In Part 1 of this article series, I set the scene for dealing with back injuries. I also identified some simplistic categories. I divided the back into three segments: lower, middle and upper. Then I divided injuries into three basic categories: acute or severe, medium, and minor. In this article I'll be focusing specifically on handling injuries to the lower back or lumbar region.
Now I'm going to introduce a concept, again simplistically presented, that'll help you troubleshoot your injury situation. I'm not expecting you to self-diagnosis, but there are times when having this skill can save a lot of grief. More specifically, this guide will show you how to respond to an injury.
This categorization is aimed at helping you provide at least a hypothesis from which you can be guided in your earliest reactions, prior to getting professional diagnosis.
This is characterized by a low level awareness of discomfort, at least when the strain is mild. If your muscle strain was more like a bigger muscle tear, this would be different. Generally speaking, the further away from the spine or center of the back, the easier it is to identify this low level pain as muscle strain. When it's closer to the center or spine, it becomes more complicated.
The greatest challenge with narrowing it down simply to a strain is to eliminate referred nerve pain. In the low back, if the "strain" feeling is in the upper segment of the lower back muscles, the less likely it is to be referred pain.
This can be treated relatively simply with a combination of rest, short-term avoidance of the contributing exercise, and any soft tissue repair treatment you can get.
I recall learning this difference the hard way. About ten years ago I experienced a growing "ache" in one of my gluteals. I assumed it was a mild strain and it simply needed to be released and returned to its prior length, so massage and stretching were my preferred treatment methods. But it just got worse, and I learned the hard way (ending up in the emergency ward many months later) that it was referred nerve pain.
One of the biggest giveaways of referred nerve pain is that it occurs on one side only. Now, this doesn't mean that it has to be referred nerve pain. But if you're doing a bilateral movement, or a unilateral movement with equal loading on either side, and you get uni-lateral soreness, then realize that there's something less than ideal going on. Either one side was weaker beforehand and got more of a workout (but you should have known this), or one side did more work. This is a sign not to be taken lightly.
This can be more complex to solve, especially considering that by the time you get to feel the referred pain, the underlying mechanisms have been there for some time. Remember, the longer you've had the issue, the longer you should allow for it to be removed – up to half the life of the time it took to develop the problem.
Because you're dealing with nerves, a much more committed, cautious and holistic approach is going to be needed from you.
This condition refers to a change in the way two or more joints face each other. Even forces can cause movement of one joint on another, and in some cases, be it through larger force or longer lasting imbalances, this altered relationship can become a little more permanent. In this case, you can usually feel something isn't right in the joint.
Provided you picked up on this early, you can remove this issue fairly quickly. It's still going to take caution in the days following treatment, and may take more than one treatment. The greatest challenge is going to be identifying the true cause so you can address this effectively, rather than simply treating the symptom.
This is perhaps more the end result of chronic conditions than any of the above. When a damaged joint is loaded, it puts up a solid protective mechanism as we discussed in the prior article. The giveaway to joint damage is when you've been rehabbing for some time and all things seem good – connective tissue length, tension and joint relationship – yet after specific combinations of movement under load, you almost always get stirred up in the joint.
This is perhaps more commonly recognized in a joint like the knee, but don't underestimate the joints of the lower back to suffer this, especially as our between-disc spaces become reduced. This is a function of gravity, age and damage.
Whilst not necessarily the most painful, this condition can be the longest lasting situation of all the above because of the relatively slow rate of healing true bone damage. If you do have degenerative conditions of the joints of the lower back, you're going to want to become at expert at what it takes to protect and enhance the life of your lower back and ability to remain active.
A Combination of the Above
You're rarely going to have any of the above acting in isolation. The best scenario would be if you experienced a mild strain in a lower back muscle away from the spine, higher up in the lower back region, from a rowing movement for example.
However, many lower back conditions feel like strains but are, at least initially, nerve impingements. And nerve impingement often is a result of subluxation or similar changes in joint relationship. (Or joint subluxation can result from or cause a muscle strain, and so on.)
There are three theories I'll share with you here in conclusion to my "applied theoretical" approach to lower back injuries:
1) The Joint Relationship
We're born with a specific combination of joint relationships, and when that changes, we run the risk of experiencing pain. If the joint gap is reduced through trauma or shortening of connective tissue, we may impinge nerve or other soft tissue, which can set up a whole host of issues at, around, up or down from the site.
It's a really simple concept that, if you can master, will guide you in your rehab and injury prevention. Although I produced this program for professionals, anyone with a strong interest in preventing or rehabbing injuries will get great practical guidance and insights from my video program Injury Prevention and Rehabilitation available at www.kingsports.net.
2) Traumatic vs. Chronic
I have a theory that most injuries can be prevented. Injuries are usually divided into traumatic or sudden injuries, and chronic use or over-use injuries. The general belief is that traumatic injuries are unavoidable. I don't buy that. I believe that for starters, many injuries labeled as traumatic were there but you may not have been aware of them, so you continued to perform a movement or used loading that was simply the final straw.
I share this to get this message across: you're going to have a lot less injuries – chronic or traumatic – if you understand the mechanisms of injuries, and therefore how to prevent them. My inclusion of length, tension, stability and posture, and the joint relationship theory I share above, are a great place to start in understanding my approach to the mechanism of injury prevention and rehab. You can learn all about them in the video series I referred to above.
3) The Bone is Simply a Messenger
I have a theory that the surfaces of the bone are in many cases simply messengers of pain, indicating that something isn't right in the soft-tissue tension and/or length. Unfortunately, when ignored, the bone pain becomes an issue in itself. However, if identified early enough, we can help what appears to be joint pain "disappear" through appropriate tension, length, stability and posture.
In reference to the lower back, consider this: Many chiropractors treat joint subluxation as the primary or sole form of treatment, and in some cases over extended periods of time. Now, unless the subluxation was caused by sudden trauma, this treatment is simply treating the symptom. Inappropriate muscle tension, length, stability and/or posture will cause that subluxation to reoccur almost immediately.
The key or solution is to also identify the cause and address this. The cause invariably involves soft tissue issues and/or training design issues. So treating subluxation with only manipulation will be inferior to a combined approach of manipulation, soft-tissue treatment, retraining stability and/or alternating length and/or tension, and addressing posture.
And then there are the psychosomatic issues, but I'm not going to open that Pandora's Box. I may have already caused the ire of some chiropractors. (I can feel the pins going into that voodoo doll!) But if you're going to benefit from this as a person who needs to be healed, that's worth the upsetting of a few healers.
Now, let's go over what you should do as soon as you experience an injury. This time period is vitally important!
A lot of times you won't even realize you caused an issue until after the workout. When you cool down (or later in the day or the next day) you feel a small niggle from the lower back. If this is the case, sit down and try to work out how you did it. Discovering this will help the diagnosis and treatment.
If you feel this low level discomfort come on during the workout, sit down (or lie down with knees bent/feet flat) and ask yourself – is this really just a minor issue? Remember, making decisions when the body is warm based on how you're feeling at that time isn't always accurate. Sometimes what feels like a minor issue when your body is warm and your mind is fully engaged in the workout can be dangerous.
Ask yourself – based on my intuition and prior experience, what's likely to occur if I keep going now? Err on the side of caution. Learn to fight and run away, to live to fight another day.
You're probably going to know about this at the time you do it. Stop, sit or lie down with knees bent/feet flat, and ask yourself – based on my intuition and prior experience, what is likely to occur if I keep going? If you want the opinion of a person who's always made the best decisions at this point, ignore mine. But if you want to learn from my mistakes, think deep and objectively about whether to continue.
Let's weigh it up: Best case, you missed a few exercises or sets, but you didn't set the injury back any further. Worst case, you did that extra set, but now you can't train for a few months and are now having lower back surgery (which I suggest you avoid).
If you're taking the conservative approach, apply some of the techniques recommended below.
Acute or Severe
This is dangerous country. If you experience acute or severe lower back pain, take the conservative option! This is more likely to occur in a loaded lower back movement such as a deadlift or squat gone wrong, but can occur in a bent-over row, or for that matter, bending down and tying your laces up. I've seen all situations.
At this stage you know you're in trouble. You're stunned by the situation and may even be bewildered, especially if the preceding movement was as innocent as tying your shoelaces. You may have just started to feel nerve pain or pinching and weakness. Your body's protective mechanisms are cutting in immediately, and don't fight them.
My recommendation is to lie on your back in a position that's comfortable, with your feet flat, knees at 90 degrees, and don't move until you're comfortable to do so. Get help to move. Your next move will be, from my recommendations, to get heat into the affected region, but don't rush this or use a position that'll aggravate. If you can, move carefully to get heat. In severe situations, bring heat to you.
Heat may be as simple as a hot-water bottle (lie back with the water bottle under your lower back) or a shower (run the jets on your lower back). How long should you do this? At least 20 to 30 minutes. Ideally you'll feel some degree of relief. Most of this, I suspect, is from reducing some of the spasm that the body initiates as part of its protective mechanism.
In the worst case scenario, or if in doubt, you may be carted off to the emergency room. I have been, so it can happen!
Medical and Physical Therapy
When seeking medical guidance in any lower back injury situations, I trust the medical consultants will conduct both scan and X-ray. Don't accept a less casual approach of not getting X-rays and scans, even if you have to ask for them. You'll also want pain killers and maybe sleeping tablets or at least muscle relaxants. Now I'm not pretending to be a doctor, just sharing with you my experiences. Certain cases of lower back pain can be at the top end of the pain continuum.
If you saw a general practitioner in the first instance, he may want a specialist to see the scans. That's fine, just don't accept the attitude that surgery is inevitable. I'm not saying it can always be avoided, but I'm saying do all you can to avoid it. There's no rush, in most cases, to make this decision. Even non-surgeon MDs I've interacted with lately have echoed this. I was impressed!
I also recommend you take those scans with you to show them to every treatment specialist you're using. Even if they don't know how to read them, it'll contribute to their education! Most will have some idea how to interpret them; the interesting aspect for you is the variety in interpretation. This isn't a concern. As long as you make up your own mind what they mean.
As you receive treatment from various professionals, ensure a holistic approach. Unless your one treatment professional is widely trained, you're going to want to use probably three or more different modalities. After two to three treatments you can determine which ones are the most effective and continue on with them. Don't accept any of these sessions that inflame your condition – your lower back will be very sensitive.
Realistically, you may not be rushing to go around to all these doctors and therapists. With acute pain you may need to remain immobile for a while.
In the case of acute or severe lower back injury, ensure you have an environment where you can be immobile yet function. In other words, where you can lie comfortably and still feel like you're getting things done. A wireless modem connection on your laptop is fantastic in these situations. Additionally, the surface you lie on should be supportive. If you now realize your bed aggravates the condition from prolonged lying, the floor may be an option.
You'll need people around you to help out with daily tasks, and you're not likely to be going to work or helping out much around the home. Create a supportive and understanding environment so you can concentrate on getting better. Most acute lower back injuries take between 6 and 12 weeks to recover from, so be patient and ready for the long haul.
Your own personal, daily rehab could take up as much as six hours in the day depending on your condition, knowledge and commitment. An extreme example may be:
1. Hot shower on lower back
2. Appropriate stretching exercises
3. Appropriate stability exercises
4. Appropriate professional or self-massage
5. Hot water bottle on lower back
Repeat up to three times a day. Considering the average time in each activity to be 15 to 30 minutes, you can see the time commitment that can be involved.
• Assess the suitability of your mattress: Is it too soft? If it's older than five to seven years, it's probably time to replace it. And remember to rotate it every month or so.
• Seats at home: Are they appropriate for your condition? Most likely you're going to need one that allows you to sit upright with some support. If you need to, get a small pillow behind your lower back.
• Car seat: When you're back to driving (driving on the kind of drugs you may be on here isn't recommended!) check that your seat is the kind that supports your back. Use all the adjustment options you can, then add little things as need be, like small lumber supports if the seat doesn't have them. My preferred position is generally upright, but if you have compression pain at the hip, you may need to recline more.
• Standing, seated and lying posture: It's critical you identify the most appropriate way to stand and sit to reduce inflammation on your lower back injury.
Rehab exercises are no longer part of your workout – they're part of your daily management. The two most common forms of rehab exercise I see you doing are appropriate level control/stability drills (e.g. thin tummy variations) and stretches (especially the hip flexors/quads).
In the case of acute or severe lower back injury, the only exercises you'll be doing initially are appropriate stretching and stability drills. I say "appropriate" in that they shouldn't be of a type or intensity that aggravates the lower back or tightens any of the muscles that surround the lower back, in particular the hip flexors and quads.
After a while (probably a few weeks or when the lower back pain settles) you can re-introduce upper body training, but avoid loading or positions that risk re-injury or aggravating the back. This means you'll not be able to pick up off the ground or a rack any considerable loads, and you won't want to be doing any loaded movements through the spine or in spinal flexion e.g. squat, deadlift and rows.
When you do return to lower body training, I recommend you find a way to be very progressive. In addition to feeling your way with your lower back and what it's capable of, you don't want to cause excessive connective tissue shortening or lengthening, which is common when exposed to exercise or loads you haven't been exposed to for a while (read "unfamiliar exercise").
Progression can be achieved by increasing the volume of the stability drills, then finding a way to load them, then moving to unilateral drills, and finally bi-lateral drills. It's not unusual to wait 6-12 weeks before recommencing unloaded training.
The last thing you'll add is loading. This may be 10-16 weeks or so post-injury at best, so don't rush it! The risks you take in erring in your decision in exercise selection or load are high. Understand that the lower back is affected by all loading and muscle length/tension surrounding/connecting to it – even the lats shortening can affect the lower back. Be smart! If in doubt, don't do it. Err on the conservative side!
Avoiding Future Reoccurrence
Once you've had an injury, the physical therapist may tell you that the injured site is stronger than ever. That's great, but irrelevant. The injured site isn't likely to have caused the injury, just been the victim or weakest link!
At risk of offending you, you have been the cause of the injury: the way you've trained historically, the way you stand, lie, sit. The way you trained on the day the injury became apparent, and the way you managed it since, is all on your shoulders. As with all aspects of life, it's all about the decisions you make.
To help you make better decisions, there are three key questions I suggest you ask yourself to avoid future reoccurrence. These are:
1. What caused it?
I assume by the time you've rehabbed the low back injury successfully, you have a fair idea what caused the injury in the first place. Assuming your hypothesis is accurate, you can seek first to correct the limiting factor (e.g. overtraining, lack of length, etc.) and/or avoid the external stimulus (load or exercise selection).
Most mainstream medical and physical therapists opt to avoid the external stimulus in their recommendations for preventing injury reoccurrence. I believe this is somewhat narrow and definitively limiting. Why live such a fear-based life? No exercise is bad. How can an exercise cause injury? The injury is caused by the person who's doing the exercise. Now before I have someone from the profession I just described suggest I just agreed with them, my preferred option is to limit the exposure to the exercise or loading until the condition that caused it has been addressed.
If it was, for example, excessively shortened hip flexors/quads that set up the lower back issue, use stretching, massage, etc. to get them to a more appropriate length. Then set training parameters – you can only do X exercise or X loading when Y occurs. For example, if you have a significant imbalance in length of your hip flexor/quads right to left, set the minimum standard for the shorter side in length before you allow yourself to do certain exercises or loads.
I do this myself. If you need help, get a professional you can trust to guide you in this, especially if you have an extensive background of lower back injury. Whatever it costs to get an appropriately trained coach to give you training/injury prevention guidelines is going to be a lot less than the pain, medical bills, and lost income you suffer from subsequent injury.
2. What may have contributed?
This takes a higher level of thought processes, but can save an innocent exercise from a lethal injection! For example, you may identify that when you strain your lower back, it's usually on a particular exercise. Go one step further – look for another common denominator.
For example, does it occur on the days you're short of time and rushing your workout? Cutting corners on your usual pre-workout preparation? Taking shorter rest periods? Being careless with your technique? On days when you were feeling run down, didn't have the right sleep the night before, etc.?
So instead of you concluding that when you hurt your back it's usually when doing exercise X, you may realize that when you hurt your back it's usually when doing exercise X and being overly tired. Now you know what to change or what to avoid when you're in that combination of conditions.
3. What signs indicate a reoccurrence or give me feedback as to how I'm doing?
There's nothing like getting injured to help you get in touch with your body. Now use this heightened body awareness to make better decisions. Once you've had an injury, especially a lower back injury that may have taken some time to heal, reoccurrence of that injury can be as simple as reversing the rehabilitation path. You've come up the path before. Remember the stages, what it felt like, so that when you find yourself sliding down that same path, you can make changes and reverse your direction.
For example, your lower back injury may have begun with relatively innocent lower back or gluteal ache and gone on to become much more, probably because you didn't know what the signs meant. One of the best ways to measure your suitability to safely train and avoid lower back injury is a pre-workout or daily assessment of the length and tension of the muscles affecting the pelvis and the stability of the same.
Put simply, when your hip flexors and/or quads are tighter and shorter, you're at increased risk of lower back injury. When your abdominal function is low and not providing stability to the lower back and pelvis, you're at increased risk of lower back injury.
Improve your ability to measure the transient variables of length, tension and stability, and you can avoid many reoccurrences of lower back injury.
Now, I know I've addressed length, tension and stability throughout this article, and some of you are going to be struggling with these concepts due to the era we find ourselves in. Every decade a different mainstream dominant paradigm pervades, and in the case of flexibility and injury prevention, we're still in the dark ages it seems.
I've glossed over that, because it's a distraction that can prevent you from experiencing freedom from pain and enhanced ability to train. So if you can put your health before your fear of social ostracization, then you will, in my humble opinion, benefit enormously from what I've shared in the above.