If you want to steer clear of lower back pain, remember this: Arch is good, flat is bad.
Back pain is anything but rare; only headaches and colds are more common. According to the National Institute of Neurological Diseases and Stroke, Americans spend more than $50 billion each year on lower back pain, which is the No. 1 cause of job-related disability in the country and one of the leading contributors to missed time from work.
There’s acute lower back pain, sometimes intense but generally short-lived discomfort resulting from injury to the lower back incurred during sustained physical activity (playing sports, doing yard work) or by a sudden jolt (being in a vehicle collision). But it’s chronic lower back pain, the kind that lasts for more than three months, that is more debilitating and more difficult to treat.
Much of that chronic pain is caused by damage to the discs — the spongy, multi-function structures that lie between the spine’s vertebrae — in the lower part of the back right above the pelvis known as the lumbar region. And much of that damage is caused by poor body mechanics — the way people stand, walk, lift, carry, reach, bend, sit and sleep — in which the back is too often flat, not arched.
“The key to avoiding lower back pain is keeping pressure off your lower lumbar discs,” said Tadhg O’Gara, M.D., an orthopaedic surgeon at Wake Forest Baptist Medical Center in Winston-Salem, N.C. “That means keeping an arch to your lower back.”
The intervertebral discs, essentially the spine’s shock absorbers, are under constant pressure, especially in the lower back, which supports the weight of the upper body. The five vertebrae in the lumbar region are naturally arched toward the front of the body, so bending forward compresses the front of these disks, which over time can force them out of position to press on one or more of the nerves emanating from the spinal cord. This condition — known as a bulging, herniated or ruptured disc — can cause pain in the lower back and elsewhere, especially the buttocks, thighs and even below the knee (sciatica). And that pain can be severe.
“People who haven’t had lower back pain don’t re alize how painful it is,” O’Gara said. “And many health care providers don’t realize how painful it is.”
So how is chronic lower back pain treated?
“The first thing to figure out is what exactly is causing the pain, because that determines what approach to take with treatment,” said Kristopher Karvelas, M.D., assistant professor of physical medicine and rehabilitation at Wake Forest Baptist. “That’s not always easy. Pain is usually related to the discs, but other causes of low back pain have overlapping symptoms and pain patterns.”
Basic diagnostic methods include physical examination, review of the patient’s medical history and patient descriptions of the onset, location, severity and duration of the pain and of any limitations in movement. Imaging techniques such as X-rays, MRI and CT scans also can be employed to pinpoint the source of pain.
Once the reason behind the pain is determined, the most frequently prescribed treatment is physical therapy, not surgery.
“I typically reserve surgery for patients who have a medical need other than pain,” Karvelas said. “There’s a large toolbox that we can go to for patients, and surgery is the last tool.”
Depending on the individual patient’s condition, physical therapy programs usually include exercises designed to strengthen back and abdominal muscles and to promote proper posture and balance. These can include stretching, swimming, walking and even yoga. But education also is a key element.
“Patients need to recognize that posture and activity are crucial in relieving and preventing back pain,” Karvelas said. “They need to learn what exercises to do on their own and how to do them properly to prevent future flare-ups.
“We can help resolve acute back pain episodes, but when we are talking about chronic back pain, the pain may never resolve completely. However, we do use a team approach to treat patients and teach people how to cope with their pain effectively.
An estimated 126.6 million Americans (one in two adults) are affected by a musculoskeletal condition–comparable to the total percentage of Americans living with a chronic lung or heart condition–costing an estimated $213 billion in annual treatment, care and lost wages, according to a new report issued today by the United States Bone and Joint Initiative (USBJI).
Musculoskeletal disorders–conditions and injuries affecting the bones, joints and muscles–can be painful and debilitating, affecting daily quality of life, activity and productivity. “The Impact of Musculoskeletal Disorders on Americans: Opportunities for Action” outlines the prevalence and projected growth of musculoskeletal disorders in the U.S., and recommends strategies for improving patient outcomes while decreasing rising health and societal costs.
“This report provides the critical data needed to understand the magnitude of the problem, and the burden, of musculoskeletal disease in our country,” said David Pisetsky, MD, USBJI president, and professor of medicine and immunology at Duke University Medical School. “The number of visits to physicians for these disorders, the cost of treating them, and the indirect costs associated with pain and loss of mobility, are proportionately much higher than the resources currently being allocated to combat these conditions and injuries.”
“As a nation, we need to establish greater funding for musculoskeletal research, improve our understanding and strategies for prevention and treatment of these injuries and conditions, and ensure that more adults and children receive appropriate treatment sooner, and on an ongoing basis, to ensure quality of life and productivity,” said Stuart L. Weinstein, MD, co-chair of the report’s Steering Committee and a professor of orthopaedics and rehabilitation at the University of Iowa Hospitals and Clinics.
Prevalence and predictions
According to the report, the most prevalent musculoskeletal disorders are arthritis and related conditions; back and neck pain; injuries from falls, work, military service and sports; and osteoporosis, a loss of bone density increasing fracture risk, primarily in older women. An estimated 126.6 million Americans were living with a musculoskeletal disorder in 2012. More specifically:
•Arthritis is the most common cause of disability, with 51.8 million–half of U.S. adults age 65 and older–suffering from the disease.
•With the aging of the American population, the report projects arthritis prevalence to increase to 67 million people, or 25 percent of the adult population, by 2030.
•Arthritis is not just a disease for older Americans, with two-thirds of arthritis sufferers under age 65.
•Back and neck pain affects nearly one in three, or 75.7 million adults.
•Osteoporosis affects 10 million Americans, with 19 million more (mostly women) at risk for the disease.
•One in two women and one in four men over the age of 50 will have an osteoporosis-related fracture, and 20 percent of hip fracture patients over age 50 will die within one year of their injury.
Cost and health care impact
The burden of musculoskeletal conditions is significant in terms of treatment and care, as well as the impact upon of quality of life, mobility, and productivity, and resulting in fewer days at work and in school. In 2011, the annual U.S. cost for treatment and lost wages related to musculoskeletal disorders was $213 billion, or 1.4 percent of the country’s gross domestic product (GDP). When adding the burden of other conditions affecting persons with musculoskeletal conditions such as diabetes, heart disease and obesity, the total indirect and direct costs rose to $874 billion, or 5.7 percent of the GDP in 2015.
Other data on the costs of musculoskeletal diseases and injuries include:
•Eighteen percent of all health care visits in 2010 were related to musculoskeletal conditions, including 52 million visits for low back pain, and 66 million for bone and joint injuries, including 14 million visits for childhood injuries.
•Arthritis and rheumatoid conditions resulted in an estimated 6.7 million annual hospitalizations.
•The average annual cost per person for treatment of a musculoskeletal condition is $7,800.
•The estimated annual cost for medical care to treat all forms of arthritis and joint pain was $580.9 billion, which represented a 131 percent increase (in 2011 dollars) over 2000.
•In 2012, 25.5 million people lost an average of 11.4 days of work due to back or neck pain, for a total of 290.8 million lost workdays in 2012 alone.
•Among children and adolescents, musculoskeletal conditions are surpassed only by respiratory infections as a cause of missed school days.
Opportunities for action
The report provides recommendations to curb the tremendous economic and societal costs of musculoskeletal disorders, including:
•Accelerating research that compares treatment alternatives, develops new treatments and evaluates possible preventative approaches.
•Improving understanding of the role of behavior change in prevention and treatment, including weight loss and self-management of conditions once they arise.
•Ensuring that a higher percentage of the affected population receives access to evidence-based treatments.
•Implementing proven prevention strategies for sports injuries, workplace injuries, and injuries in the military.
•Ensuring that all children with chronic medical and musculoskeletal problems have access to care.
•Promoting better coordination between physicians and other health care providers treating musculoskeletal disorders: primary care physicians, specialists, physical therapists, etc.
•Ensuring that health care providers, especially primary care physicians, have the appropriate training to diagnose, and if necessary, refer patients for appropriate treatment.
•Addressing data limitations, and improve systems, to improve our understanding of these conditions and how best to screen, diagnose and treat them. This includes the impact of sex and gender on musculoskeletal disorders and responses to treatment, and tracking pediatric patients through adulthood to determine the lifelong burden of musculoskeletal disease.
“If we continue on our current trajectory, we are choosing to accept more prevalence and incidence of these disorders, spiraling costs, restricted access to needed services, and less success in alleviating pain and suffering — a high cost,” said Edward H. Yelin, PhD, co-chair of the report’s steering committee, and professor of medicine and health policy at the University of California, San Francisco. “The time to act to change this scenario to one with more evidence-based interventions and effective treatments, while simultaneously focusing on prevention, doing better by our society and economy, is now.”
American Academy of Orthopaedic Surgeons. “One in two Americans have a musculoskeletal condition: New report outlines the prevalence, scope, cost and projected growth of musculoskeletal disorders in the U.S..”
She wasn’t born this way, but even Lady Gaga experienced groin pain — typically a symptom of hip disease such as arthritis of the hip — or, in her case, a hip labral tear. Groin pain is a common health complaint. According to a literature review appearing in the September 2013 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), one in four people develop hip arthritis — damage to the surfaces in the hip joint — before the age of 85 that contributes to groin pain.
Contributing factors to the development of hip arthritis and, subsequently, groin pain may include one or more of the following:
•a sports-related injury;
•prior surgery to the hip;
•infection of bone or soft tissue;
•a defect present at birth;
•problems with growth and development, and
•traumatic occupational and recreational history, bone fractures, or a history of trauma.
The specific symptoms, and the timing/onset of those symptoms, can help your doctor recommend the appropriate tests, imaging or referrals to diagnose and treat the cause of the pain.
“Individuals experiencing sudden, onset groin pain associated with trauma or bowel/bladder dysfunction, symptoms like fevers or abdominal discomfort should promptly seek medical attention,” says Juan C. Suarez, MD, lead author of the study and an orthopaedic surgeon with Cleveland Clinic Florida. “But, those with chronic pain, despite time and conservative management, also warrant evaluation.”
Young athletes participating in activities such as endurance sports, soccer, power lifting, ice hockey, and basketball are at an increased risk of developing hip osteoarthritis (OA), the “wear and tear” arthritis because of frequent, high stresses at the joint surface. In addition to hip arthritis, female athletes participating in endurance sports also are more likely to sustain hip and pelvic stress fractures than male athletes.
A detailed medical history and examination by a physician can help diagnose and manage the source of groin pain. “It is important to have a good network of physicians from multiple specialties,” says Dr. Suarez. “In my experience, the diagnosis is not always obvious and it may require multiple visits, examinations and referrals prior to reaching the correct diagnosis. A good network facilitates this process.”
1.J. C. Suarez, E. E. Ely, A. B. Mutnal, N. M. Figueroa, A. K. Klika, P. D. Patel, W. K. Barsoum. Comprehensive Approach to the Evaluation of Groin Pain. Journal of the American Academy of Orthopaedic Surgeons, 2013; 21 (9): 558 DOI: 10.5435/JAAOS-21-09-558
Rice University catcher, John Clay Reeves, felt pain in his groin after a collision at the plate with an opposing player. He thought he had pulled a muscle, but it turns out he was suffering from a common condition seen in teens and young adults known as hip impingement.
“The issue with hip impingement is not treating it, but diagnosing it,” said Joshua Harris, M.D., a Houston Methodist orthopedic surgeon. “Ball and socket pain will be felt in the groin, which often leads to an initial diagnosis of a pulled groin. Some patients can spend six months to six years seeing three to five doctors before they finally get the correct diagnosis of hip impingement.”
Hip impingement occurs when either the socket or ball of the hip joint is not round, which prevents smooth movement within the joint. In most cases, this abnormal joint movement will lead to a tear of the hip labrum, a rim of cartilage that helps keeps the ball of the joint in the socket. Hip impingement can cause severe hip pain and, if not treated, might lead to the onset of arthritis in the patient’s 40s or 50s.
“We believe that most cases of hip impingement will begin in boys from 12 to 15 and girls from 11 to 13 who play high impact sports, such as soccer, track and basketball,” Harris said. “Between these ages, the bones are still growing and strengthening, so jumping too much can cause the socket and ball to hit repeatedly and will eventually cause one of them to lose their round shape.”
The good news is that the condition can be treated with arthroscopic surgery. An arthroscope, or small fiber optic camera is placed in the joint through a small incision at the hip. The surgeon will shave off bone as needed to make the socket and ball round again and will repair the labrum with sutures, which will relieve pain and improve function in 90 percent of cases.
While hip impingement is not yet preventable, Harris said it typically does not recur after arthroscopic surgery to treat it.
“More than 600,000 hip replacements are performed each year due to hip arthritis, with between 70 and 90 percent of hip arthritis cases stemming from untreated hip impingement,” Harris said. “We believe that treating hip impingement with arthroscopic surgery can delay or prevent the onset of hip arthritis, but studies to confirm that are still pending. Once it’s confirmed, we’ll have made significant headway in treating a large public health issue.”
Reeves has been catching since age 12 and has always experienced tightness in his hips. Since undergoing arthroscopic surgery, the tightness is gone and he’s ready to get back on the field.
“My hip would click and pop, which was painful, but then it would loosen up after stretching it out,” Reeves said. “I always thought it was normal, but I was able to tell a huge difference after having my right hip repaired last year. I’m now back to doing everything I was before with better flexibility and no pain.”
Houston Methodist. “Common hip issue in teens misdiagnosed as pulled muscle.” ScienceDaily. ScienceDaily, 24 February 2015. <www.sciencedaily.com/releases/2015/02/150224182524.htm>.