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The site of injury appeared to be in the tensor fasciae latae muscle, with pain referred to the lateral knee via the fascia lata (i.e., the muscle in spasm placing tension on the iliotibial tract whenever the hip was extended).

Following the examination, the patient was given moist heat and massage (stroking downward) to the tensor fasciae latae. The patient felt considerable relief of pain in the lying position, but pain was felt in standing.

The anterolateral aspect of the left thigh was strapped from the crest of the ilium to just below the knee (in such a way as not to interfere with hip or knee flexion). The patient felt much relief of symptoms after strapping. (Nonallergic adhesive was used.)

Two days later (and again six days after that), the strapping was checked to be sure there was no irritation and to reinforce it with more tape.

Three days later, no skin irritation was found, and new strapping was applied.

Six days after that visit, the patient removed the strapping and was walking without a cane.

Approximately 5 weeks after the patient removed the strapping, a note received from her doctor stated, "The examination of [the patient's] leg assures me that she is well and there has been no residual. I feel that we can discharge her, and she can assume her general duties."

The procedure for the taping was the same as illustrated by the photographs above.

PROTRUDED INTERVERTEBRAL DISK

The basic concepts regarding flexion and extension of the spine in relation to disk protrusion play an important role in determining treatment. The following quotes are pertinent to this topic.

Nordin and Frankel state, "The forward inclination of the spine makes the disk bulge on the concave side. Hence, when the spine is flexed the disk protrudes anteriorly and is retracted posteriorly" (16). Pope et al. record the findings of Brown et al. and Roaf (17). Brown et al. reported disk bulging anteriorly during flexion, posteriorly during extension, and toward the concavity of the spinal curve during lateral bend (18). Roaf stated that the bulging of the annulus is always on the concave side of the curve and that, during flexion and extension, the nucleus does not change in shape or position (19).

This information is contrary to what many people believe or have been taught. In the analysis of low back problems and sciatica, however, this concept is important.

Strong back muscles are essential for both posture and function. Although low back muscles are seldom weak, back extension exercises are frequently prescribed. Overemphasis on back extension can contribute to an increase in a lordotic position. Quoting again from Nordin and Frankel, "The erector spinae muscles are intensely activated by arching the back in the prone position. Loading the spine in extreme positions such as this one produces high stresses on spine structures, so this hyperextended position should be avoided" (16).

Good strength in the abdominal muscles is also important to counterbalance the back muscles and to stabilize the trunk in good postural alignment and during activities such as lifting. Unfortunately, abdominal muscles are often weak, especially the lower abdominals, and not enough attention is paid to appropriate exercises.

If a disk has ruptured and is pressing on a nerve root with intractable pain and no relief has been obtained from conservative measures, there may be no alternative to surgery. However, there are many cases of sciatica, in which clinical findings suggest a disk lesion, but the fluctuation of symptoms suggest that the protrusion is not constant. Conservative treatment of many such cases has brought about effective relief of symptoms without surgery. In instances when, for some reason, the patient declines operation or the doctor does not elect to perform surgery, conservative treatment becomes the necessary alternative.

The rationale for conservative treatment is based on the premise that any bending, torsional loads, or com-pressive force—whether caused by muscle spasm, tightness of back muscles, or stress of superimposed weight on the lumbar spine— may be factors in causing the disk protrusion.

Two measures provide effective conservative treatment: First, immobilization of the back for relief of acute muscle spasm and for restriction of motion; second, use of an hourglass type of support that acts to transmit the weight of the thorax to the pelvis, and relieves stress on the lumbar spine (in much the same manner as a cervical collar is used to relieve pressure on the cervical spine).

To treat by immobilization, and for relief of superimposed body weight, a fitted support is reinforced with strong lateral and posterior stays. Following relief of acute symptoms, therapeutic measures may be instituted to correct any underlying muscle imbalance or faults in alignment.

Acute sciatic symptoms associated with protrusion of a ruptured disk often occur as a result of a sudden twist and extension of the spine from a forward-bent position, such as twisting the trunk while lifting a weight. That such a type of stress should be related to this type of lesion is not surprising in view of the fact that "rotation of the lumbar spine takes place at the intervertebral disk" (20).

Sciatic symptoms that have been acute or subacute often cause the body to be drawn into faulty alignment such that secondary symptoms of compression and muscle strain are added to the original problem. These secondary symptoms may, on occasion, persist after the original underlying problems have subsided.

PIRIFORMIS MUSCLE AND ITS RELATION TO SCIATIC PAIN

Albert Freiberg described the piriformis muscle and its relation to sciatic pain, and furnished an interesting explanation for a possible cause of sciatic symptoms (21). Although there may be numerous cases in which sciatic pain is associated with a contracted piriformis, as he described, it is the opinion of the authors that irritation of the sciatic nerve by the piriformis muscle is often associated with a stretched piriformis.

The piriformis arises with a broad origin from the anterior aspect of the sacrum and inserts into the superior border of the greater trochanter. This muscle has three functions in standing. It acts as an external rotator of the femur, aids slightly in tilting the pelvis down laterally, and aids in tilting the pelvis posteriorly by pulling the sacrum downward toward the thigh.

In a faulty position with a leg in postural adduction and internal rotation in relation to an anteriorly tilted pelvis, there is marked stretching of the piriformis along with other muscles that function in a similar manner. The mechanics of this position are such that the piri-formis muscle and the sciatic nerve are thrust into close contact. The figure below shows the relationship of the sciatic nerve to the piriformis muscle.

Gluteus min.

Gluteus med.

Gluteus max.

Piriform is

Gluteus min.

Gluteus med.

Gluteus max.

Piriform is

Glutaeus Max Med Min

Sciatic nerve

Quad. fern.

Gemellus sup Obturator int.'. Gemellus Inf. Semimembran Adductor mm. Adductor mag. -Semitendin Biceps

Sciatic nerve

Quad. fern.

Gemellus sup Obturator int.'. Gemellus Inf. Semimembran Adductor mm. Adductor mag. -Semitendin Biceps

Evaluation: The following points should be considered in the diagnosis of sciatic pain associated with a stretched piriformis:

1. Do the sciatic symptoms diminish or disappear in nonweight bearing?

2. Do internal rotation and adduction of the thigh in the flexed position, with the patient supine, increase sciatic symptoms?

3. Do the symptoms diminish in standing if a straight raise is placed under the opposite foot?

4. Does the patient seek relief of symptoms by placing the leg in external rotation and abduction in both the lying and standing positions?

The test movement to place the piriformis on maximum stretch (see point 2 above) is done in the following manner: The patient is supine on a table. The knee and hip of the affected leg are flexed to right angles. Flexion of the knee rules out any confusion with pain due to irritation of the hamstring muscles. The examiner then internally rotates and adducts the thigh passively.

In regard to point 3 above, it has been a frequent clinical observation that, during the course of examination, a lift applied under the foot of the affected side increases symptoms, whereas a lift placed under the foot of the unaffected side gives some immediate relief in the affected leg.

Shoe corrections, for cases indicating irritation resulting from a stretched, rather than a contracted, piri-formis, consist of a straight raise (usually Vs to xk inch) on the heel of the unaffected side to relieve tension on the abductors of the affected side as well as an inner wedge on the heel on the affected side to correct the internal rotation of the leg. Heat, massage, and stretching of the low back muscles if they are contracted, abdominal muscle exercise if abdominal weakness is present, and correction of the faulty position of the pelvis in standing are used as indicated.

SCIATICA

Sciatica refers to a neuritic type of pain along the course of the sciatic nerve. Pain extends down the posterior thigh and lower leg to the sole of the foot and along the lateral aspect of the lower leg to the dorsum of the foot.

Sciatica may occur in connection with various infections or inflammatory disease processes, or it may be caused by some mechanical factor of compression or tension.

Symptoms may originate from a lesion of one or more of the nerve roots that later join through a plexus to form the sciatic nerve. A protruded intervertebral disk is an example of mechanical irritation at the level where the nerve roots emerge from the spinal canal. Distribution of pain tends to extend from the root origin to the terminal nerve endings, with the result that pain is quite widespread. An L5 lesion, for example, may give rise not only to symptoms down the course of the sciatic nerve but also to pain in the region of the posterior and lateral thigh supplied by the inferior and superior gluteal nerves.

Symptoms of sciatica may arise from irritation anywhere along the course of the sacral plexus, the sciatic nerve trunk, or its peripheral nerve branches. Sciatica may arise as reflex pain from irritation of peripheral nerve endings. A lesion along the course of the nerve or its branches often may be distinguished from a root lesion by the localization of pain to the distribution below the level of the lesion.

Other than the root, there are two commonly recognized sites of lesions giving rise to sciatic pain: The sacroiliac region, where the spinal nerves emerge through the sacral foramen, and at the level of the piri-formis muscle where the sciatic nerve trunk emerges through the sciatic notch and passes either through or under the piriformis muscle.

This discussion about sciatica is concerned with faulty body mechanics in relation to disk protrusion and with sciatic symptoms associated with the piriformis syndrome. There will be no discussion of sciatica in relation to the sacroiliac strain other than to suggest that the faulty mechanics causing this strain may put tension on the sacral plexus because of the close association of the involved structures in this area.

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