Osteophytes are not always symptomatic. They start to become symptomatic if they:

• Restrict movement
• Come in contact with other bone or soft tissue
• Put pressure on surrounding nerves

As such, symptomatic patients often report stiffness and a dull ache in the affected joint that is also accompanied by decreased range-of-motion. A few examples include:

• In the shoulder, osteophytes around the joint can narrow the space available for tendons and ligaments to pass through, and is associated with rotator cuff tear or tendonitis.
• In the finger, osteophyte formation presents as a painless lump around the distal interphalangeal joint (Heberden’s node) or proximal interphalangeal joint (Bouchard’s node).
• In the spine, depending on the size and location of the osteophyte, it may affect the spinal nerve roots leading to radicular symptoms, such as numbness, pulling and/or tingling into the upper limbs or lower limbs.

A detailed medical history and extensive physical examination are performed during a visit to the chiropractor. Usually, patients suffering from degenerative diseases and/or have decreased range-of-motion during a physical examination are associated with osteophytes.

Nevertheless, as osteophytes are usually painless and their symptoms are usually due to the associated osteoarthritis, they are usually detected on radiographs as incidental findings.

With patients who present with symptoms, X-ray images of the symptomatic body part can be ordered to assess for the presence or extent of osteophytes formation. In some cases, further imaging such as, MR imaging and CT scans may be warranted.

Treatment specifically for the osteophyte is typically not required if it is painless. In fact, it is usually the associated degenerative disease that is treated and managed to reduce pain and improve function. These are usually done via conservative care which includes, rest, rehabilitation exercises, activity and/or posture modification and manual therapy. Pharmaceutical options include painkillers and NSAIDs, as well as injection therapy.

If the above care does not work, then only is surgical consult considered.

Furthermore, surgical consult may also be considered if the osteophyte presents in the finger or toe, and interferes with activities-of-daily living, or for cosmetic reasons.

1. NHS, 2019. Osteophyte (bone spur) [online]. Available from: https://www.nhs.uk/conditions/osteophyte/ [Accessed December 2022].
2. Wong, SHJ., Chiu, KY., Yan, CH., 2016. Review Article: Osteophytes. Journal of Orthopaedic Surgery [online], 24 (3), 403-10.

The piriformis is a flat, pyramid-shaped muscle of the gluteal region that lies deep to the gluteus maximus. It belongs to a group of six short external rotators of the hip: gemellus superior, obturator internus, gemellus inferior, obturator externus and quadratus femoris. It is the most superficial of these six muscles. This muscle is important for the stabilisation of the hip joint and moving the hip in multiple directions as it attaches from the sacrum on one end and to the greater trochanter of the hip at the other.

The piriformis originates from the anterior surface of the sacrum and the gluteal surface of the ilium, and inserts into the greater trochanter of the femur. Its main action is to externally rotate the hip joint and abduct the thigh when the hip is flexed. The piriformis also stabilizes the head of the femur in the acetabulum of the hip joint.

This muscle also divides the greater sciatic foramen into two foramina known as the suprapiriform foramen and infrapiriform foramen. It should be noted that various neurovascular structures exit the pelvis into the groin and lower limb through these foramina.

As stated above, a number of neurovascular structures passes through the piriformis as it exits the pelvis, and of note is the sciatic nerve. The sciatic nerve is formed by the L4-S3 ventral roots and usually exits the pelvis via a single trunk, through the greater sciatic foramen below the piriformis (infrapiriform foramen). The sciatic nerve makes it course through the back of the thigh and divides into the tibial and the common peroneal branches at the popliteal fossa. The tibial and common peroneal nerves are surrounded by a common epineural sheath from the main sciatic nerve trunk. Therefore, the sciatic nerve innervates the muscles of the back of the thigh as well as all the lower leg and foot muscles.

Nevertheless, because the development of the tibial and peroneal divisions is separate from one another, this could explain why the sciatic nerve variants develop during embryonic development. The possible relationships between the sciatic nerve and piriformis were first categorised by Beaton and Anson into the following six morphological types as shown in the diagram above:

• Type A: typical pattern, with the sciatic nerve passing below the piriformis, undivided
• Type B: the common peroneal nerve exits through the piriformis muscle belly and tibial nerve exits below the piriformis
• Type C: the common peroneal nerve exits above the piriformis while the tibial nerve exits below the piriformis
• Type D: the sciatic nerve exits through the piriformis muscle belly, as a single trunk
• Type E: the common peroneal nerve exits above the piriformis and tibial nerve through the piriformis
• Type F: the sciatic nerve passes undivided above the piriformis

The sciatic nerve can get irritated if the external rotators of the hip are tight, leading to pain radiating into the lower limb. Hence, it is important to be clinically aware of the sciatic nerve variants since they may account for the cause of piriformis syndrome. For more details regarding this syndrome, click here.

Piriformis trigger points can transmit pain to the back the thigh so the pain is not mainly concentrated in the buttocks and hip area. The medial piriformis trigger point (closer to the midline) lies along the piriformis line about an inch outside the edge of the sacrum. The lateral piriformis trigger point (away from the midline) is a few inches to the inside of the greater trochanter of the hip, along the piriformis muscle belly. These trigger points in the buttocks are capable of referring pain to the buttock region, sacroiliac joint and back of the thigh.

The psoas and piriformis are important muscles that connect the spine to the lower limbs. With the psoas from the front and piriformis in back, these muscles lend support to the spine by keeping it afloat above the pelvis. The psoas pulls down from the front and the piriformis pulls in the same direction from behind. Problems arise when this relationship is disrupted. When the psoas is tight, it pulls the lumbar spine into a deeper lordotic curve. This lifts the sacrum and ilium into an anterior tilt leading to strain on the piriformis.

If you suspect that your buttock and/or back of thigh pain may be related to your piriformis, try this variation of a stretching exercise at home. However, if you are suffering from persisting buttock and/or back of thigh pain, please do consult a healthcare professional for a more detailed assessment.

Reference

Beaton, LE., Anson, BJ., 2005. The relation of the sciatic nerve and of its subdivisions to the piriformis muscle. The Anatomical Record [online], 70, 1-5.
Keibel, F., Mall, FP, 1910. Manual of Human Embryology. Philadelphia: J.B. Lippincott Company.
Poutoglidou, F., Piagkou, M., Totlis, T., Tzika, M., Natsis, K., 2020. Sciatic Nerve Variants and the Piriformis Muscle: A Systematic Review and Meta-Analysis. Cureus [online], 12 (11), e11531.

1. Brukner, P., 2015. Hamstring injuries: prevention and treatment—an update. British journal of sports medicine [online], 49(19), 1241–1244.
2. Dolman, B., Verrall, G., Reid, I., 2014. Physical principles demonstrate that the biceps femoris muscle relative to the other hamstring muscles exerts the most force: implications for hamstring muscle strain injuries. Muscle, Ligaments and Tendons Journal [online], 4(3), 371–377.
3. Ramos, GA., Aliani, GG., Astur, DC., Pochini, AdC., Ejnisman, B., Cohen, M., 2017. Rehabilitation of hamstring muscle injuries: a literature review. Revista Brasileira de Ortopedia [online], 52(1), 11–16.

Whiplash injury, first described by Harold Crowe in 1928, is the most common type of injury following road traffic accidents (RTA). Most patients recover within 2-3 weeks following the injury. Nevertheless, a significant proportion of those with whiplash injury will transition from an acute (0-12 weeks) to a chronic (> 12 weeks post-injury) pain status which makes managing this condition a challenge.

Whiplash-associated disorders (WAD) are defined as an acceleration-deceleration mechanism of energy transferred to the head and neck relative to other parts of the body. This means that there is an abrupt change in speed causing the body to be thrust forward (neck goes into hyperextension) and then backwards (neck goes into hyperflexion) in quick succession, usually resulting from a rear-end or side-impact RTA. However, it is not dependent on the involvement of an automobile, as other mechanisms of injury could also result in a whiplash-type injury such as, skiing and diving.

Most patients with traffic injuries report pain in the neck and upper limb pain. Other common symptoms include:

• Headache
• Stiffness
• Shoulder and back pain
• Numbness
• Dizziness
• Sleeping difficulties
• Fatigue

Patients whose symptoms fail to resolve quickly often exhibit a multitude of symptoms that include, but are not limited to:

• Pain
• Dizziness
• Visual and auditory disturbances
• Temporomandibular joint dysfunction
• Photophobia (sensitivity to light)
• Dysphonia (hoarseness of the voice)
• Dysphagia (difficulty in swallowing)
• Cognitive difficulties such as, concentration and memory loss, anxiety, insomnia and depression

Chiropractic care can help relieve the neuromusculoskeletal symptoms associated with whiplash-associated disorder. This is achieved by exercise therapy which involves prescribing a program of functional exercises that act to stretch tight muscles and then strengthening the weaker ones. Chiropractors also perform manipulation therapy on the neck, shoulder and upper back to correct the misalignments sustained during injury to improve movement in those regions. Passive modalities such as therapeutic ultrasound, high-intensity laser and interferential current therapy can also help in pain and symptom reduction.

Getting a whiplash injury treated promptly is of utmost importance as it can help to prevent the transition from an acute pain status to a chronic one, with all of its associated symptoms. Should a patient be suffering from chronic WAD, chiropractic care still represents a good treatment option, but it is likely that the patient would be co-managed with other members of the healthcare professional depending on what symptoms the patient suffers from.

References

1. BruceBlaus, 2017. File:Whiplash.png. Wikimedia commons [online]. Available from: https://commons.wikimedia.org/wiki/File:Whiplash.png#metadata [Accessed September 2022].
2. Bussières, AE., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Hayden, J., Hendrickson, B., Hincapié, C., Pagé, I., Passmore, S., Srbely, J., Stupar, M., Weisberg, J., Ornelas, J., 2016. The treatment of neck pain-associated disorders and whiplash-associated disorders: a clinical practice guideline. Journal of manipulative and physiological therapeutics [online], 39 (8), 523-564.
3. Elliott, JM., Noteboom, JT., Flynn, TW., Sterling, M., 2009. Characterization of acute and chronic whiplash-associated disorders. Journal of orthopaedic and sports physical therapy [online], 39 (5), 312-323.
4. Moore, A., Jackson, A., Jordan, J., Hammersley, S., Hill, J., Mercer, C., Smith, C., Thompson, J., Woby, S., Hudson, A., 2005. Clinical guidelines for the physiotherapy management of whiplash associated disorder: quick reference guide [online]. London: Chartered Society of Physiotherapy.
5. Pastakia, K., Kumar, S., 2011. Acute whiplash associated disorders (WAD). Open access emergency medicine [online], 3, 29-32.
6. Sterling, M., 2014. Physiotherapy management of whiplash-associated disorders (WAD). Journal of physiotherapy [online], 60 (1), 5-12.

The shoulder joint is made up of the humerus (arm bone), clavicle (collarbone) and scapula (shoulder blade). The head of the humerus fits into the glenoid cavity of the scapula to form a ball-and-socket joint. The arm is then firmly kept together within this shallow socket by the rotator cuff, which is a complex group of muscles and tendons that team up to form a covering around the head of the humerus. The rotator cuff muscles which arise from the scapula and attach to the humeral head, provides strength and stability during shoulder motion.

The rotator cuff muscles, also known as the ‘SITS’ muscles are made up of the supraspinatus, infraspinatus, teres minor and subscapularis, respectively. The table shows the primary function of each rotator cuff muscle.

Between the rotator cuff and the acromion process of the scapula, is a lubricating, fluid-filled sac known as a bursa. The bursa covers and protects the muscles and tendons, keeping them from close contact with surrounding bones, thereby allowing the tendons to glide freely during arm movement. Thus, when the rotator cuff tendons become injured or damaged, this bursa may also become inflamed and painful.

Rotator cuff injuries are the most common cause of shoulder pain and disability among adults. This injury is common in patients over the age of 40, but can affect those who are younger too. They are also usually more common in males than in females. A rotator cuff strain is the over stretching or tearing of the rotator cuff tendon or muscle belly. The severity of the muscle strain depends on how much fibres were damaged, intensity of pain and the strength of muscle contraction.

There are two main causes of rotator cuff strain: acute traumatic and degenerative. Acute traumatic strains usually occur after a specific trauma such as, falling on an outstretched hand (FOOSH), or a single violent force or blow to the shoulder. Besides, prolonged or repetitive overuse of the rotator cuff over a short period of time – especially in athletes who repeatedly make overhead or forceful pulling motions are more prone to rotator cuff strain. Acute traumatic strains can also occur when overexerting during lifting or pulling something that is too heavy, or if a pre-existing shoulder impingement syndrome is already present.

Degenerative strains are as a result of the wear and tear of the rotator cuff tendon that occurs slowly over time, and it is usually painless. This type of strain is more common in the dominant arm, but if a degenerative strain is present in one arm, there is a higher likelihood of a rotator cuff strain in the opposite arm too, even if no pain is felt. It is usually associated with minimal trauma secondary to long-standing tendonitis or chronic impingement syndrome.

• Pain at the top and side of the shoulder.
• ‘Popping’ or tearing sound at the point of injury, followed by pain and weakness of the shoulder.
• Pain is worsened when leaning on elbow and shrugging the shoulder upwards.
• Unable to tolerate overhead motion.
• Pain that is present even at night, especially when weight-bearing on the affected shoulder.
• Gradual loss of range-of-motion on the affected shoulder if the injury has been persisting for a while, without treatment.
• Loss of strength in the shoulder.
• ‘Clicking’ or ‘snapping’ sounds (crepitus) during shoulder motion.
• Redness and swelling in the affected shoulder (in more severe cases).

A chiropractor would first take a detailed history to gain a better understanding of your condition. Next, a series of tests would be done during the physical examination to confirm the diagnosis, or rule it out. If the history and physical examination point towards a rotator cuff strain, it is also during this time that which of the four rotator cuff muscles are affected and the severity of injury has to be determined – it may be one or more rotator cuff muscle and findings may indicate a over stretch or a tear (partial or complete), respectively. Should there be any need for further investigation, referral for an MRI, X-ray or ultrasound imaging of the shoulder may be warranted.

For a stretched or partially torn muscle, conservative care can help improve pain, function and reduce disability. Modalities such as, therapeutic ultrasound, laser and interferential current therapies aid in reducing pain and swelling. Chiropractors also employ spinal manipulation of the neck and upper back to help ease the tension around the shoulder. These can take from 2 weeks up to 3 months to recover, and even more so depending on severity which can take up to a year of treatment to recover. For a completely torn muscle, surgical consult may be warranted instead.

The kidneys are a pair of bean-shaped organs on either side of the spine, located below the diaphragm, and behind the liver and stomach. The kidneys are responsible for filtering waste from blood plasma, thus keeping the body free from the toxic effects of fluid waste build up. They are also essential to maintain the levels of salt, pH and water in blood.

Due to their role in the removal of waste from the body, the kidneys can become susceptible to damage or infection. For example, when you do not drink enough water, calcium, oxalate, cystine or phosphate will start to accumulate, these minerals could crystallise and form stones, which usually presents as a severe sharp, stinging pain in the back. A deep, dull ache in the front, back or sides of the belly is a common presentation of kidney infection.

Meanwhile, bones, muscles and nerves make up the human back. Pain in the back can manifest in any part (cervical, thoracic, lumbar, sacral, pelvic) depending on where injury or damage has occurred. The kidneys rest against the back muscles, extending from the T12 to L3 vertebral levels, with the right kidney usually located slightly lower than the left due to presence of the liver. Therefore, it can be difficult to tell if the pain is originating from the lower back or the kidneys, or both. Due to the anatomical position of the kidneys and resemblance in presenting symptoms, kidney-related pain must be ruled out in patients with back pain, especially in the lower back. Nevertheless, back pain is extremely common hence, it is more likely that someone has back pain rather than kidney pain.

The causes of back pain are numerous. They can include mechanical causes such as muscle strains, ligamentous sprains, joint dysfunctions and disc herniations. These are usually due to overuse, poor posture or improper lifting techniques. For instance, a strained muscle can feel sharp and is worsened with movement. Nerve root pain in the lumbar spine can present as numbness and tingling sensations in the lower back that radiates into the lower limb. Pathological causes of back pain such as cancer, fracture and infection too can present as persisting pain that gets worse over time.

The main difference between lower back pain and kidney pain is that kidney pain tends to be experienced higher in the back (T12-L3 vertebral levels) compared to lower back pain (L1-L5 vertebral levels). Furthermore, kidney pain is usually persistent until it is resolved, while lower back pain can be relieved with conservative care.

The table below may act as a quick-reference guide for you to determine if you are more likely to have back pain or kidney pain:

Given that kidney pain can sometimes be confused with back pain, it is not uncommon for chiropractors to see patients having either types of pain, or both. A detailed history would be taken and a physical examination with suitable tests would be done to determine the nature of the pain. Should there be any further need for investigation, the chiropractor can also order a complete blood count (CBC) and urinalysis to assess the function of your organs. If any problems are detected with kidney function on the laboratory result, then a prompt referral to a specialist is warranted.