Anatomy: The back is constructed of box-like vertebrae which are held in place partly with the help of the shape of the bones, partly by ligaments and partly by the large and small back and stomach muscles. Cartilage discs (disci) are located between the vertebrae which act as shock absorbers. The discs lie close to the spinal canal from where nerves depart to the legs.

Symptoms: Pain and stiffness in the lower back (lumbago), radiating to one of the legs. There can be sensory interference and reduction in strength of the leg. Symptoms are often aggravated by coughing. In rare cases the nerves can be so severely compressed that problems can arise in control of bladder and bowels, requiring acute surgical treatment.

Examination: If a slipped disc is suspected medical attention should be sought at once to establish the diagnosis and which treatment should be initiated.

Treatment: If examination reveals signs of a slipped disc without alarming symptoms (problems in control of bladder and bowels or substantial deterioration of muscle/paralysis), treatment will primarily be directed at altering the imbalance between the load the back is subjected to, opposed to the level the back is trained to manage. It is therefore recommended that you are instructed (possibly by a physiotherapist) in the appropriate way to put a strain on the back, and which loads and movements should be avoided (“ergonomic guidance”). A few days’ rest and relief may be needed to subdue the pain, after which steadily increasing training should be started with back and stomach stabilising and strengthening exercises. If painkillers are required, paracetamol can be recommended, possibly combined with rheumatic medicine (NSAID). Chronic back pain may suggest stronger painkillers, however, stronger medicine should be used with extreme caution as it can quickly lose its effect and there is a risk of increased dependence on the medicine. By far the majority of slipped discs can be managed through correct training (article 1). In cases where the above treatment does not produce progress in the condition, a CT or MRI scan will be considered with a view to possible operation. CT and MRI scan and operation is therefore first considered if the rehabilitation programme does not succeed (article 2). In cases with alarming symptoms (problems in control of bladder and bowels or substantial deterioration of muscle/paralysis) acute hospitalisation is recommended for evaluation of the need for acute surgery.

Special: Training should be performed on a “lifelong” basis to reduce the risk of relapse after a successful rehabilitation. Smoking causes increased risk of lumbago by reducing the flow of blood to the cartilage discs (disci), implying that daily small injuries do not heal so well. Stopping smoking is therefore an important part of the treatment. Shock absorbing shoes or insoles will reduce the load on the back.

Anatomy: The back is constructed of box-like vertebrae which are held in place partly with the help of the shape of the bones, partly by ligaments and partly by the large and small back and stomach muscles.

Symptoms: Pain and stiffness in the lower back (lumbago), occasionally radiating to the leg (“sciatica”).

Examination: Slight back discomfort does not necessarily require medical examination, however, all cases with strong or repeated back pain should be examined. The doctor will be able to evaluate whether further examination is required, i.e. x-ray, CT or MRI scan.

Treatment: Treatment will primarily be directed at altering the imbalance between the load the back is subjected to, opposed to the level the back is trained to manage. It is therefore recommended that you are instructed (possibly by a physiotherapist) in the appropriate way to put a strain on the back, and which loads and movements should be avoided (“ergonomic guidance”). A few days’ rest and relief may be needed to subdue the pain, after which steadily increasing training should be started with back and stomach stabilising and strengthening exercises. If painkillers are required, paracetamol can be recommended, possibly combined with rheumatic medicine (NSAID). Chronic back pain may suggest stronger painkillers, however, stronger medicine should be used with extreme caution as it can quickly lose its effect and there is a risk of increased dependence on the medicine. With acute lumbago without signs of a slipped disc, assistance can be sought from manipulative treatment by a doctor, physiotherapist or chiropractor.

Complications: If the pain does not decline under the treatment, clinical (re)examination by a doctor should be performed. Special consideration should be given to:

• Slipped disc
• piriformis syndrome
• Secondary muscle infiltrations (myalgia)

However, many other causes of lumbago are found, of which some will require further examination. In the majority of cases, the treatment will be identical. It will not be possible for some to be completely free of discomfort (i.e. with heavy degenerative arthritis in the lumbar region), and the aim of the treatment will often be to reduce the frequency and degree of pain.

Special: Training should be performed on a “lifelong” basis to reduce the risk of relapse after a successful rehabilitation. Smoking causes increased risk of lumbago by reducing the flow of blood to the cartilage discs (disci), implying that daily small injuries do not heal so well. Stopping smoking is therefore an important part of the treatment. Shock absorbing shoes or insoles will reduce the load on the back.

Anatomy: The deep hip flexor (M iliopsoas) consists of two muscles. The Psoas muscle originate from the lumbar vertebrae and the Iliacus muscle from the inside of the femur. The two muscles fuse and are both fastened on the inside of the femur (trochantes minor). The iliopsoas is the strongest flexor muscle of the hip.

Symptoms: With certain movements in the hip joint the deep hip flexor (M iliopsoas) can be made to slip over one of the bone projections on the pelvis or the hip joint, whereby a slipping sensation, often accompanied by discomfort, is felt and often heard.

Acute treatment: Click here.

Examination: In light cases with only minimal tenderness medical examination is not necessarily required. In case of more pronounced pain or lack of progress a medical examination should be carried out to ensure the diagnosis. A normal medical examination is usually sufficient in order to make the diagnosis, however, if there is any doubt concerning the diagnosis a dynamic ultrasound scan can be performed, where the tendon can be seen slipping as this triggers the symptoms (article 1) (article 2), (article 3).

Treatment: The treatment primarily comprises relief. If progress is not smooth the treatment can be supplemented with rheumatic medicine (NSAID) or the injection of corticosteroid, which should be done with ultrasound guidance to ensure the optimal effect and minimal risk. Only in very rare cases is surgical treatment necessary.

Complications: If progress is not smooth it should be considered whether the diagnosis is correct or if complications have arisen. In particular the following should be considered:

• Degenerative arthritis in the hip joint
• Rupture of the superficial hip flexor (ruptura musculus rectus femoris)
• Rupture of the deep hip flexor (ruptura musculus iliopsoas)
• Outer snapping hip
• Fluid accumulation in the joint (traumatic synovitis/coxitis)
• Stress fracture in the femoral neck
• Arthritis in the hip joint

Anatomy: Externally from the iliac crest to the shin bone runs a strong tendon (tractus iliotibialis), on which many of the thighs muscles are fastened. The tendon runs close above the outer femoral bone projection (trochanter major).

Symptoms: Upon certain movements in the hip joint, a sudden slipping, and unpleasant sensation can suddenly be produced on the outside of the thigh, which is often audible.

Acute treatment: Click here.

Examination: Usually the diagnosis can be made by an ordinary medical examination. You can often prevent the tendon from slipping over the outer bone projection by holding the tendon aside, while the movements provoking the condition are performed. The pain will decrease for approx. one hour after the injection of a local anaesthetic (diagnostic blockade) around the outer hip bone projection. If the diagnosis does not appear to be certain, ultrasound is recommended (Ultrasonic image), (article), or possibly a MRI scan.

Treatment: The treatment primarily comprises relief, stretching of the external tendon and rehabilitation. It is crucial that shoes have good shock absorbing soles. In cases of inappropriate foot stance, this should be corrected with shoes or inlays. In case of lack of progress the treatment can be supplemented with medical treatment in the form of rheumatic medicine (NSAID) or the injection of corticosteroid, which advantageously can be guided by ultrasound. In severe cases with no effect from relief, correct rehabilitation or medical treatment, you can operatively split the tendon.

Complications: In case of lack of progress it should be considered whether the diagnosis is correct. This will often require supplemental examinations (X-ray, ultrasound or MRI scan). In particular the following should be considered:

• Inner snapping hip
• Bursitis on the front of the hip joint (bursitis iliopectinea)
• Other bursitis
• Degenerative arthritis in the hip joint
• Fluid accumulation in the hip joint (traumatic synovitis/coxitis)
• Stress fracture in the femoral neck

Special: Shock absorbing shoes or inlays will reduce the load. In case of lack of progress or recurrences after successful rehabilitation it can be considered to have a running style analysis performed, to evaluate whether correction of the running style is indicated.