Balancing the "Seesaw" of Lumbar Health
The latest episode of World’s Best Physio features Sam Suke cracking a recent case. The following is an educational article based on the case cracking. Below the article is a full transcript with timestamps.
Balancing the “seesaw”
Sciatica isn't always about a permanent injury; often, it’s a mechanical issue of "dosage." In this case study of a 25-year-old social worker, we see a classic example of how lifestyle stressors—like prolonged sitting during exams—can lead to symptomatic nerve irritation.
The Diagnostic Process When a patient reports hip stiffness and leg pain, clinicians must differentiate between the hip joint and the lumbar spine. By using screens like the FADIR and FABER tests, we can rule out Femoroacetabular Impingement (FAI). If these tests are negative for pain, the clinician’s focus shifts to the spine and the neural pathways.
The McKenzie Method in Action The "repeated extension" approach is a cornerstone of spinal rehab. By moving the spine into extension, we can often "centralize" or reduce symptoms that travel down the leg. In this case, the "Belly Sag"—an advanced extension where the patient exhales to allow gravity to pull the lumbar spine deeper into extension—was the key to unlocking the patient's mobility.
The Seesaw Analogy A vital takeaway for patients is that sitting is not dangerous. Rather, it is an activity that pushes the "flexion" side of the seesaw down. To prevent symptoms, one simply needs to apply a counter-balance of "extension." This proactive management allows patients to continue their daily lives (like long drives or office work) without fear, provided they perform their "maintenance" extensions
Video Transcript Summary
In this "Case Cracking" session from Exercise Thought, physiotherapist Sam Souk analyzes a 25-year-old female social worker presenting with right-sided sciatica and bilateral hip stiffness. The client’s symptoms were exacerbated by a stressful exam period and prolonged sitting (e.g., driving).
Key Assessment Points:
Hip Screen: Passive tests including the FADIR (Flexion-Adduction-Internal Rotation) and FABER (Flexion-Abduction-External Rotation) were negative for pain, despite some range of motion differences. A negative Scour test further suggested that the issue was unlikely to be structural hip impingement (FAI).
Neurodynamic Testing: The Slump test was positive (3-4/10 pain), and standing flexion revealed significant tightness in the right leg compared to the left.
Treatment Approach: Sam applied the McKenzie Method (Mechanical Diagnosis and Therapy). While prone on elbows showed no change, progressing to repeated extensions with "belly sags" and exhales significantly reduced the Slump test pain to a 1/10 and normalized standing flexion.
Conclusion & Advice: The diagnosis points to lumbar flexion-related nerve irritation. The client was advised to balance prolonged sitting (flexion) with repeated extensions (the "seesaw" analogy) and scheduled a follow-up to assess long-term hip and core strength using a handheld dynamometer.