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Is Pseudostenosis the Real Cause of Your Back Pain?

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“Baby boomer back” is the nickname doctors have for lumbar spinal stenosis. That’s because the condition mainly strikes adults over age 50. But even people in their 70s and up—or those only in their 20s—can be afflicted by spinal stenosis, a condition in which the spinal canal narrows and may compress the spinal cord or spinal nerves.

The symptoms are unpleasant, to say the least—low back, leg or foot pain that worsens when walking or standing, along with weakness, burning and/or tingling in the affected areas.

The first line of defense is usually pain medication—a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin), or nerve pain medication such as gabapentin (Neurontin). If that doesn’t ratchet down the pain, the next step may be physical therapy, cortisone injections and/or back surgery to alleviate pressure on the spinal nerve roots.

The problem is, these treatments don’t always work, and when they do, the relief may last only months, weeks or, in some cases, just days. Surgery can fail and, of course, it carries the risk for infection, blood clots and damage to structures, including nerves.

Surprising discovery: In many patients diagnosed with spinal stenosis, the symptoms are actually caused by pseudostenosis. This condition, in which the lower body structures (from feet to hip bones) are not functioning perfectly, can cause positional changes of the spine that exert pressure on bone structures or nerves, causing symptoms identical to those of spinal stenosis.

The tricky part is that an MRI may, in fact, reveal spinal stenosis—the two conditions often occur simultaneously. In my practice, I’ve found that pseudostenosis contributes to more than half of spinal stenosis cases.

Pseudostenosis is not a well-known concept—as a result, it is not considered by most doctors. Although the pain is coming through the spine, the actual cause is the poor function of the lower extremities. This is why standard treatments for spinal stenosis may be doomed to fail in these cases, even if they are done extremely well. Note: Pseudostenosis can also occur on its own, even if spinal imaging (such as an MRI or a CT scan) is negative.

Good news: Based on my clinical experience, 70% of patients with pseudostenosis experience near-complete relief of symptoms often within a day or two by making a few simple positional changes. If someone does not improve within two days, it means that the treatment did not properly address the true cause of pain.

DISCOVERING THE REAL CAUSE

Pseudostenosis has several causes. The most common are limb length discrepancy (one leg is shorter than the other) and flexible flat feet (the arch flattens when you step down). Other culprits may be any pain-inducing condition that affects the way a person walks. This may include arthritis of the feet, ankles, knees or hips…imperfect walking because of a nerve problem due to stroke or multiple sclerosis…tightness of the Achilles tendons…or a rigid flat foot.

Each of these conditions can affect your body in a way that mimics the effects of spinal stenosis, and more than one may be present at the same time, even if the patient is not aware of it. Here’s what you can do about the most common causes of pseudostenosis…

• Limb length discrepancy (LLD). Either limb may be structurally shorter than the other, or one limb may function as if it is shorter, often because of an injury. Most people are unaware of the difference.

Red flags: With LLD, standing may cause more back and/or leg pain and leg tiredness than walking. To alleviate symptoms, people with LLD often feel the need to periodically “shake a leg” or shift their weight from side to side when standing. Even a mild LLD of 2 mm to 3 mm can cause symptoms.

Another sign of LLD: You have asymmetric wear-and-tear of your shoes. Often the wear is worse on the outer heel of your shoe worn on the shorter leg.

Quick test that may suggest LLD: Stand in front of a tall mirror, and look to see if your head tilts to one side and/or if your shoulders and hips are not horizontal. This asymmetry may be seen with either an LLD or scoliosis, which often occur together. (Wearing horizontal stripes and a belt makes the assessment easier.)

Next, put on a pair of shorts and stand in front of a long mirror to look at your legs. An LLD will often cause the foot of the longer leg to turn out more than the other. Then check your feet. Each leg may have different foot deformities, such as bunions, hammertoes, calluses or a flat foot.

How to treat LLD: A lift in the shoe of the shorter leg may quickly improve pseudostenosis symptoms. Don’t go for the one-size-fits-all, shock-absorbing pharmacy inserts. A customized heel lift is critical in treating LLD. And no one will even notice that you’re using it.

Websites such as GWHeelLift.com…and my site, WalkingWellAgain.com, offer solid heel lifts made of 1-mm to 12-mm durable plastic that can be stacked to achieve the perfect height.

Helpful: You can slip the heel lift under your shoe’s insert to keep it in place.

• Flexible flat feet. Flexible flat feet are another common cause of pseudostenosis. This condition is usually easier to treat than rigid flat feet. If your foot has an arch when you’re sitting but flattens out when standing, you have a flexible flat foot.

To test yourself for flexible flat feet: Take off your shoes and socks. If you have an arch when sitting, wet your foot and step on a brown grocery store bag. If the entire sole makes a print, that means that the arch has flattened, and you have a flexible flat foot.

How to treat flexible flat feet: Both orthotics and braces are available. Orthotics are custom-designed inserts that fit entirely inside a shoe. Ankle braces include a custom foot insert as well as an extension that goes above the ankle to increase stability.

To determine if orthotic control can help, a podiatrist may apply a tape strapping to your feet to control the foot function. If done well, it may simulate the effects of custom orthotics. The Unna Boot, a type of compression bandage that is embedded with zinc oxide paste to make it more supportive, can test for more aggressive control, such as a custom brace. Patients wanting to try self-taping may use Quick Tape, available at SupportTheFoot.com.

If symptoms improve with the tape strapping, podiatrist-fitted orthotics are the go-to treatment. Custom orthotics usually cost hundreds of dollars and are often not covered by insurance. If cost is a factor, excellent over-the-counter (OTC) orthotics are available from Vasyli Medical, at Amazon.com or from a distributor at VasyliMedical.com. Even though OTC orthotics are not necessarily as effective as custom devices, they sometimes do help and cost less than $100. Ankle braces are usually covered by health insurance.

With either heel lifts for LLD or supportive orthotics or braces for flexible flat feet, long-term treatment is often needed.

Takeaway: If you’ve been diagnosed with spinal stenosis, and your symptoms did not improve or returned after treatment, consider consulting a podiatrist to see whether pseudostenosis may be the real problem. To find a podiatrist near you, get a referral from your physician or check the website of the American Podiatric Medical Association, APMA.org.

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Source: Stuart M. Goldman, DPM, a podiatrist in private practice in Baltimore who specializes in nonsurgical treatment of pain. Board-­certified by the American Board of Foot and Ankle Surgery and a Fellow of the American College of Foot and Ankle Surgeons, he is author of Walking Well Again: Neutralize the Hidden Causes of Pain. Date: March 1, 2018 Publication: Bottom Line Health
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