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Your Information & Resource Guide to Understanding Hip & Back Pain,
Its Symptoms and Treatment Options.

It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:

Mechanical Problems: A mechanical problem is a problem with the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disc degeneration, which simply means that the discs located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured discs,
which are also called herniated discs.

Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis, a condition that causes weak, porous bones. Less commonly, back pain may be caused by more severe injuries that result from accidents and falls.

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Acquired Conditions and Diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, which causes curvature of the spine and does not usually cause pain until mid-life; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. While osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, which causes fatigue and widespread muscle pain.

Infections and Tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the discs that cushion the vertebrae, which is called discitis. Tumors, too, are relatively rare causes of back pain. Occasionally, tumors begin in the back,
but more often they appear in the back as a result of cancer that has
spread from elsewhere in the body.

Although the causes of back pain are usually physical, it is important to know that emotional stress can play a role in how severe pain is and how long it lasts.
Stress can affect the body in many ways, including causing back muscles
to become tense and painful.

Listed Causes of Lower Back Pain:
Back pain is a symptom. Pain arising from other organs may be felt in the back. This is called referred pain. Many intra-abdominal disorders -- such as appendicitis, aneurysms, kidney diseases, bladder infections, pelvic infections, and ovarian disorders, among others -- can cause pain referred to the back.
Your doctor will have this in mind when evaluating your pain.

Nerve Root Syndromes are those that produce symptoms of nerve impingement (a nerve is touched), often due to a herniation (or bulging) of the disc between the lower back bones. Sciatica is an example of nerve root impingement. Impingement pain tends to be sharp, in one spot, and associated with numbness in the area of the leg that the affected nerve supplies.

Ruptured or Herniated Discs are produced as the spinal discs degenerate or grow thinner. The jellylike central portion of the disc bulges out of the central cavity and pushes against a nerve root. Intervertebral discs begin to degenerate by the third decade of life. Herniated discs are found in a third of adults older than 20.  Only 3% of these, however, produce symptoms of nerve impingement.

Spinal Stenosis occurs as intervertebral discs lose moisture and volume with age, which decreases the disc spaces. Even minor trauma under these circumstances can cause inflammation and nerve root impingement, which can produce classic sciatica without disc rupture.

Lumbar Muscle Strain
Muscle strains are the most common cause of low back pain. Patients may or may not remember the initial event that triggered their muscle spasm, but the good news is that most episodes of back pain from muscle strains resolve completely within a few weeks. 
 

Spinal Degeneration
C aused by alterations in the disc that progress to degeneration. This, coupled with disease in joints of the low back, causes spinal canal narrowing. These changes in the disc and the joints produce symptoms and can be seen on an x-ray. A person with spinal degeneration may have morning stiffness or pain while standing for a long time or walking even short distances.

Cauda Equina Syndrome
A medical emergency when Disc material expands into the spinal canal, which compresses the nerves. A person would experience pain, possible loss of sensation, and bowel or bladder dysfunction. This could include inability to control urination causing incontinence, or the inability to begin urination.

Musculoskeletal Pain syndromes that produce low back pain include myofascial pain syndromes and fibromyalgia. 

Discogenic Back Pain
Discogenic back pain is thought to be a common cause of low back pain. Discogenic back pain cis the result of damage to the intervertabral disc, but without disc herniation. Diagnosis of discogenic back pain may require the use of a discogram.

Myofascial Pain
Characterized by pain and tenderness over localized areas (trigger points), loss of range of motion in the involved muscle groups, and pain radiating in a characteristic distribution but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group is stretched. 

Fibromyalgia
R esults in pain and tenderness on 11 of 18 trigger points when touched, one of which is the low back area, as classified by the American College of Rheumatology. Generalized stiffness, fatigue, and muscle ache are reported.

Other skeletal causes of low back pain include osteomyelitis or sacroiliitis (infections of the bones of the spine). This pain is usually worse at night and is worse when sitting or standing for a long time.

Tumors, possibly cancerous, can be a source of skeletal pain.

Lumbar Spine Arthritis
Arthritis most commonly affects joints such as the knees and fingers. However, arthritis can affect any joint in the body, including the small joints of the spine. Arthritis of the spine can cause back pain with movement.

Spondylolisthesis
Spondylolisthesis causes back pain because adjacent vertebra become unstable and begin to "slip." The most common cause of spondylolisthesis is due to degenerative changes causing loss of the normal stabilizing structures of the spinal column. If the spine becomes unstable enough, back pain can become a problem.

Spinal Disk Problems
Only a person who has experienced a damaged spinal disk understands the agony and helplessness it brings. The pain can be excruciating.
Every movement seems to make it worse. 

This pain is a warning signal. If you heed the warning and take proper action,
the discomfort usually stops, and the problem can be corrected.
If you ignore the warning, you could suffer permanent damage. 

Spinal disks are supple pads tightly fixed between the vertebrae, the specialized bones that make up the spinal column. Doctors call them intervertebral disks. Each disk is a flat, circular capsule about an inch in diameter and one-quarter inch thick. They have a tough, fibrous, outer membrane called the annulus fibrosus. Inside is an elastic core called the nucleus pulposus. 

The disks are firmly embedded between the vertebrae and are held in place by the ligaments connecting the spinal bones and the surrounding sheaths of muscle. There is really little, if any, room for disks to slip or move. The points on which the vertebrae actually turn are called facet joints, which stick out like arched wings on either side of the rear part of the vertebrae. These facet joints keep the vertebrae from bending and twisting too far -- far enough to damage the spinal cord, the vital network of nerves that runs through the center of each vertebra.

The disk is sometimes described as a shock absorber for the spine, which makes it sound more flexible or pliable than it really is. While the disks do separate the vertebrae and keep them from rubbing together, they are far from pneumatic or spring-like. In children, they are gel- or fluid-filled sacs, but they begin to solidify as part of the normal aging process. By early adulthood, the blood supply to the disk has stopped, the soft inner material has begun to harden, and the disk is less elastic. In middle-aged adults, the disks are tough and quite unyielding, with the consistency of a piece of hard rubber. These changes related to aging make the outer protective lining more weak and the disks more prone to injury.

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The Basics of Osteoarthritis
Arthritis is a general term that means inflammation in joints. Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the weight bearing joints of the hips, knees, and spine. It can also affect the fingers, thumb, neck, and large toe. It usually does not affect other joints unless previous injury or excessive stress is involved.

Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a "shock absorber." The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).

Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage deteriorates, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.

Osteoarthritis affects nearly 21 million Americans. The chance of developing the disease increases with age. Most people over age 60 have osteoarthritis to some degree, but its severity varies. Even people in their 20s and 30s can get osteoarthritis. In people over 50, more women than men get osteoarthritis.

What Are the Symptoms of Osteoarthritis?
Symptoms of osteoarthritis most often develop gradually and include:
Joint aching and soreness, especially with movement.
Pain after overuse or after long periods of inactivity.
Bony enlargements in the middle and end joints of the fingers
(which may or may not be painful).
Joint swelling and joint fluid accumulation.

What Causes Osteoarthritis?
There are several factors that increase a person's chances of developing osteoarthritis. These include:

Heredity
Some people have an inherited defect in one of the genes responsible for making cartilage. This causes defective cartilage, which leads to more rapid deterioration of joints. People born with joint abnormalities are more likely to develop osteoarthritis, and those born with an abnormality of the spine (such as scoliosis or curvature of the spine) are more likely to develop osteoarthritis of the spine.

Obesity
Obesity increases the risk for osteoarthritis of the knee and hip. Maintaining ideal weight or losing excess weight may help prevent osteoarthritis of the knee and hip or decrease the rate of progression once osteoarthritis is established.

Injury
Injuries contribute to the development of osteoarthritis. For example, athletes who have knee-related injuries may be at higher risk of developing osteoarthritis of the knee. In addition, people who have had a severe back injury may be predisposed to develop osteoarthritis of the spine. People who have had a broken bone near a joint are prone to develop osteoarthritis in that joint.

Joint Overuse
Overuse of certain joints increases the risk of developing osteoarthritis. For example, people in jobs requiring repeated bending of the knee are at increased risk for developing osteoarthritis of the knee.

Spinal Stenosis
Spinal stenosis is the narrowing of spaces in the spine (backbone) which causes pressure on the spinal cord and/or nerves. About 75% of cases of spinal stenosis occur in the low back (lumbar spine). In most cases, the narrowing of the spine associated with stenosis compresses the nerve root, which can cause
pain along the back of the leg. 

What Causes Spinal Stenosis?
There are many potential causes for spinal stenosis, including:

Aging:
With age, the body's ligaments (tough connective tissues between the bones in the spine) can thicken. Spurs (small growths) may develop on the bones and into the spinal canal. The cushioning disks between the vertebrae may begin to deteriorate. The facet joints (flat surfaces on each vertebra that form the spinal column) also may begin to break down. All of these factors can cause the spaces in the spine to narrow.

Arthritis:
Two forms of arthritis that may affect the spine are osteoarthritis and rheumatoid arthritis.

Heredity:
If the spinal canal is too small at birth, symptoms of spinal stenosis may show up in a relatively young person. Structural deformities of the involved vertebrae can cause narrowing of the spinal canal.

Instability of the Spine, or Spondylolisthesis:
When one vertebra slips forward on another, that can narrow the spinal canal.

Tumors of the spine:
Abnormal growths of soft tissue may affect the spinal canal directly by causing inflammation or by growth of tissue into the canal. Tissue growth may lead to bone resorption (bone loss due to overactivity of certain bone cells) or displacement of bone and the eventual collapse of the supporting framework of the spinal column.

Trauma:
Accidents and injuries may either dislocate the spine and the spinal canal or cause burst fractures that produce fragments of bone that penetrate the canal.

What Are the Symptoms of Stenosis?
Stenosis may result in low back pain as well as pain in the legs. Stenosis may pinch the nerves that control muscle power and sensation in the legs.

Additional symptoms may include:

Frequent falling, clumsiness
Pain and difficulty when walking, numbness, tingling, hot or cold feelings in the legs.

Ankylosing Spondylitis:
Ankylosing spondylitis is a type of arthritis that affects the spine. Ankylosing spondylitis symptoms include pain and stiffness from the neck down to the lower back. The spine's bones (vertebrae) may grow or fuse together, resulting in a rigid spine. These changes may be mild or severe, and may lead to a stooped-over posture. Early diagnosis and treatment helps control pain and stiffness
and may reduce or prevent significant deformity.

Who Is Affected by Ankylosing Spondylitis?
Spondylitis affects about 0.1 to 0.5% of the adult population. Although it can occur at any age, spondylitis most often affects men in their 20s and 30s. It is less common and generally milder in women and most common in Native Americans.

What Are the Symptoms of Ankylosing Spondylitis?
The most common early symptoms of spondylitis include:
Pain and stiffness. Constant pain and stiffness in the low back, buttocks and hips that continue for more than three months. Spondylitis often starts around the sacroiliac joints, where the sacrum (the lowest major part of the spine) joins the
ilium bone of the pelvis in the lower back region.

Bony fusion. Ankylosing spondylitis can cause an overgrowth of the bones, which may lead to abnormal joining of bones, called "bony fusion." Fusion affecting bones of the neck, back or hips may impair a person's ability to perform routine activities. Fusion of the ribs to the spine or breastbone may limit a person's ability to expand his or her chest when taking a deep breath.

Pain in ligaments and tendons. Spondylitis also may affect some of the ligaments and tendons that attach to bones. Tendonitis (inflammation of the tendon) may cause pain and stiffness in the area behind or beneath the heel, such as the Achilles tendon at the back of the ankle.

Ankylosing spondylitis is a systemic disease, which means symptoms may not be limited to the joints. People with the condition also may have fever, fatigue and loss of appetite. Eye inflammation (redness and pain) occurs in some people with spondylitis. In rare cases, lung and heart problems also may develop. 

What Causes Ankylosing Spondylitis?
Although the cause of spondylitis is unknown, there is a strong genetic or family link. Most, but not all, people with spondylitis carry a gene called HLA-B27. Although people carrying this gene are more likely to develop spondylitis, more than 75% of these people never develop the disease. 

How Is Ankylosing Spondylitis Diagnosed?
The diagnosis of spondylitis is based on several factors, including:

Symptoms
Findings on physical examination
X-rays of the back and pelvis

How Is Ankylosing Spondylitis Treated?

There is no cure for spondylitis, but there are treatments that can reduce discomfort and improve function. The goals of treatment are to reduce pain and stiffness, maintain a good posture, prevent deformity and preserve the ability to perform normal activities. When properly treated, people with ankylosing spondylitis may lead fairly normal lives. Under ideal circumstances, a team approach to treat spondylitis is recommended. Members of the treatment team typically include the patient, doctor, physical therapist and occupational therapist. In patients with severe deformities,
osteotomy and fusion can be done. 

Physical and Occupational Therapy
Early intervention with physical and occupational therapy is important to
maintain function and minimize deformity.

Exercise
A program of daily exercise helps reduce stiffness, strengthen the muscles around the joints and prevent or minimize the risk of disability. Deep breathing exercises may help keep the chest cage flexible. Swimming is an excellent form of exercise for people with ankylosing spondylitis.

Medications
Certain drugs help provide relief from pain and stiffness, and allow patients to perform their exercises with minimal discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs for spondylitis treatment. Many NSAIDs are currently available. In moderate to severe cases, other medications may be added to the treatment regimen. Disease modifying anitrheumatic drugs (DMARDs) such as Azulfidine and Rheumatrex can be used when NSAIDs alone are not enough to reduce the inflammation, and help to prevent joint stiffness and pain. In addition, the relatively new drugs Enbrel and Remicade have been FDA approved for treating ankylosing spondylitis. A similar drug, Humira has also been shown to improve the pain and stiffness of ankylosing spondylitis.

Surgery
Artificial joint replacement surgery may be a treatment option for some people with advanced joint disease affecting the hips or knees.

Conclusion:

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