Your Guide to Low Back Injury Management

[MuscleScience]

Over the years I have seen many many threads on how to manage low back injuries. This thread will dive into the different types of lower back injury and the appropriate ways to manage them.

First off, this thread by forum legend, Doc Sust is a must read. http://forums.steroid.com/injuries-r...ine-rehab.html

The low back or Lumbar Spine is defined as the 5 vertebra at the bottom of the spine. The vertebra and the inter-vertebral disc in this area are the largest and most durable of the entire spine. However because of the forces that are transmitted through the lower back, it is a very common area of injury. Something that is unique about the lumbar spine is that the spinal cord actually terminates at about the L1 or L2 vertebral level and branches out into a bundle of nerves called the Cauda Equina. Remember this structure as we will be diving into its important later. There are actually many different causes or types of back pain, because of the many different structures that can be injured and generate pain.

To start we will dive into anatomy and its common patterns of injury.

Inter-vertebral disc:

The inter-vertebral disc is basically a fluid filled shock absorbing structure between each of the vertebra. Within these disc is a structure called the Nucleus Pulposus. This is a water/gel like substance that is acidic in nature but is very good at absorbing compressive forces. On MRI imaging, how much water or hydration content that is in this area tells the doctor the relative health of the disc and its ability to function properly or if it is healing properly after injury. The second important structure in the disc is called the annular fibers or annulus. This is basically a thick fibrous sack that holds the nucleous pulposus in place. These fibers are actually so strong, in a health individual that has some sort of traumatic injury such as a fall or car accident. The disc will actually crush the bone instead of rupturing. Think of the annulus as the steel belt that surrounds the the nucleus like and inner tube in a tire.


Annulus fiber tear and injury:

The annular fibers you can think of as a round tendon that is laminated. Many overlapping layers are what cause the disc to be so strong in nature. However with either repetitive stress, or acute injury these fibers can start to fray or tear just like a tendon can. These tears are often painful and can cause an ache or even shock like pain when they first happen. The disc as a whole is very good at resisting compression, but is not as good at resisting rotational forces. That is why you are not suppose to bend and twist at the waist when you pick up something, and is often a common way that these fibers can become torn. This tears can be minor in nature or can be quite severe.

Herniated/bulging disc:

Most people know or hear about this but often do not exactly know what it means. A herniated disc is a disc that has lost the integrity of its shape. The annular fibers we talked about above have become worn, stretched or torn. This causes the inner part of the disc to "bulge," or herniated into an area it is not suppose to. At any one time a person will have one or more of their disc bulging to a certain degree. It really only because a problem when the disc bulges or presses on a sensitive structure OR its inner contents "leak," out.

The disc can bulge or press on the spinal nerves, this is called Nerve Rood Compression. This is also commonly called a
"pinched nerve," or is one of the common causes of nerve compression. This is basically where the disc bulges and compresses a spinal nerve as it exits the spine. The interesting thing about this, depending on what part of the nerve is compressed symptoms can be vastly different. However, generally someone will have pain. Sciatic pain is often one we think of and we will talk about more in-depth later. It can also cause muscle weakness, sensory changes such as decrease in hot/cold sensitivity, balance/proproception, organ function, and so on.

Although uncommon but most commonly in weight lifters is something called Cauda Equina Syndrome. This is actually where a weight lifter will lift something heavy, hear or feel a pop and have instant pain. The disc will rupture and compress one or more of the different nerves that go to the bowels or bladder. The compression will actually cause a change in the function of the bowel or bladder, either causing problems starting or stopping the bowels or bladder or even cause severe sexual dysfunction. THIS IS A MEDICAL EMERGENCY, because the compression can be so bad that the brains signals to the bowel and bladder or blocked completely and one can't go to the bathroom or control going. The compression if left untreated will cause irreparable nerve damage and can lead to even death. Treatment for this when identified is immediate neuro surgery.

The inner disc material (nucleaus pulposus) is acidic in nature as I mentioned above. Because it is acidic it can damage and irritate other tissues in the lower back. It can cause damage to the vertebral body by dissolving the bone, cause inflammation to the ligaments and other tissue surrounding the disc and generally keep inflammation and pain in the area. Most people describe it as a deep boring pain that is typically not relieved by position or movement. Over time the body will wall off the acidic material and create a cyst if you will that the body will absorb which can take months to years depending on the severity of the initial injury. These cyst can become a problem if they migrate, press on a sensitive structure or cause pain. They can be surgically removed, but often are not because of the typical short duration they remain usually.

[MuscleScience]

Facet Joint Pain.

The facet joints are joints that articulate the vertebra to each other. Facet pain is often the pain you feel after you lifted something heavy and felt a pop and then pain was immediate. This is a sprained joint just like if you sprained your ankle and the processes at play are the same. The problem is, that the facets are around other structures and can either cause those tissues to experience secondary inflammation and pain. Sometimes sharp muscle spasms will accompany because of the swelling which puts pressure on the spinal nerves as they run directly below the joint an the boney canal that the joints form, these are called the inter-vertebral Foreman.

Lumbar Muscular Pain.

This pain can be caused by straining the muscles of the low back. This can be caused by heavy lifting, repetitive stress or sports injury. This is described as a pop or pulling feeling followed by gradually progressing pain over a few days. Often times people say they felt a pop, finished up what they were doing then pain came hours to even days later. This can be very severe pain or mild to moderate pain, it all depends on the amount of muscle fibers damaged. Most of the time the pull is such that icing and rest is sufficient and someone can go back to normal activities within days to a few weeks once swelling has subsided. In some cases, noticeable bruising may appear in the area which indicates a muscle tear. I actually tore one of my lumber spinal muscles to the point it was black and blue for weeks and a noticeable ball developed higher up on the spine that I still have to this day.

Many times people feel that their low back is weak and that is why the injury that area, and in some cases that is true. However, from an anatomical standpoint the lumber muscles are generally very strong and in reality. Overpower the weaker abdominal muscles which causes very problematic imbalances in muscular strength. The shear anatomical differences between the way the lumbar muscles attach to their bony points and the way the abdominals attach leads the lumber spinal muscles to have a vastly stronger mechanical advantage. As weightlifters we already know this, but the key to a strong and healthy low back. Is to have strong and balance core muscles.

[MuscleScience]

Spondylolisthesis:

This is where a vertebra has moved either posterior or anterior over another vertebra or bone relative to the curvature of the spine. The most common spot is the L5 vertebra sitting anterior to the Sacrum. This is usually caused by some sort of traumatic injury but can also be caused by degeneration, pathology or birth defect. The actual displacement is caused by a fracture in a part of the vertebra called the Pars interarticularis. This is an important structural component of the spine, the vertebra have two Pars on either side of the neural ring. If both fracture, that can lead to slipping of the vertebra upon the other. It is important to note, this can occur anywhere in the spine technically.

Often times a person will say that it is painful to arch their back into extension. In severe cases everything from mild discomfort, to sciatic to even lose of sensation in the legs and groin area can happen. Spondylolisthesis's come in grades, as measured by a percentage of slippage relative to the curvature of the spine. These grades are fairly easy to determine by xray evaluation. Determining the stability of the Spondylolisthesis is sometimes difficult but generally a specific series of xray images can help the radiologist determine how much the vertebra move in relation to each other. Stability is a key factor in how someone can manage this condition relative to its grade. Everything from simple core stabilizing exercise to specific bracing to exercise modification to surgery is the standard treatment. Most people will do very well with core stabilizing exercises. Often times people will need physical therapy or chiropractic care to manage flare ups of pain or discomfort. Surgery is often determined by how unstable the segments are and how severe symptoms are. Generally grade I and II slippages do not require surgery, grade III and above is when surgery is generally considered.

[MuscleScience]

Future use 3

[MuscleScience]

Future use 4

[MuscleScience]

Bump

[Marsoc]

I didn't read that. Is ur back hurt. I know when I stopped doing straight leg deadlifts. I noticed for instance if I were to shovel the snow. My back killed me after cuz the lack of conditioning. As soon as I started strengthing it I had no issues.

[KINGKONG]

Iam liking how this is shaping up MS!i have continual problems with my lower back that keep me from doing heavy deads..Doctors, well general practitioners can tell me very little about my issues because nothing is noticeable on a x Ray so I need to do my own reasearch and develop training to strengthen and avoid the problem areas..thanks for your time and also for reminding me to get on it..

[MuscleScience]

I didn't read that. Is ur back hurt. I know when I stopped doing straight leg deadlifts. I noticed for instance if I were to shovel the snow. My back killed me after cuz the lack of conditioning. As soon as I started strengthing it I had no issues.

You didn't read my posts above?

[Sfla80]

MS. I have not read fully. I want to jump on laptop before I get into depth on this.

Was curious any info on spondylolisthesis in this thread.?

[MuscleScience]

MS. I have not read fully. I want to jump on laptop before I get into depth on this.

Was curious any info on spondylolisthesis in this thread.?

Yes, that will be my next one just for you buddy.

[Proximal]

Nice job, MS - looking forward to your posts!

[marcus300]

Really great read MS, ive had lower back problems for yrs (prolapse disc) and this article makes interesting reading great thread.

[Sfla80]

Yes, that will be my next one just for you buddy.

Seriously, will be looking out.

[kelkel]

Good stuff MS!

[RaginCajun]

Facet Joint Pain.

The facet joints are joints that articulate the vertebra to each other. Facet pain is often the pain you feel after you lifted something heavy and felt a pop and then pain was immediate. This is a sprained joint just like if you sprained your ankle and the processes at play are the same. The problem is, that the facets are around other structures and can either cause those tissues to experience secondary inflammation and pain. Sometimes sharp muscle spasms will accompany because of the swelling which puts pressure on the spinal nerves as they run directly below the joint an the boney canal that the joints form, these are called the inter-vertebral Foreman.

Lumbar Muscular Pain.

This pain can be caused by straining the muscles of the low back. This can be caused by heavy lifting, repetitive stress or sports injury. This is described as a pop or pulling feeling followed by gradually progressing pain over a few days. Often times people say they felt a pop, finished up what they were doing then pain came hours to even days later. This can be very severe pain or mild to moderate pain, it all depends on the amount of muscle fibers damaged. Most of the time the pull is such that icing and rest is sufficient and someone can go back to normal activities within days to a few weeks once swelling has subsided. In some cases, noticeable bruising may appear in the area which indicates a muscle tear. I actually tore one of my lumber spinal muscles to the point it was black and blue for weeks and a noticeable ball developed higher up on the spine that I still have to this day.

Many times people feel that their low back is week and that is why the injury that area, and in some cases that is true. However, from an anatomical standpoint the lumber muscles are generally very strong and in reality. Overpower the weaker abdominal muscles which causes very problematic imbalances in muscular strength. The shear anatomical differences between the way the lumbar muscles attach to their bony points and the way the abdominals attach leads the lumber spine to have a vastly stronger mechanical advantage. As weightlifters we already know this, but the key to a strong and healthy low back. Is to have strong and balance core muscles.

this is where i am having pain. my hips are crooked and makes the lower left back hurt/feel uncomfortable.

[Sfla80]

this is where i am having pain. my hips are crooked and makes the lower left back hurt/feel uncomfortable.

Also have this issue, according to PT

[MuscleScience]

Seriously, will be looking out.

Just completed!

[Johnhenson]

Just completed!

I really need help MS you seem very knowledgable on this. I have 2 slipped discs in my lumbar spine, stinosis, and degeneration. I've had sciatica pain for about 10 months now and it does not go away. it started as pain in my common peroneal nerve on my fibula then slowly worked up to my hamstring then to my glute and just a month ago i felt it in my lower back. idk what to do and i fear my football career is at risk due to this. I do not feel weakness at all though but its constant pain no matter what, I've tried foam rolling my piriformis, stretching my legs out, foam rolling my back but it doesn't go away and i really want to stay away from surgery because that will set me back a lot. i was told by somebody with sort of the same problem as me to stay out of the gym and rest but do you think theres anything i can do in the gym that won't make matters worse?

[MuscleScience]

I really need help MS you seem very knowledgable on this. I have 2 slipped discs in my lumbar spine, stinosis, and degeneration. I've had sciatica pain for about 10 months now and it does not go away. it started as pain in my common peroneal nerve on my fibula then slowly worked up to my hamstring then to my glute and just a month ago i felt it in my lower back. idk what to do and i fear my football career is at risk due to this. I do not feel weakness at all though but its constant pain no matter what, I've tried foam rolling my piriformis, stretching my legs out, foam rolling my back but it doesn't go away and i really want to stay away from surgery because that will set me back a lot. i was told by somebody with sort of the same problem as me to stay out of the gym and rest but do you think theres anything i can do in the gym that won't make matters worse?

PM me bro!

[Johnhenson]

PM me bro!

i tried pming you but I'm not sure if it worked because i don't see my msg in the "sent messages" folder. i will keep trying

[Sfla80]

Spondylolisthesis:

This is where a vertebra has moved either posterior or anterior over another vertebra or bone relative to the curvature of the spine. The most common spot is the L5 vertebra sitting anterior to the Sacrum. This is usually caused by some sort of traumatic injury but can also be caused by degeneration, pathology or birth defect. The actual displacement is caused by a fracture in a part of the vertebra called the Pars interarticularis. This is an important structural component of the spine, the vertebra have two Pars on either side of the neural ring. If both fracture, that can lead to slipping of the vertebra upon the other. It is important to note, this can occur anywhere in the spine technically.

Often times a person will say that it is painful to arch their back into extension. In severe cases everything from mild discomfort, to sciatic to even lose of sensation in the legs and groin area can happen. Spondylolisthesis's come in grades, as measured by a percentage of slippage relative to the curvature of the spine. These grades are fairly easy to determine by xray evaluation. Determining the stability of the Spondylolisthesis is sometimes difficult but generally a specific series of xray images can help the radiologist determine how much the vertebra move in relation to each other. Stability is a key factor in how someone can manage this condition relative to its grade. Everything from simple core stabilizing exercise to specific bracing to exercise modification to surgery is the standard treatment. Most people will do very well with core stabilizing exercises. Often times people will need physical therapy or chiropractic care to manage flare ups of pain or discomfort. Surgery is often determined by how unstable the segments are and how severe symptoms are. Generally grade I and II slippages do not require surgery, grade III and above is when surgery is generally considered.

Awesome MS.

Basically what I have with the pain that radiates into the sciatic. Leg constantly pins and needles and numbness.

Xray showed the seperation. And insurance turned down mri.

[MuscleScience]

Awesome MS.

Basically what I have with the pain that radiates into the sciatic. Leg constantly pins and needles and numbness.

Xray showed the seperation. And insurance turned down mri.

So what you would have to do then is do some sort of conservative care such as PT, physio, Chiropractic first. if you don't respond favorably then you would/should have a justification for MRI. Do you know what grade you were?

[Sfla80]

So what you would have to do then is do some sort of conservative care such as PT, physio, Chiropractic first. if you don't respond favorably then you would/should have a justification for MRI. Do you know what grade you were?

Yeah I did PT about 6 sessions. And it was basically exactly what u said. Core stabilizing. Pt is a bodybuilder also. And was good.

I think they would have approved the mri if I got documentation from the PT. But I never followed through because at the same time my wife was going through her herniated disc and then surgery. So I put mine off.

I get spouts every so often. But something I can deal with now.

I did not know what grade. She gave me a measurement of how much of seperation...I wanna say 2-3cm. But I could be wrong.

[MuscleScience]

Yeah I did PT about 6 sessions. And it was basically exactly what u said. Core stabilizing. Pt is a bodybuilder also. And was good.

I think they would have approved the mri if I got documentation from the PT. But I never followed through because at the same time my wife was going through her herniated disc and then surgery. So I put mine off.

I get spouts every so often. But something I can deal with now.

I did not know what grade. She gave me a measurement of how much of seperation...I wanna say 2-3cm. But I could be wrong.

Ok got ya, one thing that will help when it's flared up is icing.

[Sfla80]

Ok got ya, one thing that will help when it's flared up is icing.

Icing...ok I have done the opposite.

This always confused me the when to use ice vs heat.

I have script anti inflammatory also I take when it flares.

Thanks ms.

[Pale1]

Among my previous lower back issues were sciatica, muscle spasms, & disc degeneration. Other undiagnosed issues as well I'm sure.I developed these problems throughout my 20's.

In my 40's now & have zero low back problems, I can squat, deadlift, whatever I want. I feel great now. Here are the things that got me there:

1) A good chiropractor that got my back aligned properly (also leveled my hips & I no longer need a heel lift in one shoe)
2) I do daily traction therapy
3) I do lots of lower back conditioning work, glut-ham raises, reverse hypers (my favorite), & lots of Ab work as well.

[600@50]

2) I do daily traction therapy

Pale1 what do you do as your daily traction therapy?

[Pale1]

Pale1 what do you do as your daily traction therapy?

I have a Petibon traction device that I hang from
https://pettibonsystem.com/product/c...action-regular

& this is something that I personally came up with that is very relaxing, I'll just hang like this sometimes for up to 10 min's. I took a heavy industrial sling & choked a chin-up bar with it. I roll my body upside down in it so that I'm hanging upside down from my hips. I'll try to make a video of it so you can see what I'm talking about.

[600@50]

Looks like something straight out of the torture chamber lol. But I can see how long term that could help. If you keep the cervical spine happy those results can transfer all the way down. Thanks.

[Pale1]

Looks like something straight out of the torture chamber lol. But I can see how long term that could help. If you keep the cervical spine happy those results can transfer all the way down. Thanks.

In regards to the Pettibone, I started out very gently & gradually increased the amount of traction over time by progressively letting more & more of my body weight hang from my neck. It took me about 6 months but I eventually got to the point that I can let my whole body hang from it for short spurts. I get releases & pops all the way down into my lower lumbar by doing this.

My chiro told me that it was previously believed that disc degeneration was irreversible but it's now known that the discs will regenerate with proper alignment & regular traction therapy. I truly believe that I have experienced this myself as I've gained back nearly an inch of height that I had gradually lost over the years.

[Mr.BB]

Great thread, thanks!

Any chance of upper back (cervical) version?

[MuscleScience]

Great thread, thanks!

Any chance of upper back (cervical) version?

Yep that's will be the next one, I have a bit more to finish up on this one. What I'm doing is watching posts by everyone here to see what some common injuries are so I get a good idea about what to write about. If you have something specific you would like to see then pm or post it hear.

[blackhat7]

Very helpful! Great info.

[Pale1]

I have a Petibon traction device that I hang from
https://pettibonsystem.com/product/c...action-regular

& this is something that I personally came up with that is very relaxing, I'll just hang like this sometimes for up to 10 min's. I took a heavy industrial sling & choked a chin-up bar with it. I roll my body upside down in it so that I'm hanging upside down from my hips. I'll try to make a video of it so you can see what I'm talking about.

I had forgotten that I actually had made a quick recording of my "traction sling". I'll hang like this anywhere from 5 to 10 min's. Decompresses the entire spine so far as I can tell & without stressing the knee's the way an inversion table would.
https://www.youtube.com/watch?v=cQb5b_4cM8I

[Sfla80]

MS

Had a whole situation the other day, entire back spasmed up. Locked down. Every single littlw.movement shot pains everywhere. Like being stabbed in the lats.

Ended up throwing up a couple times. And pain went into where the lethisis (spelling) is. Thought was kidney stones honestly. Was in so much pain.

Anyway told er doc my history and he got me my MRI finally. Didn't give me results but got me to a neuro appointment. And the doc was my wife's surgeon actually so trust the guy so far.

Apt tomorrow. We will see what he says.

Thanks again for the thread.

[MuscleScience]

MS

Had a whole situation the other day, entire back spasmed up. Locked down. Every single littlw.movement shot pains everywhere. Like being stabbed in the lats.

Ended up throwing up a couple times. And pain went into where the lethisis (spelling) is. Thought was kidney stones honestly. Was in so much pain.

Anyway told er doc my history and he got me my MRI finally. Didn't give me results but got me to a neuro appointment. And the doc was my wife's surgeon actually so trust the guy so far.

Apt tomorrow. We will see what he says.

Thanks again for the thread.

Good luck brother!

[Obs]

Ok, I am gonna say this being as gentle as possible... I have an extreme lower disc that moves. When it goes out, it literally takes my legs out from under me and I cant straighten up. I used to go to the chiropractor every 4-6 months to be put back in. I finally figured out a way to put it back in myself hanging upside down with my truck winch and a tow strap. I hang for 15 min and as relaxed as possible use my arms to whip it back in place. It hurts like hell.
Now my back muscles have greatly improved along with my glutes...
Now this weirds me out but now my back, when it gets pain it always gets worse day by day until I put it back in. Every time it was this way. Once it started I had to get some work done.
Now about five times recently it started to hurt and I climaxed during intercourse and when I gave it the final push and tensed my back and glutes... it popped down deep and low and settled back to its natural position... It felt probably better than anything I have ever felt! Im not kidding in the least! The pain is instantly gone! The first couple of times it was accidental but now I search for it, I wait till just the right time and crunch!
I'm not trying to be gross but I just did it and it is the most fantastic thing on earth! Has anyone ever had this happen?

[Sfla80]

MS forgot to update this.

Had MRI like I said previously. Should 4-5 mm(cm?) slip of spine.

Neuro said pt, pain shots, or surgery. Same t-lift surgery my wife just had.

Anyways this has been in last month or so.

Found a pain management doc for shots but didn't take insurance.

So off to another doc.

Pain is bad recently. Entire leg is constant 6-7 level pain. Back is typically movement pain but hits like 8s. Can't feel big toe on foot maybe more.

How do you feel about epidural shots. Most people say they do not work. Or maybe slightly prolong the surgery


Sent from my iPhone using Tapatalk

[MuscleScience]

MS forgot to update this.

Had MRI like I said previously. Should 4-5 mm(cm?) slip of spine.

Neuro said pt, pain shots, or surgery. Same t-lift surgery my wife just had.

Anyways this has been in last month or so.

Found a pain management doc for shots but didn't take insurance.

So off to another doc.

Pain is bad recently. Entire leg is constant 6-7 level pain. Back is typically movement pain but hits like 8s. Can't feel big toe on foot maybe more.

How do you feel about epidural shots. Most people say they do not work. Or maybe slightly prolong the surgery


Sent from my iPhone using Tapatalk

Sorry to hear that. Maybe PM me the radiology report.

If you have a spondylolithsis and you have a large amount of anterior slippage. Surgery maybe your only perminate option.

Epidurals are a good way to manage short term or acute episodes. However they are dependent on two things in thier effectiveness. The skill of the doctor and how well he or she can find and get the medicine to the effected area.

and if the correct area, is the medicine able to penetrate to the right tissue. I think most of the literature it shows that you have a 50/50 shot of it being effective. I question that to some extent, a skilled doc can increase that I think.

The more important point about the epidural is that it only blocks pain and reduces acute inflammation depending on what medicine/s the doctor chooses. It is not a fix or a perminate solution to what is generating the pain. Secondly, after 2-3 shots, they drastically reduce in effectiveness.

I like to treat them as my ace in the hole if you will. If nothing can touch the pain or it's so acute in nature that it's to painful to do any type of physiotherapy/spinal manipulative therapy. Then those two instances I refer to a pain management doc for that. I advise patients to not let that be the only thing they do to help with the injury. Often times the story goes like this:

Patient does yard work for 8 hours on Saturday. Patient wakes up Sunday night in extreme pain. Can't walk, sit or stand without pain. Calls GP in the morning, goes in, gets epidural. Pain goes away almost instantly or over the course of 2-3 days. Patient takes 2-3 days off from work. Feeling better by Thursday then forgets all about the back.

A year later, patient does yard work, pain flares up. This time worse, goes to GP gets epidural but this time it doesn't touch it. Then goes to PT/Chiro/ Physio. Finds out that back healed improperly and formed large amounts of scar tissue etc.

As you can kinda see, At this point, the epidural is no longer a viable option for managing the pain. So as I said above, I like to keep that option in my back pocket for times either post injury or only if we can't do any physical work without considerable pain. The key is rehabbing the injury so large amounts of inflammation producing scar tissue doesn't build up. When you don't do rehab, scar tissue will lay down in a meshmash of non-flexible non-coherent fiber patterns. During rehab we stimulate the body to cause the scar tissue to form along lines of stress. So that it lays down into a nice, compact and flexible manner. This drastically reduces the risk of reinjury and if injury does occur. Reduces the magnitude of the pain and inflammation process.

That is why I think physical medicine is so important pre post injury for everyone.