Have you recently been involved in a falling injury and now have back pain? Here are some common causes of back pain after a fall and what steps to take to be properly diagnosed and treated if necessary.
Low Back Pain
I will explain each diagnosis, but 97% of all low back pain is classified as being discogenic, apophyseal joint pain, non-specific pain, sacroiliac joint pain, fracture, spinal stenosis or as a result of severe scoliosis. Included in these classifications but only at a percentage of 0.04% is cauda equina syndrome, which is an emergent condition and will be discussed with due diligence below.
Intervertebral discs (talk about discogenic, disc herniation, rare cauda equina – page3)
In between each of your vertebrae, there is a jelly-like substance called an intervertebral disc. Sometimes, in the case of an injury, prolonged posture or an other biomechanical dysfunction, our intervertebral discs can move backwards into the area where our spinal cord and nerve roots are located. There is a difference between a disc bulge and a disc herniation, BUT neither should be considered a life-long sentence for pain or dysfunction. People tend to become terrified of the diagnosis or disc herniation, disc herniation or degenerative disc disease and that should not be the case. When one of the intervertebral discs of the low back moves backwards, it creates inflammation, swelling and irritation around the nerve roots of the spinal cord. That process typically results in pain in the lower back, hips, buttocks, thighs and sometimes even into the lower legs and feet. A disc bulge is simply when the intervertebral disc moves backwards but doesn’t rupture all the way into the spinal canal (where the spinal cord and nerve roots are). This movement backwards still causes swelling and inflammation in the area, which can result in pain and other symptoms. A disc herniation is when the intervertebral disc moves backwards with enough force and pressure that it ruptures into the spinal canal. Just to further clarify, just because you have a disc herniation does not mean you need an MRI or surgery.
What you need is a thorough examination to determine what the next best step in your care should be. That’s the cool thing about seeing a chiropractor. We thoroughly examine each patient, performing a sequence of different tests and also feeling around the area, to functionally triage, which means determining whether a trial of chiropractic care is the best bet or if a referral to another healthcare professional is warranted. The way that we test and assess to determine if the low back pain is coming from the intervertebral discs is through a thorough patient history with a few specific findings and an end-range loading exam. Two findings that you may notice on your own and that need to be confirmed by a professional (and further evaluated) include pain going down only one leg below the knee, muscular weakness in one leg and leg pain worse than back pain. End-range loading refers to taking joints to their furthest range of motion repetitively and then evaluating the patient response.
Taking the joints of the low back to their end-range of motion can effectively move the intervertebral discs to reduce inflammation, swelling and irritation around the spinal cord and its nerve roots. When this occurs, the patient’s pain will migrate from where it is (foot, leg, thigh, buttocks, hip, lower back) closer to the spine and may even increase in that location. That phenomenon is called centralization (meaning moving more towards central). The presence of centralization is the most sensitive and specific way to diagnose low back pain being discogenic in nature. If we can produce centralization, we know without a doubt that the patient doesn’t need an MRI, the patient doesn’t need surgery, and that the patient will be able to respond to a conservative trial of care of repetitive end-range loading, soft tissue mobilization and spinal manipulation. If end-range loading doesn’t produce centralization, then a further examination is necessary to determine what the pain-generator is.
There is one more VERY important point worth noting on the topic of disc herniations and low back pain coming from the intervertebral discs. There is a diagnosis called cauda equina syndrome that is a rare but emergent condition. It only occurs in 0.04% of low back pain cases (4 out of every 1,000), but needs to be discussed. It occurs when one or more of the intervertebral discs herniates into the spinal canal and impinges on the lumbar and sacral nerve roots that provide sensory and motor control of the genitals and bowels. Cauda equina syndrome is diagnosed by the 2 following presentations:
Urinary retention progressing to incontinence in the setting of low back and leg pain with numbness and/or weakness is 90% sensitive and 95% specific for the diagnosis of cauda equina syndrome. Early identification will improve outcomes. If frank incontinence occurs, outcomes are poor. Therefore, telling your doctor about the urinary retention is vital.
Saddle paresthesia/anesthesia and impaired sexual function (erectile dysfunction in males and lack of sensation in females) are also described features.
Spinal stenosis refers to a narrowing of the spinal canal where the spinal cord and nerve roots are located. There are certain things that can predispose to spinal stenosis such as prolonged poor posture and repetitive injury, but this is a degenerative process that takes time to develop and doesn’t usually present until after age 60. To further explain the process, your spinal cord and nerve roots is located inside and protected by the vertebral column in a region called the spinal canal. There are several structures that can either enlarge or degenerate, enclosing the space and increasing pressure on the spinal cord and its nerve roots. That process can produce a significant amount of pain and dysfunction characterized by certain findings:
Age over 60
Pain in both legs
Leg pain relieved by sitting
Leg pain decreased by leaning forward or flexing the spine (leaning forward on the grocery cart)
Leg pain worse than back pain
Pain during walking and/or standing
Pain relief upon sitting
The goals with spinal stenosis is to increase mobility in the upper and mid-back and hips, and also to find the patient a repetitive movement or exercises that they can do throughout their day to manage their symptoms and improve their everyday function.
Facets (bony articulations)
The facets of your low back are the bony articulations on the backside that allow for and control the movements of bending and twisting. They are protected by capsular ligaments, which are densely packed with receptors that perceive those movements and are also highly innervated. As the facets are highly innervated, they can be a significant source of pain and dysfunction in certain patients with certain presentations. There are a certain set of features that characterize low back pain resulting from the facets. The following cluster of tests has 92% sensitivity and 80% specificity for facetogenic pain:
Pain well relieved by laying down
Four out of six positive on the following:
Age > 65
No exacerbation with coughing
No exacerbation with forward bending
No exacerbation when arising from a bent forward position
No exacerbation with backwards bending
No exacerbation with backwards bending and twisting
Muscles, ligaments or tendons
The spine has many ligaments, tendons, muscle and fascia. Dysfunction or injury to these structures are recognized sources of low back pain. The best way to determine that these structures are the underlying cause is through palpation of the area by a professional such as a chiropractor. Additional characteristics may include grossly abnormal body postures, recent changes in body posture and reduction in symptoms with postural correction during the examination process. This diagnosis is generally as simple as treating the tissues with manual therapy and correcting the patient’s posture throughout the day.
The sacroiliac joint (SI joint) is a joint that consists of the sacrum and the ilium. The sacrum is the one of the base bones of the spine (just before the tailbone) and the ilium is the part of the pelvis that you can feel when you put your hands on your hips. Like the previous diagnoses, the SI joint has a specific set of tests for determining dysfunction. The cluster of tests is called Laslett’s cluster and is named after Dr. Mark Laslett. It consists of 5 tests, of which at least 3 need to be positive for the diagnosis of SIJ dysfunction.
Hip Referral (OA or osteonecrosis)
Hip and pelvic pain may also mimic a low back pain complaint. These sources should be considered after ruling out the previous diagnoses and according to another specific set of characteristics. Disease or dysfunction of the hip joint may refer to the spine, particularly the low back area, and the two most common causes are osteoarthritis (“gray hairs in your joints”) or osteonecrosis of the femur head. HOWEVER, both of these diagnoses are degenerative processes that take time to develop and therefore don’t’ occur just from a single injury or trauma. With that said, it is possible that an injury could aggravate an already existing diagnosis or osteoarthritis or osteonecrosis and also an injury can start the degenerative process. With these two diagnoses, pain is usually felt in the front and/or back of the hip as well as in the buttock region, often in a “C” shape around the hip. It is also fairly common to experience thigh pain in the front or back.
Another hip diagnosis that can refer pain to the lower back is greater trochanteric pain syndrome, which is an umbrella term for gluteal tendinopathy, iliotibial band thickening and trochanteric bursitis. The specific terminology of the diagnoses doesn’t matter in determining your prognosis, its purely an academic matter. We care about how we can improve your everyday life. Greater trochanteric pain syndrome can actually produce pain in the low back and all the way down the leg to the foot. With that said, radiating pain down your leg can several causes and should not just be labeled “sciatica” without a thorough exam and education process. This can be caused from an injury or trauma but is again more commonly an ongoing degenerative process. One common finding that you may notice on your own is pain right at the bony part of the side of the hip (greater trochanter). With that said, this finding should be evaluated by a professional to determine the diagnosis and best option for treatment if necessary.
The last hip disorder that may refer to the lower back is muscular pain from trigger points and tightness in the deep muscles of the glutes and hips. These muscles include the gluteus maximus, gluteus medius, gluteus minimus, piriformis and the upper part of the hamstrings, among others. Just like the previous presentations, there are tests to determine exactly what the cause of the pain and dysfunction is. Some things you may notice with pain coming from the muscles are pain in the back of the hip and thigh, leg pain, low back pain and buttock pain that is worse when sitting or walking. These muscles may also be tender to the touch. Its important to be evaluated by a professional that specializes in palpating the muscles, joints, etc. such as a chiropractor to determine what structures are the underlying cause.
Fracture (page 3)
A vertebral fracture may also be the cause of low back pain, especially after a fall or significant injury. This cause should be considered with a patient over 70 years old, with significant trauma and/or with long-term corticosteroid use. Over 70 years old, the prevalence of osteoporosis increases especially in women. With osteoporosis, bones become less dense and more fragile, therefore predisposing to a fracture. With long-term corticosteroid use a process called avascular necrosis occurs in the bones, which also weakens the bones and increases the risk for fracture.
Spinal scoliosis refers to abnormal curvatures in the spine of at least 10 degrees. These large curvatures can create abnormal stresses on structures like the vertebra, intervertebral discs, muscles, joints, ligaments, tendons and even internal organs. Pain often results in one way or another with scoliosis, but it should be noted that scoliosis is not a life-long sentence for pain or dysfunction and there are things we can do to improve the function even if we can’t reduce the curvatures. Additionally, there is a better chance of improving the curves at younger ages, so the earlier scoliosis is diagnosed and treated the better.
Rare but important to rule out (page 3)
The following diagnoses are rare but important not to miss in the presence of low back pain.
Visceral disease such as an aortic aneurysm with or without dissection, pelvic disease, kidney disease or gastrointestinal (GI) disease accounts for 2% of low back pain complaints.
Non-mechanical spine disorders such as tumors, infections or several different types of arthritis (did you know that there are different types of arthritis and arthritis is just a broad umbrella term?) accounts for 1% of low back complaints.
Lastly, <1% of low back complaints are as a result of Paget’s disease, hyperparathyroidism or hemoglobinopathies. The bottom line of these rare causes of low back pain is that we shouldn’t jump to conclusions and assume the worst, but rather trust your doctor to thoroughly examine and diagnose you properly.
Upper or Mid-Back Pain
In the presence of the upper or mid-back pain after a fall or injury, the most likely cause would be from dysfunction of one or more of the ribs. The ribs have many different attachments and structures that surround those attachments to the thoracic spine and to the sternum (breastbone). Falling or even sleeping in a bad position can strain, sprain or damage any of these structures and can cause significant pain. The most painful movement with rib dysfunction are typically taking a deep breath in and quick twisting movements of the mid-back. Rib strains of the muscles usually have a better and quicker prognosis than a ligamentous sprain. Ligaments and cartilage take longer to heal because they have less blood supply and nerve supply. Muscular strain around the ribs generally just requires manual therapy, joint manipulation and potentially some rehabilitative or stabilization exercises.
Fracture of the thoracic spine has the same presentations and characteristics as fracture of the lumbar spine as discussed earlier. Fracture should be considered after a significant trauma, over age 70 or with long-term corticosteroid use.
Rare but important to rule out
Some less common diagnoses that are important to rule out include heart attack, tumor, infection or a visceral disease of the kidney, gallbladder, appendix or pancreas. These emergent disorders stress the importance of seeing a professional for a proper history, examination, diagnosis and triage.
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