Finding my entry point

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Hey all, I’m trying to get back on track following an injury on 6/5 and could really use some advice. I was on week 10 of the Beginner Program (though I’ve been barbell training very consistently for over a year now) and I probably got a little greedy with the paused deadlifts — they’re an unfamiliar movement for me and I was pulling what turns out to be an e1RM in excess of my conventional deadlift e1RM. I felt a very large pop in my lower left back on the third rep and immediately set the bar down. I’m familiar with the BBM advice on how to handle this, so I tried to stay positive, walked around as much as I could, and later in the day, did some bodyweight squats and RDLs — I was awfully sore, but I was confident it would be only a few days inconvenience like past back tweaks (of note, they’ve all felt like delayed-onest muscle strains of the low back — no acute popping noise). I continued like that, adding just a tad of weight to the RDLs, until Friday, when I decided to try a very light workout.

For that Friday 6/9 workout, bodyweight squats felt fine, and 45lbs, 65, and 85 all felt quite strong; at 95lbs, I still felt great but suddenly experienced another painful pop in the same location after a few reps, which left me hurting even worse — pain on that left side of my lower back, but also lots radiating down through my left quad and adductors, and lots of paresthesia on the left thigh. I did see a doctor at that point who wasn’t worried (no red flag symptoms) but prescribed some Norco since I was sleeping terribly and ibuprofen/acetaminophen weren’t cutting it.

A week later, on 6/16, I was still sleeping terribly, hurting constantly, but improving some, but I bent over to tie my shoes and had yet another painful pop — by miles, the worst one yet. I spent that day writhing on the floor in pain, helped only a bit by a few 15mg doses of Norco. The week since then has been more of the same — I’m much better than the first day, but it’s hard to sleep, my back, quad, and adductor hurt at unpredictable times in unpredictable ways, and my skin sensation is really weird.

So, my questions: 1. I understand reducing intensity and searching for what I can do that doesn’t cause pain, but that doesn’t seem to work in this case where anything or nothing can cause unexpected excruciating pain. I don’t know how to dial in the entry point if I’m terrified that the next 5 pounds will cause me weeks of horrible pain all over again. How might I go about this?
2. I have critical family and professional obligations right now and the pain is making it exceptionally hard to focus on them. For now, my training is infinitely less important to me than getting these on track. I know movement and stress will help with healing if dosed appropriately, but I can’t risk further injury for the sake of pursuing strength. Is there a difference in how to think about training right now if the goal is simply reducing pain and managing to sleep through the night?
3. With these challenges and priorities in mind, would the low back pain template be a smart place for me to focus? I checked out the trial and can’t find a clear description anywhere of what the “hip extension” exercise is that’s heavily used through the first week (I assume that’s in the eBook for the paid version), but the rest seems like a lot more activity than I feel confident enough to tackle just yet. Thanks, all — I really appreciate any advice you can share.

[Derek_Miles]

First, I hope you are seeing some progress with daily activities. What you are describing from the initial injury to now is relatively typical, but that does not make it suck any less. We tend to associate those pop moments with more of a strain type injury. That being said, I’ll be entirely clear that we don’t have any really good evidence with which to make that as a definitive thing. It is an instance though where I would definitely slant towards the “bio-” mattering a bigger deal. The prognosis of those is good, but it is not uncommon to set off symptoms again with some lighter weight training.

With the symptoms radiating into your leg now, that does change the trajectory and the first step from a rehab perspective is working to centralize symptoms. One of the first ways we check that is by having athletes do repeated flexion and repeated extension. In both of these instances, it’s better to think of it as moving more than trying to find where end range of motion is. Remember, we’re trying to alleviate symptoms, not increase them. There are two positions we can check these in.

Flexion standing- Standing up, bend forward like you are going to touch your toes 10 times. Emphasis on like. If you find you can go a little farther or symptoms start to centralize (move out of your leg and more into your back) then you have a flexion preference. From here, you can work more into those patterns to get moving again (more on this in a minute).

Flexion on your back- This is the easier version if things are really flared up. On your back, pull one knee to your chest, then the other. Repeat this 10x as above and see if symptoms centralize.

Extension standing- Stand with your hands on your hips and lean back like you are going to look at the ceiling. Go as far as you can tolerate and repeat 10x. If this centralizes symptoms, you have an extension preference.

Extension on your stomach- Laying on your stomach, press up like you are going into upward dog as far as you can tolerate, repeat 10x

If you centralize, that is great from a prognostic side of things. For whichever direction, the exercise in the beginning is starting with the repeated flexion or extension exercises (whichever one worked, you do not need to do both). Beyond that, it can be good to start with some very basic exercises like glute bridges (20x or to tolerance), clamshells (20-30x to tolerance) and I cannot emphasize this enough, go on some walks. One of the biggest things that tends to loosen things up is moving in some light, easy ways. The big priorities are calming this down to where you can sleep through the night and where you can do daily activities without issue. If you can start with a 10 minute walk and increase it to 20 minutes, it still is short of being able to do everything, but you have doubled the amount of time you can move.

If it does not centralize- you can still start with the short walks and build from there, but you don’t need to perform the repeated flexion/extension.

The set of exercises that people tolerate early on tends to be different for radiculopathy but as a rule the guidelines right now are gentle and slow. To your point 2, you don’t need to focus on the pursuit of strength right now but rather getting to where things are feeling better. I will typically have athletes start with things like lunges through tolerable range of motion, light sled pushes, and machine work. Having the constraints for range of motion in play tends to make it easier to control and avoid anything quick that will setoff symptoms. The oversimplified advice here is the more the motion is controlled, the better it tends to be tolerated.

For reintroducing barbell work, I would hold off until you are sleeping through the night without issue. There are plenty of ways to occupy training without needing to squat or deadlift right now. I would start back with pin squats and cap RPE at 6/7. You don’t need to get that close to failure to keep your gains and once again, the biggest priority is symptom relief. If you are squatting 2x/week, you can take one session and set the pins to tolerable (or what you feel is safe) range of motion and work on taking the weight up in that range. The next session, I would drop the pins one hole, and work a little lower with some lighter weight. You can also get some more volume in here with things like a leg press or hack squat but still, I would keep that RPE 6/7 cap in place.

Deadlifts-I would start with RDLs where you can control the range of motion or pull from blocks under the same principle as the pin squats above.

Bench-You can start with variants like feet up bench press and add in the extension as symptoms allow.

How symptoms tend to behave in these instances is more of a red light/green light than slowly fading away. They tend to progress into good days and bad days and the goal is to chain more good days together. It is pretty common for when symptoms are present for them to still be at a higher intensity. I would pay more attention to the trends week over week versus day to day.

From your report here, I would say this would likely be better off working with one of us on the rehab team where we can talk through expectations and modify workouts according to your symptoms as well as answer any questions you may have. The low back template could also work in this instance, but given the critical family and professional obligations, it is likely better to be able to discuss what is going on the fly as opposed to working through it on your own.