by Dr. David Borenstein M.D. updated 2/2022
As one of the foremost experts on back pain and inflammatory conditions of the spine Dr. Borenstein has earned the recognition and praise of the medical community by being named an outstanding specialist in rheumatology in Washingtonian magazine and Best Doctors in America. He is past president of the American College of Rheumatology and author of author of several books on back and arthritis for both physicians and patients.
Ask The Expert About Back Pain
Could it be Acute Muscle Spasms?
I am a 35 years old male who was diagnosed with a herniated L5-S1 disc (annular tear) around 9 years ago at MRI. The usual symptoms at that time were: stiffness when sitting more than 30 minutes, acute back pain episodes every 1-2-3 months with some numbness in left leg. As a result I was standing for about 1 hour after each 30 min of sitting (alternating between the standing and sitting), swimming, low back exercises and walking for about 2-3-4 hours every other weekend - all of this helped to manage the pain. In the last 1.5 years I noticed that I get sudden extremely sharp low back pain (especially if slightly bending) after standing 1 hour or walking more than 1 hour - this was never the case before. These episodes of pain are not accompanied by sciatica, the pain goes away in a matter of seconds, still it is so sudden and strong that I can nearly collapse, after I can feel my back muscles weak and stiff. Meantime I can sit longer periods of time now (more than 1 hour) without same level of pain as back in the day - basically the situation is the other way round now - less able to walk long distances, I am able slightly longer to sit on a chair (up to 1.5 hours). The 2021 MRI shows the same shallow based prolapse associated with annular tear as in 2014 MRI, a loss in disc height compared to 2014 along with a new endplate oedema and a foraminal stenosis due to disc bulge with no foraminal compression (no facet osteoarthritis, no signs of nerve compression). The neurosurgeon could not explain the changes in my back pain and standing/walking patterns. Would you kindly know what potentially may be the cause in having sudden, extremely strong, short term episodes of pain, specifically after standing/walking 1 hour ( that nearly cause me to collapse) and what could I do next? Just to say that during all this time I still continued to swim regularly and do some back exercises. Many thanks in advance.
Whenever I read a story about back pain that comes and goes very quickly, the topic of muscle tension needs to be considered. Acute muscle spasms can be debilitating for short periods of time and then relax. Not uncommon, the events can occur when the muscles are fatigued after taking a long walk or standing for a period of time. A physical exam at the time of the attack may demonstrate a muscle that is severely contracted and tense. A change in position may break the spasm and result in relief. A physical therapist might be helpful for this problem without the need for medicines.. .
Is walking good for Osteoporosis?
Walking, or weight bearing exercise, is the forgotten part of therapy for osteoporosis. Most patients believe that calcium , vitamin D and some form of drug therapy is what is adequate for increasing bone mineral density. Placing pressure on the skeleton is important in maintaining and improving bone mineral density. Adding weights is not necessary. Just try to walk on a regular basis.
Q. Is going to the chiropractor good for a backache?
Chiropractors may give a number of therapies, some helpful and others not. Some studies have suggested the manipulation of the lumbar spine can be helpful in acute low back pain. Manipulation of the cervical spine should not occur. Visits to physical therapists would be a better alternative.
Q. I am DX'd with AS and have an unnatural bend forward. My doctors tell me it is Kyphosis and I am eligible for surgery. What is the incidence of Kyphosis in people with AS? And can it contribute to heart failure?
Kyphosis is a forward bend of the thoracic spine. This can occur in individuals with a number of different problems including osteoporosis as well as ankylosing spondylitis (AS). In AS, the forward flexion can occur with fusion of the spine. If the spine is fused and the individual is forced to look at the ground and not ahead of themselves because of kyphosis, an operation of the thoracic spine may be necessary to change the angle of the spine. If the forward angle is very severe, cardiac function may be affected .because of decreased flow to the heart. The best therapy is to try to prevent kyphosis with some of the new therapies which can slow the progression of disease.so that surgery is not needed.
Q. What causes knee pain in the morning?
The short answer is yes you should see a doctor, preferably a rheumatologist or orthopedic surgeon. Knee pain can occur with or without an injury. Inflammatory arthritis can occur without any specific cause. Not all pain around the knee may not be related to the knee joint but to structures around the knee like tendons, ligaments, and bursae. Therapy for this kind of pain may range from rest, to exercises, salves, oral medicines, or injections. A rheumatologist or orthopedist should be able to identify the painful area and what to do for it.
Q. When can you walk after heel spur surgery?
As opposed to answering this question specifically, this inquiry is one that should be asked to the performing surgeon with any operative procedure, on a heel, a knee, a hip, or a spine. The area of the body makes a difference as well as the specific procedure. Asking non-surgeons is of very little value. Asking surgeons who do not do the procedure is not useful. Asking surgeons who do the procedure but do not know the specific patient gets closer to useful information in general but not completely pertinent. The best answer comes from the doctor who is going to work on the heel. One should not have a procedure without knowing what the expected outcome will be and how long is the expected recovery time.
Q. Does physical therapy help with arthritis in the back?
The short answer to this question is yes. The longer answer is more complicated. There is more than 1 form of back pain. These are over 60 types of problems that can cause back pain. There is more than one way for physical therapy to help with these multiple forms of back pain. A physical therapist will try to determine the specific cause of an individual's pain and will generate a treatment plan to improve an individual's function. To learn more about back pain and the therapies for this problem go to thespinecommunity.com
Q. Is there a link between low back pain - facet joint issues—and neck pain (both constant) and RA? Can a patient have ankylosing spondylitis simultaneously with RA, even if the blood marker isn’t present?
This question brings up a number of issues that involve the similarities and differences between ankylosing spondylitis and rheumatoid arthritis. Both are illnesses that are caused by abnormalities of the immune system, but the effect on the human body is different. Rheumatoid arthritis is an inflammatory arthritis that primarily attacks the peripheral joints like fingers and toes. The cervical spine may be affected later in the course of overwhelming severe disease attacking the synovial joints with loss of bone at he very top of the spine (C1-2) and the facet joints in the lower cervical spine causing instability (subluxation). Rheumatoid arthritis rarely attacks the lumbar spine.
A Rebuttal to a Study Publicized in the New York Times Science Times Section
A Rebuttal to a Study Publicized in the New York Times Science Times Section
Lumbar Spinal Stenosis: Symptoms And Surgical Treatment Options
If you constantly suffer from leg or lower back pain, or sciatica, you may have lumbar spinal stenosis.
Ankylosing spondylitis (AS) is an inflammatory arthritis that may involve the facet joints of the lumbar spine. However, the first area of involvement is the sacroiliac joints. The eventual result of the inflammation of AS is not bone erosion, but bone fusion, the exact opposite of RA. The entire spine may become involved with the inflammatory process resulting in fusion of the entire spine involving the facet joints, including those in the cervical spine.
Is it possible that both illnesses exist in a single patient and the answer is yes. It is easier to make both diagnoses if the individual is B27+ and rheumatoid factor or anti-CCP + and has involvement of fingers and toes and sacroilitis. In these unfortunate individuals, the most effective therapy would be an anti-tumor necrosis antibody which is effective in both illnesses.
Q. I have back pain and osteoarthritis. Can the pain that flares up be due to doing too much exercise? Specifically gardening.
Yes gardening can make the pain worse but there are things you can do to improve the pain.
Q. What is spinal stenosis?
Spinal Stenosis refers to narrowing in the spinal canal or neural foramina that puts pressure on the nerves within. Here is a good overview Spinal Stenosis
Q. What can I do to reduce my daily pain from fibromyalgia and arthritis
- Your question suggests that your bulging disks and back pain are causing you foot pain. All of us have bulging disks particularly at the end of the day. They might cause some back discomfort but would be an unlikely cause of foot pain. In order to affect both feet, nerve compression would be occurring on both sides of the spine with sciatica. which is not described in your complaints. What you describe suggests local problem with the feet. The foot is a very complicated structure. It is impossible to suggest any specific remedy without more specific facts. The fact that an ice bath helps suggests that swelling may occur and that is reversed by the cold temperatures. We walk on our feet every day and that ay make healing slower than we would like. Injections can weaken tissues and may not make them better over the long term. Staying with the program can have long term benefits.
Q. I started with a right side stiff neck, it then moved into my shoulder and upper back. All my right from my neck to my foot hurts now. I get spasms, burning sensations, stabbing pains etc. I was diagnosed with rheumatoid arthritis in June but my rheumatologist says all these symptoms cant be with rheumatoid arthritis. My gp keeps saying it's coming from tight muscles. Any ideas?
- Stiffness of muscles has become a common problem during the time of COVID-19 with or without RA. It would be unlikely that RA, for this duration, would be causing problems with the joints in the neck to cause a stiff neck. Computer time has increased as individuals are working longer hours at home. The trapezius muscle which is the large muscle on the side of the neck that runs from the back of the head to between the shoulder blades can become fatigued and will tighten and pain. As this muscle becomes more involved, it will recruit other surrounding muscles to support it. Low back pain can occur as a secondary problem because of increased sitting. I recommend for everyone, with or without RA, to get up on a regular schedule. Do gentle stretching of the neck and back muscles. Temperature applications, ice massage initially, or a heating pad, later for no longer than 10 minutes can help with muscle symptoms.
Q. Can playing too many sports cause rheumatic diseases? My son plays a lot of sports and always complains of wrist pain. Can playing too many sports cause rheumatic diseases?
- In general sports activities will not cause inflammatory arthritis. Sports can cause mechanical issues like ligament and tendon injuries that can cause arthritis years later. For more information about spine arthritis go to the spinecommunity.com for additional information. You can learn more about Rheumatoid Arthritis here.
Q. Should people with rheumatic conditions worry about running out of medicine? I am a 40 year old female. I want to know should people with rheumatic conditions worry about running out of medicine?
- In general, an adequate amount of medicines is available. The concern about hydroxychloroquine has been eased with the studies that show the absence of benefit of this drug to prevent and treat COVID-19. A large stockpile of this drug was put aside. It is now available for patients with rheumatoid arthritis and systemic lupus. Tocelizumab is a drug being used for patients who have severe COVID disease. Despite this use, no shortage of supply of this biologic has been reported. For ongoing information about drug supplies, you may get additional information on theSpineCommunity.com website
Q. I have been battling back pain for the past 10 years, and I'm 28! I feel like because of this age, I am often turned away for the pain I am experiencing, or getting an appointment can take 6 months. I will provide you with some back story, followed by my question. -S Shaped scoliosis of the thoracic/C-Spine @ T6-C7. -Normal lordosis -Loss of cervical curve -Multiple Subluxations -Gait abnormality -DDD - C/L-Spine -Minor Disc bulge C5-6, C6-7 -L4-5: Mild disk desiccation. Mild broad-based bulging disc and minimal degenerative facet hypertrophy I have been through multiple physical therapy treatments, chiropractic (not helpful), and acupuncture (helpful).
- Your history suggests a significant scoliosis with multiple subluxations. I get concerned in these circumstances whether excessive movement (hypermobility syndrome) is playing a role. Under those circumstances a physical therapist can be helpful. A spinal surgeon or rheumatologist may be helpful in monitoring the scoliosis and the exercise routine
Q. I am in chronic, sometimes debilitating pain with flare ups from the base of my skull to my inner hips. I get tingling on my face, as well as to my finger tips occasionally, and have great difficulty with focusing, and memorization. I've blamed my anxiety medication for these two issues, and was then also prescribed Adderall to stay focused at my mentally straining job. I have seen a medial doctor yearly since this began, all with different additions to my diagnoses. The only doctor I have yet to see is a rheumatologist.
- A number of your symptoms seem neurologic in origin like tingling in the face. I believe a neurologist may be most helpful in that setting. They can determine if it is more a brain versus a spine problem.