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“Sciatica” is one of the conditions people seek acupuncture treatment for most frequently. As you will say in the case below, most of the time it is not actually sciatica which people are experiencing. I have prepared the following case study for you in order to give you an idea of how we evaluate and treat such pain with acupuncture. I hope the insight it gives you provides you with the confidence to seek treatment if you are suffering from this type of pain.
Case Study – Sciatica or PIrifomis Syndrome?
A 28 year old male came to the office on a Saturday with pain in the left posterior hip. The pain had begun several days earlier while working (physical labor). He had a strong ache in posterior hip with a radiating sensation down the leg. Additionally, the sensation made him feel anxious and uneasy, causing difficulty sleeping. Ibuprofen helped it only slightly. He had diagnosed himself with sciatica.
What Is the Sciatic Nerve?
The sciatic nerve is composed of nerve roots from the L4, L5, S1, S2, and S3 vertebrae. They merge to form a single, large nerve which exits under a bony arch called the sciatic notch. The sciatic nerve runs through the pelvis, travelling under the piriformis muscle before heading down the back of the leg.
It separates into two branches at the back of the knee to form the tibial and peroneal nerves, which supply the lower leg and foot. The sural nerves branch off from the tibial and peroneal nerves, terminating in the foot.
The sciatic nerve provides motor input for bending the knee, bringing the thighs together (adduction), and flexing and extending the ankles and toes. It conveys sensation from the back of the thigh, the entire lower leg, the ankle, and the sole of the foot.
Sciatica Vs. Pseudo-Sciatica
Many people experience the symptoms described above and identify it as sciatica. In reality, most of the time they are experiencing “psuedo-sciatica.” What is the difference?
True sciatica is a set of symptoms caused by irritation or compression on one or more spinal nerve roots in your lower spine, not the sciatic nerve itself. This could be due to a herniated disc or spinal stenosis,. The nerve roots which merge together to form the sciatic nerve are under pressure. This is a form of radiculopathy. (Radix is a Latin term meaning root, and pathos is a Greek term for disease).
In reality, what most people are experiencing is a form of muscular tightness, called piriformis syndrome. In this case, the sciatic nerve is directly irritated or compressed by your piriformis muscle, deep in your hip. The symptoms of piriformis syndrome may affect the buttock and hip, as well as traveling down into the thigh and leg.
What is the Piriformis?
The piriformis muscle originates at the sacrum (the flat bone beneath your spine in the center of the pelvis) and attaches to a bony knob (the greater trochanter) on the femur (thigh bone) on the outermost part of the hip.
The function of the piriformis is to externally rotate and abduct the hip. This means turning your hip outward and bringing your thigh outward to one side while your hip is bent. This happens when raising your knee and bringing your leg out when getting out of a car (which can be one of the painful movements when it is inflamed). It is also involved in walking, running and standing.
Causes of Piriformis Syndrome
Ordinarily, the sciatic nerve is directly underneath the piriformis. Occasionally, people have an atypical anatomical variation. Sometimes, the sciatic nerve passes directly through the piriformis, which can lead to piriformis syndrome. More commonly, there is inflammation of soft tissues, muscle spasm or both, causing nerve compression.
This can happen with direct trauma such as a car accident or a fall. However, it is most likely the gradual tightening of the piriformis muscle is due to poor posture and overuse. Activities, such as long distance running or prolonged standing without proper stretching and strengthening of piriformis muscle will contribute to piriformis syndrome. However, in my experience, people who sit for a long period of time with poor posture, especially drivers, seem to suffer from this the most.
Symptoms of PIriformis Syndrome
Symptoms of piriformis syndrome can be variable. Some of the common symptoms include:
- Pain in the opposite sacroiliac joint
- Pain with sitting standing or walking for more than 20 minutes
- Intense pain while sitting
- Sensation of pins and needles, numbness, burning, tingling, or itching down the back of the thigh, usually stopping above the knee
- Pain improves with movement
- Pain when moving from sitting to standing
- Foot numbness
Differentiation: Sciatica VS. Pseudo Sciatica
One way to tell is to consider WHERE the pain is felt:
- In piriformis syndrome, buttock and hip pain is typically more common than lower back pain.
- In sciatica, the leg pain is usually greater than lower back pain and the pain may extend below the knee. The affected leg may also feel heavy.
Another way to tell, is the effect of MOVEMENT
- In piriformis syndrome, the pain typically increases while sitting for long periods of time and/or during hip movements.
- In sciatica, raising the affected leg while lying down (while keeping the other leg straight) may induce pain.
The primary physical test for sciatic like symptoms is the Straight Leg Raising (SLR). The straight leg raise places stretch on the sciatic nerve as it passes through and around the structures of the pelvis and traverses down the posterior aspect of the thigh. The straight leg raise test is performed with the patient on their back. The examiner gently raises the patient’s straight leg, and the test is considered positive when the patient experiences pain along the lower limb. In this case, the test was negative (which is good).
The patient was walking with an antalgic gait. Muscle testing revealed weakness at the gluteus medius (resisted hip abduction) and the tensor fascia latae. Palpation revealed extremely tender points at the piriformis and gluteus medius.
The purpose of the physical exam is to identify areas of muscle tension and weakness. Acupuncture points are selected based on their neuroanatomical relevance. The majority of points chosen are motor points. Motor points when stimulated, especially with electrical acupuncture, can normalize the tension in a given muscle. This, in turn, reduces pressure on the underlying nerves and gives pain relief.
Acupuncture was given in the first session to the following points. The points are given with their acupuncture nomenclature, as well as the important anatomy they reference.
GB-29 : Motor Point of Tensor Fascia Latae
GB-30: Motor Point of Piriformis.
UB-53: Superior Gluteal Nerve: innervates Gluteus Medius, Gluteus Minimus and Tensor Fascia Lata.
UB-54: Inferior Gluteal Nerve: innervates Gluteus Maximus.
UB-37: Descending Branch of Posterior Femoral Cutaneous Nerve/Biceps Femoris Motor Point
UB 57: Lateral Head of Gastrocnemius Motor Point
The superior gluteal nerve was connected to the lateral gastrocnemius motor point for 10 minutes of electrical stimulation. Then gua sha was performed to the posterior hip and thigh. Upon standing, the patient felt better but still had some pain in the anterior aspect of the thigh. So treatment was performed to the following points:
ST-31 : Upper Rectus Femoris Motor Point
ST 32 : Lower Rectus Femoris Motor Point
These points were connected with .5 hz electrical stimulation for 10 minutes.
After the treatment, the patient had complete relief. The relief lasted for several hours, upon which the pain came back, but not as severe. The patient required ibuprofen later that night, but by the next day the pain had abated substantially. Upon return to work on Monday, the patient was able to work with some restriction. On Tuesday, we had a follow up visit. The pain was mostly resolved, we performed a treatment similar to the first, and the patient was released with a simple exercise to do at home for prevention.
It is important not to just treat the painful areas, but also muscles that contribute to movement of the leg and back as a whole. In addition to the piriformis itself, the Gluteus medius (the hip abductor) and tensor fascia latae are almost always a part of the treatment. In this case, it was also necessary to treat the hip flexor. These areas of weakness can be uncovered by careful exam.
Also of note, the acupuncture points are selected based on what neuroanatomical structure they relate to, versus the traditional selection of points based on meridians. This, in the author’s opinion, creates an approach which is both more reasoned and more accurate.
Not every case resolves so quickly and easily. The chronicity of the condition, structural imbalances, age, and diet all play a role. In some cases, Chinese herbal medicine such as Du Huo Ji Sheng Tang is added. However, most cases can at least improve if not be totally resolved with acupuncture and Chinese medicine treatment.
“Have you heard of dry needling?”
“My physical therapist wants me to try dry needling. Should I?”
“What is the difference between dry needling and acupuncture?”
Have you heard of dry needling yet? Maybe you have heard about it from your doctor or physical therapist. Perhaps you have friends who have experienced it and they have suggested you try it. It’s different than acupuncture! Maybe you know it involves acupuncture needles. If you’ve seen it, it looks like acupuncture, but it’s not acupuncture. Or is it?
There’s been a lot of confusion around this topic for the past several years. So, at long last, I decided it is time to clarify the differences and similarities of what acupuncture and dry needling are. Since I am an acupuncturist, let’s first take a quick look at what acupuncture is, and then see how dry needling fits into the picture.
What is Acupuncture?
Acupuncture finds its historical roots in ancient China. Acupuncture first made it’s way to the US in the form of TCM, or Traditional Chinese Medicine. Acupuncture uses stainless steel, sterile needles to stimulate areas within the body. The purpose of acupuncture is to relieve pain, reduce stress, and improve function.
How does acupuncture work? Here is where it begins to get tricky. We have a traditional understanding of how acupuncture works (which some acupuncturists still use today), and a modern understanding of how acupuncture works (which is what I use in my practice). What is the difference and why does it matter?
In the traditional understanding of acupuncture, the body is considered to have a vital energy. This vital energy, or “Qi” flows along lines called meridians, This energy can become stuck due to trauma, overuse, or stress. This energy stagnation can result in pain and dysfunction. Stagnation can be relieved by stimulating acupuncture points along the meridians. The acupuncture points can be located where the pain is, or the can be located in other parts of the body, such as the ear, hand or foot.
The modern understanding of acupuncture, on the other hand, is concerned primarily with muscles and the nerves which supply them. From this perspective, treatment is given to “trigger points,” or knots which form in the muscles. The trigger points also form due to stress, trauma or overuse. Placing the needle in the trigger point causes the muscle to fasiculate, or “twitch,” which is usually followed by profound relief of pain and stress. The action of causing the muscle to twitch with a needle is also what is called “dry-needling.”
Why is it important to understand these two concepts? Because dry needling is nothing other than doing acupuncture according to the modern understanding. This is the conceptual framework used by physical therapists, chiropractors, and even some acupuncturists (including myself).
In other words, ALL dry needling, IS acupuncture. But not ALL acupuncture is dry needling. Put another way, dry needling is just one technique, or method, of acupuncture. The physical therapist has access to this technique, but not ALL the styles of acupuncture. There are very effective acupuncture styles which involve putting needles in locations far away from where the pain is, Which means, SOME acupuncturists will treat you in a similar fashion to a physical therapist, and some will not.
Pros and Cons
The first question that springs to many people’s minds is, “Which is better?” The better question is: “Which is better for me?” Traditional acupuncture or dry needling both need to fit into a comprehensive treatment plan. A good clinician always starts with evaluation, questioning, examination, and diagnosis. These should all come before any technique is decided upon. I use my clinical experience to determine which acupuncture technique is going to best serve the person in front of me. Sometimes dry needling is absolutely the best thing I can do for them. Sometimes a traditional technique is better. Most often, I mix and match using 2 or more styles to come up with a combination that fits the unique individual.
The pros of the dry needling technique are that it can very often produce extraordinary pain relief, quickly. The cons are, it can be uncomfortable initially, and sometimes can produce soreness for a day after treatment. Additionally, some conditions can be aggravated by it. My approach has always been to carefully choose when to use it, and start slowly to see how much a person is comfortable with, and increase over time. This has produced the best results for me.
Should You Try Dry Needling?
Many people have recently learned about dry needling and are eager to try it, understandably so. I first began the dry needling approach in 1999. Chances are, if you have been my patient, you have already had dry needling. If you have ever felt the muscle “twitch” during treatment, you have had dry needling. (If you ever heard me talk about the muscle locations or the “green triangles,” you know what I am talking about). Until recently, I just called it “acupuncture.” No one knew the difference. But today, with the increased awareness of different healing techniques, I take the time to indicate when we are using this method.
If you haven’t been in for awhile, and would like to experience this fabulous technique, give us a call today. one of the wonderful things about acupuncture is that there is always more to learn, and I am constantly finding new ways to better serve you.
Also, if any of you have any questions, give us ac call today! I am always happy to answer your questions.
Greetings and happy holidays! I hope this finds everyone well. I have some exciting things to share with you. This year I celebrated my 15th(!) year in practice. It seems hard to believe. Persisting in anything for 15 years is a challenge. One of the things that keeps my going is the constant search for newer and more powerful acupuncture techniques. I have traveled around the country, gone to endless seminars, and read dozens of books. Acupuncture is a huge field and there are many, many styles to choose from. There are many Chinese styles, but also Korean, Japanese, Vietnamese, and even western style or “dry-needling.” I have explored many of these but over the years I came to rely on the treatment of “trigger points” as a primary tool.
The trigger points (or “knots”) in the muscles are the source of a great many pain problems. For years, I have studied trigger points and how to release them. Many of you are familiar with the acupuncture trigger point techniques I have used and the profound relief they can provide. Getting the muscle to twitch or “jump” (sometimes referred to as dry-needling) can release tension and pain instantly.
As good as these techniques are, I am always on the lookout for ways to make them better. To find a way to make them faster, more accurate and more powerful. I constantly research and test new methods. Some work ok, some are so-so, but rarely do I find something that blows me away. I can honestly say finding the EXSTORE system was a game-changer for me.
In the past several months, we have introduced the EXSTORE method of assessment and treatment. Those of our patients who have experienced this technique have been very happy with the outcomes thus far and we are excited to tell you about it. In 15 years of practice, nothing else I have found has made such a huge difference.
The EXSTORE system is a method of assessing pain patterns quickly and finding the root cause. Basically, we test the strength of the muscles to find which ones are neurologically inhibited (weak). These muscles are not doing their job of supporting the body structure and can lead to pain and dysfunction. After pinpointing which muscles are weakened, we apply acupuncture plus electric stimulation (similar to a TENS unit), which immediately “wakes up” the muscle, changing the strength instantly! When the muscles are reawakened, the body will be able to move better and the painful situation will improve, often dramatically.
The EXSTORE technique is combined with all the other methods we have, including cupping, gua sha, kinesiotaping and others. However, it is now the foundation on which these other techniques rest. This combination has produced much better results than I have had previously, for sciatica, neck pain, knee pain and many other common conditions. It even works great for IBS, PMS, and other internal complaints. If you have not experienced this technique I invite you to call today at 630-369-3237 and give it a try!