Acute L4 symptoms with PR Deadlift in first meet

Pain & Rehab Forum [Moderated]
1

I’m 59, and my wife and I completed our first meet two weeks ago.

With last deadlift (which got white lights) I had acute left L4 “cramping” … I coached myself to avoid catastrophization, and tried to enjoy the moment. But each day worsened … now with RPE 9+ pain with walking > 20 yards or so … lateral malleolus feels broken, and burning pain in posterior butt/hamstring, but all better with lumbar flexion like sitting.

No motor symptoms

Contralateral (but less severe) pain took up most of 2019-2020, but resolved, and I trained through it. But I can’t train through this … unloaded standing hits RPE 10 (I.e. makes me quit) after 60 seconds or so, but resolves with flexion.

It would be a good time to hear imaging rationale in ACUTE situations, like this. I’ve coached my self and others to wait before, but somehow need to hear advice like this personally this time

So, without “red flags” like motor symptoms, urinary retention, cancer hx, fever, etc., is there ever a rationale for imaging in acute disc herniation?

2

Howdy,

Thanks for joining the forum and congrats on the meet, though I’m sorry we’re “meeting” like this. I have a feeling you already know the answer based on what you wrote, but it’s different when you’re the one who can’t stand for 60 seconds, so here it is anyway.

No, absent red flags, there’s not really rationale to image something like this in the short term, for the reason you already know: it won’t change what you do. The threshold for imaging is whether the result would change management, and pain severity by itself doesn’t meet it. What meets it is either red flags (progressive or significant motor loss, saddle anesthesia or retention, cancer/infection/fracture suspicion) or that you’re weighing an intervention that needs imaging to plan, meaning surgical or epidural steroid injection (ESI) candidacy.

That conversation generally doesn’t open until severe symptoms have failed conservative management, usually around the 6-week mark, or a progressive deficit appears. ACP and Choosing Wisely say as much. Of course, none of this is particularly useful when you’re in pain, but by itself it’s a reason to treat symptoms rather than to image.

As you know, acute radicular pain like this tends to peak early and settle substantially over a few weeks, and most resolves on conservative management. Your 2019-2020 side resolving is your own proof of concept.

Practically, you’ve already found flexion offloads it, as does being seated, so you can probably figure out some movement you can do with those things in mind. Bias your positions and movement toward what’s tolerable, e.g. obviously machine work, but also standing stuff with supoport like a supported split squat or bw squat (holding onto the rack). Reintroduce load and additional movements as it calms.

When the acute phase passes and you want a structured way back, the low back rehab template is built for this, and our rehab consults are there if you’d like to have someone else providing guidance

Further reading

1 Like
3

That’s the reassurance that I needed …

I had a friend mention that ESI in acute herniations may be helpful for symptom relief … which brought up the imaging question. It’s tempting since short walks ramp up to RPE 10 “tap outs.”

Can you describe the point to consider a rehab template? Specifically, once I am able to get “any” loaded ROM of barbell lifts, is that the point?

(Also, this isn’t our first meeting – we met in 2019 at a BBM seminar, and it was that that helped me be confident about my first episode, to thanks again!)

4

I think if you’re having issues finding exercises you can do, the template is a good resource for options and how to find that entry point. The template is not only barbell exercises, especially to begin with. I think if you are up to do some seated- and machine-based exercises, the template is probably a good idea in the near-term.

Good to hear from you again. I miss doing those seminars. Maybe we’ll get back to doing them someday…