In our modern lifestyle, we are facing certain types of symptoms and diseases which are widely common.

They have a great impact on our lives and on our work performance.

Since a vast majority of modern industrialized society are office-based workers, suffering from low back pain is interfering with the day routine of a large section of the population.

Here in this article, we will discuss the different types of low back pain. And this may give you a clue on how to look at the problem from a professional point of view.

 

How to distinguish different types of low back pain?

Actually, only doctors can answer this question. This is true, in general. But having a scientific background about the problem helps you make a better choice when it comes to the decision of the treatment.

Also knowing the exact description of the situation, you are suffering from, will raise the RED FLAGS for the seriousness of symptoms that may need immediate medical evaluation and treatment.

 

What are the types of low back pain?

Nonspecific Low Back Pain:

This is the type that most people suffer from at some point in their lives. The severity of the pain varies from mild to severe. No clear reason for the pain. Most of the cases are sudden-onset.

Sciatica which is the pain of the nerve root:

This means that the nerve coming out from the spinal cord is irritated or pressed on. The patient feels pain along the course of the nerve. Therefore, in most cases feel the pain down a leg, or even as far as the calf or foot. The patient may feel pins, and needles, numbness, or weakness in part of a buttock, leg, or foot, because of irritation and the pressure on the nerve.

When part of the inner softer part of the disc bulges out (prolapses) through a weakness in the outer harder part of the disc, this case is described as prolapsed disc, or slipped disc. . The prolapsed part of the disc can press on a nerve nearby.

A rare case called Cauda equine needs urgent medical treatment:

Some of the RED FLAG symptoms we mentioned above occur here,

1. numbness in the saddle area (around the back passage (anus)) and weakness in one or both legs.
2. low back pain plus problems with bowel and bladder function, which may cause the inability to pass urine.

But what Cauda equine syndrome means?

This is a disorder where the nerves at the very bottom of the spinal cord are pressed on. Which is really rear. This condition needs URGENT treatment to prevent the nerves in the bladder and bowel from becoming permanently damaged. The patient is highly recommended to see a doctor immediately if you suspect cauda equine syndrome.

 

Less common causes may include:

Osteoarthritis, Ankylosing spondylitis, Rheumatoid arthritis.

These three causes are inflammation of the joints (arthritis) of the spine.

Where Osteoarthritis, usually occurs in older people, Ankylosing spondylitis is another form of arthritis that can occur in young adults, which causes pain and stiffness in the lower back. Rheumatoid arthritis can affect the spine but usually affects other joints too.

 

How low back pain develops?

Either immediately after you lift a heavy object.

Or after forceful twisting movement. In some cases for no known cause.

Some people just wake up one day with low back pain.

Typically, in nonspecific back pain, the pain is located in one area of the lower back but sometimes it spreads to one or both buttocks or thighs.

The pain is eased by lying down flat. And often be worse when you move your back, cough, or sneeze.  So, we can say that nonspecific low back pain is of mechanical nature because it varies with posture or activity.

Even if the attack of low back pain improves quickly, within a week or so. However,

It could be further attacks in the future, (i.e. recurrence).

Also, the patient may experience minor pain in an on-off fashion after the initial bad bout of pain.

If the pain persists for several months or longer, this is called chronic back pain.

When to suspect a more serious underlying cause?

Generally talking, if any of the following occur then it may not be nonspecific low back pain, there may be a more serious cause.

• Constant back pain that is not eased by lying down or setting.
• Pain that radiates to the chest or is higher in the back behind the chest.
• Gradually developing pain which slowly gets worse, over days or weeks.
• Any weakness in any of the muscles in a leg or foot.
• Inability to feel anything (numbness) in any part of your bottom or leg.
• Using steroid tablets for more than a few months.
• Symptoms that may indicate inflammatory (arthritic) causes such as ankylosing spondylitis.

1. 1. Pain which is worse in the second half of the night or early morning, after waking.
   2. Stiffness, in addition to pain. Of the back muscles in the morning after getting up from bed.
   3. The pain is partially relieved by activity.

• Symptoms that may indicate cauda equine syndrome.

1. 1. Bladder symptoms such as loss of balder sensation, and incontinence.
   2. Numbness around the back passage (anus).
   3. Incontinence of stools.

• Symptoms that may indicate a fracture in the spine. The main ones are:

1. 1. Pain following Traumatized events such as road accidents or falls from a height.
   2. Pain after minor trauma in people with the thinning of the bones (osteoporosis).

• Symptoms that may indicate infection or a spread of cancer: affecting the spine.

1. 1. Pain onset in a person over 50 year’s age, or under 20 years of age
   2. Pain that disturbs sleep

• Symptoms or problems in addition to pain such as:

1. 1. If you have cancer in any part of the body.
   2. High temperature, or unexplained weight loss.
   3. If the patient injects street drugs.
   4. If the patient has a poor immune system. For example, Chemotherapy, or AIDS.

When to do tests?

Tests such as X-rays, MRI scans, and blood tests, may be devised in certain situations. This is mainly if there are symptoms, or signs during a doctor’s examination, to suggest that may be a serious underlying cause for the low back pain.

 

How to treat low back pain?

For sudden–onset (acute) attack of nonspecific low back pain.

Stay active:

Move around as soon as possible. If possible (if the pain is not very severe) keep doing normal life activities. And in general, do not do any activity that may cause more severe pain. Of course, you will feel some discomfort when you are trying to keep active. Maybe having some walking will be a good idea, and then gradually increase the distance as tolerated.

Sleep in the most comfortable position for you, whatever is the comfortable surface. In the past traditionally patients were advised to sleep on a firm mattress. However, no evidence to support that a firm surface has a better outcome.

Try to go back to your job (if any) as soon as possible. There is no need to wait until you feel completely pain-free. Returning to work helps to relieve pain by getting back to a normal pattern of activities.

Physiotherapist-designed exercises at home can help to recover more quickly. It is now known that the advice of having rest until the pain eases, was wrong. Research showed that it is more likely to recover more quickly by getting moving again and by getting back to work as soon as possible.

Medication:

There are commonly 3 categories of medication that can be used for the management of pain.

• Anti-inflammatory Painkillers: Most commonly used ones are: ibuprofen can be prescribed by your physician, or you can buy directly from Pharmacy (over the counter, without a prescription). Diclofenac, naproxen. Which needs a prescription. Important to know that some people cannot use anti-inflammatory drugs, for example, patients with high blood pressure, Asthma, kidney failure, or heart failure.
• stronger Pain killers: such as codeine is an option if anti-inflammatory drugs could not be used by the patient. Also, the patient may take (codeine with paracetamol). One of the side effects of using codeine is constipation.  
• Muscle relaxant: such as diazepam which the physician may prescribe for a few days if the back muscles become very tense and make the pain worse. It is important to know that this medication is a member of a group of medications called benzodiazepines which may be addictive if used for a long time, and should be taken for as short a time as possible.

Other treatments:

Treatment may vary and the situation should be reviewed by a doctor if the pain becomes worse, if the pain persists beyond 4-6 weeks, or if symptoms change.

Other pain-relieving techniques could be applied, and always there are new treatments for back conditions as well.  When? If the pain persists beyond 4-6 weeks, or if symptoms change.

 

Persistent (chronic) low back pain

In the case that the low back pain lasts for longer than six weeks, it will be called chronic. In some cases, it lasts for months or even years. The most common pattern is when the symptoms follow an irregular course. Which usually means long periods of mild or moderate pain may be interrupted by bouts of more severe pain.  In some cases, the symptoms can be constant.

But how to treat chronic back pain?? . Actually, initially the treatment is similar to the sudden-onset (acute attack).  Which means painkillers and staying active as tolerated.

Other groups may be prescribed by doctor antidepressant medicine in the tricyclic group. For instance, amitriptyline. This group of medications has separate other actions separate from their action on depression. They are used in many different painful conditions. Including back pain.

Knee pain because of ligaments injuries

Many people especially athletes suffer from knee pain because of ligament injuries, and usually, these kinds of injuries limit their activities, careers, or in general their lifestyle.

But what are ligaments injuries?

To understand this you have to put a spotlight on the structure of the knee.

Structure of the knee

There are four bones around the area of the knee joint: the thigh bone (femur), the main shin bone

(Tibia), the outer shin bone (Fibula) and the kneecap (Patella).

The main movement of the knee joint is between the femur, the tibia, and the patella.

There is tough connective tissue (articular cartilage) that covers the ends of the tibia and femur and the back of the patella around the knee joint.

Why do we need cartilage in our knees?

The articular cartilage reduces friction between the bones of the knee joint and helps smooth movement between them.

Each knee joint also contains an inner and outer meniscus, which are thick rubbery pads of cartilage tissue. They are C-shaped and become thinner towards the middle of the joint.

Also, there are four ligaments around the knee joint. A ligament is a tough strip of connective tissue that joins one bone to another bone around a joint. These ligaments have a very important role in stabilizing and supporting the knee when it is moved into different positions.

Furthermore, each ligament has a different job to do:

• At the inner side of the knee, there is the (so-called), medial collateral ligament. (MCL). It runs between the Femur and the Tibia on the inner side of the knee. It helps to protect and stabilize the knee joint against any forces on the side of the leg. Also helps in limiting the number of knee moves from side to side.
• At the outer side of the knee, there is the (so-called), lateral collateral ligament. (LCL). It runs between the Femur and the Fibula. The function is to protect the knee joint against any forces on the side of the leg. Again this ligament does not allow too much movement of the knee from side to side.
• Inside the knee joint, there are two ligaments. The first one is (the so-called), Anterior Cruciate Ligament (ACL). It runs diagonally connecting the front (anterior) of the Tibia to the back (posterior) of the Femur. This joint also helps to stabilize the knee joint by controlling backward and forward movements of the knee.
• The second one is inside the knee is the (so-called) Posterior Cruciate Ligament (PCL). It also runs diagonally across the knee, it is also connecting the back (posterior) of the Tibia to the front (anterior) of the Femur. The ACL and the PCL cross each other inside the knee joint and some people call them the cross ligaments. (Cruciate means CROSS-SHAPED).

 

The knee joint is surrounded by a protective joint capsule. This is lined by a special membrane called the synovial membrane. Which produces the main lubricating fluid for the knee, the so-called Synovial fluid.

How does the ligament injury occur?

They may be stretched (sprained), or sometimes torn (ruptured). A ligament sprain happens when the fibers that make up the ligament are stretched and just a few fibers are torn. Most knee ligament injuries are sprains and not tears and they tend to settle down quickly.

• If you have a direct blow to your knee
• Knock into something with your knee
• The knee may go beyond its usual range of movement. In some incidents during a fall, or landing during sports. Or even after a sudden movement.

The ligament of the inner side of the knee (medial collateral ligament, MCL), was injured.

It happens when your leg is stretched out in front of you and the outer side of your leg receives a blow at the same time. It happens in almost any sport. And happens in all age groups.

 

The ligaments inside the knee, the front ligament (anterior cruciate ligament, ACL), injury.

The injury happens if you land on your leg and then you twist your knee in the opposite direction quickly, where it is slightly bent. Just like what happens in basketball, football, and tennis. Because the muscles around a woman’s knee aren’t as strong as those around the man’s knee, in general women tend to have injuries to their ACL more frequently than men.

 

Inside the knee, rear ligament, (Posterior cruciate ligament, PCL) injury.

It may be injured during accidents, particularly car accidents. But how?

If the dashboard hits the front of your bent knee and your lower leg is forced backward.

It may also be injured from the front whilst it is stretched out in front of you with your foot on the ground. In a game of soccer for instance.

In the beginning, you may not notice any symptoms. However, you may notice that there is a pain that comes on when going up and down stairs or when starting a run.  Sometimes you may feel unstable when walking on uneven ground.

How does it feel when you injure your knee ligament?    

The symptoms depend on the severity of the injury rather than the ligament that is injured. The ligament that is completely torn may produce more in the way of symptoms than a ligament that is just sprained.

Symptoms may include:

• Swelling of your knee. When a ligament is injured, there may be some bleeding inside your knee joint from the damaged ligament. Which may cause knee swelling. Minor ligament sprains may cause little in the way of swelling. However, torn ligaments may lead to a lot of knee swelling. Which may be produced very quickly.
• Pain In the knee.
• A popping sound or snapping feeling. Sometimes this could be felt if the ligament is completely torn.
• Tenderness in the area around the knee on touching. This is maybe more generalized and severe if the ligament is torn.
• In complete ligament tears, movement can be severely reduced; whereas, in more minor sprains you may have a relatively good amount of knee movement.
• A bruising around your knee can sometimes be obvious, and not necessarily occurs at the time of the injury, it may take some time to develop clearly.
• The feeling of instability of the knee. This may cause you to limp. Again it depends on how much your ligament is injured. You may be able to stand if you have just a minor sprain.

 

How is the knee ligament injury diagnosed?

In the first place, you have to see a doctor, your doctor has to know more about the injury by asking detailed questions about your symptoms and how you feel the pain, and where exactly you feel the pain. Also through physical examination, the doctor looks for signs of swelling in your knee.

They have special examination techniques and look for special signs specific to ligament injury.

For example, a drawer sign.

When the examiner, tries to do sliding of the knee joint forward and backward. Exactly, when he is trying to move the Tibia (the bigger leg bone) under applied stress. This sign when exiting (positive), backward or forward; means laxity or tear of the posterior/rear, or anterior/front cruciate ligament of the knee accordingly.

Radiology studies:

If your doctor suspects a more serious knee ligament injury, they may refer you for a special type of radiology examination called an Ultrasound Scan. Or a Magnetic Resonance Imaging (MRI) scan. By using these studies doctors may be able to recognize any tears or ruptures in the knee ligament.

Treatment of the knee ligament injury:

During the first few hours till the first few days, what should you do?  And what you should not do?

What to do:

• Protect your knee from further injury.
• Your knee needs to be in rest, for at least 2 days. But how to do so?
• Use crutches.
• Start some kind of exercises to help keep your knee joint moving and mobile, as soon as you can tolerate the exercises. Do not keep your injured knee immobile for too long.

 

• Ask your doctor about the timing and the kind of exercises that fit your injury.
• Apply some ICE for at least 10 to 30 minutes. Be informed that more than 30 minutes applying of cold will damage the skin. And less than 10 minutes would not be effective.
• It is a good idea to use a bandage with compression to limit the swelling. Be noted that mild pressure is not uncomfortable or too tight and would not stop the blood flow to the joint.
• Always try to use tubular knee support, and the pharmacist will help in choosing the right size.

And be advised also to remove the bandage after 48 hours. Because you need to allow for some movement of the joint. However, sometimes it may be needed to keep the bandage for a little more time to reduce the swelling of the joint.

 

• It is a good idea to elevate the limb in a way, it will improve the joint swelling. Try to keep your foot on the injured side up on a chair, supported by a pillow under your knee.
• Rehabilitation to get your knee back to normal.

What you should not do:

• Heat (which does exactly the opposite of Ice on blood flow), should be avoided during the first 72 hours, however, after 72 hours heat may then be soothing.
• Any vigorous kind of training, or exercise.
• Massage may increase bleeding and swelling.
• Alcoholic drinks. Which reduces the healing process, and increases bleeding.

Medical Therapy:

• Paracetamol and codeine: for Paracetamol the adult dosing is two 500 mg tablets, four times a day. For a few days. If the pain is more severe, Codeine could be prescribed. Which is more powerful?  But has some side effects like constipation, and drowsiness.
• Anti-inflammatory painkillers: are also called NSAIDs. They have two benefits, first to reduce pain. And second to reduce swelling. Some of them you can buy over the counter (no prescription is needed), for example: However, some needs a prescription.
• These NSAIDS have some side effects like stomach pain, and bleeding from an ulcer. Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to use these medications.
• Topical anti-inflammatory.

Physiotherapy:

Physiotherapy aims to increase the range of movement in your injured joint. If you are referred to surgery to repair a torn knee ligament, it is likely to be advised to see a physiotherapist first.

Knee braces:

Your doctor may advise you to wear a special brace to support your knee while the damaged ligament heals. This special brace allow some bending and extending movements but not allowing movement from side to side. However, a knee brace is not suitable for all patients, this will be decided by your doctor.

Surgery:

Some indications for the surgery after knee injury will be:

• If the patient is an athlete.
• If more than one ligament has been injured.
• If you hurt another part of your knee, along with the knee ligament.
• If the physiotherapy and the rehabilitation therapy did not work well.
• If you have hurt the side ligament (lateral collateral).
• In reality, surgery is most likely advised to repair the front inside ligament (anterior cruciate ligament).
• The decision, to carry on surgery or not, depends on various factors like:
• Was the physiotherapy effective or not?
• How actively you are moving on a daily basis.
• If you have any other medical condition.
• If you have another medical injury in your knee.
• After all, the decision to do the surgery may be discussed between you and your doctor.

 

How to protect yourself from ligament injury?

There are some facts to know about ligament injuries:

• Warming up during a game or sports training time is very effective in preventing injuries.
• Warming up for 5 to 10 minutes and gradually escalating the activity level, will increase the blood flow to your muscles, and help to loosen up your joint movement.
• Wearing a knee brace is controversial.
• Exercising regularly is recommended.
• There are some groups of muscles that help to support your knee. Known as hamstring and quadriceps. It important to build –up the strength of these muscles to support your knee structures.