case where there's any type of leg pain, loss of sensation, electricity, and especially on both sides, we have to consider the possibility that it is not a muscular injury or a joint injury in the actual leg or even arm if we're talking arms with referred type of this type of symptomology. Um, it is common, extremely common for people to chase down pain and they feel like it's in their foot, in their calf, in their hamstring. And they're chasing it down with foam rollers and, you know, massage techniques and all this type of stuff when really it's residing more at the top.

And the analogy that I usually use with people is that if you have two rivers, let's just say five rivers, make it easy. All the rivers have one contributing body of water. And let's just say it's a lake. All these rivers come off this lake. Now, all of these rivers have pollution in them, just riddled with like paper and like trash and like the water's all green and whatnot. And so, logically thinking, you have to think, well, probably that the lake above it, feeding all five of these rivers, has the same stuff, has the same pollution. And it's a problem that the lake is being, uh, it's, it's being polluted, not necessarily stopping the people at the river level.

So, this is what happens with radiating types of conditions, burning, searing pain, loss of sensation, uh, especially of the legs, uh, and more so on both sides again, because there's multiple rivers. If we're using that same analogy, we have to assume that it's well above and up into the area where these two spots connect. Um, and that would be more of looking at the low back, the sacral area, and even sometimes higher, um, you could have brainstem, uh, issues or even, uh, gosh, this is a little bit getting up more out of my realm. But, um, and there's even conditions like, say, Lou Gehrig's disease or, uh, things like that where, uh, multiple sclerosis where you have really odd symptoms happening on both sides.

And it's not great to chase down these symptoms, down the legs and arms, because it's really not going to be fruitful at all. And it's going to be really, really frustrating when you actually find out your actual, uh, diagnosis. So, we have to consider what is the commonality in here. And it's also really easy for most people to understand that with heart attacks, no one, I've never met anybody who says, hey, can you, can you massage my arm? My left arm really hurts. My face just feels like it's, it's numb. Can you just rub them? No, like, like we're all in an understanding that heart attacks or all those symptoms that go along with heart attacks, the sweating and whatnot, it's from the heart attack.

So, we kind of leave them alone and we address the heart. And the same thing goes with, like I said, this bilateral or both-sided quote-unquote sciatica type of pain. We usually look back into the spine. Um, so now this person, uh, when they came in, they said they had one side of the leg pain when they came in. I said, did you ever have both? And he said, yeah. And it seems like it flip-flops. And also times during which working with them, it flip-flopped a little bit then too. And his back really doesn't hurt that much, but it's down into his buttocks area and his leg and, and so on. And it's really, I see that he's not correlating the back or postural stabilization or trunk control to this condition.

Now, obviously, if you have some type of radiating pain, especially on both sides, I usually suggest people get MRIs or some type of advanced imaging to show the quality of the spine up there. Um, and the spinal column, the nerves coming out and all the components around there. And, uh, actually, it's really, it's actually common for, for people that are, when we send out for MRIs, we're actually, they come back negative. And actually, I remember having a, uh, a person in that they had, they had really severe back pain and their MRI was completely clean, completely clean. And it's, you don't always find stuff in there.

And so we call this, we call this connection clinical correlation. So if you have like a large herniation or a large finding, let's say a tumor, whatever the heck it might be within the MRI. And it looks like it, beyond reasonable doubt, can create the type of symptoms you're describing, then yes, we address that. And that would be our focal point of care. And all the rehab and all the treatment we give you and so on. Now, if it looks like it's completely normal, we might start looking elsewhere. So this guy, maybe, let's just say he had one side of leg pain. We might check out into the hip, uh, a condition that some of you probably have heard of would be piriformis syndrome.

Um, that nerve that is probably irritated on this guy, um, could be entrapped within sections of the hip. And a really common one is the piriformis. Um, and some people are anatomically different and they have this nerve running through two sections of a muscle and the muscles can kind of squash it down. And if you're not familiar with how, uh, symptoms of a nerve condition, uh, how they happen, a nerve is actually really, it's, we used to use this, uh, water and hose analogy, or if you step on the hose, wherever you step on it, it's still going to create the end result at the end. It's going to stop all the water from coming out of the end.

And basically this is how it works. So regardless of where it is entrapped, sometimes you will have very similar presentations and it will seem like sciatica, quote unquote, to you, to you guys. So, um, with this gentleman though, like he, he was worse with bending forward and, um, he was worse with a couple different activities, but especially rotating. Um, rotating is one motion that is really bothersome to people with, uh, some back conditions. So, and this is why we developed exercises such as pal off press and so on, is to make sure that we're really good at stabilizing and resisting rotation, uh, as part of rehab.

So we can do it through everyday life. Now, one thing that I thought was interesting really about his case was, I know we've gone down this route before and I, I'm bringing all this stuff up because it's, it is at the top of my mind. And I think the more that you guys are familiar with that it does happen, the more you can also combat it from your side too, because it is, it's something that if we have to keep readdressing it with you, then it just takes more of your time. Choose up your time in the office and in life in general, it just takes longer to get to the root cause of a condition. Now, I always tell people to look at their injury as, or look at themselves as a science experiment, experiment.

So you don't ever really want to change like, so in a, in a scientific experiment, we want to figure out there's, say there's three variables that we want to see which one has the greatest change on, uh, whatever it might be, how a coffee tastes. So we might put in sugar, we might put in milk and we might put in, gosh, what else do they put? Uh, let's say stevia and then we'll have people taste. Now, if we put them all in at once, this person doesn't really have an answer. I mean, we don't really know, I mean, if they had, if they, if they liked the taste of the coffee, we don't know which one had the greatest effect on what, uh, on, on what their taste buds were all about.

So we can really clean up and troubleshoot, like, what is the best thing to put in this coffee for this person? And rehab kind of goes the same way, or at least I want you to think of yourself as a science experiment. Change one thing at a time, okay? Because it might seem like everything hurts and you don't want to get on the ground and you don't want to sit in a chair and you don't want to go play baseball or run and, and squat. Squatting is a big one I've seen. Now, I mean, you squat through everyday life. You might as well be really good at it. And who's to say squatting in a different depth is not, a different depth is not okay.

And who's to say that it's not when you're just sitting there and not actually the movement of getting down and getting up. So we can break these things down into parts. And I actually did a YouTube video on this just recently. Um, I think I called it like getting control of your, your injury or mentally defeating your injury because this is really what we do go through with some people. And it takes like 20 minutes to get them to write this stuff down, figuring out exactly what bothers them. Now, the reason why I bring this up is because this guy coming in, and this is the reason why he was a challenging case, is because he was resistant of many things.

And it, and I totally understand it's, it's, I would be very afraid of doing certain activities too. And some rehab if it, if it, uh, if it ended up bothering me and, or, or later on the next day, the next week and so on. And if, if I feel like the progress of my care is not, or it's, it's shaky, I would be a little afraid too, but still working down that path of being a science experiment and getting some mental control of your condition is super, super important. Because you can be just absolutely paralyzed in, with the pain, paralyzed to the point, and that's not physically, but mentally paralyzed to where you actually stop your life.

You stop your rehab, you stop your activity. And before you, before you can even look up, you've lost about five, 10 years and you're like, well, you know, I really wanted to play baseball. Um, I had a, actually I had a teammate who he was, gosh, he was probably about 45 or 50. Um, he would always tell me how fast he was like running fast, you know, back in his younger days and, and he'd steal bases and whatnot. And I'm like, Hey man, how come you, how come you don't really, why don't, why don't you run anymore? So he actually usually gets a pinch runner whenever he possibly can. And he's like, well, whenever I run, whenever I sprint, my hamstrings hurt or it hurts me.

I'm like, okay, when's the last time he sprinted? He's like about 20 years, you know? So it's, it's been so long that, I mean, there's a buildup process in this. There's a buildup process with anything. There's baby steps all along the way. And when you succeed at one, you take the next challenge one day at a time. And yeah, you will run into those things which create flare ups. And that's totally okay. And I actually have a sign on my wall at my office that says, flare ups happen. Deal with it. Get used to working hard. You know, it, it, it happens. And this is what makes people into better people.

It's adversity. And I know it sounds a little preachy there, but for the most part, injuries are kind of the same way. Um, I do remember actually I had this, I'm coming up with all these, uh, stories actually. Uh, I don't have, gosh, I'm sure I got a lot more stories. I'll stop with this one about, um, the, the people that I've worked with, with this type of thing. Um, but there was a girl that came in. I told her she was about, she was a, she was, she was a quick runner. She was really, really quick. But the funny thing was that she was probably, let's see, 25. She didn't run in college or high school and she was doing road, she was doing road races currently, but she was quick.

And I told her she was one good injury from being an awesome athlete. And the reason is, and I've talked to her, I talked to her coach about this, is that she would not comply with programmed rest days. You know, her rest day, like, you know, you ask her to take it easy, work on some other type of aspects of, or that would improve her running. She would still continue to, instead of running, she might do, you know, 50 miles on the bike. And I just said, I mean, look, you're, you're one good injury from really dialing in what your body can tolerate and you, you can start respecting it and stop abusing it and give it what it exactly needs.

And obviously I don't do a lot of programming for, uh, for running. So I'm not going to, I'm not going to go too deep down into what, what we needed to do exactly with her. But for the most part, she did get one injury and I mean, she's still very quick, but just knowing what your body needs is a big, big thing. Did I get tangented? I think I just tangented, tangented a ton. Anyways, we'll go back to the, uh, so we had the bilateral leg pain, uh, or sciatica quote unquote, or why does everyone call it sciatic by the way? I keep hearing my sciatic and I'm almost about to do a, a YouTube video or a podcast or an article on this word, my sciatic, because we don't really have that.

Um, it's, it's almost like a butchered, it's a really, really butchered term that people have started using. I don't know when they started, but in case you're wondering the correct, the correct terminology here. So sciatic, there's sciatic pain, but the sciatica is the condition or actually I believe it's a symptomology. It's not really, I guess it is a diagnosis. I don't think it should be honest. I think it's more of a symptom pattern. Um, and then there's, uh, the sciatic nerve, but my sciatic, it seems kind of butchered. Anyways, so I'll stop on that, but I might have an article, uh, just to address it.

Cause I feel like the people that use that probably need more knowledge in what the condition is. So, cause they're saying my sciatic anyways, no, we don't, no disrespect to anybody. Just trying to make it better. Okay, so he had pain down one leg, sometimes two, worse with bending forward, stretching wasn't working a ton. Um, so really what I want to do is figure out what he's already doing and what has not worked, what has worked and so on. And the only thing that we really, uh, found that he was lacking on a lot of was trunk stabilization and being able to, uh, actively engage his trunk and core while he's actually moving around.

And the types of activities that he told me that he was hurting himself on, they could really be changed. And, and he actually even kind of alluded to it. He said when he used, you know, when he used his hips, the back pain decreased or it was less severe. So leading into that, and I know that we've talked a bit about, uh, trunk stabilization and being able to use the hips. Like the whole thing with the hips now are we need to make them move better. So the back and also for, we go even further onto the knee, they don't have to take all these, uh, ambient motion and they're able to do their job a little bit better.

And then we get less injuries along the way too. So I really focus on training of the hips, uh, in multiple directions at my office. Now, what does that mean? So the hip is a ball and socket joint. Uh, it has a ball and a socket. The ball is on the actual femur bone and the socket is in the pelvis. Now, the beauty of a ball and socket joint is that it moves so many different directions, but also too, we need to be able to control it because just like everything else, if I haven't thrown a baseball in a long time, I need to work on some mechanics and the hip is kind of the same way. If you haven't used it in a while, then you need to just retrain it.

And a lot of times it comes back quickly in regards to the movements, but the strength doesn't always come back quickly because that degrades a little quicker over time. So I like to work on having people in forward-backward plane motions, uh, which is usually how you'll pick up heavy objects such as deadlifting, um, squatting to get down to the toilet. You obviously do that. Lunging, I think is important because when you get down to pick up something, you should probably be lunging rather than bending forward and using your back. You need to be using your hips to do all the work. And then rotating too.

If you're a weekend warrior, you definitely have some aspect of rotating such as with golf, um, because that joint again does spiral kind of amongst itself because the ball just spins in the socket. Um, and also side to side motion. And these are things that I definitely recommend that everybody start to incorporate into their, their rehab program. Um, having, having good torso control and, and a strong core is important, but if you don't know how to use your hips below it, it's kind of a waste of time. So I think you have to kind of do both. So, uh, I hope this is helpful to you guys so far. And if you have, if anyone has any questions, again, for me, leave it on the P2 Sports Care site.

I'm going to stop now, probably right now on this one, because I can see it going so many different ways. Um, and also too, I am having some guests on the podcast very soon. I just barely figured out how to use a mixing board and proper microphones and Skype. And, uh, I actually was wanting, I have a list of people that I wanted to go around and talk with an interview because I think they're interesting people. They're interesting. Um, they're in, they have a lot of things to give back to you guys as listeners in regards to really advanced knowledge, but some basic stuff too. I have, but I had an issue with when I'm working here at my own office, then it's hard to get out and meet these people and they have busy schedules too.

So learning how to attach a mixing board to Skype has been breakthrough. And I am pretty much there having it all dialed in and I want to do this every week for a very long time. So if you guys have people that you think that I could interview and also that they have good information they can share with everybody else, I would love to interview them. So if you have somebody, feel free to email me info at p2sportscare.com. Again, that's P the letter to the number sports is plural care.com and just have them reach out to me. I always like to meet, uh, new and different people and, uh, I'm learning stuff every day and, uh, I'm here to share with you guys.

So if you haven't checked out the, the website already, by the way, uh, there is a ton of free information on there. I spent tons of time writing articles and I still continue to do so. Uh, by the way, if you find any spine spelling errors, please let me know. I'm terrible at proofreading, but I do have a proofreader to hopefully, uh, minimize those. Um, but there's tons, there's tons of free content on there on different types of conditions, which you probably have, or your mom has, or your dad, or your friend, um, your training partner. And I tried to take all this information that is on the internet that I thought was good, that I respect, that I read.

And I tried to gather the best references and then reword it into a way that I thought was better and put it there for all you guys to read. So you don't have to go anywhere else because sometimes you go to other sites, say Wikipedia, and you're, you're looking at the, you're looking at ball and socket of the hip. And then you have seen that the, uh, you can't even read the Latin on the page because it was written intended for someone like me to read, which is not really fair because then you're not going to get anything out of it. So, uh, let me digest it for you. So again, ptsportscare.com. Take care.