Massage & Bodywork

September/October 2010

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table lessons BY DOUGLAS NELSON MAN, THAT'S JUST WRONG… J. was an athletic young man attending college on a basketball scholarship. Unfortunately, one day in practice, he had a terrific collision with a guy who should have been playing football, and J. suffered an immediate disc injury in his low back. At that time, he presented with all the typical symptoms of a low-back and disc injury, which was a symphony in three parts: back pain, pain radiating to the buttock, and pain radiating down the leg. His athletic trainer and his doctor (both of whom are excellent) kept close tabs on him and helped him navigate through the injury process quite well. Using injections and other therapies, the inflammation of the disc seemed to be much reduced. In the usual course of events, the pain retreats to the original injury site, that is, the leg pain will abate first, followed by the pain in the gluteal area, and then finally the low-back pain recedes. Most perplexing to J. and his medical team was the fact that while the disc showed clear evidence of healing, the pain in the legs remained. Even though the pain in the back and buttock was all but gone, the leg pain remained unchanged, if not worse. His trainer and doctor were perplexed; this was really an atypical progression for this type of injury. J. was fearful this could be a permanent condition that would impact his basketball future. I assessed J.'s structure and saw nothing of note that might be relevant to his pain. Having him lie supine on the treatment table, I assessed his hamstrings for length. His left hamstring was at 145 degrees, quite limited, but I have seen many hamstrings this restricted (ideal is 170 degrees). His right, the side of the pain, was at 115 degrees, which is probably the most restricted hamstring I have ever seen. "Whoa. You weren't kidding about your hamstring being tight. This is really quite restricted. Tell me what happens when I stretch your hamstring. Is it painful or does it feel like the muscle just can't lengthen more than that? (If the stretch was painful, this could be a guarding response to protect the nerve rather than muscle tightness.) Tell me where you feel it the most." "Right here," J. said as he pointed to the bicep femoris belly. Keeping the hamstring on a stretch, I asked J. to arch his neck into extension and then bring his neck into flexion to see if that changed the sensation in his hamstring. No change. (If it did, the cause would be neural tension, not true hamstring shortness.) "I think I can explain what is happening to your hamstring and how it relates to your original injury. Beyond the original trauma to the low back, which must have been pretty intense, the disc was clearly affected. Disc injuries often refer to the buttock, which probably explains why you felt pain there in addition to the low back. "The disc injury often irritates a major nerve exiting the spine, either directly or by subsequent inflammation. The nerve is like a root system for a tree; as it travels downward, it has many branches, one of which serves the hamstring and the muscles in the back of your leg. The progression is this: you injure the disc, which sensitizes the nerve. The nerve however, innervates all these leg muscles, which also become highly sensitized and therefore respond inappropriately to stimuli. "In the most logical progression, as the nerve heals, the muscles should, too. The operative word here is should. Research has shown that muscles served by an irritated nerve root are more likely to develop something called trigger points than other healthy muscles. These trigger points can restrict range of motion, cause deep aching pain, or mimic the tingling or burning sensations of nerve irritation. "Here is the irony: the trigger points in your leg replicate exactly the symptoms of the original injury, even though the nerve root inflammation has improved. Is that bizarre or what?" J. summarized the dilemma differently: "So you are saying that the low-back injury sensitized the disc, which caused the nerve problem, which then caused the muscles to hurt. Even though the low back and disc caused this mess, muscle pain, the third link in the chain, is now independent of the thing that caused it in the first place. It is like A causes B, B causes C, but C stays when A and B get better." "That's pretty much the story," I replied as I nodded in agreement. "Man, that's just wrong." instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com. Douglas Nelson is the founder and principal 82 massage & bodywork september/october 2010

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