Training with a Back Injury
Garrett McElfresh, PT
October 20, 2004 01:05 PM
I think it was Rousseau who said that Man's biggest problem was that he wasn't content to simply sit tight and stay in his room. Rousseau probably dressed that up a bit, but we all know that sitting tight in our rooms just ain't a viable option for kettlebell dudes, deadlifting fanatics, tactical specialists, and physical culturists. So, if you're a human and you find yourself doing more than Super Sizing your Happy Meal, chances are you're going to get injured. And if you're anything like me you won't be too happy about it. It's the no-brainer of the millennium: Injuries suck. To my mind injuries serve no purpose besides reminding us we're human. Hey! I know I'm human. Stop messing up my training!
Injuries come in all shapes and sizes, but since I have a back injury I figured I'd talk about that. The only back story you need regarding my injury is this: I've pulled 500 lbs from the floor wearing nothing but Chuck Taylor's and a shit-eating grin and my back (heck, my whole body) always felt right as rain. Last December I lifted 50 lbs from the floor utilizing lousy biomechanics...it was 5 a.m. and my cat was involved...and "all of the sudden" I'm an instant member of "The Back Club." I guess that's why they call them "accidents."
So, you know, I'm a physical therapist, I know some other PTs, a few ortho docs. I get myself checked out. I tried to check myself out but got hung up doing the "Self Straight Leg Test." Do not try it at home. After much dinking around I decided to have an MRI. I don't know about you, but I really like to know as much as I can about what's going on "in there." Knowledge is power and power will help you heal. A PT buddy of mine commented, "Man, the only reason to have an MRI is so the doc knows where to cut." I don't like to dis fellow PT's, but at that moment he could not have been more wrong. I should probably give you the Reader's Digest version of my diagnosis and symptoms. DX: "Mild" Annular Ligament tear at L4-L5 and L5-S1. Symptoms: Localized back pain: None whatsoever. Radiating or Radicular symptoms: my right foot gets hot/cold, and I get intermittent "hot pins" in the foot and ankle. Pretty textbook stuff for chemical irritation of the L4-S1 nerve roots. Intense pain? No. Frustrating and stupid? You bet. These symptoms just come and go, often regardless of my activity or my body position. God, I would hate to have me as a patient! Wait a sec...damn!
Allow me to touch on a few things I've learned about back stuff reading and surfing, and to outline what I've been doing workout-wise to rehab myself. Don't worry, kettlebells factor heavily.
With many back injuries the exact origin of the pain is hard to pin down. Even MRIs don't always tell the whole story. Age-related degenerative changes to discs and disc herniations are probably the most common causes of back pain. But that's really vague, right? What does that mean and what can we do about it? As we age (once you hit, say, 25) discs can and will lose their ability to bind water. As a result their mechanical properties diminish, they absorb less force well, and they can produce low-grade inflammation. This can set the stage for disc protrusion or herniation, or worst case, rupture. Whatever you do, don't say "slipped disc" or "my back went out." It is 2002. You might as well say "lumbago."
The widely accepted illustration of a herniated disc is an extrusion of disc material pushing against your spinal nerve root. But what if the presence of this "pinched nerve" doesn't directly correlate with the intensity of your pain? Everyone, and I mean everyone, has bulging discs. It is quite common and often asymptomatic. What if sciatic pain is there but there is no bulging disc? Is it the piriformis? Maybe. Probably not.
I had many "straight dope" type rap sessions with my ortho doc. He's one squared away honcho. He knows a thing or two about a thing or two, and like a good little PT, I picked his noggin clean. It seems many docs are focusing on The Annular Ring as a source of back and sciatic pain. The annular ring is the ligamentous "band" that is the outermost layer of the disc. It contains a really dense fabric of nerve fibers and vast amounts of inflammatory proteins that can greatly increase your perception of pain and suffering. Aren't we lucky? Now, annular tears happen all the time. Most of the time they are no big deal. But if the tear is big enough or deep enough, look out. And, my doc mentioned, sometimes there can be an inward growth of nerve fibers into the annular ring which can facilitate pain or "changes in sensation" within that intervertebral segment. So what to do?
Surgery vs. No Surgery. My all-time hard line on surgery is this: only as a last resort. Especially with back issues. There are many instances where surgery can and should be done: cauda equina syndrome (bladder/bowel problems, progressive motor loss, etc) or simply symptoms that have not resolved over time with conservative measures. But for most other scenarios, research is showing that surgery can help in the short-term, but long term effects are simply not known. Post-surgical scarring can often cause repeat symptoms. Robbing Peter to pay Paul. As far as I'm concerned those bastards have enough of my scratch already!
My experience with my injury has been that what makes me feel best, and makes me feel like I'm healing, is a smart workout. It can be tricky. Cut your skin? You know the tissue turns over in about 7-14 days. Tear your annular ligament? Sorry, those fibers HATE to remodel. They scar like mad, but the scars are more prone to re-injury. You experience the "saw tooth" pattern of recovery. That means "good days and bad days." You want just enough force going through those tissues to stimulate growth, get a nice fluid exchange in there, and make yourself feel like you've worked out. Any more or less and you are just not hitting therapeutic levels. You may experience a slight increase in symptoms after a workout. Maybe a few hours afterwards, or the next day. This is okay. What is not okay is pushing yourself into and/or through pain. This is the Black Forest of self-restraint.
If you feel PAIN doing whatever activity it is, modify it or stop it. Better walk away before you crawl away. The goal with exercise is to get all the muscles in and around the vertebral segment working in concert to restore or maintain the normal biomechanics of that segment. It's that simple. This article is aimed at Party Members, not my average patient. I won't go into the really basic San Francisco Spine School rehab stuff, or try to virtually teach the "Pelvic Tilt." And I know most of the Party Members could probably get an honorary Robin McKenzie Master's Degree right now. We all know the virtues of cardio, martial arts, dynamic flexibility, and muscle tension techniques. The real obstacle in rehab training is finding the right mix and knowing that your injury can often inhibit your ability to achieve the contractions necessary for extreme stabilization. Not to sound like a broken record, err on the side of caution.
My workouts these days consist of kettlebell swings, snatches (1 and 2 bell versions), cleans, clean and presses ( 1 and 2 bell versions), pull-ups, Hindu push-ups, bridging, Evil Wheel, and lots of power breathing. I am working back into Full Contact Twists. I used to do 2 Pood snatches, windmills, and bent presses all the livelong day. I am not tolerating those yet. I also have a "rotoscoliosis," a lovely rotational twisting in my spine, that I'm sure is full of mischief with regards to my injury. Before the injury I never knew I had it! But I bet it makes it tough for the fibers to line up, and it reduces my tolerance for twisting.
I do everything these days in a circuit:
- Pull-ups: GTG 1-5 or 5-10 reps.
- Snatches or Cleans 10 each arm (1, 1.5, or 2 Pood)
- Hindu Push-ups 20-30 reps
- Evil Wheel or Power Breathing 5 reps
- Bridge (forehead to mat) 30-60 seconds.
- Repeat 3-4 times with little or no rest.
I have been alternating these workouts with 1 or 1.5 Pood high rep snatches, shooting for 100-200 continuous reps. With the 1 Pood I'll alternate 25 right, 25 left and keep going until I need to stop, or I'll alternate 10 left, 10 right with the 1.5 Pood the same way. I like working with the 2 Pood but I have to keep the reps lower, so I'll do 5 reps and plug in more sets. I also tolerate 2 kettlebell cleans and snatches with the 1.5 Pood (I don't have a second 2 Pood yet) I usually do 5-10 sets of 5 reps, or 3-5 sets of 10 reps with those exercises.
The bottom line is this: You MUST use your own symptoms as your guide. No one else can do that for you. Sometimes the pain is like overnight mail...you won't know you did too much until the next day. It's okay. This is good information. If you use it the right way.
It helps to work with a doctor, therapist, or trainer you trust. If you are all alone in your basement or garage and are in pain, staring at a heavy loaded barbell or a 2.5 Pood kettlebell, please take a moment and reflect on why it is you train. Is it for fitness? Yes. Is it to maim yourself? Probably not. Sometimes we walk the long road as strength folk. Many doctors will look you in the eye and call you crazy for lifting anything heavier than a Preferred Provider Pay Stub. Shame on them. They will never know True Greatness. Kettlebell lifting and PTP techniques can and should be utilized if you tolerate them. Power breathing and dynamic tension relaxation drills directly play into exactly what your back needs. Proper form is EVERYTHING, and if you are training with an injury you must NEVER go to failure. Sometimes this is easier said than done. But Comrades, when was easy ever worth squat?
Garrett McElfresh, PT
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