[gnick]

#30330

Thanks so much for the ability to post and ask for feedback here! I’ve had chronic pain issues for 17 months now and am seeking advice on how/if they might all be connected.

History: 35yo, runner for 20 years, 8-time marathoner, no known health issues or injuries

Timeline:
November 2017: started experiencing bilateral shin pain, mis-diagnosed via x-ray by orthopedic as muscle issue, sent to 5 weeks of PT, no improvement
February 2018: new orthopedic found right tibial stress fracture, evident in the initial x-rays, 8 weeks in a walking boot
April 2018: cleared for all activity, started chiropractic care to address hip imbalance (potentially the fracture cause, having ruled out anything else: had biomechanical gait analysis, full PT evaluation, fitted for new orthotics, clean lab work and BMD scan)
May-Aug 2018: shin pain and overall muscle tightness persisted
Sept 2018: right lower leg x-rays and MRI returned clean, sent to another round of PT for dry needling, cupping, graston, interx + deep tissue massage with minor relief
Oct 2018: low back pain began
Jan 2019: chiro ordered low back x-rays followed by orthopedic ordering low back MRI

X-Rays Lumbar Spine Six Views Findings:
Five non-rib-bearing lumbar-type vertebral bodies are present. There is a well-corticated appearing lucency traversing the right L1 transverse process, which may reflect a remote ununited fracture versus congenital nonunion. There is normal spinal alignment. Vertebral body heights and intervertebral disc space heights appear preserved. The oblique views demonstrate no evidence for pars defects. There is a congenitally ununited appearance of the posterior elements of S1. No evidence for an acute osseous abnormality.

MRI Lumbar Spine w/o Contrast Findings:
The lumbar vertebrae maintain normal height and alignment. The disc spaces are maintained. There are degenerative signal changes at L5-S1. There is evidence of an annular tear at L5-S1 with associated broad-based disc bulge abutting the anterior thecal sac. This does abut both traversing S1 nerve roots. There is facet hypertrophy. No significant central canal or foraminal stenosis is noted. No evidence of disc protrusion or herniation.

At L4-5, minimal disc bulge. Mild facet arthrosis. No central canal or foraminal stenosis.

No significant disc bulge is seen at the other lumbar levels. No other evidence of central canal or foraminal stenosis.

Pain:
Back pain can be described as dull and achy on-and-off throughout the day, equivalent on both sides, worse with too much activity (on my feet all day or walking over a mile), worse when sitting more than an hour or with any kind of travel/time in the car, no sensitivity to touch, does not radiate, no pain in the buttocks.

Shin pain is bilateral but mostly concentrated in the right leg, sharper pain after activity, otherwise throbbing/aching/sensitive to touch on-and-off, worse at night, no sign of weakness.

Current:
Since the MRI findings, I have consulted with a neurosurgeon at the Texas Back Institute in Plano; was dismissed, told to do no impact activity indefinitely and to take Advil. I had an ESI in March with minimal signs of relief but have the option to try a second ESI. I also started with a new chiro in March and have tried decompression, ultrasound, graston, cupping, theragun, etc. with only minor relief over 6 weeks time.

I still have an obvious hip imbalance (legs are not “even” and have been measured to be physically equal) that can be adjusted at chiro but does not last beyond a day or two. I’ve been told that surgery is the next likely option to address the annular tear having tried everything else, but I’d like more knowledge as to whether it’s the source of the shin pain or if that’s a secondary issue due to the hip imbalance, i.e if the hip/muscle imbalance were corrected, would the back pain be alleviated and able to heal without needing surgery or vice versa?

Have you seen this issue with an L5-S1 tear/shin pain relation – no other radiating pain down the butt or legs aside from overall muscle tightness. Any ideas on how to address cause/effect further from a holistic standpoint?

[Donald Corenman, MD, DC]

#30348

Male or Female? With the amount of running you do, I would not be surprised if you might be developing osteoporosis or at least osteopenia. A bone densitometry would be the next step, especially if you are female but even if male.

Your two potential fractures (tibial stress fracture and “well-corticated appearing lucency traversing the right L1 transverse process, which may reflect a remote ununited fracture” make me suspicious of a bone formation disorder.

You have typical findings for a runner with some degenerative disc and facet changes (“There are degenerative signal changes at L5-S1. There is evidence of an annular tear at L5-S1 with associated broad-based disc bulge…There is facet hypertrophy…At L4-5, minimal disc bulge. Mild facet arthrosis”).

For your back, a good Pilates rehab program guided by a well-trained physical therapist and possibly facet blocks or epidural injections depending upon your examination. Shin pain could be from “shin splints”, activity induced compartment syndrome or stress fracture.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[gnick]

#30350

Well, I do suppose gender would be helpful – I’m female. BMD scan last August was as follows.

TECHNIQUE:
Bone mineral density evaluation was performed using a DEXA Hologic bone mineral density unit.
FINDINGS:
The bone mineral density (BMD) is given in grams per square centimeter (g/cm2):

LUMBAR SPINE:
BMD(g/cm2) T-score Z-score
L1: 0.86 -1.2 -1.2
L2: 0.95 -0.7 -0.7
L3: 0.94 -1.3 -1.3
L4: 0.88 -1.6 -1.6
Total: 0.91 -1.3 -1.2
Findings compatible with osteopenia.

HIP: Femoral neck: 0.75 -0.9 -0.7
Total: 0.87 -0.6 -0.5
Findings compatible with normal bone mineral density.

IMPRESSION:
The patient has normal bone mineral density. No significant increased risk of osteoporotic fractures seen.

My PCP told me to start taking calcium as preventative caution and (ironically) to do more load/weight-bearing exercise but was otherwise unconcerned. He did test B6 for Hypophosphatasia and it came back normal. I’ve asked everyone I’ve seen since the BMD if it’s a factor, and no one has placed prominence in it over the MRI results, but it sounds like something to look into further.

Thank you for your time and feedback; that gives me several avenues to consider.

[Donald Corenman, MD, DC]

#30353

A female who exercises extensively (as you do to be in condition for a marathon), can lose her periods and hence, her estrogen which is essential to keep bone quality high. I am surprised that the report noted “The patient has normal bone mineral density. No significant increased risk of osteoporotic fractures seen” when you had a -1.3 for your spine which this individual notes is osteopenia. I suspect a bone metabolic issue. You might check with an endocrinologist.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[gnick]

#30362

I’ve done quite a bit of research on the female athlete triad and inquired about it with my PCP, but aside from the BMD findings, I’ve not experienced any symptoms – which doesn’t at all mean it’s not a factor, just not something I’ve pursued. I’ve not seen an endo though, so may check into that. Thanks again for your time!

[Donald Corenman, MD, DC]

#30363

Please keep in touch with the Forum for our own educational purposes.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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