Herniated Disc vs SI Joint vs Piriformis Problem (How To Know The Difference)

hey everyone what's up this is dr charlie johnson appreciate you checking out my channel and in this thought i want to share with you how you can sort of differentiate between si joint problems disc problems or even piriformis issues they cause pain in a very similar location and a lot of times it's kind of muddy and difficult to tell so i want to help you differentiate between these issues as i recently got a question about how to do that and so to do that i've created a detailed step-by-step flow chart that sort of lets you inside my brain and lets you see sort of how i think um you know when somebody presents me with these issues so my hope in sharing this flow chart is that you can follow along get some clarity about what could be causing your issue without needing you know x-rays mris other tests and or visits uh visits with specialists okay so if you're new to my channel i'd also recommend you check out my um expanded version of this flow chart even more detail than what i'm going to share with you today it's called better than an mri diy diagnostic guide you can download that above and or in the comments below and i'm pretty much sure everything i know about diagnosing these very mysterious problems uh in that flow chart so make sure that you check that out also if you enjoy what you're learning today and you want a copy of the flow chart that i'm about to share please check out again either by clicking here and or in the comments below or the description um my free facebook group i call it my diy diagnostic network for those people with unresolved back butt or sciatica problems so if that's you and you want a copy of this flow chart um please go ahead click that link answer a few basic questions and i will approve you into the group so look forward to seeing you inside there now let's dive into it this is a helicopter view of the flow chart we're going to review today so buckle up take a seat find some comfort because we're going to walk through this step by step again to help you differentiate between s i disc and or piriformis problems all right so let's take it from the top so first things first just recognize if you have a back or a si joint problem there's a very quick way to sort of rule it in or at least kind of get you in the wheelhouse of of answering the question hey is this a back problem or an si joint problem well if it is one of these issues it almost always hurts to move your back so what i want you to do is i want you to try to move your back in the directions below that i'm going to show you to see if they reproduce your pain so you can see here there's a couple uh motions that move your body forwards as well as some that move it left and right sideways and then some motions that test the backward planes of your body so what i would do if i were you and please by the way like if any of these things you know are going to send you into terrible pain and or you're restricted in your ability to do these things for whatever reason right then please don't do them but ideally we can sort of you know test the different motions of the back to see if we can reproduce your symptoms so what i would do is i would take a seat and i would test this one first so go ahead and slowly gently bend forward as if you're trying to touch or palm the floor and you want to see does that reproduce your pain numbness tingling or symptoms wherever they are after you come back on up go ahead and move your body or your trunk over top bend forward over top of your left knee if you want you can take your hands put it on your left knee this way you can kind of support yourself as you go down and push yourself back on up then go ahead and go over the right knee so test straight forward over to the left and over to the right now let's stand on up and let's go the opposite direction so go straight back put your hands on your hips feet shoulder width apart for balance go straight back as much as you can tolerate again you're asking yourself does this reproduce my back butt or leg pain now what i want you to do is i want you to stand we're going to go back to the left i want you to twist your trunk to the left first and then bend straight back so you're going to rotate first left and then extend straight back and now what i want you to do is twist the right and bend back as far as you can so we've tested straight back and rotated and bent back to the right and rotated and then back to the left and now you're neutral again hands or feet shoulder width apart just for balance hands on the hips go ahead and just bend to the right so right standing side bend and then bend to the left so you can see how this sort of moves the body forward backwards right and left as well as some in between directions there and helps us really get an idea of like how moving the back changes your symptoms maybe it does maybe it doesn't but here's the takeaway if moving your back does not reproduce your pain then chances are very high that it's not a back problem it's also very high that it's not an si joint problem so if you're like okay charlie i moved my back and there's really no problems there then again check out my better than an mri diy diagnostic guide because chances are that it's not a problem here and you maybe need to look into something else if you're still confused and or if you're still unsure then you can retest them if you want to see or you can just keep reading all right so um if you're someone who moves their back and maybe you don't even have any back pain but it causes some type of problem in your butt or your leg then keep following along because chances are it might be one of these things so just keep watching all right the first and most common issue or cause of back pain is without a doubt uh disc problems okay and there's many different types of disc herniation stick around to the end of the video because i'm actually going to share with you a type of disc problem um that completely uh goes against what most people think of when they think of disc issues okay so um really funky stuff here stick around we're gonna talk about a couple different types of disc issues but first things first right just ask yourself you know do you have any back pain pain located at or above the belt line and if you do right then it's probably a back problem and there could be many things that cause back issues but again disc problems are very common right and so i want to start up here and i want you to ask yourself do you have back pain and leg pain numbness or tingling that travels down the leg below the level of the knee into the calf shin or even foot we call this radiating pain this points to there probably being some type of nerve irritation this is not as common only about 10 percent of people experience this but generally if it's below the level the knee into the foot it's usually sharp shooting burning and fairly severe and so you want to confirm if this is a nerve problem by doing this straight leg raise test so you take your painful leg do this very slowly there should be no question about whether or not this is positive or causes a problem or not okay so go ahead and do this on your painful side and if it hurts and causes your leg pain it's very stiff and difficult to do this is what we call a positive straight leg raise test it's a really good screening test that picks up a lot of just nerve irritation all right so if you have this chances are very high that you have sciatica and what could be causing it well disc problem is actually the number one cause of sciatica but what i want you to do to kind of maybe even confirm it to kind of put the nail in the coffin and say absolutely i you know chances are very very high that i have a disc problem because i want you to try that same straight leg raise test on the good leg all right so let's just say your painful leg is the right leg so you do it okay ouch right that's a positive straight leg raise on that side but now what i want you to do is i want you to do the good leg your opposite side again if your right leg is a painful like you do the left leg or if the left leg is painful leg you do the right leg so you want to raise your good leg and if you say ouch raising my good leg causes me to feel leg pain i was tingling or whatever on my bad side then we call this a positive cross straight straight leg raise test and this is a very diagnostic test for disk problems so chances are 90 or more that you've got a disc problem especially when you combine those it's very very high we'll get to kind of the story and how people describe disc problems in a moment but i want to review this real quick let's just say for whatever reason you have pain understanding goes all the way down the leg you know into the calf or foot but the leg raise is not positive meaning it's okay when you do it doesn't really cause any problems then it seems still because of how far the symptoms go down the leg you have some type of nerve irritation right but the only other thing that could do that there are things beyond this but the most you know common diagnostic thing as far as problems with the muscles the bones of the joint would be something called spinal stenosis and we've sort of come up with an algorithm or a sort of a cluster of findings that might indicate this so i don't want to spend too much time on this but just recognize that disc herniation is generally occur for younger perhaps you have this lymph delay but your leg raise is normal or you eight are you a little bit older than 50. do you have leg pain that's worse than back pain do you have leg pain i was thinking that's increased when standing and walking do you feel much better when you're sitting bending or walking forward we call this a shopping cart sign maybe you go to the store and you feel symptoms your leg but when you bend forward it feels much better and you have symptoms in both legs and this can kind of point to what type of spinal stenosis you might have if you said yes to many of those things but that being said if you're watching this video then you probably fit in the vast majority of um you know folks and most folks who have these types of symptoms going all the way down the leg um below the level of knee into the capsule or foot will have a positive straight leg raise which indicates some type of sciatic nerve irritation or sciatica you may or may not have a cross straight leg raise it's not necessarily needed to diagnose a disc herniation but if you have both chances are very very high to this problem all right so now let's just review sort of the story right who it affects and sort of the um symptoms right so again younger folks there's higher um volume within the disk of folks who are younger generally the pain is central lower back pain it may shift from side to side maybe it starts center in the in the low back then maybe goes to the right or goes off to the left slightly pain is generally worse first thing in the morning because this pressure is highest in the morning there's often trouble straightening or standing up after you've been in a seated position maybe there's a long car ride or something like that you go to stand up and it's like right that type of thing pain is often worse while sitting driving bending lifting twisting coughing or sneezing also increases pressure within the disc pain is generally better walking standing or lying down but as we'll review her in a little bit there is a specific type of disc issue that i can actually cause um terrible pain when standing and walking but it might feel better when you're sitting so we'll review that uh here shortly again pain is generally central uh and or slightly off the one side along the level of belt line there's often this roller coaster of back pain so you know hey charlie in the past like my back's gone out on me it's hurt for a few days right uh and then it gets better and often what happens is you know it'll get better and then it'll go out and it'll get better and you kind of ride this roller coaster of the back going in and out right and if it's really yucky really bad you might notice what we call a lateral shift which is where your whole body is sort of tilted forward into one side and then again the number one cause of sciatica is a disc problem now we've done some studies and we can go a step further and say hey if this is you then you kind of determine what nerve is affected without an mri or anything and so these are actual drawings taken from a study um of people where we've sort of irritated the nerve at certain levels all right and if you impact the l3 nerve by the way l3 is not commonly affected uh by the discs in the low back meaning there are sort of many nerves in the low back but the most common levels of disc herniations are l4 and l5 so higher lumbar l that's what that stands for higher lumbar disc problems or nerve problems are not very common but anyway l3 you can see it causes pain mostly in the front even down to the knee and some pain in the back of the leg l4 does happen but again not as common as a problem with the l5 nerve um si jointy pain even though it's not an si joint problem it's actually a problem with the fourth nerve in the back buttock pain goes down the back of the leg and you can see definitely some thigh pain in front of the leg pain groin pain even right l5 if you have a problem with the l5 nerve then you will have pain a little bit in the frontal leg but mostly you can see in the back of the leg and the side of the leg and if there's a problem with the s1 nerve then it's almost exclusively in the back the back butt and the calf and or even in the heels where most people describe these issues all right so that helps you give an idea because each nerve sort of controls a certain area of real estate if you will as far as sensation and just feeling so depending on where you feel your symptoms you can see there's a lot of overlap here so it's not super helpful but the higher lower back nerves lumbar nerve roots cause pain more towards the frontal leg the lower ones mostly towards the back and so nerves are like highways they carry information such as feeling which is in these drawings as well as movement so another thing you could do is you could say hey i've got this l5 problem wow like charlie seems like i'm following this flow chart right along boom boom boom right and i've got symptoms in this area now what you want to do is say hey like how is the strength how is the juice flowing through that nerve and do you have still strength to the muscles that that nerve plugs into so to test the l5 nerve it's very simple you can just perform heel walk so go ahead and kind of march on your heels you do that or you know are you not able to pick one of these toes if so points to a problem with the l5 nerve and maybe you're saying hey like yeah i have it in the back of the leg but it's not on the side leg it's all down the back leg even towards the heel and by the way towards the pinky toes so like the fourth and fifth toes is more of an s1 problem go ahead and try going up on your toes so doing like a heel raise or a calf raise so do one leg see how that feels do the other leg see how that feels and if the function of the nerve is impacted to a certain extent you may see that you've lost strength in that area all right so you can test that out okay so that's that again this type of pain that goes below the level of the knee and the foot sciatica due to nerve irritation in the back is not very common so this term is really thrown around but honestly it only occurs about five to ten percent of people so what else can cause pain in the leg if you have some leg pain so i'm going to skip if you have back pain only for a second and i want to go to the other extreme which is the majority of folks who feel back and leg pain and these folks generally describe the pain as dull diffuse achy versus up here it's sharp shooting severe and travels in a very narrow band it's electric like the song right it's electric um but these folks again it's kind of more broad and so do you have back pain and butt or leg pain that remains above the level of the knee without numbness or tingling this is called referred pain so we know that if we irritate structures in the back and we leave the nerves completely alone they can send signals from the back into the butt or even into the leg now most of the times if this is referred pain not due to a nerve problem but instead just referred from aggravated joints or discs in the back the pain generally stays above the level of the knee all right so what i want you to do just to rule out a nerve issue just try the straight leg brace try it on your yucky side if it hurts and causes leg pain then this is positive and chances are very high you've got sciatica and you can follow the flow chart that way again you can download this by um checking out my free facebook group and requesting to join if you try this straight leg race test and it's a little tight but there's no real problem and i would expect that if you don't have symptoms available a little below the level of the knee i'd expect that you know maybe when you do it feel the tightness but it's not really like nothing zapping down your leg you're not significantly limiting your motion then if you're less than 50 chances are very high just based off stats again back uh disc problems are probably the most common cause of back pain and so chances are very high attorney diss so then ask yourself hey do i match these criteria does this story resonate with me if so this problem if you're older than 50 then chances are less probable that it's a disc issue and instead maybe we're thinking spinal stenosis or degenerative disc disease ddd or degenerative joint disease or maybe a problem with the joints in the lower back we call these facet or z joints all right i'll create another video on that now if you have back pain only i want to revisit this and you have no leg pain no butt pain no leg pain numbness tingling nothing like that then you don't have sciatica you just have local pain just referred pain and for whatever reason it hasn't gone to the butt or anything like that whatever you've done has just stayed locally again sort of on that belt line and so chances are very high yet if you're less than 50 it's a disc issue you're greater than 50 it might be one of these things all right so you see that these structures joints discs things like that they in and of themselves can just cause local pain and or referred pain into the butt or even in the leg just because you have leg pain doesn't mean you have sciatica do this test if you have this test and it shoots pain down the leg and chances are very high you've got sciatica and if symptoms are sharp shooting severe travel on a very narrow band they're electric they're burning things like that they go below the level of the knee and you've got pins and needles and things like that chances are very high you're going to have a straight leg raise and that you have sciatica again not very common not as common as probably people make it sound preferred pain is much more common all right so that kind of reviews disc issues as well as some other things in the spine now let's talk about s-i joint problem so maybe moving your back usually back to one side causes some type of problem and you've made it to this point but your pain is not located at or above the level of the beltline the pain is a little bit lower so now the question becomes is like all right one-sided pain below the level of the belt line slightly lower sort of in that dimple area it may or may not extend into the buttock area but you have no numbness or tingling in the leg so let me zoom in on this so you can imagine you've probably seen this on some people right people are wearing some wearing some low rider pants or something like that or even look in the mirror right you might see two little dimple areas if you put your finger there kind of right on that dimple area it's often painful and this is the location of pain for people of s i joint problems it may or may not refer into the leg it very rarely goes below the level of the knee and it's usually again one-sided so you move the back it causes a problem but you don't have back pain it's a little bit lower into one side in this dimple area it's estimated that 18 to 30 percent of people with back problems have this as the cause of their issues you can see the joints on either side the joint between the sacrum and the ilium or your hip bones you have one on either side and here's some things you can check out to see if you're consistent with all right so age greater than 50. we've actually found that si joint problems seem to be more prevalent in people who are a bit older if it's something that occurs in younger folks it's generally females who are postpartum meaning during or after pregnancy again this isn't perfect but the idea is that generally it's folks who are a bit older one-sided pain pain does not cross mid-line or side shift so if you're saying dr charlie like i have it on the left side right now dimple area but then like the next day it's on the other side that's kind of funky it's not super consistent with an si joint problem there's no pain above the level the belt lines there's no what we call back pain all right there's often pain with transitions just like disc problems you know you can be sitting and then you can stand up and get some type of jab in that area there can be pain rolling over in bed again there's no numbness or tingling because the si joint is a joint therefore it can't give you nerve-like symptoms unlike this right right behind the disc is the nerve root if you have a large enough disc problem it can push on the nerve root or irritate it which is why disc problems can sort of directly or indirectly however you want to think about it cause numbness or tingling all right and then what you want to do is do some movement test so does it hurt to do this motion it's just a single leg bridge we found a lot of times this causes some type of stress to one side of the body and you can think of the s i joined as a stress relieving joint and this will often bother that side of pain or do this this is not so easy to do on yourself but kind of flex your hip up to around 90 maybe slightly above what you're trying to do is just drive your hip straight down so does it hurt to do this we call this a thigh thrust test and finally maybe you notice that you have a yucky rotation extension test usually to the side of pain so if you have one-sided pain below the low belt line on that dimple area and everything makes sense and during the movement exam you twisted and you went oh and you felt it in that area again this is more evidence to believe that it could be an si joint problem all right so now let's talk about a disc extrusion this is sort of uh an interesting type of disc herniation because the classic disc problem causes pain as you've seen probably on the internet um you know when you bend or when you sit or when you drive right and slouching is bad right rounding your back is bad because it pushes the jelly you know out the back and things like that well this actually presents almost the exact opposite so it is prop uh possible to have disc problems and i see this actually fairly commonly it and of itself i would say is not very common but the people reach out to me right they might say charlie what's so weird is like i never hear anybody talking about disc problems that hurt when i stand on a walk so it doesn't make sense right say no actually disc problems can cause pain when you're standing when you walk and it might feel great to lie down or to sit down and round your back all right so this type of disc problem i'm talking about is a disc extrusion or this could be something due to maybe piriformis syndrome so in this case moving the back generally causes a problem but maybe you feel no back pain but the leg is on fire all right so let's talk about this and let's clear this up so look maybe you have no back pain currently so it doesn't seem like a back problem maybe two at all right but think back maybe you've had back pain in the past but currently now you're saying charlie my back's fine but my leg is really the problem my legs on fire so again you have no back pain currently maybe you had it in the past some stiffness or some tweak or maybe you got over some type of back going out on you recently and then maybe it took a few days and now you just have leg pain leg pain numbness and or tingling so what i want you to do is i want you to try this straight leg raise test and generally if you have leg pain numbness and it goes below the level and in the foot again it's usually due to some type of nerve irritation so go ahead and try this and chances are very high that it will cause your leg pain and if so sciatica there's no doubt sign of irritation again the number one cause of this is a disc problem but it could be something else so hang in there okay so now what i want you to do is i want you to try the straight leg raise test on the good leg you didn't pain for like ouch now do it on the good leg and if raising the good leg causes you to feel pain on your bad leg then again we call this a positive cross straight legacy test and it's very specific diagnostic for a disc problem and disc extrusion starts to sound more probable so again so far no back pain charlie like my back feels pretty good it's a little bit stiff like i've had some back problems in the past a few weeks ago like it was bottom note it's pretty good now um yeah when i move my back yeah you're right it does shoot something in my leg but like my back's pretty good it's got to be a piriformis problem do the leg raise ouch right maybe or maybe not you have this cross straight leg raise but let's talk about disc extrusions we'll get to piriformis syndrome in a moment so is your pain worse when walking or standing when being upright doesn't sound like a disc problem because charlie that's not what i've been told this problems present like no it's possible and if so it might be a disc extrusion pain might be better might be better sitting reclining or lying down you just have to offload things might feel better when you slouch or when you round your back actually there might be little to no back pain but it's primarily leg pain so leg pain is going to be much worse than the back pain you might not even have any back pain at all that might have worn off all right and again this is due due to sciatica you may be shifted or crooked if this is the case and then we think about which nerve is affected we can kind of go back to these drawings hey if the l3 nerve is affected you know front and back l4 kind of groin front of the thigh maybe down to the knee mostly frontal leg a little bit of the back of the leg too l5 predominantly in the back you want to check the muscle function try walking on the heels make sure you're good there and you're going to have you know if you have an s1 problem you're going to have symptoms in the back leg all the way down to maybe like the pinky toes little toes the heel calf things like that check the muscle function the strength by doing heel raises see if you can get that heel up now let's just say you have no back pain straight leg raise is fine so you're like charlie can't be a disc extrusion because when i move my back it's totally fine so moving forward is good forward to the right forward to left sideways sideways right like all these different motions you're testing the whole clock all the different planes of the back motion back motions and there's no reproduction of your buttock or leg pain well that essentially rules out the back if you have a disc extrusion moving your back almost always or should reproduce your symptoms if it doesn't then you start to think huh something lower the back moving the back cannot switch on my symptoms so could it be something in the buttock piriformis syndrome then go ahead and test these motions so laying on your side hip flexed up just a bit kind of raising the leg up this activates the piriformis muscle doesn't have to be perfect doing so will again contract the piriformis muscle and if the piriformis is a problem generally causes pain and what you can do is you can lay on your back do kind of a classic figure four stretch which many people with piriformis syndrome are recommended to do and that will often reproduce your pain so you can see taking the knee and kind of pulling it up to the opposite shoulder feeling a stretch in the buttock that's going to lengthen or stretch the piriformis muscle and if that's a problem if a muscle is a problem it's when you contract or when you lengthen or stretch or pull on it right it's generally going to cause symptoms so do those two motions and so we can go more into detail there but i really wanted to cover this idea of disk extrusion because actually it's something that i've chatted a lot a lot i've chatted with a lot of people recently and um it's common enough where people think even it's not a disc problem sometimes it's not but people think that because they have no back pain that the pain in their butt or in their leg is due to piriformis problem or you know not a back issue but then when they go ahead when they move their back all kinds of different directions it reproduces the pain in the button down their leg and that means it's something in the back it might not be disc extrusion it might not be a disc problem it could be a joint something like that but this is something that's common enough that i wanted to share with you and what's really interesting about this is that most people are led to believe that disc problems present a certain way bending lifting twisting sitting driving well some people disc extrusions love that and they have trouble standing and walking right so then you know doing the classic press-ups and all the classic approach to treating disc problems might actually make this worse so this is kind of where we talk about the next step right um also something to recognize here look um if the cross straight leg raised test is positive meaning raising the good leg reproduces pain on the bag leg then it is not piriformis syndrome so repeat if the cross straight leg raise test positive then it may or may nausea with a disc problem but if it's positive then it is definitely not piriformis syndrome all right so hopefully this is useful again if you want an expanded version of this guide you can check out my better than an mri diy diagnostic guy where i go through many other diagnostics and or things diagnoses that can cause back butter leg problems and or if you want a copy of this specific guide that i went through today talk about disc extrusion si joint problems and everything you see here and you can kind of check it out download it zoom it in and just walk through it yourself again then you can click here and or in the comments i think i pinned one there it'll take you right to um you know applying to to get access to my free facebook group that diy diagnostic network answer a few questions chances are very high that i'll approve you into the group and you can download this in the resources section so um that is all i got hopefully this was useful again if you found it useful go ahead hit the like smash the subscribe button okay that helps me out helps get the word out about sort of what i do so i appreciate that and you know let me know in the comments you know what do you think you have after doing this do you think that you have a back problem does moving your back not cause any problem maybe you think you have something else you need to check out the expanded diy guide right so let me know your thoughts on this if it was helpful and or not and i would love to um you know follow up and answer any questions you might have thanks so much everyone until next time chat soon

Channel: Dr. Charlie Johnson, PT

Views: 18,517

Keywords: physical therapy, dr charlie johnson pt, piriformis syndrome, sciatica, piriformis test, piriformis stretch, sciatica pain, sciatica test, sciatica stretches, si joint, si joint test, sacroiliac joint pain, herniated disc, glute pain, buttock pain, piriformis issues, si joint dysfunction, lower back pain causes, low back pain causes, si joint pain symptoms, herniated disc symptoms, herniated disc test, disc extrusion, piriformis pain, lower back pain, sciatic nerve pain

Id: 2ziQcfoSVOo

Length: 29min 5sec (1745 seconds)

Published: Wed Sep 07 2022