I was born in 1971.

In 1986 I did taekwondo for 6 months or so and became a lot more flexible. However, I always found my hamstrings extremely tight – especially on the left – and found stretching them uncomfortable. Nevertheless, I made good progress and was almost able to do the splits eventually. Once I stopped this training, my hamstrings quickly regained their usual taughtness and I discovered that I was very uncomfortable sitting on the floor with my back straight and my legs extended in front of me. I can still not do this, despite the fact that my father, mother and younger sister (all of whom are shorter than me) can all do this.

Around 1988 – being a basketball enthusiast - I was trying to increase my jumping ability by depth jumping (eg. http://gladstone.uoregon.edu/~j15/lr/lr_index.htm), something I had read about in a bookshop. To achieve this, I jumped repeatedly off a 4 foot high ladder onto my parents’ lawn perhaps 10 times, and repeated this perhaps 4 times.

After this regrettable exercise, I found that I experienced sharp pains in both knees when running or climbing up stairs. During 1989 I managed to not play basketball for 39 day consecutive days, so concerned was I about allowing my knees to heal and to being able to play again. They did improve, but generally became very painful after every match unless I was already conditioned from having played a few times in the same week. I visited a doctor who arranged for my knees to be x-rayed and he said they showed nothing. He advised me to take some anti-inflammatory tablets. I don’t recall these doing much if anything for me. I found that putting Chinese deep heat ointment on alleviated (masked?) some of the pain temporarily but made me smell bad.

I managed to stay very healthy for the next 10 years, playing basketball only a few times a month and going to the gym regularly. I also experienced pain sitting for more than 20 minutes with my knees bent, eg. At the cinema or at a desk. I constantly had to extend my legs and slouch to alleviate the pain in my knees. I hardly ever caught a cold and never got sick. I never felt better than when I was 24 years old.

In 1998 I spent many hours at work and at home sitting at a computer. I often found myself slouching and having to correct my posture a few times a day. Try as I might – including adjusting the height of the screen and chair – I was unable to sit comfortably in a correct posture for more than a few minutes. I was able to slouch and type for up to 5 hours at a time and got a lot of work done.

One incident does perhaps deserve some mention. We were moving house around 1998 and I was lifting a heavy box full of books and other stuff. I felt something nasty in my back give way but felt no pain. I was extremely concerned for a few days. Thinking back, this felt quite similar to the 2002 basketball incident I describe below.

Some time in 2001 I started to feel some intermittent small sharp pain in my lower back. I can’t say now which area was affected. At first the pain was present for a few days and then it went away. It then returned, worse and more persistent. My GP advised me to see a sports physiotherapist. This person had a terrible bedside manner and made my back pop by lying me on a bench and twisting me. He also administered traction and some ultrasound to little effect. I left feeling sore and very bruised, but had improved slightly the next day. The pain lingering and not wanting to repeat the experience, I saw Dr A. He told me to take some tablets and come back if they didn’t help. I took the tablets for a few days and they didn’t help. As he didn’t seem interested in my problem, I didn’t return. Around the same time I visited a chiropractor, who did listen and did seem to care. He organized for me to have an x-ray of my lower back and pointed out that my final disc was about half the thickness of a healthy man my age. He said it wasn’t something I should worry too much about at the moment, but that I should stop doing gym exercises which but a strain on my spine (eg. squats). I modified my gym routine and started swimming. These two activities appeared to help but the small pain only reduced for an hour or so. I was unsure as to whether to do more or fewer hyperextensions in the gym. It seemed to hurt when I was doing it but felt somewhat better for a while afterwards. Swimming was time consuming and boring and it started to make my eyes red and contributed to eczema returning to my fingers. I continued to go to the gym and swim roughly once a week. The pain seemed to be under control and at least not worsening. I started playing basketball again around once every fortnight during winter and kept my games short. They resulted in headaches and painful knees due to my lack of fitness. These would disappear in a day or so.

Around 9 Jan 2002 I went to the park early in the morning to play basketball with a friend. As the courts were busy, we had to wait for our turn. For around 30 minutes we waited in the cold, impatiently praying that the next game would be ours. When our time came, I had already decided what I was going to do once I got the ball – spin around to my left, jump up and shoot the ball off the backboard. As I span, I felt something give in my back – slightly higher up than my usual pain, and not dissimilar to the pop induced by the sports physiotherapist. It was a completely new sensation and worried me, but as I felt no pain, I continued to play, albeit tentatively. After 10 minutes or so, I knew something was wrong so I stopped playing and curled up on the floor to try and stretch the affected area. When I got home, I tried to sleep it off but found that I could barely get out of bed so sharp was the pain. The pain subsided over the next 3 days, to be replaced by a tightness in the muscles of my lower back.

For the next year or so I put up with this, hoping that it would go away. My back felt weak rather than painful, but always tight and sometime sore from the tightness. I visited a few doctors again – the only one I remember was a Chinese acupressure fellow who jabbed me in the back of the knee with his finger. Apparently my “channels” were blocked and he needed to stimulate the “qi” to flow again. I submitted myself to his painful treatment 3 times and admittedly the muscle tightness subsided a little. One thing he tried which did nothing except give me a rash was to tape a big “teabag” of Chinese herbs to my back for 48 hours. He was a well-meaning fellow and I would have gone back were it not for the fact that I could only lie on his bench (face-down) if I bent my knees to 90 degrees as his consulting room was so small.

Back in Australia for a holiday, a sports physiotherapist quickly suspected a disc problem (via a slump test), gave me some exercises to do at home and sent me off to do my first MRI.

The MRI clearly showed that I had a moderately prolapsed L5-S1 disc. This did not necessarily mean much, because apparently there are people with the same diagnosis but no pain, and there are people in the same pain as me but with no prolapse. However, I felt that we finally had found the source of the problem – the disc is the same area as the pain, and we could therefore call it something and stop playing expensive and painful guessing games.

A sports medicine specialist I saw said I didn’t need an operation as it probably wouldn’t help much, but I could look forward to a lifetime of this pain which I could seek to control through regular back exercises such as I had been given. He sent me to have a massage, anyway, saying it might help a bit and that I should ask the massage therapist about my prognosis.

The massage therapist (in the same building) was brilliant. He explained to me that my transversus abdominus was a little used muscle around my spine which could be strengthened to the point where I would be able to stabilize the spine and live with relatively manageable pain. He showed me where it was, how to exercise it and gave my constantly tightened back muscles a good massage giving me the first real relief of tension since the January incident. While I didn’t relish the fact that I would never be pain-free, I went back to Hong Kong with at least a plan to do something about it, and a name to contact – someone who had been trained in Australia and who should be able to continue looking after me. I also made the resolution to sort out my pain by the end of the year (2004), whether it meant having and operation or not.

The person I was directed to didn’t have the same approach. She put me on a traction machine for a while and then explained to me that the way to cure me was to apply “deep tissue manipulation”. She told me that this would cause intense pain but was necessary to promote circulation in the affected region and to enable the area to heal. She demonstrated her approach on one visit and ever since that visit, my pain became even more unbearable. I did not return to see her and felt at a loss again.

Some of the exercises recommended to me in Australia called for the use of a Swiss ball. In 2004, I searched on the web and found a seller in Hong Kong of Australian-made balls. I bought one for work and one for home and started doing exercises at home religiously. These exercises were always uncomfortable and did nothing to alleviate my pain. The lady who sold me the balls directed me to a physio clinic. I made time twice a week to attend for several months. I went through an examination by professional, caring people who recommended Pilates. I found this mentally difficult as the movements being asked of me were so slight and I was given no objective indication of progress. To make things even grimmer, one of the people treating me said she was in constant pain too, despite doing Pilates religiously for years.

Around this time, my uncle referred me to Dr B, a pain specialist. Dr B was concerned but seemed too busy opening a new clinic to properly diagnose my problem. He was convinced that it was myofascial pain due to a thin layer of muscle under my skin, and recommended trigger-point injections up and down my back to force the muscles to relax, followed by several weeks of physio and massage. He said I should be pain free for a round 6 weeks, which should be enough to break the pain cycle. Apparently pain causes the muscles to bunch up, which then causes even more pain. This made some sense to me as by then I had pain from stiff muscles all the way from my buttocks to my shoulder blades, all due to the L5-S1 pain. I wasn’t convinced that the pain was all due to the muscles, though, as I knew that there were times when I could relax my muscles and still feel the source of pain in my lower back. I called it “the source of all evil”. Nevertheless, this sounded like it made some sense, and I went into hospital early one morning to have around 24 injections into my back, including a big one conducted under x-ray, into my right sacroiliac joint. While the pain seemed to come from L5-S1, I was able to lie on the floor with my lower legs on a chair or bed and pop my right sacroiliac joint and L5-S1 to relieve intense pain temporarily. The week before the injection, I directed Dr B’s attention to the sacroiliac joint instead of L5-S1 since I felt the pain was worse there.

The injections were conducted under mild anaesthetic or something which made me drop off during the procedure. I woke up back in bed when a physiotherapist visited me. As evidence of the procedure, I was given an incomprehensible x-ray and had a big bruise on my right buttock. I was given lots of Bengay cream and some Dolorgesic-32 tablets. The former made me smell bad. The latter did nothing for me. While the hospital bed was wonderfully comfortable for my back and knees, within 36 hours, I was back to normal – same pain, same area, plus a bruise.

The physiotherapist that visited me was helpful and recommended the DBC programme – a set of exercises from Finland which are specially designed for back pain patients. I consulted Dr C on this and he also highly recommended it before I tried anything more drastic. I was told that some patients see immediate improvement, some take several courses before they improve, and some see no improvement. The success rate of 80% seemed promising but I was sceptical about anything to do with muscles succeeding any more. I attended 2.5 courses of DBC (around 5 months, 1.5 hours, twice a week) and was unable to alleviate the pain or make much progress on my strength or flexibility. The physios there were very positive and encouraging.

At the same time, I was having massage. This was successful in alleviating the pain for the duration of the massage and maybe the next 30 minutes. It made me realize that a lot of the pain was due to muscle tightness, but also that the source of the pain was L5-S1 and that this was not getting any better. By then I was in constant pain every waking moment from a stiff back. I was spending all my time at work, eating, sleeping, or lying on my back at home. I even had to lie down at lunchtime in the office, and weekends were a nightmare. I started to have serious problems sleeping, generally sleeping very poorly during the week, and trying to catch up on the weekends. I felt that, while everything else in my life was fantastic – job, wife, son – I could not function as a father / husband / friend anymore and felt as though I was just someone who pays a mortgage. I could not wait for the next massage session – it was like a drug – and I was grumpy and worn out the rest of the time. I had baths nearly every night at home to try and relax the muscles. I slept on the floor most nights with my legs on my bed.

When I realized that this was going nowhere and that I was just spending all my savings on treatments, I resolved to try one last treatment before undergoing surgery: acupuncture. I visited an acupuncturist in Central and he was extremely competent and professional. He told me that if I didn’t see an improvement after 3 sessions I probably shouldn’t continue. He went into overtime to try and do his best for me – not just acupuncture but massage and advice on home exercises. While I felt relaxed after the first session (including a hot bath at home), the next day I was back to my usual self. The second and third sessions were less and less effective. One week later I was in surgery.

Dr C had explained that the operation – anterior spinal fusion – would remove the instability that existed at that joint. Apparently the instability was causing the pain by causing the ligaments around the spine to become inflamed, rather than anything touching a nerve. He appeared extremely confident and assured me that I’d be walking again 3 days after the operation.

The operation was a stressful time. I had intense toothache two days before the procedure, and had caught a cold and was worried that this would ruin things. Somehow, the cold was solved with an extra injection before the operation, and the toothache went away as fast as it had come.
Suffice to say, everything worked out as Dr C had predicted. After the anaesthetic worse off I was in the worst pain I’ve ever been in my life. I asked for painkilling injections as often as I could, which was once ever four hours, and couldn’t sleep for 3 days in a row. The wound seized up anytime I looked at anything, or even had a more thought for the first 48 hours. I cried my eyes out if someone bumped into my bed or touched me. I couldn’t see myself walking on days 3, but I did – with the help of a walking frame. I felt like a 90 year-old. The next day I didn’t need the frame, and a day or so later I was out and walking home – albeit slowly.

After a slow week at home with daily walks to the zoo, I went back to work with a corset on in Jan 2005. If I sneezed – it was the middle of winter – I ended up in intense pain. If I stubbed my toe while walking – easy to do when you’re not walking the same way - I’d be in inflamed pain for 48 hours. I was taking Cataflam for the first time and found them to be extremely effective, but they only lasted for about 7 hours. Another strange thing that happened for the first weeks after the operation was waking up in a cold sweat at 3am and needing to take a Cataflam. As these can only be taken after food, I’d eat some cereal, take a walk around the playground and take a tablet, before getting back to sleep 2 hours later.

At work, I found myself able to sit upright at a desk for the first time in years and was relatively safe from bumps and having to bend over. After a few weeks, I could sneeze again without fear. After around two months, the stiffness in my foot went away – the latter being from curling my toes back to avoid stubbing my toes on even pavements.

I could feel I was getting better – sleeping better, walking properly. The pain in my wound had gone and the pain in my back was fading. After two months I remember turning over in the night and feeling whole again – no pain, no weakness, just being me again. Around the same time my knee pain subsided – I was ecstatic. I was able to sit properly for several hours in a row and get out of a chair and go to the toilet like a normal young man. My life was coming back. I was able to smile, enjoy my son and bear inviting neighbours around for dinner.

Around the same time, I found two new sources of pain, sharper but less disabling than before the operation. One was in my right sacroiliac joint when I tried to get up from a sofa or bean bag. The other was in the L4 area if I’d been sitting on the edge of a desk. I theorized that these pains were temporary and due to the fusion having occurred and the rest of my body started to have to adjust to the new loads.

The theory didn’t pan out. Those pains have become worse every day. While I have had a few pain-free minutes (once after swimming and once in the middle of the night), for the most part my back was starting to stiffen up again. The source (or more correctly, the area where I felt the pain) was the right sacroiliac joint. I could pop it and gain some relief but the sharp pain in the joint did not seem to want to go away by itself. Once again, I couldn’t bend over, run (my knee pain returned), change my son’s nappy, lift any furniture, etc. I could, however, just about sit at a desk for the purposes of work. This was never natural. I always felt weak and some discomfort due to muscle stiffness or sacroiliac pain. Consequently, I could do my job, but not work the longer hours that I really need to do it well. Weekends were very difficult again. I woke up stiff every morning. Of course, the knee pain made going up or down hill a struggle.

In May I returned to DBC. I completed 2.5 courses and made good progress in strengthening my muscles and exercising in less pain. I was in more pain when doing the exercises than before the operation but hoped that this would recede even further. The two movements that caused me the most pain werer raising my pelvis off the ground using my trunk muscles, and getting up from a lower back stretch.

The tablets (Voltaren, Cataflam and the Dolorgesic) did nothing for me at the time. I started taking a multi-vitamin and a fish body oil tablet daily.

I had 3 theories as to what was the problem. Remember that the post-op pain reduced to zero at the end of Feb 2005 and then built back up again lower down:

1. The joint fused properly but misaligned. For a few weeks around the middle of 2005, the pain seemed to move around from right sacroiliac joint, left sacroiliac joint and L4, suggesting to me that if L5 and S1 were fused but at slightly twisted relative to each other, this would constantly irritate those areas.
   
2. My right sacroiliac joint was unable to handle the new stress from my upper body weight which used to borne by the disc at L5-S1. For some reason, this is worst when I bend forward and bearable when I am standing.
   
3. The fusion failed and the instability in L5-S1 was somehow manifesting itself in pain in the right sacroiliac joint and elsewhere. This was Dr C’s opinion.
   

In November 2005 I tried electro-shockwave therapy with Dr D aimed at my right SI joint. This was painless and non-intrusive but ineffective. Then Dr C injected steroid into the facet joints at L5-S1 to see whether that would help. The theory was that it would help alleviate the pain momentarily if the fusion had been unsuccessful. It didn’t help, but at least we knew the fusion was stable.

A few weeks later, a CT scan indicated something abnormal in my SI joint at the pain source. According to the radiologist's (?) report...

The sacro-iliac joint appears slightly asymmetrical. The joint space is not widened. There is suspicion of some slight increased density in the anterior aspect of the right sacral ala at the S2 level and there is suspicion of an ill-defined radio-lucent line. It is uncertain whether this could be due to an undisplaced hair line fracture. Otherwise no definite bony lesion is seen. There is no subarticular erosion.

No lesion is seen in the right iliac bone. There is some defect in the left iliac bones below the crest. This may be the donor site for bone graft.

The position of the cage for the L5/S1 fusion appear satisfactory.

The L5/S1 facet joints are unremarkable.

The slight sclerotic changes and the radiolucent line in the right sacrum raises the possibility of a stress fracture. Otherwise the sacro-iliac joints are unremarkable. The position of the L5/S1 fusion device is satisfactory and the L5/S1 facet joints are unremarkable.

A steroid injection into the right SI joint was ineffective in reducing the pain, however I had a suspicion that the local anaesthetic (which wore off within an hour) may have been partially effective in reducing the pain. I am not sure because the soreness of the injection site made it hard to tell.

In Dec 2005 I went to Australia and visited four different specialists who had the following things to say:

Neurosurgeon #1
“I am not the right sort of specialist you should be talking to.”

Pain management specialist
“Your body is extremely sensitive now after so many years of pain that you really need to recondition it to help you manage. I recommend the Feldenkreis method but don’t know anyone in Hong Kong who can do this with you.”

Neurosurgeon #2
“Your fusion looks good, although in Australia we don’t do this operation. We’d use an artificial disc like Pro-disc L or Maverick. As a next step, you might try RFD – radio frequency denervation.”

Podiatrist
“Your ankles are pronated and this is probably putting a lot of stress on your knees. With orthotics in your shoes, you should be able to relieve some of the stress on your knees.”

I got the orthotics and they appeared to help my knee pain for a few weeks because I could crouch properly and therefore put less stress on my lower back.

When I returned to Hong Kong in Jan 2006 I had another pair of facet joint injections at L4-L5 and this seemed to do nothing for my right SI pain, but at least I don’t have inflammation at L4 anymore.

In Feb 2006 I was advised to have a blood test to check for arthritis and this came back negative.

In June 2006 I visited Australia again for the sole purpose of sorting out my back at a spinal clinic. I had injections under X-ray at the L4, L5, SIJ and hip levels and none of them did the slightest thing for me. The doctors at the clinic suggested that prolotherapy or an implanted electrical pulse into the right SIJ might be helpful but since I had to return to work in Hong Kong, we didn’t explore either of these treatments.

In August 2006 I went for some tests on my heart to see whether the pain I had after taking Arcoxia was something I should worry about. They could find nothing wrong with it, although I stopped short of taking a blood test as I got busy.

In October 2006, my knee pain was quite high but I could still use them. It helped to wear shoes with no heel (eg. sports shoes). Walking up and down hills / steps was horrible.

I have constant dull pain in my lower back which is caused by the right SI joint pain. I can audibly pop my right SI joint when it is loose (eg. in 2006 this was after a shower or swim but now I can do it at any time), despite the fact that this joint is supposed to be very strong. I sleep badly and rolling over in bed is something I need to do carefully.

I am taking the following supplements but can’t say whether they do anything:

Cod liver oil capsules (3 times a day)
Glucosamine capsules (3 times a day)
Multi-vitamin (Once a day)

In January 2007 I got around to scanning the various films and discovered that theory #1 could be justified as L5 and S1 are misaligned by 3 degrees.

How significant is a 1% misalignment? Given the irregular and large surface area of the SIJ, I imagine it could be significant. [Once I figure out how to do it on Blogger, I will upload some Photoshop mock-ups of how the joint might look with S1 rotated to the left 3 degrees.]

At the end of January, I took these findings to Dr C and I demonstrated my SIJ popping for him. By putting his hand above my right buttock, he was able to feel and hear it. He (resignedly) proposed SIJ fusion on one or both sides. I asked whether there was any other hope such as physiotherapy and he reminded me that I had already tried that unsuccessfully. He admitted he had only ever done a SIJ fusion (in the case of SIJ infection).

We talked about breaking the cycle of pain so I could have successful exercise, and he suggested I try some Naprosyn anti-inflammatory tablets which I hadn’t tried before:

Naprosyn 250mg, two tablets, twice a day after meals
From Fri 26th Jan - Sun 4th Feb

I took these for a week and they did nothing. At least they didn’t cause heart pain like the Arcoxia.

On a separate topic, I should note that I woke up on Sunday 7th January with a sore and stiff neck. My wife was able to relieve the stiff muscle on my left shoulder about 2 weeks later through massage, but my neck seems to have lost some of its mobility and is a little painful at some angles. I imagine this was caused by lifting my whole weight with my arms when getting up from the floor or a chair in the previous few weeks. The Naprosyn was supposed to help that too but they didn’t.

In Feb 2007 I went to see Dr E who advised against a fusion of the SIJ and recommended swimming instead. He admitted he had never done such a fusion before.

A week later I saw a physio who gave me a massage which relaxed the muscles in the region but caused a sudden huge sharp pain in the right SIJ. He asked me to stretch my pyriformis and hip flexors 3 times a day for a week and return. He also gave me the name of Dr F - a younger orthopaedic surgeon - who might have a different opinion about my back.

Dr F spent time (over an hour) to understand my predicament, and asked for copies of my MRIs and X-rays. He asked me to do another set of extension / flexion X-rays in his clinic to see whether the fusion was indeed successful. Bending backwards for the extension X-ray was very uncomfortable (especially as I was in a standing position) but I managed to hold the position enough for a reasonably clear X-ray. I will write more in my next post about Dr F’s diagnosis.