Bulging Disc Programming Adjustment

[azeemqwerty]

So I had a long post months ago of what i thought was a tendinopathy or strain or perhaps even bursitis (for the last 6 months, even with adjusting loading and programming) but it has not been getting better really. The last month or so I also noticed that i have very light pins and needles in the bottom of my left foot (as well as the pain in my glute and from below the knee to the ankle) so i followed up with my doctor and he thinks it could be a bulging disc all along, that is irritating a nerve. He ordered an MRI (thank you Canadian health care system) but I dont know when that will be, nor if it is even important to see since the prognosis is pretty good regardless of what it is.

The last 4 weeks or so I decided after months and months of still loading the spine with squats and deadlifts (even very light loads) that I would try doing even lighter weights and adjust how I am loading the spine/legs by doing walking dumbell lunges instead, for higher reps and sticking to RPE. There has been some progress I think so I may do this for a little while longer before going back to squats and deadlifts (deadlift range of motion had to be reduced prior but still mostly there for squats).

My questions are:

Would there be potentially more benefit in doing something like a belt squat? or is this potentially putting myself in a trap of avoiding spinal loading (even if just for a matter of a few weeks/months)? Or just stick to things like walking lunges (currently in my deadlift and squat slots in my programming). I mean i do still overhead press with manageable pain, but at this point it has been 6 months of daily pain I would just like to start doing what I can to aid the healing process.

Would there be benefits to doing things such as dead hangs? From my very brief research the evidence seems pretty anecdotal. To "help" decompress the spine and help maintain grip strength (although I doubt itll be enough force for either).

Thanks!

[MikeAmato]

Hi, thanks for the questions! Before going into the specific questions, I would say you're going a good job of adjusting your training and finding ways to remain active and load yourself in some format. Even with confirmation via MRI that you have findings of lumbar disc changes, symptom presentation and pattens can be highly dependent person to person. Unfortunately, it's not as simple as increased load on the spine = more symptoms due to the complexity of pain and nerve physiology. That being said, we can flip that in a positive light by focusing on how you tolerate certain activities.

So back to your questions, if you're finding that lighter load activities like walking lunges are more tolerable and allow you train, that's a great place to start. I don't see why you couldn't try a belt squat and gauge if you're comfortable and tolerating that activity. Most cases like this are helpful to find that starting point and being comfortable with slowly progressing from there, allowing for flexibility in the program week to week.

As for the dead hangs, the evidence on spinal traction isn't that supportive. If you find some benefit in performing chin ups, hanging leg raises, etc, I don't see a problem with that. I just don't think you need to introduce "decompression" to the spine, since compression on our body is a constant. And going back to if there's disc finding, tolerable increases in compression/load may be beneficial in tissue healing.

Like I said earlier, radicular symptoms as you're describing can be a frustrating symptom presentation (I can relate a bit having had my own experience with it in the past as well), but doing what you've doing so far, and continuing to find ways to train is great. I'd likely have further questions about your daily activities, work, etc. since that will help build a bigger picture, but let me know if that makes sense on the specific questions you asked. Also, are you currently/had you been receiving any treatment, medical or therapy wise?

[azeemqwerty]

Thanks for responding!

In terms of work, I am on my feet all day (customer service at a library) and I do not like to sit as it is typically painful, especially after getting up from being seated for a while). Then either I go to the gym before work or after work. I drive very short distances as well. I do notice that by the end of the week that things tend to feel a bit worse, but far better than if i had been sitting at work in that same time so thats a win in my books. I have noticed some temporary relief from when i do isometric ab work such as planks and side planks on my GPP days.

In the first 2 months i was going to physio and i have seen my doctor regarding it about three times just following up with progress or regression/change in symptoms. In physio they just recommended adjusting, said I had neural tension, was imbalanced, and to do very nonspecific exercises to make up for these imbalances. It did not help, in fact some things made it feel worse after so I stopped.

The tougher part is that even loading at the gym it is hard to guage that the load was appropriate or not until later in the day and even up to the next day to determine if it was too much - it also seems to vary almost day to day and RPE does not seem to sync with the resulting pain afterwards so I have been trying to stay on the more conservative side (such as the lunges). But I do try to remember the idea of embracing the process - and the almost critical period in which things are improving and perhaps symptoms and pain may subside completely but that I should still try to be more conservative and titrate things up slowly.

I will start to belt squat and see how that goes, and keep an eye on the overhead press to see how pain is afterwards and if modification of the load is needed.

[MikeAmato]

That's fair, and it's not too uncommon that radicular symptoms can be frustrating from that stand point, with high variability and delayed onset of symptoms. I think the important thing to focus on, like you said, is embracing the process and keeping track of variables you can control: RPE, load, exercise variation, daily activity, etc. I wouldn't worry too much about the imbalances and corrective exercises, but I think you've already figured that out as well. As long as you're comfortable with taking your time and titrating up slowly while deciding what's a tolerable level of symptoms, you should definitely see some progress. Keeping the focus on function and training will go a long way.

[azeemqwerty]

While i understand it is highly complex and there are tonnes of variables and inter-individual variation; any idea the length of time something like this would take to return to baseline? Just curious because I am approaching 7 months now and its mentally quite fatiguing.

Also, belt squat today went pretty well, followed by overhead press which went less well but its tolerable.

[MikeAmato]

That's a fair question but it is hard to give time tables based on what you said (variability), and that can definitely be one of the more trying pieces when it comes to rehab. However, I think it can come back to how you we frame these situations on different levels, making time a positive variable. Sometimes what's helpful is breaking down what your goals are, and separating them into short and long term goals. While returning to baseline is definitely an appropriate goal, sometimes we can be a bit lofty by shooting for one big goal. Even the concept of "returning" to baseline can be challenging. This is where I sometimes have a discussion about setting a new baseline, one that can even be better than what your previous baseline was. So, some questions that might help you frame the timeline of this situation would be:

What was your previous baseline, prior to these symptoms occurring?
If you were to fast forward in 3 months, where you want to see yourself in terms of function/training?
Is there a goal we can set for 1 month for now that you feel can push you in that direction? i.e. Increasing your belt squat to ____.

Also, I'm stoked the belt squat went well! As long as the overhead press is tolerable you can keep playing with it.

[azeemqwerty]

Baseline I kind of think of in a tiered approach. One is being able to do simple daily tasks with no pain. Sitting down having a meal, standing for longer periods of time, going to the bathroom, driving, would be great to have no pain doing. Then there are previous exercises even at light loads and then there is returning them to previous strength and size (squat 380lb and deadlift 430lb - 5'10", 172lb) again since I have been able to maintain the upper body movements. I do know those may take longer to regain however and I am okay with that.

Again the harder part seems to be that i can do these with tolerable pain in the gym and feel okay in the gym its afterwards that i feel like i went beyond what i could tolerate - which is why sometimes still i am skeptical about the overhead press - I will have to experiment it in isolation (I tend to pair it with a lower body movement).

In 3 months I would like to be able to sit pain free and do those movements at light loads, bonus if the tingling in the bottom of my foot and occasional numbness near the ankle are gone too.

1 month, I will work to set a goal in the belt squat since it is a new movement and i think write now im just getting the technique and slowly upping the loading to tolerable levels of pain/discomfort outside the gym after. I like that Idea.

If I find the overhead press is bothering me, any suggestions for a shoulder movement to explore? I found that incline CG press irritated the spine, and seated dumbell press is hit and miss.

Thanks again!

[MikeAmato]

That all sounds very reasonable and that plan should get you moving in the right direction. For overhead press, you could always try a single arm standing DB press. It'll cut the load on your body by more than half and you'll still be able to train the shoulders with a good stimulus. After a block of this, I'm sure you could fold the barbell press back in at lighter intensities and moderate volume (~8 reps).

[azeemqwerty]

Thanks again. Had an appointment scheduled for 5 months I have been waiting for with a Physiatrist only now it has been booked over and I have to wait until October. One of the downsides to universal health care. Incredibly frustrating, I'm sick and tired of being in pain every single day.

But I will try to plug those in, standing and seated perhaps for the shoulder press and I will monitor the belt squat, yesterday didn't feel too good after (but I did isometric abs at the end and that always helps for a while). Might try rack pulling (or RDLs) for light loads as well since it has been several weeks since I've tried that again.

And I'll try to focus on goals (short and long term). I'm really hoping I won't need that appointment come October, just sometimes I feel like I have no idea what to do to help move forward.

[MikeAmato]

Where are you located in Canada? There's a chance we can find a trusted provider for you, but I'm not entirely certain if it's possible within your system.
You have some good ideas right now to make steps forward, but if you find that you need more structure and guidance we also provide rehab consults and programming. Keep us informed how things go and we can make some decisions from there!

[azeemqwerty]

Thank you again for your insight and all the information Barbell Medicine gives out.

I am in the Greater Toronto Area (just outside Toronto actually). It can be tough finding evidence based treatments these days - a lot more perpetuation of minor imbalances, weaknesses, knots, and fac release treatments to anything under the sun.

But thank you, i will try to stay focused and work towards smaller goals step by step.

[MikeAmato]

You're welcome! Yes it can be tough in most places, Toronto being no exception I would imagine. Off the top of my head I don't know anyone in that area I would recommend, but I will reach out to my network to see if there are options.

[Austin Baraki]

@JHG is in Toronto

[azeemqwerty]

UPDATE: So it has been 7 months, and the MRI I had 3 weeks ago did confirm it is a bulge/extrusion of the L5 disc, pressing on a nerve (and some narrowing in the surrounding area). My family doctor did recommend that I go through physiotherapy which I am open to and thankfully have work coverage for. Any tips on politely declining for passive modalities? It seems that is a lot of what most physiotherapists or chiropractors keep pushing.

My doctor also said that it should be fine for me to get back into training within range of motion and loads that do not worsen symptoms and very cautiously increase over time. He also did say that I may need to modify my training for years, but I am choosing to take that with a grain of salt lol There are some truly strong lifters with histories of disc herniation pressing on nerves and even broken backs that are just fine long term.

I am however continuing based on my knowledge and education as well as my doctors suggestion of remaining with a non-invasive form of treatment. He did prescribe me some stronger NSAIDs for particularly bad days for limiting how much it is impacting my day-to-day life (acetaminophen was not cutting it a lot of the time). I find some relief for a few minutes after doing isometric ab work as well (like planks, side planks) so I will continue doing that as well.

[Austin Baraki]

UPDATE: So it has been 7 months, and the MRI I had 3 weeks ago did confirm it is a bulge/extrusion of the L5 disc, pressing on a nerve (and some narrowing in the surrounding area). My family doctor did recommend that I go through physiotherapy which I am open to and thankfully have work coverage for. Any tips on politely declining for passive modalities? It seems that is a lot of what most physiotherapists or chiropractors keep pushing.

You don't need tips for this. You are the patient, you are autonomous, and you can consent to or decline whatever intervention you want.