I thought this could be interesting for a few in the forum as well as hopefully giving others insight on how acute low back pain is managed.
Onset:
Mechanism of injury: A flexion moment is created at the bottom of the front squat at the lumbosacral junction. Although slight, the lifter (foolishly) lost his stability in an attempt at further depth resulting in a ‘dive-bomb’ eccentric portion of the lift. This caused a rapid loaded sacral counter-nutation which is damaging to the annular fibers of the lumbar discs, most likely L5-S1. Injury is likely cumulative in nature.
Brief history: Coming out of the hole on the fourth rep I felt a pop in the lower lumbar spine just above the base of the sacrum. Popping was accompanied by immediate tightness in the area. Pain onset was minutes to hours later increasing in intensity until the night where it’s remained steady. Extension and right rotation are provocators. Pain is referred into right SI joint during provocative movements. No radiating symptoms.
Working diagnosis (I did a full exam on myself): Posteriolateral disc lesion.
Treatment goals: Prevent progressive radiating symptoms (this has happened before, last time degraded into sciatica). Eliminate pain during gait. Return to squatting pain free.
Plan: Unloaded lumbar extension based exercises, anterior hip static stretching, hip capsule mobility, McGill’s big 3 (curl up [beginner modification], side bridge, and bird dogs). All exercises will be performed at least once per day with stretching and capsular work being done as often as possible. Lumbar flexion is contraindicated until further notice. Re-evaluate after 2 weeks. NSAID use will be limited to only when necessary to aid in getting to sleep.
Caveat: This plan was developed after a full ortho/neuro/physical exam. This information is being provided for informational purposes only and is not meant to aid in the diagnosis or treatment of anyone’s specific injuries. Hopefully this serves to provide a commentary of the effectiveness of conservative treatment and portray an accurate timeline of positive outcomes for this type of injury. If not made apparent already, this is me so no privacy laws are being violated.
Please let me know if you have any questions or comments, I look forward to answering them.
Why the hip stretching and capsule work? Does iliopsoas typically go into spasm with disc lesions (should I know that by heart???) and for that matter wont piriformis as well given the lower level of the lesion? In your next phase of treatment will the SI joints need to be evaluated for movement? What is happening to the disc with right rotation; I know the left innominate is anteriorly rotating and the right innominate is posteriorly rotating… is the sacrum tilting to the left? Does that mean theres a shear force on the disc?
I have only assessed an acute disc lesion once before… did not go so well, it was the end of my shift and a colleague asked me to just start the assessment while he finished with a client. Well he never came over, I was tired and had never dealt with such an acute back before but it was a great learning experience! So forgive the barrage of potentially stupid questions.
The hip flexor stretching is to reduce anterior pelvic tilt. It’s more for long term issues than acute, but in the time being APT is putting me in excessive extension–especially during gait–which is painful. The right rotation provocation was a bit confounding but I had it narrowed down to a disc lesion and a SI ligament sprain. Both are handled somewhat similarly, so I’m working with disc currently. I did mostly my own exam so I was limited to what I could assess, but looking at SI movement would be somewhat useful. However, in my case, palpating or moving anything in the lumbar spine and sacrum is pretty painful so the information you would get from that specific test might not be worth additional patient discomfort.
Acute disc lesions are difficult to assess because the patient is in so much pain. You want to examine everything and be thorough but you have to keep patient comfort in mind so it’s probably better to get the bare minimum to confirm a disc and move right on to treatment. Grade the lower extremity MRS, find provocating movement, valsalva, straight leg raise, and move on to treatment. To be honest you get most of the information from the history and patient antalgic lean, then ROM and SLR/WLR will typically tell you where the lesion is.
But, my case is a less obvious disc I think. I have no radiating pain. SLR was negative while Valsalva increased pain but didn’t induce radiation. I can squat pain free but once the pelvis starts tilting posteriorly the pain increases which leads me away from SI.
Those are good questions and I encourage more. I am confident in this treatment plan and expect a significant decrease in all pain within 2 weeks. It’s nice because I know the patient will follow the treatment protocols
[quote]CroatianRage wrote:
The hip flexor stretching is to reduce anterior pelvic tilt. It’s more for long term issues than acute, but in the time being APT is putting me in excessive extension–especially during gait–which is painful. The right rotation provocation was a bit confounding but I had it narrowed down to a disc lesion and a SI ligament sprain. Both are handled somewhat similarly, so I’m working with disc currently. I did mostly my own exam so I was limited to what I could assess, but looking at SI movement would be somewhat useful. However, in my case, palpating or moving anything in the lumbar spine and sacrum is pretty painful so the information you would get from that specific test might not be worth additional patient discomfort.
Acute disc lesions are difficult to assess because the patient is in so much pain. You want to examine everything and be thorough but you have to keep patient comfort in mind so it’s probably better to get the bare minimum to confirm a disc and move right on to treatment. Grade the lower extremity MRS, find provocating movement, valsalva, straight leg raise, and move on to treatment. To be honest you get most of the information from the history and patient antalgic lean, then ROM and SLR/WLR will typically tell you where the lesion is.
But, my case is a less obvious disc I think. I have no radiating pain. SLR was negative while Valsalva increased pain but didn’t induce radiation. I can squat pain free but once the pelvis starts tilting posteriorly the pain increases which leads me away from SI.
Those are good questions and I encourage more. I am confident in this treatment plan and expect a significant decrease in all pain within 2 weeks. It’s nice because I know the patient will follow the treatment protocols :)[/quote]
I think your pretty spot on with the disc lesion. The mechanism of injury seems pretty clear. Im not sold on SI joint injuries being as prevalant as some of these gurus claim. I have seen it, but usually its one or two mobilizations and the pain reduces quickly.
The only other thing I could add is maybe try and gap it to the L (if your having R sided pain) for an extended period to get some relief.
MRS exam on L4-S1 is unremarkable. No nerve root involvement at this point. I’m managing this much better than I did last time so my guess is it won’t degrade. I think you’re right about the SI joint sprain. I’d also throw in facet pain as overused. It seems like pain with extension = facet no matter what. Gapping to the left is basically how I have to sit/lounge at home. Finding a comfortable resting position and trying to stand up from that position are brutal right now, other things I can typically work around.
The good news so far, is that after I very carefully do the McGill and extension exercises the pain is reduced greatly, almost to no pain.
I’m also dropping all hopes of weightlifting in the future. It’s not worth the risk of re-injuring this thing. Especially since it was only at 240. Once I’m healthy again I’ll have to reevaluate whether keeping the weightlifting shoes is a good idea and will raise my depth considerably. A complete switch to box squats might be in order.
[quote]CroatianRage wrote:
I’m also dropping all hopes of weightlifting in the future. It’s not worth the risk of re-injuring this thing. Especially since it was only at 240. Once I’m healthy again I’ll have to reevaluate whether keeping the weightlifting shoes is a good idea and will raise my depth considerably. A complete switch to box squats might be in order.[/quote]
Na, you just need to revamp. Although its good to work a quick squat and eccentric to elicit stretch shortening cycle at times, the majority of your lifts should be moderate tempo. I do quick squats like these during a speed strength block with 30-50% maximum. The eccentric just appears too rapid at this point (quick eccentric does help you lift more weight) and also too deep. I am a fan of whole range squats but honestly do not recommend going much past 90 (90-100) loaded with >50% maximum. Too much stress on the meniscus and also the tendency to do just exactly what you did, which was fold under fatigue with a flexion moment.
No traction. I have access to a distraction unit that the other doc in the office has, but I want to treat this the same way I would with a patient. That being said, I probably would manually apply traction to a patient, but I don’t think it’s necessary for me at the moment. I’m following what I think is McKenzie protocol (never been to a seminar, just read chapters in a book about it so I’m not positive) and I’ve already progressed a lot in two days. Since this morning even I probably have at least 50-75% reduction in pain. It’s amazing how effective this is.
Haha, right? Everyone worships the guy. He’s clearly very smart and good at what he does, but everyone talks like he’s putting out these revolutionary protocols that have never been seen before. Every single mobility WOD I’ve watched is either SMR, PFS, or static stretching. His book didn’t make it into my office library, just sits on my shelf at home. I definitely have buyers remorse.
Woke up this morning and for the first time since Wednesday didn’t have pain. Right rotational pain seems to be greatly diminished, if not resolved. Extension pain only arises at end range, where before it was through the whole movement.
I think the acute inflammatory stage is over. The reason this happened so quickly is because I haven’t flexed my spine since injury and did my exercise protocol every day. I will continue what I’m doing through this week and probably re-eval on Friday. If everything continues along the path it’s on now, which I highly suspect it will, I will return to the gym Monday to revamp my squat and start working on my strength again. All said and done, this will hopefully be a successfully treated disc derangement in 1.5 weeks with no imaging, 2 uses of NSAIDs (1 time was more for a hangover than the back), 1 adjustment (that was in the wrong place, and I shouldn’t have gotten), 1 application of Kinesiotape, and no additional manual therapy.
[quote]CroatianRage wrote:
Haha, right? Everyone worships the guy. He’s clearly very smart and good at what he does, but everyone talks like he’s putting out these revolutionary protocols that have never been seen before. Every single mobility WOD I’ve watched is either SMR, PFS, or static stretching. His book didn’t make it into my office library, just sits on my shelf at home. I definitely have buyers remorse.[/quote]
Haha, ya thats why you get a hand me down online copy and look at it once n forget it.
Hi. If is possible, can you please tell me exactly what type of exercices you did and what type o streching you did as well. I want to now, is look like I got similar problems and I want to start a reabilitation program. Cheers, Gabriel
Everything I do is listed in the original post. Stretching the hip out wasn’t necessary for this treatment plan but it actually helped quite a bit. Just find something that doesn’t flex your lumbar spine or increase pain. One of the only exceptions to increasing pain when performing rehab is the extension work with a disc. It will likely increase pain right at the disc, but decrease peripheral symptoms, which is more important.
Another update:
Subjective: Long bouts (2+ hours) of sitting create what I would describe as soreness or discomfort in low back. I was on airplanes all weekend which didn’t help. Waking up in the morning still with a very minor twinge of pain .5-1/10.
Objective: Lumbar AROM WNL with no pain in all directions. BW squat and PVC overhead squat pain free with full ROM. Gait is pain free. All treatment goals met.
Plan: Continue McGill’s big 3 and increase intensity as necessary. Mobilize hips and thoracic spine/shoulders as much as possible. Return to the gym–squats will be high bar and end at or slightly below parallel, deadlifts will be with dumbbells, will have to evaluate press and bench as the hard arch may be aggravating. Everything will be light and moderately high volume. Re-evaluate after 1-2 weeks.
One month post injury I am returning to the gym full time. I am currently able to squat slightly past parallel with minimal/no posterior pelvic tilt. Squats are now done in Chuck Taylors without knee sleeves to encourage full ROM throughout the lower quarters. I also switched to sumo deadlifts and they feel much better. Both of these changes have exposed that my hamstrings are painfully weak and I’ve found out that during squats and deadlifts I’ve always shifted the weight forward to put the stress on my quads and low back.
Thats a pretty good turnaround time for a disc! Gotta drive through your heels with squats though, best cue I use is imagining youre trying to push the ground apart.
Yeah, I think I’ve always told myself that “quad dominant” lie as an excuse to cheat the movement to compensate around weak hamstrings. Hopefully this thread can highlight that these issues don’t have to be incredibly expensive to treat with surgical consults and tons of imaging. To be honest, I wanted to Xray my back out of curiosity, but I had to fight the feeling.
Some things I’ve learned (some I already knew but was too stubborn to admit):
incorporating breathing and core bracing strategies before lifting is better for me than doing a mobility warm up.
using weightlifting shoes and knee sleeves to compensate for lack of ROM is a bad idea.
I’m more proportioned to do sumo deadlifts. I was able to do more weight with a neutral spine even though I’ve only done it 3 or 4 times.
Weightlifting is not for me, I’ll stick to powerlifting movements and MAYBE power cleans eventually. Full clean and snatch isn’t worth the risk in my case.
Extension based protocols are incredibly effective when done correctly.
