Alice’s sciatica

Here is the testimonial of Alice who accepted to share with you her story and her experience of her sciatica. She wrote this post and allowed me to translate it in English and publish it here.

Part 1: The vicious circle

It all started in October 2018; I was 26 years old. After a hectic cycling session, I wake up overnight physically unable to stand up. A radiating pain catches me and prevents me from using my back. It was a sciatica of the left leg. I was then prescribed a treatment made of anti-inflammatory medication and a large amount of bed-rest until pain goes away (which I greatly regret). This vicious circle lasted almost 3 years with episodes: I was having medication and bed-rest every 2-3 months. Besides physical pain, invisible for others, I started feeling a real malaise. I was always wondering: “How explaining what is happening to me whereas I always have been cautious about having a perfect lifestyle?” I was a high-level athlete, I was exercising, I do not drink alcohol nor smoke … I decided I would find the mechanical cause of my symptoms.

Part 2: The end of the vicious circle and the beginning of physiotherapy

During these 3 years, I developed a fear of movement. I feared experiencing my back pain. To be safe, I avoided every activity which is wrongly thought to be dangerous: I stopped lifting heavy things, I never bended forward without bending the knees, I stopped physical activity … I avoided using my back to protect it. Despite all my precautions, I was still experiencing several pain episodes and still could not identify its cause. Until June 2021 where for the first time, anti-inflammatory medication did not help any more. I was suffering day and night, and I could barely sleep because pain was waking me up. I was then prescribed an MRI and its conclusion was that I had a disc herniation. I was then immediately referred to a specialist to have injections. The issue was that this option terrified me as one of my relatives had a bad experience with it. In consequence, I decided to get a second opinion with different doctors. One of them suggested me to try physiotherapy.

Part 3: what I learned with physiotherapy.

I did not know what physiotherapy was, but I had great expectations about it. During the first session, I learn that, as many of us, I was misinformed about back pain and that bed-rest may be unhelpful. As well as physiotherapy session, I started to progressively go back to normal life and be less cautious about using my back (I started lifting things, go back to sport …). As I was really involved in the process, I did my exercises between sessions with great diligence. I felt better but not done: my progression was really fluctuating, and I had that feeling of weakness in my left leg that never left me. I also was struggling to understand why I was not cured despite taking that therapeutic approach seriously. It was when I read a scientific paper about back pain that it finally made sense. I understood that my back pain was not necessarily linked with a mechanical factor but could also be linked with psychological factors. I realized that in one hand I was expecting too much of my physiotherapist which created an adverse pressure; and in the other hand I was doing my exercises in a robotic way without trying to feel their effects on me and hence not knowing what was good for me and what was not. As I was frustrated by not finding a mechanical cause since all these years; I kept digging in the psychological field winding up until 2018. Here I realized this year was emotionally overwhelming as I lost one of my parents, few months before the onset of my pain. As I am introverted, it may be likely that my uneasiness expressed throughout my back pain. After accepting all this, I approached my physiotherapy sessions with a new perspective: being more connected to my feelings in my body and being resilient. Since then, sessions have been more helpful.

Part 4: My life today

I am now able to cope and manage my pain, which means identify what exercises are helpful for me according to how I feel. I am not yet cured, I may never be, but I am happy to be back to an (almost) normal life!

Tennis Elbow = Lateral Elbow pain / tendinopathy LET = Epicondylalgia

Several names exist for this issue: Tennis elbow, lateral elbow pain / tendinopathy, epicondylalgia, epicondylitis … They all refer to the same diagnosis.

Is it frequent?

It is a frequent issue among 35-54 years old people. It affects 1-3% of general population with an increased risk among smokers, manual workers, or tennis players.

How long is it?

For many persons, symptoms are self-limiting. Studies show that 83 to 90% of people without any treatment improve significantly at one year, although sometimes incomplete recovery. However, 1/3 of people still experience discomfort after 1 year despite treatment. A large proportion of people experience recurrence of symptoms after initial episode. Estimates suggest that 5% of people do not respond to conservative interventions and undergo a surgery with variable outcomes.

What is it, what is happening?

Tennis elbow is multimodal, it is not only a mechanical or structural issue. Current models suggest changes in the tendon’s matrix and cells, in combination with changes of the pain system and modifications of sensory and motor system.

How is it diagnosed?

It is diagnosed through a clinical examination by reproducing symptoms loading affected tendons. Pain can be reproduced on the epicondyle with palpation, resisted contraction of extensors of wrist or middle or second finger, and gripping. An in-depth clinical examination may be required to exclude other possible causes.

Shall I undergo imaging?

MRI and Ultrasound imaging have a very good capacity to exclude this pathology but a poor capacity to identify it when signs on imaging are present. Indeed, the same changes on imagery can be found in asymptomatic people. Studies show that we find the same changes in MRI in 50% of cases and in 53% with US in asymptomatic persons! However, when symptoms are present changes can be found in 90% of cases. In addition, studies show that severity of changes on imaging are not related to severity of symptoms for this pathology and other chronic tendinopathies. Hence the fact that imagery can exclude this problem but not diagnose it.

Which factors can affect improvement?

Universal treatment efficient for every person with tennis elbow unfortunately does not exist. The fact that this issue varies greatly among individuals suggest that a tailored treatment may be more beneficial. 6 factors influencing outcomes have been identified:

  1. The stage of the problem: reactive / degenerative or in between. It may change the treatment suggested
  2. Severity of initial symptoms. When they are more intense and disabling, the long-term prognostic is not as good.
  3. When Central Sensitization (CS) is present, the prognosis worsens. CS is a complex modification of central nervous system making light stimuli very painful, with changes in temperature perception leading (among other) cold to become painful.
  4.  When shoulder or neck pain is associated, it may affect outcomes too. Neck pain is frequently associated with altered long-term results, while shoulder pain is frequently associated with altered short-term outcomes.
  5. Associated neuromuscular impairments lower prognosis. Strength deficit of extensor of wrist, grip, or all affected limb and a speed deficit and muscular reaction time of both arms in patient with unilateral tennis elbow have been reported. If these are not assessed and treated when present, they may contribute to chronicity.
  6. Psychosocial factors and work-related factors have been linked with increased risk of developing tennis elbow and with a lower one-year prognosis. They include use of tools, heavy loads, repetitive movements, activities involving strength with wrist flexion and low control on work.

In addition, we know that tendons’ health is largely affected by lifestyle. The following elements are risk factors of developing tendon issues:

  • Smoking
  • Obesity
  • High fatty food intake
  • Hish processed food intake
  • Physical inactivity
  • High cholesterol levels
  • Diabetes
  • Sudden changes in activity levels

What are available treatment options?

Pharmacotherapy: Results of oral nonsteroidal anti- inflammatory medication in the treatment of tennis elbow are conflicting. They are speculated to be more efficient in reactive phase.

Corticosteroid medication: We have strong evidence that corticoid injection therapy allows a short-term pain relief but lead to poorer outcomes at 6 month and 1 year and an increase in recurrences when compared to no treatment or physiotherapy. In addition, adding a multi- modal physical therapy program do not ameliorate the late delay in recovery or recurrence observed after a single corticosteroid injection. Therefore, corticosteroid injections are not recommended as a first line treatment.

Antidepressant or antiepileptic drugs may be appropriate for patients with severe pain where central sensitization is suspected, although no studies have been conducted in this population to date but it has on other groups like people with fibromyalgia.

Prolotherapy PRP and nitric oxide patches have demonstrated long term effects on patients with persistent epicondylalgia (>3 months). However, their efficacy depends on the technique used in combination as when used with stretching only they have not demonstrated any effects.
Despite current interest there is growing evidence that injection of autologous blood or platelet- rich blood products is not effective in treating tennis elbow.

Manual therapy (MT): We have moderate evidence of immediate effects of MT on pain and pain-free grip and short term benefits when used in conjunction with gradual exercises. There is also evidence that MT of cervical and thoracic spine has additional benefits in addition to local treatment when these areas present limitations.

Therapeutic exercises: Exercises are paramount in the treatment of tennis elbow with evidence of exercises alone or as a component of a multimodal approach. For patients with persistent epicondylalgia, exercises have shown a quicker reduction in pain, less sick leave, less medical appointments, and an increased work capacity. Despite clear benefits, currently there is no recommendations on type, intensity, frequency, or optimal duration for exercises. Current guidelines recommend a gradual increase in resistance, with focus on wrist extensors. There are conflicting views on pain during exercise, some authors insist on avoiding pain while others think it should stay tolerable (5<10). Given the heterogeneity of the clinical presentation and pathology it is more likely that optimal dosage may differ for each person according to stage, severity, and functional demand before injury.

Education: Natural history is self-limiting. Delays may be long 12 weeks of rehabilitation, sometimes 1 year to obtain an improvement of symptoms that may be incomplete. Recurrences may happen. Some factors increase the risk to develop the condition or that delay recovery. Rehabilitation is multimodal and tailored to individuals. Initial rest (regarding provoking activities) is important then gradual loading is required to recover the function of the limb. It is crucial to gradually reintroduce more strenuous tasks and to reduce tendon load if recurrence is experienced.

Bibliographie / Sources :

(Coombes, Bisset, & Vicenzino, 2015; Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013; Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949.

Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119.

Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295.

Making the most of physiotherapy

First, I would like to recommend you to read the CSP article on what is physiotherapy if you are not familiar with physiotherapy.

Then, you will find in this post a wonderful Blog made by Tina, a person who experienced back pain, persistent pain and physiotherapy. She decided to share her experience through a blog, to inform people that may go through the same journey.

Here is her Blog:

Here is the link of her leaflet: