Case Study – Lumbar Disc Injury
Low back pain affects up to 80% of the population at some point in their lives. The vast majority (90%) improve over 3 months and up to 50% have re-occurrence at some point in the future (1). The lumbar intervertebral disc is a structure that can be the cause of pain. Here we discuss a case of lumbar disc injury and pathway to recovery.
A 25 year old active male presented to the clinic 2 weeks after sudden onset of low back pain. Let’s call him Luke. Luke described the pain occurred whilst jogging, following which he was unable to stand up straight. He had high levels of pain 7/10 and was restricted in his ability to bend and twist. He described an increase in pain with sitting, standing and any repetitive bending or twisting tasks. After the day of injury he presented to his GP who arranged an MRI. Luke then went back to his GP to discuss the results where he was informed that his imaging showed “L5/S1 broad based disc bulge with an extruded component, abutting the exiting S1 nerve roots bilaterally, more pronounced on the right”. Following his MRI he was referred to a specialist for an opinion. He spent that first week mainly inactive and resting.
L4/L5 and L5/S1 are the most commonly reported area for low back pain /injury (3). Disc changes can be described as degeneration, bulge, protrusion, extrusion or simple irritation. The terminology commonly known as a herniated disc is a condition affecting the spine in which the annulus fibrosus is damaged enabling the nucleus pulposus (which is normally located within the centre of the disc) to herniate also known as a protrusion or extrusion. Studies have demonstrated that imaging findings of spinal degeneration associated with back pain, such as disc degeneration or protrusion are present in a large proportion of both symptomatic (painful) and asymptomatic (painfree) individuals, thus assuming that disc changes are responsible for the patients presentation should be done with caution (4-6). At this point in time this may be sounding overly negative, however if we jump ahead and give spoilers this young man is back in the gym and playing basketball without any pain within 6 weeks.
Luke presented to Physiotherapy clinic 10 days following the occurrence of his low back pain. He now had 3/10 constant, low back pain at rest and still was aggravated by sitting, standing and any repetitive bending or twisting tasks. He had stopped his regular basketball training and gym work. In the gym he trained 4-5 x per week and alternated between push, pull and legs. For those unfamiliar this means; one day he would train upper limb press movements (eg bench press, shoulder press, tricep extensions), the next day he would train pull movements (eg chin ups, single arm dumbbell rows, shrugs, curls) and then the third session he would train legs. He avoided doing any deadlift movement as he wasn’t confident with it and would sometimes lead to back soreness. For all squats he had to elevate his heels and could only maintain half range without losing form or becoming unstable and had also been known to lead to back soreness. He therefore would prefer not to squat and use alternatives such as a hack squat or leg press He described having previously had 2 short episodes of low back pain which went away after a week and did not seek treatment for.
After taking a thorough history described in part above, we looked at Luke through a range of movements, tests and exercises. Luke had a reduction in forward bending range to just below his knee and a reduction in bending backwards (lumbar extension) both limited by mild pain and reported stiffness. Repeating these movements did not change pain but reported feeling a little less stiff. When sitting his ability to twist side to side was restricted (thoracic rotation 45 deg) without any significant pain. Tests looking at his neural mobility and sensitivity were carried out and whilst tight were not painful. These tests, active and passive straight leg raise and a slump test are commonly used to help identify sensitivity in neural pathways. The straight leg raise test involves lifting one’s leg whilst keeping the knee straight. A change in pain as you lift higher or add dorsiflexion is a positive test. The slump test involves sitting on the edge of the bed with head down and shoulders slumped, Luke then tries to straighten one knee, then the other. We are looking for a change in pain or restriction in range of motion. Luke had no symptoms with these tests indicating that he wasn’t getting any neural irritation or restriction. Despite Luke’s MRI suggesting that his disc was abutting the nerve root his signs, symptoms and assessment findings didn’t support this. Tests to assess for symptoms at the hip joint and SIJ were also conducted to rule these out as a cause of Luke’s pain. We also assessed his technique on a lightweight squat and deadlift.
First Session Treatment
During our first session together we discussed some key findings from our assessment. This included that his symptoms were likely related to his lower back and intervertebral disc, however his extrusion was not causing any neural irritation or compression as mentioned above. We also discussed that lumbar disc bulge size doesn’t predict any need for surgery and that based on his presentation he could continue conservative management with favourable prognosis (8). Other general advice around keeping moving, avoiding prolonged sitting was discussed. His initial review with his specialist would later agree with this course of management. We also discussed some of the mobility restrictions he had and the impact that has on his ability to squat, jump and deadlift. Some manual therapy techniques were performed that increased range of movement into rotation and forward bending after reassessment, without any increase in pain. A plan was made to increase activity and suitable exercises for his initial rehabilitation including low level strength exercises and daily mobility exercises. Luke was also able to ask any questions he had specifically about the plan ahead, prognosis and returning to basketball.
Second Review – 5 Days Later
On second review Luke had been completing his exercises diligently and had mild pain constantly (1/10) and was worse at end range forward bending midway down his shin and end range rotation (3/10) 55 degrees. Further assessment was taken for strength and endurance measures of abdominals (modified plank), back extensors (GHD Back Extension Hold), lateral trunk endurance (side plank). Gym exercises were trialled and initial return to gym program was developed including;
- Goblet squat with counterbalance plate
- Front Foot Elevated Split Squat
- Side Plank (Knees)
- Broomstick hip hinge
- Deadbug banded
- GHD back extension hold
Additionally we enabled him to return to his upper body gym training with modifications to reduce stress across his lower back. Light running and basketball drills were also introduced as part of a plan to move towards a return to sport. Further manual therapy was done and subsequently there was no pain in end range movements.
Week 3 Review
After 3 weeks Luke had no resting pain and was aware of his back only after prolonged forward bending (he had spent some time in the garden). His return to running and drills had been feeling good and gym work also pain free. His ability to complete controlled squats and deadlifts with lightweight (20kg) was comfortable. His lumbar and hip mobility was now pain free and could maintain end position without symptoms. He had managed well with squat and deadlift technique work, however still had notable ankle restriction. His gym program progressed to include heavy machine based leg work (hack squats, hamstring curls, leg extensions, calf raises), plyometrics, loaded trunk exercises and full body movement patterns. These included:
- Drop Jumps
- Lateral Hops
- Front Squat
- Romanian Deadlifts
- Fitball Banded Trunk Rotations
- Banded Deadbugs with double leg extension
- Weighted Back Extension – GHD
He returned to basketball training with some mild restrictions and completed a running program to aid return to full fitness.
Week 6 Review
At week 6 Luke had played his first basketball game back and felt really good. He had been managing full leg days as he did prior to his back injury and this week was his second week at a full training load. He had improved on all strength and endurance measures and was executing his front squats and Romanian deadlifts with good technique and moderate training loads (80% bodyweight including the bar). He had no concerns regarding his back and was confident loading it. We changed his gym program and made progressions for the next month. Luke was keen to continue monthly check ins over the next 3 months to help continue mastering his lifting mechanics and for guided gym based progressions to aid performance goals he had around his basketball. Upon discharge he had improved in all strength and power measures, which translated to performance as increased vertical jump height and change in direction ‘quickness.’
Luke is just one example of how a debilitating back injury and disc injury diagnosis can resolve and one can return to sport and daily life without concerns. Additionally he was able to address mobility and technique defectis that helped him move better in his sport and achieve further performance goals.
Lewis Craig (APAM)
Masters of Physiotherapy
Featured in the Top 50 Physical Therapy Blog
- Bressler HB, Keyes WJ, Rochon PA, Badley E. The prevalence of low back pain in the elderly: a systematic review of the literature. Spine. 1999;24:1813–9. doi: 10.1097/00007632-199909010-00011.
- Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc Herniation. [Updated 2022 Jan 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan
- Al Qaraghli, M. I., & De Jesus, O. (2021). Lumbar Disc Herniation. In StatPearls [Internet]. StatPearls Publishing.
- Carragee E, Alamin T, Cheng I, et al. Are first-time episodes of serious LBP associated with new MRI findings? Spine J 2006;6:624–35 doi:10.1016/j.spinee.2006.03.005 pmid:17088193
- Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am 1990;72:403–08pmid:2312537
- Kalichman L, Kim DH, Li L, et al. Computed tomography-evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. Spine J 2010;10:200–08doi:10.1016/j.spinee.2009.10.018 pmid:20006557
- Gupta, A., Upadhyaya, S., Yeung, C. M., Ostergaard, P. J., Fogel, H. A., Cha, T., … & Hershman, S. (2020). Does size matter? An analysis of the effect of lumbar disc herniation size on the success of nonoperative treatment. Global Spine Journal, 10(7), 881-887.
- Richardson, C., Jull, G., Hides, J., & Hodges, P. (1999). Therapeutic exercise for spinal segmental stabilization in low back pain (pp. 992-1001). London: Churchill Livingstone.
- Ferreira M, Ferreira P, Latimer J, Herbert R, Maher C: Efficacy of spinal manipulative therapy for low back pain of less than three months’ duration. J Manipulative Physiological Therapeutics. 2003, 26 (9): 593-601. 10.1016/j.jmpt.2003.08.010.
- Ernst E, Harkness E: Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials. J Pain Symptom Mgmt. 2001, 22 (4): 879-889. 10.1016/S0885-3924(01)00337-2.
- Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG: Spinal manipulative therapy for low back pain (Cochrane Review). The Cochrane Library. 2004, Chichester: John Wiley & Sons, Ltd
- Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG: A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med. 2003, 138 (11): 898-906.
- Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American journal of neuroradiology, 36(4), 811-816.