How To Know If You Have A Herniated Disc, Piriformis, Hip, or Sciatica Problem Without An MRI!

hey everyone dr charlie johnson physical therapist here uh super excited today to come um to you with a complete diagnostic guide uh if you're dealing with anti any type of lower back uh buttock hip um leg maybe sciatic type problem as you'll see there are many diagnosis it's sort of a uh mysterious or diagnostically uh murky area so if you're watching this video and you have some type of back butt hip leg type problem maybe you've gone to see an orthopedic doc um you know maybe a bunch of different physicians gotten second opinions third opinions fourth opinions uh and you've gotten various diagnoses hip bursitis s.i joint piriformis syndrome herniated disc what the heck is going on i want to be a voice of sanity and clarity as it relates to this topic so i'm coming to you with what i believe to be uh and i'm sure it will evolve and i'll continue to perfect it but one of the best diagnostic videos as it relates to this topic so again this is dr charlie physical therapist this is my specialty helping people uh with back butt hip uh leg pain regardless of the diagnosis uh and i teach people how to use movement as medicine so as you'll see in this diagnostic guide you don't need an mri or an x-ray uh to determine the cause of or the most likely cause of your pain or problem uh in fact you can use your story compared or not compared your story combined with motion which you can do at home uh to begin to sort of put the pieces together and determine what's going on with you so that being said i'm gonna share my screen here also uh when you see this document you're gonna wanna get your hands on it so i'm gonna put a link below you can just click it download it and look there's a lot of information here but i want you to have access to it so that being said let's go ahead and let's share my screen here hopefully this works and here we are okay so i'm going to walk through this idea of again do you have back buttock hip and or leg pain if so you're watching the right video uh i'm gonna walk through everything so everything from you know you having back uh you know butt and leg pain maybe numbness and tingling uh you know hip pains all kinds of different stuff with different tests you can do and we're gonna knock that all out right now so um i don't know grab a comfy seat or if that's painful stand up walk around i don't care what you have to do but hang on in there um you know there are a lot of videos out there that uh have you know talk about the telltale signs of a disc herniation i have a video like that spinal stenosis uh you know sciatica piriformis syndrome but they're all in isolation and that's difficult because i feel like there's not one um video that kind of links everything together and connects all the dots for people so again that's something that even though it's going to be a long video here you know you can fast forward and scroll through uh you know to kind of fit uh whatever you're looking for or find whatever you're looking for but at the end of the day i think it's useful to have everything kind of compared so you have a contrast black and white right next to each other so you can get the big picture understanding of how you should be thinking through what could be going on um you know with your back butt leg uh and or hip problem so that being said let's get rolling so first things first just like i said you want to think of your medical diagnosis like a deck of cards so look again the area of the kind of low back hip pelvis leg it's super complicated um i used to teach gross anatomy so cadaver go in dissect people uh and you know test students uh and clinicians on that anatomy and it's very uh anatomically complex which makes it diagnostically very complex at all but you know some examples of some uh kind of things that we should be thinking about again i think of diagnosis like a deck of cards so when somebody comes to me uh say you were to chat with me about your uh issue i'm constantly like flipping between hey what is the medical diagnosis and then not included in this video but what is the movement diagnosis because you know let's be honest the medical diagnosis that's what everybody wants maybe that's why you're watching this video but at the end of the day regardless of the card right that comes to the surface and seems to be the most likely thing going on at the end of the day um the question always becomes so so what what do we do about it right so um we're gonna work through the medical diagnosis portion of things today maybe i'll create another video on the movement diagnosis portion of things but uh just get that any given points right you know could it be the disc could it be uh itvan hamstring problem uh piriformis syndrome hip bursitis arthritis sciatica labral tear um etc so these are the things that when you're going to see an orthopedic doc or whoever they're probably floating through their head and we're just trying to do the best we can to kind of shuffle those cards and come up with the most likely diagnosis again i don't use as a physical therapist i do not use x-rays and or mris it's not something directly at my disposal to determine the cause of things and we'll talk about why in a minute but a cool thing is for you that you can walk through step-by-step this guide literally this is my brain my thought process for the most part on a flow chart or a mind map as we have right here that walks you through how to be thinking about and how to be rolling in or rolling out what could be going on so hang on in there two things are needed for an accurate diagnosis your story and a movement exam so as you'll see um you know i have some pictures of sort of maybe where you're describing um you know what hurts maybe some things that make it feel better make it feel worse these are all important things to kind of aid in the diagnosis and then a movement exam as you'll see i have some motions later here in the video that i want you to go through if we think you have a hamstring problem or an si joint problem etc so these are really important and then you know people think and or request demand that they have x-rays or mris or some type of image to figure it out but really they're just misleading i can't tell you how many people you know have a pain in the hip and then they say well the doctor i'm waiting here at the doctor says because they say i need an mri of the back to see if that's the problem you don't need that because they are going to find something wrong in the back because the majority of people have uh pain or problems or sorry problems uh via an image and often feel no pain so it may or may not actually be the problem it could be uh rabbit hole so that being said they're really only four times that you need images so signs of cancer uh and these are sort of the criterion that i increased the risk of somebody's chance of say having back pain as a result of a tumor or something like that or cancer previous history of cancer is a big one there fracture so you'll see here i don't have to read through them all again you'll have access to this document but you want to think about older uh generally females um you know maybe not the best bone health uh infection and or nerve damage so yes you can have a herniated disc with zapping pain down the leg or sciatica due to something else uh and look as long as you're not having a loss of strength unable to kind of walk on your heels which tests the l5 nerve unable to walk on the toes the first nerve in the sacrum the s1 nerve um you know or you're not having true loss of feeling true numbness not just funkiness in the leg but true numbness uh or you're not having loss of bowel or bladder control then you know an image is it's not gonna do a whole lot it might again give you an idea of what's causing of it then so what how do we solve that so um that being said again the reason images are all not all that useful and i want to give you the kind of this this diagnostic guide that's better than an mri and based off of movement and your story those two things are needed for the most accurate diagnosis possible is because of this so many studies kind of combined here uh but basically these are image imaging findings and people without pain so take 100 people off the street who feel no pain 69 of them are going to have labral tears in their hip 50 of them are going to have some degeneration on their tendon some tendonitis or tendinosis of their hip joint or um sorry of the tendons on the outside of their hip the glute tendons 15 are going to have hamstring tears these people feel no pain uh si joint inflammation a lot of low back arthritis and disc bulges are very common and again these people are perfectly fine they're smiling and they feel no pain so um here we go this is super important to say i know you're saying get right to the info but this is super important so um where people get confused about various diagnoses is that they don't understand this basic rule or concept all right just get this now maybe it's not the best picture to represent it but it's what i've got for now so here's kind of like a river and you know this these houses or these destinations these houses represent maybe various diagnoses or areas of pain the hips the s.i joint the hamstrings maybe i could put one here the piriformis right um and you know other areas down the chain they are downstream meaning if you have a problem at your lower back and you can see there's like a an issue there log fell across the stream it's causing a blockage so if you have a problem at your lower back notice how it can affect anything below or anything downstream of it and this is important because if you have s-i joint pain and piriformis pain and you go through those tests and you're like oh i have all those things but you also have discovered that you know you have a back problem or what seems to me is most consistent with a back problem which is upstream then these diagnoses are not likely meaning if you have an upstream problem a back problem it can cause anything downstream to become sensitive to hurt so if you do the tests in the presence of a back problem a nerve problem if you find that you have that don't look any further because you have to fully rule that out as the cause first because if you have a back problem in the presence of an issue up at the back or with the nerves in the back um then it might it might hurt to contract your hamstrings it might hurt in the butt it might hurt in your hip bursa it might hurt down in your calf or you might feel like you have plantar fasciitis right things like this because this is upstream and as you can see it can it has the ability to affect everything downstream all right so um an upstream problem like the back can refer downstream so in the presence of a back problem um you know if you're being told you have bursitis and piriformis and si joint problems all downstream well of course because the back is sort of like the main panel box it has the ability to kind of provide feeling and refer pain to those areas so it's going to cause everything downstream to be sensitive or become affected so we want to look first at the back and if we sense something there or something with the nerves up up at that level then forget about any other diagnosis uh the most likely diagnosis or problem is that it's from the back the others yes it's possible you could have a couple things going on there but at the end of the day you know you want to think of the most upstream problem because an upstream problem has the ability to affect everything downstream and make it seem like there's other diagnoses when really the main problem is that say back issue or something like that so um hopefully it's helpful i may touch on that in a little bit but one final thing is that you know say we find that you you don't have a back issue or through this kind of mind map you think hey i don't really have a back issue i have no back pain etc um i have a hamstring problem well a hamstring problem for example is down here along the the river if you will problems do not uh refer upstream so hopefully that makes sense problems with a certain area do not refer upstream so if you have an si joint problem it's not going to cause your back problem directly as the primary source or origin of symptoms yes it might make you move weird because of that you're compensating etc but as far as the primary like um you know sight of tissue the tissue source of pain or the diagnosis is not going to refer upwards hopefully that makes sense a hamstring problem won't cause an si joint problem because it's downstream a knee problem is not going to cause an si joint problem directly from a direct link of referred pain all right again you can move differently if you have a knee problems can cause other things but as far as the diagnosis remember we're talking about diagnosis from the standpoint of a medical diagnosis not a movement diagnosis so hopefully it's helpful but again a back problem can cause all these things because they're downstream so um i know i repeated myself a few times i just want to make sure that's somewhat clear we'll make we'll bring more clarity to it as we go so here we go so do you have back buttock hip and or leg pain so if you're watching this video that's probably a yes let's start from the top so here we go all the way up here says yes i have lower back pain pain along the beltline region so i'm talking about this is what i mean by back pain back pain is not down here back pain is right across the line of the belt all right with or without leg pain numbness or tingling now go a step further do you have pain numbness or tingling that travels down the leg below the level of the knee into the foot if yes so this is a pain drawing okay so this is where you would kind of mark it imagine you were trying to fill this out and say where do i feel pain you might have some stiffness in the back but the pain the the deeper red the more intense the symptoms let's just say is kind of how i made it um you might have pain really bad in the calf or the back of the knee or maybe numbness and tingling down into the foot so if this is you is the pain worse in the leg than it is in the back often people who have certain problems with the back and the nerves as you'll see sciatica they complain of hey you know i had some back trouble but now i don't even notice my back my leg is so bad that uh you know my back isn't the problem or so they think right so um you know if it is then i want you to try this so this is what we call a straight leg raise test it's a really good test um to determine if you have sensitivity in the nerves okay so that being said you want to do this first on your good side all right so let's just say that my problem was on my right side then i would do this test on my left side so you know you can simply just straighten the leg pull the toes up on the good side and then compare that to the bad side now what you'll notice is we do this straight leg raise and it's a problem or it's positive okay meaning it reproduces your pain or has lack of motion you'll do this on the good side and say hey it feels pretty good and then you'll go and it'll cause some type of real you know tightness or pain in the back of the leg with maybe uh some numbness tingling shooting down the leg it should reproduce your symptoms that's why you have to do it very gently don't push it beyond you're just trying to see is it is there something there or is it completely normal so hopefully it makes sense so that's called the straight leg raise test it's a really good test to determine if you have sciatica or nerve sensitivity so do it on a good side compare that you should see that if it's positive it's significantly limited and reproduces your symptoms all right um so yikes that hurts and causes my leg pain then chances you have sciatica are super good pretty much you have it there's no question so now you have to ask yourself what could be causing it and while there are you know they're definitely more than just one cause of sciatica as you'll see the most common cause is a herniated disc without a doubt so l4 l5 disc herniation or something there with that disc is the most common cause of sciatica and a positive straight leg raise if your symptoms kind of look and feel like this and you have some back stiffness or pain um we'll talk more about the symptoms of herniated disc in a moment but just so you know there's certain mapping to where these nerves control or give sensation or feeling to right so most people with an l4 l5 herniation you know they feel symptoms that start the nerve is affected we know that because you have a positive straight leg raise they start here kind of go to the outside of the knee some people feel like they just have knee pain but it's actually due to a sensitive nerve and then it wraps to the shin and it goes kind of to the top of the foot the big toe that's the most common nerve affected s1 nerve is also commonly affected which causes pain here kind of this little shaded goes down the back of the leg hamstring so back of the thigh and into the calf maybe even into the heel or bottom of the foot or as you can see the small little pinky toe if you want to call it that all right so not only if you have this drawing can you tell by kind of following this that you have sciatica but then you can kind of determine the level of nerve affected if you follow um this path all right so now let's just say though that you've got this stuff you've got some back stiffness and then some you know one or both sided leg pain numbness and tingling um and you do the straight leg raise and it's a little tight but there's no major problem so you do it on your good side well we'll just say this was a good sign you do it on your bad side right and it's really no issue you feel pretty good then you have to ask yourself hey could it be something else so in this case i just worked with a gentleman this morning you know he would be exactly this so do you have spinal stenosis well then there's characteristics associated with that so for example this is not just my experience per se this is all based off the evidence and various clusters of findings that um have been sort of researched or validated to be um you know most consistent or predictive of say in this case spinal stenosis so age greater than 48 so generally older or more mature more wise if you will so age greater than 48 leg pain is greater than the back pain and true spinal stenosis so sometimes there's some back stiffness but mostly it's the legs um both sided leg symptoms is most common but it can just be one leg um and if it's both legs then there's generally a problem at the central canal so if you think about it we'll come over here if there's a problem at the central canal the main kind of i don't know pathway of the river if you will the main stream all right then you can see that it affects both legs so that's why people with central canal stenosis or narrowing have symptoms that go down both sides because well something up here block the flow to both legs all right if there's just you know imagine i took this um log and i took it and i put it down here right near the uh the si joint area or the buttock area well that's just a one-sided problem so the in this case the left side would still have water flow or uh no problem with the nerves it would it would uh it would be fine there would be no symptoms the right side would be the one that's affected so depending on if it's central or one-sided which we call zoom out here lateral recess or foraminal stenosis that's a one-sided type of spinal stenosis and obviously you can have a combo of the two all right um but another thing with spinal stenosis kind of in that cluster of findings leg pain numbness and tingling is increased with standing or walking when the spine is in an upright position why because when your spine is upright you close down on where the nerves exit you cause some reduced blood supply to the nerve bundle the base of the spine we call this neurogenic claudication to reduce blood supply reduce oxygen and the nerves just can't really breathe therefore they don't function as well you get symptoms maybe weakness um when you're upright but then if you sit or bend forward so there you are walking you get symptoms and then you look for the nearest bench and you sit down it will start to um resolve itself all right so uh leaning on a shopping cart so a positive shopping cart sign you're walking leaning forward or up a hill which causes you to pitch forward a little bit that often feels better than say walking down a hill or just walking upright why because when you bend you create space you kind of gap the joints in the spine where the nerves exit versus when you're extended you kind of close down on it that's called neurogenic claudication all right and basically what we found is if you have four out of five one two three four five you have four of these uh there's a 76 chance that you have spinal stenosis so uh hopefully that's helpful but in the case of spinal stenosis because it's not like an acute inflammatory process of the nerve it's kind of this thing that's very mechanical when i walk i compress um you know the nerve bundle and then when i sit it goes away there's not really an inflammatory process involved there so you're not going to have problems with just pulling that nerve in a seated position so the straight leg raise is going to be pretty much negative in all my experience if you have spinal stenosis but you'll still kind of follow down this path because you have leg pain numbness and tingling that goes below the level of the knee maybe even into the foot so hopefully that's helpful there okay so now let's zoom back out so now let's just say that you have back pain butt pain or leg pain above the level of the knee it should say and or leg pain above the level of the knee without numbness or tingling so you've got back pain you've got some butt pain maybe even some hamstring pain or you've only got back pain so this is the primary area where you should feel symptoms but it can refer some of the joints and some of the structures can refer um you know uh just kind of down to the knee so that's why i should be above the level of the knee and you have no numbness or tingling do this test anyway just to see just to check might as well so this again is a straight leg raise test to say hey it seems as though you have no numbness and tingling you don't have symptoms that are really bad in the leg at least below the level of the knee which is most consistent with a nerve problem but let's just do this test anyway just to make sure there's no nerve sensitivity cool so go ahead again test the good leg test the bad lid what you'll likely notice is that you don't really have major limitation or pain it doesn't reproduce the leg pain it doesn't jolt pain down the leg why because the pain is what we call refurb so in this case the pain is you know electric burny shooty um yeah numbness and tingling all those nerve-like complaints here you might have some symptoms to kind of radiate but those are referred from a structure like a disc or a joint or something like that so again the most common cause of back pain is a herniated disc so do you have a hernia disc well to kind of clarify a little bit more from up above where we were at uh what are the the major symptoms i mean a lot of people think we need again an mri to figure this out we pretty much don't i mean we have good evidence that's looked and compared people's stories to images and then come up with some kind of narrative or story of what a herniated disc looks and sounds like so you know i can predict that somebody has a disc problem with pretty good certainty without even needing an image um that being said it's usually central lower back pain that may shift from side to side so you might notice that um you know hey it was central and kind of went a little right and then the next day a little bit left but for the most part should just be kind of central spanning across that belt line just like i drew sort of in this picture right um is the so is the pain worse first thing in the morning often symptoms are worse uh first thing upon getting up why because disc pressure is highest in the morning there might be trouble straightening or standing up after sitting that transition of sitting and standing might be kind of hard um you know to get up tall and then once you walk around maybe it feels a little bit better pain is worse generally sitting driving bending lifting twisting coughing or sneezing why all of these motions increase pressure um in the abdominal region the coughing and sneezing and the others within the disc itself so if you have a disc problem and you increase pressure in it um it doesn't feel good so uh pain is often better when walking standing or lying down it's just a more neutral less compressive positions for the spine or the disc um yeah pain central or slightly to one side along the level of the belt line kind of repeating myself but again it can shift i increase pain with coughing sneezing or straining again i just wanted to get this out there i didn't edit as good as i should but just to reiterate there uh and then you have this roller coaster of back pain so you know you have this history of yeah my back went out a few years ago i was lifting something or doing something and then it got better and then you know a year two later goes out again and then it goes out again and you know usually what happens every time gets a little worse so you start with just having some back pain and maybe some buttock pain and then it becomes full blown sciatica generally the worse the disc problem becomes in this case right or a really telltale sign is that you look something like this have you ever looked in the mirror if your back went out on you and you have what we call a lateral shift so you're kind of crooked bent forward and it's hard to straighten up tall that is i mean no mri needed pretty much a lateral shift especially if you've got this other stuff going on okay um so that being said you know if you have no leg pain or limitation of straight leg raise it says there's not a nerve problem there might be another problem in the back that's referring symptoms into the buttock or the upper leg but um there's no nerve problem the other thing that can refer kind of pain along the back and or into the buttock maybe even into the leg uh would be what we call facet joint basically the joints in the spine so at every level right you have joints that kind of stack and touch one another and these are called z joints or facet joints so one-sided um pain at or above the level level of the belt line so unlike a disc which causes like general stiffness usually it's going to be just maybe down on the left side or down on the right side um and you know again there's gonna be no numbness or tingling because it's not a nerve problem so that being said there are some other things we can do to tell this but just a general overview for you okay so now we do all that yeah we covered all that and remember look if you're doing this right now and you're like wow i did the straight leg raise charlie and that was really clear but i was also told i have like a hamstring problem or or a piriformis problem or a bursitis problem don't worry about it this is the first thing you need to address and remember this thing's upstream so it can cause you to feel aches and pains you go to the massage therapist if you have a nerve problem and they're going to poke in your calf they're going to poke you know um on your it band they're going to work your hamstrings you're going to say oh oh and you're going to think you have all these problems because you have all these sensitive areas well that's because the wire which is really hot travels and has the ability to kind of send signals to all those areas so in the presence of a of a problem upstream stop worry about and focus on the most upstream diagnosis if as you're working through this you find that something's most consistent with it if it's upstream of something else you think you have the upstream problem rules all okay so you could just stop if you if you figure that's what you got just stop shut the video off okay now um i don't have a i don't have back pain so this is for people who say i don't have it up here charlie my back feels pretty good um but i do have buttock and or some type of hip you know leg stuff okay so it's not your back so if you don't have back pain the chance that it's your back is very low so let's just kind of you know get that off the table right away um i worked with the lady of the day she said i have no back pain um at all but she has some leg stuff uh and they took an mri of her back and they found nothing well why would they take an mri or back if you're not complaining of any back pain and the reason is because they're searching for something because they don't know how to go through a good kind of thought process and exam they're searching for something to find something so they can treat something because that's what they do they use you know injections or pills or surgery and they rely on the findings of mris or images i rely on the story careful listening careful reasoning and then movement exam to determine not only what i think is going on but then natural um treatment using movement as medicine so that being said if you don't have back pain pain along the uh it's not your back so let's go up here and start off with kind of some hip stuff so do you have groin pain so do you have pain that is mostly again the red is like the primary of symptoms maybe you have some buttocks and some outer hip but really some groin pain and it may refer so the blue area is like the secondary area of symptoms that you might feel if you have a groin problem or pain in the groin then what i want you to do is i want you to do this figure four stretch test so i'm hoping this works and it records let's see so i'm just gonna have you watch this so that you can see how to do this seated figure four stretch test is something i sort of came up with it as you will or if you will as a quick screening tool to determine hey what is the motion um in the hip is it stiff is it normal is it excessively flexible compared to the other side so just let's watch this all right in this video i want to demonstrate how to perform the seated figure four stretch test which is a test to determine is your painful hip or buttock area is it loose symmetrical to or tight with regards to the pain-free or less painful side so how do you do this you're going to sit in a chair you could also do this on the floor but just sit in the chair and you're going to take your pain-free side or your minimally painful side decide it hurts less your good side i will just say it's my right side and the side that hurts is my left side all right so obviously reverse it if it's opposite for you but let's just say this is the pain-free side my right side take that ankle up put it on your knee and just see how far does the knee flop towards the floor take a snapshot mentally of sort of you know that angle or how far uh it goes and sort of what it feels like and then do the same thing to the bad side the painful side and let it flop if the knee goes further towards the floor then your figure four stretch test indicates that the painful side is more loose it's more flexible it's floppy if it moves the same as the pain-free side then you have symmetrical motion it's not tight or loose it's just the same and if it's hard to get up there and the knee barely can drop at all and the knees pointing you know sticking up in the air then you've got tightness on that side let's go back to this and i hope that that recorded but remember there's this little button whenever you download this below this video i'll include all this download it should link to that and you can watch that so um that being said you have groin pain so you're gonna do that figure four stretch test remember you're gonna compare the good side so again if this is a good side do it and then compare it and do the bad side and in this case you'll find that oh man you might notice that my painful side is tight that's a finding of tightness in that figure four stretch test so if you're lagging way up there compared to your good side then you've got tightness okay so a tight figure four stretch test um which would indicate the hip is stiff and painful now there are many things that can cause that but look if you're a little bit again older or wiser age greater than 50 consider that the primary diagnosis or a suspected diagnosis is hip osteoarthritis so an arthritic condition of the hip that's just causing progressive um stiffness and pain in the hip so you'll notice this because you'll have difficulty putting on socks so if you think of how that motion looks in life that's basically putting on your socks right so you'll notice that if you've got a figure four stretch test well that's a sock test basically so you have trouble putting on your socks you'll notice tightness and reduced motion compared to your good side you'll have groin pain groin pain is pretty much like the number one complaint of people with a hip joint problems within the hip joint um in this case a little bit older hip arthritis is the most suspected you'll have morning stiffness so a common arthritic complaint if you will is that hey you know i feel pretty stiff in the morning or after i've been sitting pain stiffness getting up from a sitting position or out of a car but then as i get going maybe it loosens up it warms up a little bit all right and then you'll notice that it's sort of a gradual onset a lot of times there's not like a moment in time when people remember doing something sometimes it might be like a little slip off a curb or something but for the most part um it's a gradual onset over the years or over the month that the hip hip just started to get stiff okay so if the painful side is tight um you find that it's stiff and painful via that figure four stretch test uh but you are less than 50 so you're a little bit younger then you still could have some uh arthritic changes but if it's a problem within the hip joint which most uh people have groin pain they have a problem within the hip joint um then consider that maybe you have something called fai femoral acetabular impingement femoral head of the femur acetabular the socket impingement so when you're doing certain motions uh like this right or as you can see here this funky motion which is you know kind of bringing your hip up rotating it out right you're gonna get like oh man your good side is gonna go no problem and your bad side is gonna go oh man you probably lost that motion another thing you can do is just you know pull your knee up to your chest or go even into a child's pose and you'll probably notice that you can't go as far because you get that pinchiness in the hip and in the groin so a lot of people describe this um fai which is most kind of consistent or linked to a possible labral tear whether that be traumatic you were doing something ice skating and the leg went out and you felt something or it's just a degenerative labral tear maybe you're approaching 50 or around that age and you have some type of degenerative condition of that labrum you'll get this pinchiness our painful feeling in the groin a lot of people describe it as a pinch and you'll be really limited and this will be uh provoking of your symptoms so again do this stuff i'm not here to hurt you i'm here to help you do this stuff cautiously okay um or others so there are a lot of other things that can cause problems within the hip joint um these are mostly kind of mechanical or musculo skeletal um type of diagnoses but keep in mind that yeah you can have funky things that affect the structure of the femoral head avascular necrosis did a little a little bit of some other things but these are the most common if you have a hit a stiff and painful hip and it's something orthopedic um these are the most common kind of conditions okay so now that being said okay so you do the figure four stretch test follow it down here charlie no my painful side this is a good sign my painful side moves just as well or it's loose it's floppy well they consider that but you have pain in the groin right and by the way notice you don't have back pain right in this case you don't have numbness and tingling so pain in the groin you should have already gone through the top part of this mind map to get to this point so we're kind of working through it like that you know consider again that you might have some type of labral problem uh femoral acetabular impingement for whatever reason bony problem or other um again you you do this little test or you do that um you know the seed of figure four stretch test you might have good motion but it still might be painful uh then consider again this might be um you know the diagnosis or say do i have it here you know i treat a lot of younger people or athletes and this is something again it's kind of outside the realm of some of the other diagnosis as an outlier but i've seen a lot of especially in a female runners although it can happen in males who are high impact sports uh these things called bone stress injuries so a stress fracture basically of the hip or pelvic area or a stress reaction so for example like shin splints or a stress reaction of the lower leg bone but you can have kind of similar things up in the hip hip joint socket kind of pelvic area uh that can cause pain in the groin and it can look very much like a labral tear or you know some little arthritic change or something like that but uh and the reason that it's difficult to diagnose is because an x-ray doesn't do a great job of picking these things up especially in the early phases so really you need some type of mri or bone scan to pick these things up but that being said i treated many people who um thought they had label tears but when you look closer at it they hop on one leg and they get kind of a sharp pain in the groin uh they're a runner they're a female nothing partial to females but there's something called the female athlete triad which is this idea of hey you know i don't have the most regular periods so the menstrual cycle is a little bit irregular um maybe they've had an eating disorder some type of nutritional deficiency that their uh diet is not the best uh and maybe they've had a dexa scan uh or they have underlying but they don't know it yet some type of lower bone density so you put these things together with running or high impact sports with maybe another thing on here should be a sudden change in training so you know hey quarantine started or i don't know track season started or i decided that you know one of my friends was doing a race and i just wanted to do it and i hadn't trained for it well that's a sudden increase in training and if you have these other things uh brewing then a perfect storm can be created where you have this bone stress injury uh bone stress fracture or uh reaction that occurs within or about the pelvis or femur and can cause you know pain in the groin that seems like some of these other things so that being said a little bit of a tangent there but i think still think it's necessary because i've seen it enough now let's go down to this so again you don't have back pain but you still got butter leg pain maybe it's not you're still watching um you know it's you don't have pain in the groin but maybe you just have this idea of you know you have pain in your butt without pain numbness or tingling but you just have this central buttock pain so literally you're saying hey charlie no it's just like it's just right here in the center of my butt not down here we'll get to that in a minute but right in the center of my butt is where i notice my symptoms cool so again while there can be several diagnoses for that the most common um that i've seen is piriformis syndrome all right uh and you know what i would say and i have another video on this maybe i should link to that but you know the way to diagnose this is obviously go through the other go through the other parts of the map you know first make sure it's nothing there and then if you've made it to this point go ahead and do these two tests so do the figure four stretch you've been doing to try to treat it right so do that motion on your back you see the arrow here pull it up towards your opposite shoulder on your good side and then to your bad side um and see what you've got so you might notice that that kind of causes a pain a hurt so good but it still hurts pain in your buttock where you get symptoms um then that you know that's a way to stretch a tissue so rule would have it that if a tissue is aggravated and you stretch it it should hurt also if you contract it which is the second test it should also hurt okay so go ahead stretch it see does that hurt if so okay might be piriformis syndrome provided i went through the rest of the map and it doesn't seem like anything else you're starting to narrow down on it then go ahead lay on your side you'll notice here if i zoom in my legs sorry i wore black pants uh legs are the knees are not together i kind of lifted that knee and then i kind of just slightly rotated that hip up the hip should be about at 90 degrees here and see does that reproduce again your buttock pain does it or does it not if so again it's most consistent with like a piriformis problem okay so now do you have pain in your buttock without pain uh back pain numbness or tingling so it's not a groin problem it doesn't seem to be hip arthritis you know the hernia disc up top doesn't really seem to be it uh so it doesn't seem to be a back problem uh it doesn't seem to be a stress fracture a labral tear nothing i don't have groin pain charlie um you know central buttock pain not so much it doesn't seem to be that here we are this is another common diagnosis that is overlooked so um do you have pain now look at this drawing instead of being central but sorry looking at my bottom here instead of being central but do you have it kind of right underneath it's right in there where the uh hamstrings kind of attach to the pelvis where the pelvis meets the leg is basically how people describe it with maybe some radiation into the muscle belly of the hamstrings so you have pain on your sits bone oops sorry do you have pain on your sitz bone where the leg connects to the pelvis should be a question mark but if so consider that maybe it's a high hamstring tendinopathy so you've got your hamstring muscle group that joins right there could it be something you have an unhealthy tendon um and it's causing you pain and this can be chronic pain that people go for years um and can't seem to solve so now can you go ahead two movement tests here just to verify again you've gone through you don't seem to have anything else so you're narrowing in on this can you reproduce your pain doing this single leg deadlift this top one or a diver so go ahead and you know do it on your good leg so if this is the pain-free side do it and you a diver is really like your arms are out you're gonna do something like this and then do it on your bad leg oh right there charlie gets me right in my butt cheek okay that's one test the next thing i want you to do is a heel dig so lay legs straight kind of the side of a chair or whatever a bench and autumn it doesn't matter take your heel of the pain-free side first 90 degrees and try to crush into that chair or you can even use like a big kind of yoga exercise ball um over there in the corner you can't really see it but anyway um really anything there all right uh and then do it on your painful side and heel dig and see oh does that reproduce my butt pain when i'm heel digging if so you got pain here it's not anything else you ain't got no numbness and tingling right uh this hurts you can barely do it and this hurts and it hurts to sit on a hard surface because you're running your butt bone and it hurts to say walk uphill walk upstairs where you're generating force through that leg squat walk or specifically running a lot of runners have this problem or athletes are doing higher impact a lot of jumping plyometric activities uh and bonus if you've noticed a recent change in you know training volume you're running more miles running more frequently then if it looks like a duck and it quacks like a duck it's probably a duck so it's probably a high hamstring problem all right again you shouldn't have any back pain this is not going to cause any back pain or if you do um then you should focus on that diagnosis as the most likely diagnosis because it's upstream all right so just to reiterate that now let's just say it's not that my pain is kind of up here charlie i kind of described it as my back but it's just one side and it's kind of on that dimple so i'm not going to show you my butt but there's basically dimples if you look in the mirror and a lot of people they can see kind of little bony bump all right and you might have some symptoms kind of radiate down the leg sometimes a little bit even to the front of the hip whatever this is kind of the main referral pattern here's another pick on like an actual person it's my wife so l4 l5 is the bones in the lower back you've got your hip bones that kind of go out to the side those would be your ilium and then you've got your sacrum so sacroiliac joint which is right there on her little dimple there she said where is it she said oh there it is after i pointed it out to her that is where people get pain in the s-i joint if the s-i joint is a problem we call that a fortin f-o-r-t-i-n finger sign all right so again here's like another little diagram right there where the s i uh joint is okay there's one on either side but usually this is just a one-sided problem occurs about 18 to 30 percent of people with what they believe to be back pain but again this is not pain above it's one-sided pain almost always and there's no pain above the the level of the belt line so there's no back pain if you really zoom in and ask people where their symptoms are this is below the level the back which is here all right um pain going from a sitting to standing pain rolling over in bed uh there's no numbness and tingling because this is not like a disc problem which can push on a nerve this is a joint s i sacroiliac joint um you know a couple movement tests here so go ahead and see compare to a single leg bridge so i'm on one leg and i'm just literally thrusting my hips up and kind of holding there you can straighten this leg if you want but it's a little easier if you bend it do this on the pain-free side and do this on the painful side and if this reproduces pain uh in the area that you're describing right and it's not anything else and then you do this test i call this a self thigh thrust test basically so what you're doing here i'm not going to lay down because my headphones will yank but you're going to lay down bring that leg to 90 and you're pushing along the axis of that lower leg bone you can get somebody else to do it if you want you can hold your leg and someone can apply gentle pressure you're kind of pulling straight down as if you're trying to um drive this leg bone into the ground picture it's like a stake or a piece of rebar or something like that or you're trying to drive it into the ground to cause some type of stress at the s.i joint if it hurts to do these motions and again it's not anything else up there and you've got all these things plus maybe uh you know you you've had a recent pregnancy or you've had pain since pregnancy a lot of con a lot of times common in females um then you know that would be like an extra bonus that again i didn't add here but something i've seen a lot so consider it maybe a sacroiliac joint problem okay so now you're saying nope still not me charlie get to the point what's going on do you have pain locally on the side of your hip so what i want you to do is i want you to do that figure four stretch test again if you haven't watched it yet already again you can click this little link and watch it but again the idea is you're comparing the flop if you will of your good leg to your bad leg and you're seeing is it the same motion is it looser does it move more or is it really sticking up in the air so if you've got what we call lateral or pain on the side of the hip which would be here so just so you know here's kind of my hip bone you go down there's the point of my hip right this is kind of where we're talking about the pain on this area all right if you do the figure four stretch and the painful side is more tight and you're again older than 50 a little bit more wiser if you will more mature uh then consider that it could be again a hip arthritic condition so hip arthritis is it listed multiple places because it can cause pain just on the side of the hip it can cause buttock pain only or it can cause groin pain so groin pain and buttock pain are the most common but i've seen people where they just have pain on the outside of their hip and they're told that they have bursitis or something like that when in actuality they have a stiff and painful hip bursitis doesn't cause the hip joint to be really stiff and sticking up in the air it causes the hip joint to be sensitive if you compress certain things or lay on it or whatever but it doesn't cause actual you know changes in the ability for the joint to move so if that's the case consider that the hip joint for you is just referring to the side of your hip and that just for you that's just where your symptoms or your hip joint refers okay so hip arthritis again difficulty putting on socks groin pain stiffness etc we already went over this um also you know could it be that you have some type of progressive impingement you know some bony change in the in the hip joint where it's just not allowing the hip joint to move um most consistent again with like a labral tear or something like that pinchy painful feeling in the groin not only is that flop in the figure four limited but you might notice that coming up is oh really painful and pinchy same thing with arthritis you know so here's the thing it's gonna be tight and painful in upward motion an inward motion like i have here or this motion in both like an arthritic and often like a labral tear type of presentation so if you have stiffness like that it's something almost without a doubt within the hip joint itself i'm just trying to tease out the most common things for you okay so uh let's just say now you do the figure four stretch test and it's symmetrical or loose well it could be a labral tear because not all label tears if they're not that severe will cause like excessive stiffness but again you might have this pinchy feeling you might go through this what we call fader flexion adduction internal i know it seems like maybe my legs going out but really look at the hip the hip is rotating in the leg is going out uh rotation um this position will provoke symptoms again also though in a hip arthritis so that's why if you're a little bit younger maybe consider more this if you're a little bit older and have some of the other symptoms associated with arthritis maybe more of a hip arthritic thing okay but now aside from problems within the hip joint there can be some problems with outside of the hip joint so in the hip joint problems like boney kind of joint capsule you know labrum they're kind of all in the hip joint that cause like that stiffness but if you have just like a glute tendon problem if you have hip bursitis then again you're not going to be limited in your motion it might be a little bit painful to kind of push yourself to extremes of motion but you actually might notice that you have more motion on that side and the problem might be that you have a weak and painful versus a stiff and painful hip so that gets more into the treatment side of things what do we do about it but just get that it could be hip bursitis if you've just got lateral or pain on the side of your hip without the stiffness so very tender to touch on the outside we actually call this a jump sign when i used to work with orthopedic surgeons you lay on your side with your knees bent up and you find the point of the hip bone and the bursa lies just behind it and when you push on that sign the surgeon will go hey how does this feel boom and then you go oh that's it that is generally consistent with hip bursitis again in isolation if you have other things other things that are upstream could cause you to be sensitive on the outside of your hip right so just remember that it's very important because you shouldn't walk away from this and say i think i have this this this and this you should start with again looking at the most upstream problem and trying to narrow that down knowing that a back problem can cause you to feel like you have hip bursitis but it's the back causing referred pain there or causing the structures in or about the hip to be sensitive so um don't get confused by you know doctor said this this this this and this well there's probably one thing the most upstream upstream thing causing all these problems okay enough of repeating myself there so um you know you might not be poking on it but you might be trying to sleep and you notice man i just cannot sleep on that side okay so um that's another sign of maybe a hip bursitis the technical term for this be greater trochanteric hip bursitis because the greater trochanter is just that uh the prominence on the outside of that femur you know as it kind of uh hooks and becomes you know closer to the skin on the outside of the hip here so right behind that greater trochanteric hip bursitis which is a fluid-filled sac to kind of reduce friction there so when you provide compression or friction to it uh it can cause pain glute tendinopathy it's gonna be really hard to tell um the difference here because you likely have a combo potentially in many cases so the glute tendons attach almost right where the bursa is and they're going to be aggravated it's going to be tender to sleep on that side it's going to be obviously sensitive to push on if you get an injection for a bursa problem you might notice if you have a glute tendon problem things feel better well because they're pretty much in the same spot so it doesn't really help you diagnostically so people think like hey you know the doctor said i'm gonna get a shot in my bursa well that's a little hard to just say i only put the medicine in the bursa right the steroid and the numbing agent so they they numb the whole outside of the outer hip you know they could be numbing the nerve the sciatic nerve which runs very close to the back of the bursa could be numbing the bursa or they could be numbing the hip tendons and again from a treatment standpoint you want to be careful about putting a steroid right near a tendon because steroids eat tendons for lunch all right so they can cause damage to tendons uh if it's something you're consistently getting done you want to try to avoid steroid injections if you think you have a glute tendon problem that being said the presentation is very similar okay um okay so what else we got all right we're almost there okay hang on in there so you're still at the end of this you're like i don't know what the heck's going on charlie i don't just have uh you know central buttock pain i don't have really any of this stuff okay um but i've got this buttock pain without back pain i've also got some leg pain numbness and tingling so you would have picked this up maybe because maybe you've already tried the straight leg raise but again you know you don't have back pain in this case people with this problem truly do not report back pain and if they do it's often kind of something that's like a shiny object it's a little misleading because they they have it or they had it but it's not currently contributing so that being said um you don't have back pain but you have buttock pain with numbness or tingling going down the leg what could it be so if yes try this again do your good leg to your bad leg if you've got it which you probably do if you have numbness or tingling you have significant restriction on the painful side then you have sciatica now what could be the cause most common cause would be piriformis syndrome do the same thing do these motions and see if it reproduces your buttock pain or in this case and or your numbness and tingling going down the leg you might notice okay um you know do this leg lift again same thing see if i can track that does it kind of send some signals down my leg or cause pain in the butt test those things out now it could also you know i would question because the number one cause of sciatica is not piriformis syndrome it's a herniated disc i would cause you to question am i sure i don't have back pain or has my back going out on me a lot or could it be that so just to kind of circle back here so um that being said you know check back do i have pain along or just above the belt line even if it's just a little bit maybe touch back and try these kind of clearing tests if you will so try the cobra lay on your belly push up as far as you can try sitting with the knee bent so the nerve is on slack try sitting and bending forward and rounding the spine and seeing what happens uh if you need if you know that you naturally have pain just sitting find a really soft surface find a couch so that it so that you're not getting pain from pressure you're getting pain from actually testing this motion and look if you can do these motions you're like i'm not sure maybe it is a disc problem how can i tell well do these motions and if you move pretty darn good you can get your arms all the way straight up you can bend forward and you don't have a clear reproduction of your pain or signs of major loss of motion or stiffness then it's probably again not your back so it's another way to kind of rule it out and then you go back to hey could it be this and you narrow in on that so did i miss anything that's enough this is by far my longest video and again i apologize but i don't apologize because i feel like if you're serious about getting to the bottom of this problem you need everything in one place because if you just look at this in isolation but nobody told you that if you have pain here but you also have pain up here then this is probably more likely to cause then you just are hopping around the internet watching a bunch of random videos so again i wanted to be kind of the person who connects the dot free because i have a lot of experience in treating these conditions um if you want to chat with me directly just visit www.calldrsanddoctorc.com i'd love to chat with you set up what i call a pain-free planning session to see if we can get you to um you know feeling better give you some clarity whatever you may need um that being said this is it folks okay so i don't think i need to review anything else uh keep in mind this idea of upstream thing being able to uh cause pain numbness or tingling anywhere downstream uh realize that images are overrated in most cases okay while there are some signs and sometimes that you might need an image um they're rare and realize that with a good uh practitioner who listens to your story and combines that with a really solid movement exam as well as reasoning you can sort through this deck of cards on your own and hopefully from this video you um you know have some take homes again uh i will include the link to this i'll just let you download it so you can try to walk yourself through this and hopefully get some clarity about what could be going on which will maybe inform the next steps about what you need to do for treatment so that being said i hope this helps you diagnose things at home wherever you may be uh and put your mind at rest and again gives you some clarity so again this is dr charlie hope you have a great day let me know in the comments below like the channel subscribe let me know if you have any questions i would love to communicate with you thanks so much

Channel: Physical Therapy & Johnson

Views: 66,095

Rating: 4.930131 out of 5

Keywords: royersford, limerick, phoenixville, collegeville, philadelphia, king of prussia, trappe, physical therapy, herniated disc, sciatica, spinal stenosis, piriformis syndrome test, piriformis syndrome, neurogenic claudication, hip bursitis, hip osteoarthritis, hip arthritis, hip joint arthritis, hip arthritis test, labral tear, hip labral tear, FAI hip, Hip FAI, Hip bursitis, greater trochanteric bursitis, high hamstring tendinopathy, high hamstring pain, sciatica test

Id: pWowPQ_3Coo

Length: 59min 30sec (3570 seconds)

Published: Sat Feb 06 2021

Reddit Comments

[u/dilligaf2008]

I’ve come across Dr Charlie’s videos before and i like his no-nonsense style (and like listening to his accent too - reminds me of my cousins!)

LOTS of information and it’s a long video but i found myself nodding intently through a lot of it :)

Flowchart if you don’t want to click on the YT link https://drive.google.com/file/d/1pBFqAgLDxLlsdU-RJC3Zkn14MmnzjV8h/view

[u/verootigy]

The flowchart seems consistent with the path many medical practitioners initially follow for lower back pain that presents mechanically - as in “i really hurt my back, please fix it”.

But longer term chronic back pain is a whole other flowchart i would suspect.