Herniated Disc Rehab Options?

Pain & Rehab Forum [Moderated]
1

Hey everyone, new here. Forgive me if this question has already been answered, but I wanted to provide some history.

About 17 years ago I suffered a lower back ‘injury’ while heavy lifting at work, which caused severe pain and loss of mobility at the time. This was initially treated through Osteopathy, which (for whatever reason) worked, so there were no scans and no formal diagnosis. Over the years however, I would suffer recurrence of that pain at regular 6-12 month intervals - there was never any one ‘trigger’ apart from stress, though the pain would almost always appear suddenly (following some form of sudden movement) and last for a period of days or weeks.

I eventually found that the most effective treatment when the pain reappeared was to simply try and operate as normally as possible, moving the problem area through the full range of motion, and taking NSAID’s to take the edge off when needed. I picked up a few stretching exercises which were at times very helpful and at others not at all. But in any case, I would usually return to baseline (either no pain or easily tolerable pain) within a couple of weeks max, though there were also 1-2 occasions where it remained severe for months on end.

However, despite being fitter and more active than ever over the past few years, the pain started reoccurring at much shorter intervals than before, averaging once every 2-3 months at various levels of severity. It is slightly different in each episode, and can range from dull stiffness and soreness in the lower back and legs, to sudden, sharp, stabbing pain throughout the lower back, hips, glutes, legs, and ankles (though predominantly on the left side of my body). During the last episode back in November 2019, I was given cortisone injections from my local GP, and although it seemed to have a low/moderate impact on the pain, it did not actually speed up my recovery and eventual return to baseline.

Now, in the current instance, I had just started the BBM Beginner Template in February, and was doing really well with my Deadlifts and Squats. One day about 6 weeks ago I was doing Squats, and experienced a sudden sharp pain in my lower back as I locked my knees at the top. I was able to complete my workout, and although it still felt a little tender the next day, I returned to the gym and started my workout with Deadlifts, thinking the best medicine was to simply keep training. Perhaps I got hung-ho and overloaded the bar, but when I tried to start my 3rd set at RPE8 (4 x 120kg) - something ‘popped’ or ‘clicked’ and the bar didn’t make it more than about 2 inches off the ground before I dropped it in agony.

I returned to the gym a few days later, with the intention of reducing the load or simply completing my workout with an empty bar if I had to. From memory, I think I was able to squat 30kg about 4 reps before having to stop due to the pain. I could not Deadlift at all. As the gyms are currently closed, I have spent the last month doing squats and deadlifts at home using 15kg dumbbells, which (with painkillers) is tolerable, but which does not seem to be aiding in my recovery - as each session is followed by a significant increase in pain for an hour or two.

Although there has been a mild degree of improvement since the most recent ‘incident’, I finally decided to go and see a Dr who specialises in Orthopaedics and Sports Medicine. I had an MRI done of the area, and we reviewed it today. He confirmed I had a herniated disc (L5, I think) and this was placing pressure on my spinal cord. It was very obvious when you looked at the image. Whether this is a new injury, or the reoccurrence of the old one, I do not know. His prescription was to do a series of 3 Cortisone injections into the area, while doing a course of physiotherapy. These would apparently be more effective than my previous Cortisone injections, because these would all be focused on one area, and would be complimented with specific forms of physiotherapy designed to push the disc back into place, or something.

The problem is that these particular injections are not covered by my health insurance, (thus making them expensive for me) and I am already skeptical as to whether they are even necessary and effective. At the same time however, I want this pain to go away, and I am not seeing a great deal of progress with my own exercises etc. At present, the degree of mobility I have is slowly improving, but I cannot walk or stand for more than about 2-3 minutes without the emergence of pain, which after about 5-10 minutes becomes severe to the point that I must crouch or sit down for a while. Cycling is virtually painless, but I will always suffer an increase in pain once I get off my bike.

Google says that a herniated disc can be treated with moderate and regular exercise, and should usually repair itself eventually, but in this case it doesn’t seem to be happening. Again, the pain tends to come and go in different areas, with different levels of severity. There are (brief) moments when I feel no pain or loss of mobility at all, and others where it feels as bad as ever. What is the best road to rehab for me?

Any thoughts or advice would be much appreciated.

Thanks!

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Hey, thanks for reaching out. I am sorry you are experiencing this and I will do my best to provide you with some good information. There is a good bit to unpack here so this may get a little verbose. First, it is not uncommon to have recurring symptoms but I am glad to hear you were able to manage for sometime through activity modification. It is often difficult to provide specific advice without more information on what your training history has been, what your symptoms entail, and what your current goals are but I am going to give a more operational heuristic from which to start. It sounds like your symptoms are primarily in your lower back which is as excellent as it can be to experience pain from a prognostic standpoint. I would disagree with the recommendation for the cortisone injections as the evidence for their efficacy is weak at best. Plus, multiple steroid injections is rarely a good idea and unless the physician is planning to do these with fluoroscopy, there is not a lot of accuracy in where they are aiming. Discs do not get pushed back into place with either physical therapy or injections but there is some good evidence that they do heal over time.

The ultimate goal should be to find a place from which you can start moving and normally I try and have individuals focus on increasing “x.” It sucks that right now you are limited to only being able to stand or walk for 2-3 minutes but if you can start getting to 4-6 minutes, you’ve doubled your tolerance and are moving in the right direction. From there, it is working to be able to do things for longer periods of time while adding more “things” to the list of what you can do. Sometimes it helps to work with a rehab professional in these instances as it is easy to lose sight of what we can do because we are focused on what we cannot. If you can cycle, I would use this as a starting modality to continue being active. From there, it is about finding exercises that you can start with and build from there. Physio can be good for helping to find that starting point and if you interest is in more barbell oriented movements you may be better off talking to Michael Ray, Amato, Charlie, or myself through a formal consultation to work through a plan. Typically, the more chronic an issue is, the better it is to have a clinician with whom you can talk through the process as you return to training.

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Hi Derek,

Thanks a lot for the response and sorry for the belated reply. The situation is now as follows:

The last week or two has seen a noticeable reduction in overall pain levels (in frequency, duration, and intensity) and an increase in general mobility. The pain I got from prolonged walking or standing seems to be somewhat less frequent. It is by no means linear or predictable within any sort of pattern, but has nonetheless improved across a period of weeks. Recently I have put most of my focus on cardio (cycling) and body weight exercises (pull ups, push ups, planks etc) and so it would appear that this has helped in some way. However I can still feel (and see) a slight ‘twist’ in my hips to the left, and still experience both soreness, stiffness and sharp pains at random, so I want to proceed with caution.

In any case I (unsurprisingly) decided to forgo the Cortisone injections on grounds of their excess cost and low efficacy, but chose to pursue the Manual Therapy option, as the excess cost was negligible and I basically have nothing to lose by doing so. My first Physio appointment was this morning, and the guy basically said there were no quick fixes and guarantees, but that he wanted to try ‘working’ with the smaller stabilising muscles in the lower back and lower abdomen. He said there was no way to manually push the prolapsed disc back into alignment, but he spent some time massaging the muscle around the disc to ‘encourage relaxation’. At least that’s the way I understood it anyway - I am a New Zealander living in Germany, so the language barrier is often a problem on the finer points of any given topic.

He then gave me a basic, delicate exercise to do at home, which involves lying on my back with my knees up, and lightly extending my spine so that the lumbar region is raised up off the floor ever so slightly. I then gently contract the lower abdominal muscles as if I was going to perform a crunch, but again only ever so slightly - the idea being that I am only using smaller muscle groups. Then, maintaining this position with my hips level, I slowly turn my right knee/leg about 45 degrees down to the right before bringing it back vertical, and do the same with the left knee to the left. This can be done for 12-15 reps at a time.

For all I know this could be little more than quackery (kinda felt like it), but it was pleasant and I can’t see it doing any harm. The plan is to do another 5 sessions over the next month or so (unless I become convinced it really is a waste of time) and continue to carefully and progressively overload my resistance training. I am unsure how many other exercises (if any) he wants to introduce over the course, but we will see. I tend to believe that carefully managed resistance training and patience will do me more good than anything, which he also supports.

Which brings me to my next question, we have just got word here that the gyms will be reopening in 10 days time, so my primary concern right now is deciding on an appropriate program to follow once I get back in there. At the time this injury occurred in March, I was on week 4 of the BBM Beginner Template. Prior to that I had about 4 years of fairly regular resistance training and about 1 year of ‘casual’ barbell training. Since the injury and the lockdown, my strength is way down and I’ve put on body fat. I now have joints popping and clicking all over the place and I’m in pretty bad shape compared to 6 months ago.

I have read Jordan’s article in the latest BBM newsletter ‘Getting Back to the Gym after a Layoff’, which appears to be a lowered-intensity version of the Beginner Template. Obviously the objective here is to provide a bridge back to your previous strength/capacity by using lower RPE targets and incorporating more variety - which makes sense. I guess I am just wanting as much feedback and advice as possible on the most optimal approach for me. I.e. this template assumes ‘normal’ physical condition without the presence of an injury.

Would you recommend this template for me, and if so, how can I best adjust it for pain? I often find it difficult to judge my ‘true’ RPE and level of fatigue when I am experiencing sharp pain, as it is very distracting and unpleasant, and I often feel I could go heavier and do more were it not for the pain. Squats being a prime example. Should I simply approach RPE as a factor of ‘general tolerance to the combination of fatigue and pain’? For example, whatever I do - make sure that the pain does not exceed 5/10? I want to do as much as I can, but I do not want to go backwards by aggravating the injury.

The question of when to push through and when to pull back is obviously very difficult to answer, but I believe that I have definitely pushed myself too hard in the past. I understand that these are all complex and subjective subjects, though my goals here are very simple - reduce pain and increase strength/capacity as efficiently and safely as possible. I would then re-start the BBM Beginner Template from Week 1 once my lifting capacity reaches the corresponding level.

Any general feedback or advice would be greatly appreciated. Would love to book a consultation but right now it’s just not possible.

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Well, I just wanna state for the record that my back has massively improved over the past 2-3 months - and without surgery or any serious intervention whatsoever.

Let this be a testament to self efficacy for anyone else who might be in a similar position. It has honestly been an incredible, enlightening, and rewarding experience. It has also demonstrated to me that most Doctors really are just doing guesswork most of the time. Two different Doctors told me I needed serious intervention and ‘shouldn’t even be walking’, and one of them told me I needed invasive surgery - which I summarily ignored in favour of self-rehabilitation.

In short, I am back to where I was before I had this injury, perhaps a little stronger. When it first happened, I could not even bend down to touch the bar, let alone pull anything off the ground. The act of squatting with an empty bar was painful enough to make me fear I would never lift again. But through persistence and patience (starting with body weight and moving up from there), I am now comfortably at 265lbs for reps on squats and deadlifts - working through the rest of the BBM Beginner Template.

I do take painkillers sometimes to take the edge off after a particularly heavy session, but that’s it and I am less reliant on them with each passing week. I did do a short course of physical therapy, but that was literally just a weekly spot massage which achieved nothing in terms of recovery. In any case there were no medical treatments and no surgery.

Moral of the story, is that even when all seems lost, and Doctors are giving you nothing but doom and gloom, it is still possible to work your way back to health and mobility. Had I followed their ‘professional advice’, I would be in a far worse position, most likely hobbling around in pain, losing muscle, and wasting time. Neither of them ever recommended resistance training of any kind, and both were shocked when I told them what I was doing. They seemed genuinely mystified and intrigued that my self-prescribed treatment for back pain was to train and strengthen my back… Who would have thought?

As an addendum to this: my flat mate went to see one of these same Doctors today on account of some relatively mild lower back pain. He simply wanted to get a certificate to take a few days off work, but found himself being lectured to about his ‘weak back’ and the need to ‘do more back work’. He proceeded to inform the Doctor that he was regularly pulling 440lbs and squatting 407lbs, which seemed to make no difference. We doubt this guy has any idea how much weight that is, or what kind of strength is involved with those numbers.

These are the same types who are telling us to put on a face mask one day, and take it off the next.

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Adam,
I apologize for not seeing your post back in May but I am happy to see you achieved resolution of symptoms and are back training. We do have good clinical prediction guidelines with which to base prognosis for radicular symptoms but sometimes it is an issue finding practitioners who are aware of, and adhere to those guidelines. Your moral of the story is entirely accurate in terms of possibility and often it is a hard sell to convince individuals that this will take care of itself. I am glad you followed an active approach and are back to training regularly.