Surviving Lumbago: The Low-Down On Back Pain

iStock_000014522484Small85%. That’s the percentage of you who will, at some point, be plagued by low back pain. Sure, there are more exciting topics out there, but maybe none more pertinent to the majority of us.

One word of advice: don’t help your friend move his refrigerator down the stairs. There. That is all.

Have a nice day.

I see people come in in droves with low back pain, often with a history of helping a buddy move this piece of furniture or that appliance. Tell your friend to stay put. Moving is overrated.

For me, my bout with low back pain was less sexy than that. It was also less noble. No, I was on a boat and bent over to lift the cushion that covered the built-in cooler. It’s ok. You can laugh. That cushion was as light as you’d expect. I never claimed to be a manly man. My take-home message from that was that almost anything can exacerbate an episode of mechanical low back pain. You move the wrong way, with or without weight involved, and bam – “threw” your back out.

My episode was mild, lasted a few days, and never came back. But, when you do have lumbar pain, you’ll have to make a decision about whether you need to see a doctor. That’s when you’ll want to reference this post. Maybe bookmark this. You know your time is coming.

Since I’m an emergency physician, I have to point out the things that I look for that make me think this is NOT just strain of the muscles of the low back. In other words, if you have low back pain and these confounding factors, you should go see a doctor.

• trauma – if you fell off a ladder onto your back, or your crazy cousin hit you with his car, you need to be seen. There could be a broken bone causing your pain. Get an x-ray.

• weakness – if you have legitimate weakness, not just pain with movement, but the “I can’t pick my foot up off the floor” weakness, you need to be seen.

• loss of bowel/bladder control – inability to urinate, or peeing and pooping on yourself should be cause of concern. Sounds obvious, right? Seriously, go to the hospital.

• risk for infection – fevers are a red flag for me. If you are chronically on medications, like steroids, that put you at risk for infections, or if you have a nasty habit of shooting up illicit drugs, especially if you’re running a fever with your back pain, go see a doctor.

• risk for cancer – if you have cancer, or had cancer, you’re more likely to need x-rays, especially if your pain is lasting a while, or you didn’t do anything to cause it.

Assuming you simply tweaked your back and are suffering, you might be able to get by without seeing a doctor. The first thing you need to understand is that most mechanical low back pain gets better in 2-4 weeks. That’s not a typo. I didn’t say 2-4 days. So, part of figuring out if you need to be seen is setting reasonable expectations for your recovery.

Most of the time the pain in the low back is from straining muscles and ligaments. Sometimes it’s from a bulging disc. If you notice the pain radiates from your low back down your leg, it might be a disc that is bulging (also called herniated). Even most of these get better without surgery.

So, what to do. Try taking ibuprofen and Tylenol for your back pain. You can try a heating pad (low to medium setting, and don’t fall asleep on it), or you can try an ice pack (for 10-15 minutes out of each hour while you’re awake). If you can get that area numb, it doesn’t hurt so much. Don’t sleep on anything really hard or really soft. A nice, firm mattress is the best. If you lie on your back and put a pillow behind your knees, this can relieve some of the pressure on your back. Gentle stretching and strengthening exercises can be helpful.

If the pain is too much, you may need to see a doctor for some prescription pain relief. Use this only as a last resort. Narcotic pain medications tend to delay how long it takes you to get better from your back pain. In addition, they are addictive.

Some people benefit from seeing their MD, or going to physical therapy, or by seeing a chiropractor. The studies show that they all get you better at about the same rate, just each using different modalities.

So, when you do hurt your back, try some home meds and ice. And time. That’s the main one. Come see me if you have one of the worrisome features we discussed, or if your pain is just not manageable. Or, if you need a work note. We specialize in those, too.

What experiences have you had with low back pain? How long did it take to improve?

Snap and Pop: PL guide to ankle injuries

Icing a sprained ankleThis feels wrong. Like I’m about to do some shady insider trading with you , or something. Every industry has its secrets. Medicine is no different. But, that’s what this blog is about: sharing medicine’s little secrets so you know when you need us.

Ready? (speaking under my breath): Not every twisted ankle needs an x-ray. There. I said it. Glance over my shoulder, no medical information police around… I think we’re good.

Sprained ankles hurt. They swell. They bruise. They resist bearing the weight of our bodies. Most people who have participated in sports know the prescription for a sprained joint is R.I.C.E therapy, right? Rest. Ice. Compression. Elevation. But, doc, don’t I need an x-ray to make certain it’s not broken? As usual, the answer is not necessarily. I’ll explain.

Let me clarify one thing first. Broke and fractured are the same thing. One isn’t better than the other. To medical providers, the two have the same exact meaning.

Let’s start with a little anatomy lesson first. The long bones from the knee to the ankle are the tibia and fibula. The tibia is closer to the middle of the body, the fibula along the outside of the lower leg. The tibia is bigger and bears weight for us. These two bones bulge out around the ankle and form the medial (toward the inside of the body) malleolus, and the lateral (toward the outside of the body) malleolus. Lots of ligaments are around the ankle to hold it all together like duct tape.

How do I know from examining you whether you need an x-ray? Studies. There are these clinical decision tools called the Ottawa Ankle Rules. They were developed by our northern neighbors in Ottawa, Canada. The researchers originally looked at over 1000 patients with ankle injuries. Then they validated their findings with tens of thousands of patients. These rules don’t predict that there is absolutely no fracture. It’s looking for fractures that need to be treated differently than a sprain. This is good research. Trust me. I’m a doctor.

So, the Ottawa Ankle Rules help me see a patient with an injury and determine if he needs an x-ray. Just because the rules say you need an x-ray, doesn’t mean there is going to be a fracture. It just means I can’t rule out a fracture by examining you. I need some pics.

Who needs an x-ray?

Unable to bear weight. So, if you’re unable to bear weight (4 steps) BOTH at the time of the injury AND in the emergency department, you need an x-ray. It doesn’t say it won’t hurt to walk, it just asks if you’re able to. If you could walk initially, but later can’t, or vice versa, that doesn’t meet the criteria.

Tender over the back or bottom tip of the medial malleolus (inside of the ankle). So, feel that bump on the inside (medial malleolus). If you’re looking at your ankle standing up, go to the back part (we call that posterior). If the bottom 6 cm (2.5 inches) of the back part or the bottom tip is tender, you need an x-ray. Basically, if only the front (anterior) part is tender, no big deal. That’s a sprain.

Tender over the back or bottom tip of the lateral malleolus (outside of ankle). Same as above, only check out the outside bone. Still, we’re paying attention to the back (posterior) part, not the front.

You’ll notice there isn’t anything in here about swelling. Ankle sprains and fractures swell. Now, the doctor still has to use good judgment. If the patient is intoxicated, or there are other severe injuries (we call these distracting injuries), x-rays may be needed.

How do I use these when I see a patient? I usually explain why I don’t think an x-ray is necessary. If she still wants it, I usually oblige. Peace of mind is sometimes worthwhile. But, getting out of the ED an hour or two faster without an x-ray is also valuable.

I tend to get more x-rays in children, open growth plates and all, but there is data that says these rules can be applied to reduce the number of x-rays for kids as well.

Next time you twist your ankle, you may still need to see the doctor for pain control or a good splint, or just to make certain you are applying these rules properly (we’re the trained professionals). But, maybe this helps your openness to the idea that you may not need that x-ray you would have otherwise expected was necessary.

What ankle injuries have you suffered that, looking back, may not have needed an x-ray?