Lumbar Spinal Stenosis and Hip Arthritis | OEP366

In today's episode: Lumbar Spinal Stenosis and Hip Arthritis I discuss...
-How lumbar spinal stenosis and hip arthritis can look like each other.

-How to tease out which is which

-How to help your patient decide if they should have a hip replacement or spine surgery and so much more!

(Video) Classic signs of hip arthritis
(Video) Lumbar Spinal Stenosis explained

(Paid Webinar-Lumbar Spinal Stenosis Webinar)

✅Are you looking for One on one Coaching? We have it!
✅ Hop onto our email list? 👉👉 Click HERE

Say "Hello" to RangeMaster, our new show sponsor.
👉Get your FREE BlueRanger Pulley: email Jim@myrangemaster.com and enter Ortho Eval Pal in the Subject line.

Support OEP today!

Want to join the OEP community? Click HERE to jump onto our email list. SUBSCRIBE at the bottom of the page.

Ask me your ortho evaluation questions and I will answer them on the show: paul@orthoevalpal.com

Come visit our WEBSITE!! Click HERE to check it out

Be sure to "follow" us on our new Facebook Page

I finally made it to Instagram. Stop by and check us out

Are you looking for One on one Coaching? We have it!

Be sure to check out our 500+ videos on our YouTube Channel called Ortho Eval Pal with Paul Marquis

#stenosis #arthritis #lowbackpain #hippain #podcasts #PTpodcast #medical #health #orthopedics #Physicaltherapy #DPT #Medicalproviders #sportsmedicine #athletictraining #chiropractic #occupationaltherapy

Transcript

Hello everyone and welcome to episode 366 of the Ortho Eval Pal podcast. I'm your host, Paul Marquis, and today we're gonna be talking about lumbar spinal stenosis and hip arthritis. We'll talk about how lumbar spinal stenosis and hip arthritis can look like each other. We'll discuss how to tease out which is which. We'll also talk about how to help your patient decide if they should have a hip replacement or undergo spine surgery and so much more. But before we get started, I just want to mention our sponsor, Rangemaster. Rangemaster is known for their shoulder rehab equipment. They offer products from shoulder wands to finger ladders, overhead pulleys to shoulder rehab kits. Rangemaster is your one stop shop to help with the treatment of frozen shoulders, post op rotator cuff repairs, total shoulder and reverse shoulder replacements, and so much more. If you'd like to get a free sample of Rangemaster's Blue Ranger pulley system, just email jim@myrangemaster.com and add Ortho Eval Pal in the subject line and they'll get one over to you right away. So folks, first thing I want to say about today's episode is that I'm not going to get too deep into the technical hip arthritis and lumbar spinal stenosis stuff only because I have episodes that are specific to each of these and we could be here all day just on each topic, okay? So there's a lot between the two of them, but one thing I see a lot of is this combination of the 2 in the same person. So that's one of the reasons we're talking about this today. The second thing I want to discuss is that I am not an orthopedic surgeon. I'll be giving information here from the perspective of a PT who has seen a tremendous number of these patients, alright? So keep that in mind as we get going. If you ever have questions about anything we discuss or my opinions, please send me your opinion, send me your thoughts. I love communicating with folks about this stuff and having great conversations so we can all kind of learn how to make these patients better because it's really why we're here, right? So, let's get started. It's very common to see patients with both lumbar spinal stenosis and hip arthritis, and both of them can contribute to low back pain. One can contribute to the, you know, the low back can contribute to the hip and vice versa. So what I want to do is start off with a differential here to try to figure out which is which, alright? So when we talk about lumbar spinal stenosis, we are gonna see a patient who comes in that has neurogenic claudication, alright? They tell you this story. I can walk about a 100 feet and then I have to bend over a little bit or I have to take a seat for a couple of minutes then I can get up and I can walk the same distance. And it's worse if I straighten out while I'm walking. It gets, you know, my legs become weak. I have pain shooting down my buttocks. It's usually on both sides. Sometimes they'll feel a tingling sensation in their legs. That's very common when you see somebody with lumbar spinal stenosis. It often comes, you know lumbar spinal stenosis often comes with back pain because this population of patients also have a lot of facet arthritis. Okay, so patients with lumbar spinal stenosis don't like extension and those who have L2, L3, L4 spinal stenosis, can have radiating pain that goes into the hip and into the anterior thigh and it can be very deceiving, you know, if this is coming from the back or if it's coming from the hip area. Hip osteoarthritis presents with groin pain, deep lateral hip pain. You know, they'll say it's like right in there. They'll put a finger kind of at the piriformis and one in the groin and they'll say right between where my fingers would meet in there is where this hurts. They'll often complain of pain radiating down to the knee but not past the knee. So osteoarthritis hips can give you pain in the front of the thigh, all the way down to the knee, but not past it. Okay? People with hip away also will complain of that leg giving out. You know, they get up out of a chair and they have to stand there for a little bit because if they get up and take off too quickly, the leg kind of gives out. And it's really because of a painful inhibition that they're getting. Alright, so what are some of the similarities between hip osteoarthritis and lumbar spinal stenosis? Well, they both like this very slightly flexed posture of the hip and the low back. This is their comfort zone, okay? Kind of that loose pack position for the spine and for the hip at the same time. Okay, they both can cause a sense of weakness in the leg, okay, either neurologic weakness or reflex inhibition from pain and inflammation, that makes a leg feel like it wants to give out or feel weak. Both of the diagnoses can cause hip pain, groin pain, anterior thigh pain. So how do you differentiate between the 2 of them? Well, one of the things I do is I try to not combine spine and hip motions at the same time. So maybe I'll put the patient flat on their back, supine position. I will take their leg. I'll place them in kind of a ninety-ninety position or basically going to keep their knee at about 90 degrees of flexion. I'm going to try to flex the hip passively. Oftentimes you get to that 90, 90 5 degrees, sometimes even worse than that 70 five-eighty degrees and they develop this real significant increased pinching feeling in the groin. You add a little bit of hip internal rotation, it gets worse. You adduct the hip, basically the FADER test, and they want to go through the roof. You know, I just had a guy come in the other day. He's like, I've been having pain for a year. My provider doesn't wanna order an X-ray, and I'm just going downhill fast. I'm 60 years old. I wanna retire this year. I teach spin classes, but I can't even get my leg up and around onto the bike anymore. Having a hard time getting around with the pedals. And so I put him on the table. He had 0 to 70 degrees of hip flexion and grabbed my arm violently to stop pushing, and I was going gently also. He had this significantly sharp pain, very limited motion, adduction internal rotation were severely painful also. And when he was walking, had this really this real loss of extension of the hip. And so had classic signs of hip arthritis. So that's how I like to assess it. We kind of take the back out of the picture. Now a lot of people who have hip away have this severe driving deep ache that can go into the SI joint and even to the low back, pelvic area, and gluteal region. So that's why it can somewhat, it can be a little deceiving sometimes. I'll take that patient out of that position. I'll keep them on their back. I'll do a little axial traction of the hip in the loose pack position and it's like, you know, complete relief. And if they get that, that's very indicative of hip OA, all right? So people with lumbar spinal stenosis really won't get that much relief from doing those maneuvers. Okay? When the patient walks, they cannot extend the hip well when they have hip osteoarthritis, so the glute kind of hitches or winks a little bit on that one side. That's very, very common. Alright. Now if a patient says, I can't put on my socks or shoes, and what they do is they have to, like, grab a hold of their pant leg and put their ankle up onto the other knee so that they can get to their foot. But they can't really flex the knee pure flex the hip purely straight up into flexion, but they have to abduct and externally rotate to get that foot up there. That is classic hip OA. Okay? Because you're getting this pinch in the anterior hip. It's basically bone spurs, butting each other and, that'll give you some trouble. Now people with lumbar spinal stenosis love to flex, okay? They wanna be in the spinal flex position because it opens up the vertebral foramen and decompresses the nerve roots and they just get this sense of relief, less pain down the leg, You know, less weakness, less tingling, and it even calms down some of that back pain because it opens up those facets that are arthritic typically and they're not getting so irritated there. So, you can see here why it is so easy to confuse the 2. Now, some people just have one that looks like the other and you can tease those out and lucky for the patient. But to be honest with you, it's very common for patients to see, you know, this especially when you get into your sixties seventies, quite a common presentation. Now I wanna walk you through the walk. Okay? I want you to understand when they're walking, what is happening and why, some people may have both. So just you have to really envision this now. When you're going from mid stance to terminal stance phase of gait, okay, we all know you should have about 10 to 20 degrees of hip extension, okay, when you're in that terminal stance phase of gait, but let's just say, just imagine this, that we could suddenly block you at 0 degrees of extension so that you can't get past that, okay? The only other way to keep your stride equal, which is what your brain wants to do, okay? It wants to keep an equal step length and so the only other way to let that leg get behind you is to anteriorly pelvic tilt, okay, at the pelvis, alright? So like any other overuse issue, if the ilium is constantly getting thrown into the anteriorly pelvic tilted position, the lumbar spine is going to hyperextend. This jams up the facets, it closes the vertebral foramen, therefore the nerve roots get impinged a little bit more, the facets become hypertrophy, they get a little thicker, they start to take up space and this is where we start to have these issues with patients having neurogenic claudication. So basically this leads to some overused break down of the joint and degeneration of the facet joints. So, I'm not gonna go over the specific treatment of each. I have YouTube videos that talks about this. I have a 1 hour webinar where I go through the comprehensive evaluation and how I like to treat this in physical therapy, with manual techniques and flexibility and whatnot. Now I go through all of that through, our webinar, which is on the website. I discuss lumbar spinal stenosis basically from beginning to end. I also have a little handy ebook where I talk specifically about lateral hip pain discussing all of the sources of lateral hip pain, so how we tease out all of these things. The ebooks are nice because you can just click on a link. It takes you to a video of a patient who actually has an issue or me doing a special test, which is so you're not just reading it. You're seeing visuals of how these are done, and you can even, get the videos that attached to it that work really well. So I'll add a bunch of these links to the show notes just so that it's easier to access and easier to see this on real patients, like what a real arthritic hip looks like when they can't reach their feet and whatnot. So, that will be added to the show notes. So what I wanna do to finish with is to go over how you can guide your patient in regards to undergoing hip surgery or spine surgery. There is some amount of controversy about which you do first and I see this all the time. It's maybe because I live in a population or in an area where the population is a little more elderly that we see a lot of this. But patient comes in, they have hip arthritis, severe hip arthritis, severe lumbar spinal stenosis. They go see a spine doctor and the spine doctor says, You need to have your hip checked. Go see a hip specialist. The hip specialist will say, I don't think this is your hip. I think this is your back. You need to go see a neurosurgeon. And this can go back and forth and it's very confusing for the patient. They don't know what to do. I've seen so many of these that personally, what I like to do in guiding them and saying, yes, there is some solution. Now, maybe you have both, maybe you have to have both taken care of. Which one do you do first? And in discussions that I've had with neurosurgeons, it seems like the research and literature out there drives people toward having the hip replacement done first because it takes that biomechanical stress away from the hip joint and therefore the pelvis doesn't tilt anteriorly as much, doesn't stress the low back as much and therefore they can get quite a bit of relief from that. So what I do is if I feel that a majority of the patient's hip, low back, thigh pain is coming from the hip, I might recommend that they try an intra articular hip injection. It's relatively low risk, and you see how the patient responds if 3 or 4 days go by and the patient comes back and says, Now this is incredible. I feel so much better. My back pain has gone away. And I've seen this in many cases where people have had tens of 1,000 of dollars of work regarding chiropractic care, lumbar spine injections, MRIs and all this and, they come into the clinic and I do a simple fader test to find they have severe hip arthritis. They have a hip replacement and of their back pain goes away, their, you know, their anterior thigh pain goes away. Life is better. They, you know, they become functional again, and so oftentimes if I'm suspicious that it's the hip causing most of the discomfort, they get this intra articular injection. If nothing changes at all, then we need to be much more suspicious that this is the lumbar spine. Now we could do the same thing with the lumbar spine. Patient can have either some facet injections or transforaminal injections at the area that would be most likely to cause hip or anterior thigh pain. And same thing, if they get significantly better, we know where the majority of the source of the pain is coming from and that may help a surgeon target that area a little bit better. So these are suggestions that I make on occasion. I have, you know, very good working relationships with neurosurgeons and orthopedic surgeons and so we've often had these conversations and sometimes we drive patients in these directions just to get a better idea, to get a better target, to help optimize what they're doing. Because there's nothing worse than having a lumbar decompression or spinal fusion. And they come out of it and they're just as miserable in 6 months as they were before because they're still having hip osteoarthritis pain. So it's also important to take into consideration which diagnosis impedes the patient's quality of life the most. If they do, maybe they have a job that requires them to flex the hip a lot and they just can't anymore, and they need to continue to work or maybe they need to optimize a hip flexion, get an anterior lateral, you know, hip arthroplasty just so they can get back to doing that. So those are some things to take into consideration. Again, I'm not an orthopedic surgeon or neurosurgeon, remember that. Patients look to us for, you know, oftentimes a lot for advice regarding the direction of their care. We spend a lot of time with them. You know, it might be an hour, hour and a half at a time, 2, sometimes 3 times a week, working with them, you know, for a couple of weeks and You really get to know them, they get to know you and they really, have a lot of faith in what you say and so giving them some good sound advice or suggestions can really help them, you know, head in the right direction. So that's my take on a very loaded topic today folks. I hope I was able to keep this short and concise enough for you to take some information back to the clinic with you to bring back to your patients and help them get better faster. I hope you enjoyed today's episode. I'll leave You lots of links to resources regarding lumbar spinal stenosis and hip osteoarthritis in the show notes. Send me your questions, and I'll do my very best to help you out. I hope you all have a great week. Be kind to each other and take care.