Exploring in vivo Sciatica Case Studies – Strongman Competitor

The following Strongman Case Study have been supplied by a Private Facebook Group.  Thank you guys for sharing.  All Case’s have been diagnosed with Sciatica, each with a individual’s story of events and symptoms. The name “sciatic” came via Latin from the Greek “ischiadikos” which means “subject to trouble in the hips or loins.”  WARNING: there are moments of frankness!

Case Study 2

Patient: 54 y/o Man Ranked 1st Bolton’s Masters Strongman (Competed since 2011)

Event that provoked Sciatica: Strongman competition believes it was a loose yoke.

Symptoms: “Pain through both legs during Competition”

Previous injuries: (specific details unknown)

• Issues with left shoulder
• Bilaterally torn biceps
• Torn left latissimus dorsi and tricep
• Torn right hamstring (8 years ago)
• Torn a quadricep – not sure which one/side
• Dropped 2 atlas stones on feet: left foot has nerve damage, right foot has most pain

Meaningful Task: Being able to walk for more than a mile? without pain down my right leg – from hip/glute height down to foot.

Current Symptoms: Right-side sciatica

Diagnosis:

1. NHS Physiotherapist diagnosed: Under-active glutes (no reason for this given).
2. MRI diagnosed: Worn discs (unable to remember which ones)

Treatment:

• Physiotherapy prescribed Cobra stretch (for spinal mobility)
• Foam Rolling; low back, thoracic spine, glutes, hamstrings, calfs, quads then with ball roll piriformis area, low back, and SIJ’s
• Stretching, although stretching makes the symptoms worse – although it makes walking for longer easier.

Lifestyle

Personal Trainer, S&C Coach and Sports Therapist

Applying Hypothetical Deductive Reasoning (HDR):

“Glutes not firing”

Argh… one-way to tip my calm and neutral mental equilibrium – quote this to me and you’ll receive my 101 lecture on poor, inaccurate and misleading nomenclature of the Manual Therapy Industry! Let’s not mess around here.  Muscles are designed (we could debate this term ‘designed’ in another lifetime) to do a job i.e. from pumping blood around your body to creating locomotion (movement).  During locomotion they work in pairs (extensors and flexors), Newton’s 3rd Law of Motion: for every action (force) in nature there is an equal and opposite reaction. Unless you have ‘severed’ the main nerve connection and all it’s motor end points to the ‘muscle’ in question, diagnosed with a specific disease/disorder – then this is not possible.  Or you are dead?

The term “your glutes are unable to recruit optimally” may be a better description of your findings.  And if they are not recruiting optimally, then what affect does this have on the person? And is it relevant to their symptoms and inability to go about their active daily living (ADL) tasks? Is it a part of why they are unable to complete their Meaningful Task (the thing they want to be able to do)? If the non-optimal recruitment of the glutes is your finding, then isn’t the most important question: “Why the glutes not recruiting optimally“?  What is driving the glutes to not  have the capacity to contract? This is the most important question, is it not?

A muscles ‘capacity’ (the total of things a muscle can produce) is being compromised, therefore it is unable to reach it’s ‘capacity’. A muscles capacity is relative to the physiology, biomechanics, and psychology of the person the muscle belongs to.  For example: Physiology; muscles work optimally in a narrow range of almost zero acidity, being acidic stops the rate-limiting enzyme from working (Mertz, 1987) and directly inhibits the contractile action of muscle fibres.  Biomechanics; Passive force is the force that comes from elongation of connective tissue components of the muscle tendon unit. Passive tension is a significant factor affecting movement at the extremities of joint range of motion (ROM). The increase in passive tension limiting range of joint motion is quite apparent in multi-articular muscles and is called passive insufficiency.  Psychology; muscle contraction occurs when a muscle cell lengthens or shortens. Contraction is controlled by the central nervous system comprised of brain and spinal cord. The brain controls voluntary muscle contractions, while the spine controls involuntary reflexes.  For voluntary muscles, contraction occurs as a result of conscious effort originating in the brain. This is muscle capacity.

So maybe the right questions at the time of the symptoms being reported may have been:

• “Why were the glutes not able to recruit optimally”? and
• “Is this a part of the picture that is driving this man’s limitations/symptoms”? If not, it’s not important at this time.

“Foam rolling”

Tight? Hmmm…

Generally people get on a foam roller or ball to massage a muscle in their body because it feels either ‘tight‘ or ‘uncomfortable‘, or, it’s because everyone else is doing it (sorry, but i was a Personal Trainer for 15 years, I have witnessed first-hand the ‘waves’ of Trends and Cult’s).  There has been lots of criticism on Social Media, and with colleagues, over the last 18 months regarding Manual Therapists using the terminology ‘tight‘ to describe a finding.  ‘Tight‘ generally means; fixed, fastened, or closed firmly. An adjective that describes a sound, taste, or in this context, a feeling or an observation.  It’s a persons perspective, their perception of what they feel and see.  Therefore, using the word ‘tight‘ to describe a feeling or observation is true to the people involved.  Just to note: a feeling or observation are both primarily exploratory, in research it’s better known as ‘qualitative findings’ and have their place in supporting EBM.  But is using the term ‘tight‘ true in the sense of muscle capacity? Physiology? Biomechanics? Psychology? *Discuss below in Comments*

Foam Rolling concerns!!!

If you have completed your HDR on the Patient/Client (P/C), and your findings define that foam rolling is needed as part of the ‘Release’ phase of their rehabilitation plan – then crack on.  But to use a foam roller because something is tight or uncomfortable concerns me.  My concerns are “How do you know what you are trying to ‘un-tighten’/release/loosen is not the very thing that is protecting you from further complications”?  Twenty years ago I was introduced to a a tool used in psychology: The ‘Drama Triangle’.  Stephen Karpman, M.D., developed his “drama triangle” – victim, rescuer, persecutor – almost 40 years ago. The triangle maps a type of destructive interaction that can occur between people in conflict. When I hear people are foam rolling area’s of ‘tightness‘ or ‘discomfort‘ the Drama Triangle leaps in to my foresight… “What if the very muscle you are trying to change the tension on is the ‘victim’ of the non-optimal capacity of the muscle”? Exploring the Drama Triangle in more depth as a Biomechanist and Clinical Anatomist, it suggests we may be able to apply this Drama Triangle of conflict to Biomechanics.  NOTE: None of the content in the Drama Triangle I have re-drawn has been changed from the original work of Karpman – the statements strangely align themselves nicely with non-optimal biomechanics!

NEXT WEEKS BLOG:

• Multiple factors of sciatica; foot driven sciatica
• Release of the piriformis
• Injury mechanics that may drive sciatica