"Radicular syndrome of left lower extremity", probably sacral: Experience? Outcomes?

[vtdad]

So this summer, the good folks at Barbell Medicine got my unstuck lower body lifts unstuck by tinkering with volume and diet, and helped clean up my form. I'm still losing weight, but very slowly (down from 280 this year to 208, but now losing less than 1lb/week, BF low 20s). I made it up to DL 275x3, squat 275x1 (245x5), bench 187x5, and OHP 113x1 during a recent week of triples and singles. But the week before Thanksgiving, I had a gradual onset of mild tingling and numbness in my left big toe. I took a couple of days off, scheduled an appointment with my PCP, and did a little bit of light training while waiting.

My new PCP turned out to have a background in sports medicine. She poked and proded me, but couldn't figure out how to reproduce the symptoms on command. She prescribed Ibuprofen and said I could continue training if I didn't do anything dumb.

Well, I went back to the gym and did a fairly normal squat workout. The day after, the tingling and numbness had spread through my left foot, and I had occasional mild muscle twitching in my lower calf. I got back in to see my PCP the same day, and we eventually found the troublespot: There's a spot on my left glute, very roughly above the piriformis muscle and a little towards the outside, which will reliably produce tingling throughout the foot when jabbed.

So I decided to stop training entirely, and my PCP put me on 800mg of Advil 3 times per day, in an effort to bring down inflammation. She ordered sacral and coccyx X-rays, and a set of lumbar X-rays to be safe, but she doesn't expect to see much. If symptoms don't improve in a week, or if they worsen before then, she'll be able to justify an MRI, but apparently the first step is anti-inflammatories and a bit of waiting.

So, my questions:

• Does this treatment plan sound reasonable, under the circumstances?
• Are there any mild exercises which might help?
• What's the typical range of prognoses for something like this when it's caused by lifting?

Thank you very much for any insights or experience that you can provide! I want to be an informed participant in my care, and know what to look for.

[vtdad]

The mystery deepens.

X-rays are back.

You do have some mild facet arthropathy (this would be similar to saying arthritis) at the L5-S1 level. This is where your lumbar spine meets your sacrum.

In doing some additional research, it seems as if there are some mixed reports on whether or not this could account for the symptoms that you are having.

Some experts say that facet inflammation can cause symptoms in areas below the knee, while others are less convinced. It is certainly not a common reason for distal pain presentations.

Well, I guess it's Advil, time and no training. Despite the discussion in this thread, which reported mild facet arthropathy (among a lot of other disk problems) and a much more serious version of the same symptoms, this seems like an unlikely weightlifting injury. I also found this thread. We'll see, I suppose.

[vtdad]

Upon further reflection, there are facts which suggest that the facet arthropathy might be a red herring:

• When the doctor jabbed my left glute, she sound a sore spot that could trigger a stronger version of the symptoms.
• The symptoms are strongest in the portions of the leg corresponding to L5 (and S1) on most nerve charts, but they occasionally wander into L4 or S2 regions. So there's a chance that this is affecting the sciatic nerve as a whole, and not just a particular nerve root (assuming I understand anything at all about how this works, which I don't).
• Squats have routinely left the deep muscles under my glutes sore in the past, requiring stretching and foam rolling.
• The seated or lying pyriformis stretches may help, but the problem is intermittent enough that it's hard to be certain.

So I'm going to propose to my doctor that we add pyriformis syndrome to the list of hypotheses, alongside "facet arthropathy", and consider trying some mild pyriformis interventions, since they're easy. We'll see what she recommends.

[vtdad]

Current treatment is 800mg of Advil 3 times a day, with meals, and various pyriformis stretches. The pyriformis stretches help—sometimes a little bit, sometimes dramatically.

Symptoms are mostly mildish, but they remain. My toe and foot sole are still tingling. Sometimes it's easy noticeable. Sometimes I have to focus to feel it. Occasionally, I get a bit of random muscle twitching in my glute or sensations of heat or cold. I think things are getting gradually better, but I'm obviously in this for the long haul.

As usual, I wish that I had backed off much more aggressively before reaching this point, even though both my coach and my PCP (who specializes in sports medicine) thought training should be safe. Now my only choice is to wait and heal. Nobody really knows what happened, not without an MRI, and it's hard to justify an MRI when the symptoms are slowly getting better.

[Joel Chapman]

I take it you don't have a very long training history? This is a fairly common "injury" for those who strength train.

[vanslix]

I take it you don't have a very long training history? This is a fairly common "injury" for those who strength train.

It is quite common for the piriformis to cause radiculopathy.

[vtdad]

Joel Chapman, vanslix: Thank you for your suggestions!

These symptoms took several months to diagnose. I'm going to explain what we finally learned, in case it helps somebody using the "Search" function in the future.

At first, I figured that the nerve symptoms in my left foot (and occasionally leg) were caused by my much-abused pyriformis muscle. But when the symptoms started showing up in my right foot as well, and the foot pain became seriously intense, my PCP suggested that this might be a sacral spine issue. Imaging revealed a few minor issues at L4/L5, but nothing conclusive. The spine specialist said, "You need to go talk to neurology."

And over at neurology, they were at least able to put a name to the problem: I have a "painful, length-dependent, small-fiber neuropathy." This means that the small, unmylinated nerves in my feet are failing, starting with the longest nerves first. Symptoms include pain, tingling, partial numbness, and hot/cold sensations. But my strength, soft-touch perception, vibration perception and proprioception are all unaffected. This diagnosis was confirmed when the symptoms moved into my right hand, as shorter and shorter nerve fibers were affected.

Unfortunately, neuropathies are notoriously hard to diagnose, because those long peripheral nerves are the canary in the coal mine for dozens of conditions. But the exact neuropathic symptoms can help narrow it down. My symptoms typically correspond to one of three things:

1. A diabetic neuropathy.
2. A vitamin deficiency.
3. The early stages of some obscure hereditary neuropathies—but my ancestors come from the wrong countries for this to be likely.

So we ruled out (2) with some blood tests and a couple of vitamin supplements. So the interesting possibility is (1). Diabetic neuropathies are the most common neuropathies in the world, and the symptoms are an almost exact match. So we tried a blood test. And my A1c came back at 4.9, which says that my average blood sugar over the last 3 months has been excellent. So we're still trying to figure out what's causing this.

One possibility: I've lost over 75 pounds in the last 15 months. Even if I'm not diabetic now, I might have been prediabetic before the weight loss. And it's known that when diabetics get their blood sugar under control, some of them develop neuropathic symptoms afterwards. The diagnostic test for this an oral glucose tolerance test (the same one they give pregnant women), which can reveal glucose-handling irregularies even with a normal A1c and fasting blood glucose. Over a third of patients with a mysterious neuropathy have poor oral glucose tolerance results. So this is something that another forum member might encounter some day. And if you're getting tingling in your feet and it's working its way in towards your core, it isn't always a mechanical injury—it may be a nerve issue.

In my case, there's some good news, too: Exercise helps control the pain. So I'm back in the gym again, and I've restarted my linear progression from where the bar slowed. I've definitely lost some strength, but that's fixable. Also, if my problem is related to glucose control, then the best treatment would be "eating clean" and exercising hard.

Anyway, if we ever figure out the underlying cause, I'll try to update here again.

[Mugaaz]

I had some crazy radiculopathy from cervical issues. I don't agree that best plan is just to wait an heal. Training made it better for me, and when I took periods off the symptoms tended to get worse. Obviously where is horrible radiculopathy you can't train. If it is light, then it can be VERY useful because it will help you figure out exactly what you are doing that is causing the issue. You need to use this information to fix the form issues that cause it, or figure out alternatives way to train if technique changes don't help.

Also, every doctor and nuerologist I saw for help with this was an absolute and total waste of time and money. Miss Cleo could provide more help. Unless you want surgery or drugs, there is nothing they can do. Figure out EXACTLY what activities and body positions cause and aggravate the issue and then change or stop doing them. Ibuprofen will help if inflammation is making the issue worse, but I found it did nothing for pain. Bengay/Icyhot were somewhat effective, but only for short doses. Was still worth it, because sleep was impossible without them.