3 Things You Should Know About Disc Related Leg Pain

Low Back Pain With Referred Leg Pain

Man With Disc Related Leg Pain

Your doctor tells you you’ve got a bulging disc. Is this what’s causing your low back and leg pain? What does it all mean? Will it get better or worse? Will you need surgery or will conservative treatment be able to help?

Although the diagnosis of a bulging disc sounds scary, there are 3 things you should know about bulging discs that will, hopefully, relieve some of your anxieties and point you in a positive direction toward better function…

What is Disc-Related Leg Pain?

Disc-related leg pain typically presents as low back pain with referred buttock, thigh, or leg pain, that worsens with flexion activities like sitting and bending.

Sometimes, symptoms can also include a shift of the trunk to one side or the other, a reduced curve in your lower back, and limited mobility of the lumbar spine into extension (leaning back).

What we’ve found is that this referred leg pain has a tendency to change location – sometimes reaching as far as the foot, other times confined to the low back or buttock areas. These changes are usually related to changes in posture or certain activities and are quite predictable1,2.

We call this change in location of referred pain ‘centralization’ when it moves closer to the buttock or low back – which is what we want to happen.

‘Peripheralization’ occurs when the pain moves further down the leg.

3 Things You Should Know About Disc-Related Leg Pain

1. Disc Bulges Are Common

A recent systematic review of 33 articles3 looked at MRI findings of 3110 people without pain. The results show that degenerative changes and bulging discs are commonly seen in MRI findings of pain-free individuals as well as those with low back pain.

  • Disc Bulges are seen in 30% of 20-year-olds and 96% of 80-year-olds

Again, these findings are in people WITHOUT PAIN. This tells us that bulging discs are common and that they aren’t necessarily going to be the source of your pain4,5,6.

So, rather than getting fixated on MRI findings, Physical Therapists provide treatment based on the presentation of your disc-related symptoms7 – low back pain with referred leg pain that tends to centralize with repeated movements.

2. Most Disc Bulges Go Away

Traditionally, an indication for surgery is a large disc herniation8. Interestingly, however, the largest disc herniations are those most likely to have the greatest reduction in size over time9,10.

In fact, in most cases, the natural course of a bulging disc involves a reduction in size over time11,12,13.

Let me reiterate that: most bulging discs resolve spontaneously – completely or partly – within 1 year, proven on MRI studies14.

I won’t bore you with extensive details on how this actually happens. In short, though, an inflammatory reaction leads to resorption15,16,17 by certain cells18,19.

More importantly than getting hung up on the MRI results, though, you should know that your symptoms can improve – and have been proven to improve with nonoperative methods20,21.

Although there are good outcomes with surgery, there are also good-to-excellent results reported in more than 90% of patients treated non-operatively22. In 4 to 10-year outcome studies, there is no difference in outcomes comparing patients who underwent surgery and those treated without surgery23.

3. There are Steps You Can Take to Improve Your Symptoms

Remember, centralization happens when certain position changes cause referred pain to move closer to the low back and can even cause symptoms to diminish.

In Physical Therapy, we use positioning, manual techniques, and repeated movements – known as McKenzie therapy24 – to help centralize and diminish your symptoms.

McKenzie therapy has been shown to be more effective in the short-term than NSAIDs, educational booklets, strengthening25, and manipulation26. Plus, those who respond with centralization to extension movements have better outcomes in the long-term compared with other treatments27.

So, what does McKenzie therapy look like?

First, you need to find your directional preference28:

  • Do your symptoms improve in extension (see prone lumbar extension below), flexion (forward bending), or lateral (side-bending)?
    • Most people with disc-related leg pain respond better with extension
  • If you find that you do well with extension, then, you might benefit from repeated movements in extension…

Repeated Extensions in Prone:

Repeated Extensions for Disc Related Leg Pain

  • Lie face down on a mat
  • With elbows under your shoulders and hands in front of you
  • Press down with your hands, lifting your upper body towards the sky
  • Keep the hips on the mat
  • Extend your back to end-range (as far as you can)
  • Hold for 5-10 seconds
  • Return to starting positions
  • Repeat this multiple times
  • Note- you should be pressing with your hands, using your arm strength to lift your upper body off the ground, not your lower back. Yes, your arms will get tired (bonus exercise!)

Modified Repeated Extensions In Prone:

Repeated Extensions prone on elbows

  • If pressing up from the hands is too difficult:
  • Lie face down
  • Elbows under shoulders
  • Press up from floor, lifting head and chest
  • Hold 5-10 seconds
  • Return to floor
  • Repeat multiple times

Question: What have you found to be a helpful treatment for Disc-Related Leg Pain?

  1. McKenzie RA, May S (editors)(2003). The lumbar spine mechanical diagnosis and therapy. Waikanae: Spinal Publication Ltd, p. 355-65. ↩︎
  2. Donelson R, Grant W, Kamps C et al (1991). Pain response to sagital end-range spinal motion. A prospective, randomized, multi-centered trial. Spine;16:S206-12. ↩︎
  3. Brinjikji, et al. “Systematic literature of imaging features of spinal degeneration in asymptomatic populations.” AJNR AM J Neuroradiol. 2015:1-6. ↩︎
  4. Milette PC, Fontaine S, Lepanto L et al (1999). Differentiating lumbar disc protrusions, disc bulges and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations. Spine;1:44-53 ↩︎
  5. Hamanishi C, Kawabata T, Yosii T et al (2004). Schmorl’s nodes on magnetic resonance imaging. Their incidence and clinical relevance. Spine;19:450-3 ↩︎
  6. Beattie PF, Brooks WM, Rothstein JM, Sibbitt WL et al (1994). Effect of lordosis on the position of the nucleus pulposus in supine subjects. A study using magnetic resonance imaging. Spine;19:2096-102 ↩︎
  7. Milette PC, Fontaine S, Lepanto L et al (1999). Differentiating lumbar disc protrusions, disc bulges and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations. Spine;1:44-53. ↩︎
  8. Postacchini F. Spine update: results of surgery compared with conservative management for lumbar disc herniations. Spine 1996;21:1383–7. ↩︎
  9. Bozzao A, Massimo G, Masciocchi C, et al. Lumbar disc herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology 1992;185:135–41. ↩︎
  10. Maigne JY, Rime B, Deligne B. Computed tomographic follow-up study of forty-eight cases of nonoperatively treated lumbar intervertebral disc herniation. Spine 1992;17:1071–4. ↩︎
  11. SaalJA,SaalJS,HerzogRJ.Thenaturalhistoryoflumbarintervertebraldisc extrusions treated nonoperatively. Spine 1990;15:683–6. ↩︎
  12. Komori H, Shinomiya K, Nakai O, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine 1996;21:225–9. ↩︎
  13. Bozzao A, Gallucci M, Masciocchi C, et al. Lumbar disk herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology 1992;185:135–41. ↩︎
  14. Reijo AA, et al. Determinants of spontaneous resorption of intervertebral disc herniations. Spine. 2006;31(11):1247-1252. ↩︎
  15. Doita M, Kanatani T, Harada T, et al. Immunohistologic study of the ruptured intervertebral disc of the lumbar spine. Spine 1996;21:235–41. ↩︎
  16. HirabayashiS,KumanaK,TsuikiT,etal.Adorsallydisplacedfreefragment of lumbar disc herniation and its interesting histologic findings. Spine 1990; 15:1231–3. ↩︎
  17. ItoT,YamadaM,IkutaF,etal.Histologicevidenceofabsorptionofsequestration-type herniated disc. Spine 1996;21:230–4. ↩︎
  18. Virri J, Gro¨nblad M, Seitsalo S, et al. Comparison of the prevalence of inflammatory cells in subtypes of disc herniations and associations with straight leg raising. Spine 2001;26:2311–5. ↩︎
  19. RothoerlR,WoertgenC,HolzschuhM,etal.Macrophagetissueinfiltration, clinical symptoms, and signs in patients with lumbar disc herniation. A clinicopathological study on 179 patients. Acta Neurochir (Wien) 1998;140: 1245–8. ↩︎
  20. Komori H, Shinomiya K, Osamu N, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine 1996;21:225–9. ↩︎
  21. Rust MS, Olivero WC. Far-lateral disc herniations: the results of conservative management. J Spinal Disord 1999;12:138–40. ↩︎
  22. Saal JA, Saal JA. Nonoperative treatment of herniated lumbar disc with radiculopathy: an outcome study. Spine 1989;14:431–6. ↩︎
  23. Weber H. Lumbar disc herniation: a controlled, prospective study with ten years of observation. Spine 1983;8:131–40. ↩︎
  24. McKenzie RA, May S (editors)(2003). The lumbar spine mechanical diagnosis and therapy. Waikanae: Spinal Publication Ltd, p. 355-65. ↩︎
  25. Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother. 2004;50:209-216. ↩︎
  26. Petersen T, Larsen K, Nordsteen J, Olsen S, Fournier G, Jacobsen S. The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial. Spine (Phila Pa 1976). 2011;36:1999-2010. http://dx.doi.org/10.1097/ BRS.0b013e318201ee8e ↩︎
  27. Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther. 2007;87:1608-1618; discussion 1577-1609. http://dx.doi.org/10.2522/ptj.20060297 ↩︎
  28. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004;29:2593-2602. ↩︎
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