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Old 03-13-2012, 02:48 PM   #1
Drew Leonard
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Bulging/degeneration in L4-L5 and L5-S1 discs

Hi All,

In January 2011, I (Male/31/6'2"/175) joined a CrossFit box after a decade of Globo Gym lifting workouts. I was doing 4-5 WODs per week with no injury issues, and loving it just as so many on these boards do. My form was never ideal due to mobility issues, particularly tight hamstrings and shoulders, but I was aware of it and working hard (both in the box and at home) on improving those problems.

At some point in November, I gradually started to feel minor pain in my lower back. I mostly noticed the pain only after periods of prolonged sitting. After it failed to disappear in two weeks, I decided to take the month of December off to rest it. By the end of December, when the pain hadn't changed, I went to an orthopedist who diagnosed it as a muscle strain, prescribed an anti-inflammatory (Diclofenac 50mg), a muscle relaxer (Soma 250mg), a month of 2x/week physical therapy, and more rest from exercise (suggesting only gentle swimming, which I have done religiously). After another month there was no improvement and perhaps some worsening, so the doc prescribed an MRI.

The MRI results (the summary of which is attached, in case any is interested) showed:
L5-S1: mild posterior bulging, slight degenerative arthrosis of facet joint, no spinal stenosis, no significant neural foraminal spondylitic encroachment, possibly a 2-3mm benign cyst on facet joint.
L4-L5: degenerated disc, mild circumferential bulging, and possibly an annular tear.
Other discs/vertebrae/etc. are normal or have minor degeneration with no bulging.

The orthopedist said that these results were "not too bad", and prescribed two rounds of cortisone injections, more physical therapy (with a higher-end therapist for athletes than I had used the first time), and continuation of the medication. He also casually suggested that I should never do CrossFit again, which was somewhat devastating.

After the first injection a week ago (in L5-S1, I believe, and attempted removal of the cyst), I feel no improvement, and am starting to get desperate. It seems like no matter what I do (rest, fish oil, stretches, ice/heat, meds, PT, injections) the pain does not go away, and instead is just gradually worsening, to the point where I now avoid situations that involve sitting for any length of time. I start the next round of PT soon, I purchased the McKenzie "7 steps" book and will begin that immediately, but I'm not sure what else to do.

A few questions for any kind souls that have continued to read this far:
1) Any suggestions for alleviating the pain, other than what the doc has prescribed or what I am already doing?
2) For PTs or docs out there, assuming the pain eventually subsides, do you agree with my doc (who has no personal experience with CrossFit) that I should never do it again? If you disagree, are there certain movements (eg, heavy squats or deadlifts) that I should permanently avoid. Or, if the pain goes away and I drastically improve my mobility, do you think I can return to all movements eventually?

I am not so obsessed with CrossFit that I would be willing to do it at the risk of worsening a serious injury, but 1) I can't seem to determine how serious this injury is, what caused it, and why it won't go away, and 2) I don't know anyone with expertise in both PT/sports medicine and CrossFit, so it's hard to know what I can and can't do from now on.

Thanks for reading, and for any advice.
-Andy
Attached Files
File Type: pdf MRI Results.pdf (203.5 KB, 293 views)
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Old 03-13-2012, 05:40 PM   #2
Sean Rockett
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

Quote:
Originally Posted by Andrew Leonard View Post
Hi All,

In January 2011, I (Male/31/6'2"/175) joined a CrossFit box after a decade of Globo Gym lifting workouts. I was doing 4-5 WODs per week with no injury issues, and loving it just as so many on these boards do. My form was never ideal due to mobility issues, particularly tight hamstrings and shoulders, but I was aware of it and working hard (both in the box and at home) on improving those problems.

At some point in November, I gradually started to feel minor pain in my lower back. I mostly noticed the pain only after periods of prolonged sitting. After it failed to disappear in two weeks, I decided to take the month of December off to rest it. By the end of December, when the pain hadn't changed, I went to an orthopedist who diagnosed it as a muscle strain, prescribed an anti-inflammatory (Diclofenac 50mg), a muscle relaxer (Soma 250mg), a month of 2x/week physical therapy, and more rest from exercise (suggesting only gentle swimming, which I have done religiously). After another month there was no improvement and perhaps some worsening, so the doc prescribed an MRI.

The MRI results (the summary of which is attached, in case any is interested) showed:
L5-S1: mild posterior bulging, slight degenerative arthrosis of facet joint, no spinal stenosis, no significant neural foraminal spondylitic encroachment, possibly a 2-3mm benign cyst on facet joint.
L4-L5: degenerated disc, mild circumferential bulging, and possibly an annular tear.
Other discs/vertebrae/etc. are normal or have minor degeneration with no bulging.

The orthopedist said that these results were "not too bad", and prescribed two rounds of cortisone injections, more physical therapy (with a higher-end therapist for athletes than I had used the first time), and continuation of the medication. He also casually suggested that I should never do CrossFit again, which was somewhat devastating.

After the first injection a week ago (in L5-S1, I believe, and attempted removal of the cyst), I feel no improvement, and am starting to get desperate. It seems like no matter what I do (rest, fish oil, stretches, ice/heat, meds, PT, injections) the pain does not go away, and instead is just gradually worsening, to the point where I now avoid situations that involve sitting for any length of time. I start the next round of PT soon, I purchased the McKenzie "7 steps" book and will begin that immediately, but I'm not sure what else to do.

A few questions for any kind souls that have continued to read this far:
1) Any suggestions for alleviating the pain, other than what the doc has prescribed or what I am already doing?
2) For PTs or docs out there, assuming the pain eventually subsides, do you agree with my doc (who has no personal experience with CrossFit) that I should never do it again? If you disagree, are there certain movements (eg, heavy squats or deadlifts) that I should permanently avoid. Or, if the pain goes away and I drastically improve my mobility, do you think I can return to all movements eventually?

I am not so obsessed with CrossFit that I would be willing to do it at the risk of worsening a serious injury, but 1) I can't seem to determine how serious this injury is, what caused it, and why it won't go away, and 2) I don't know anyone with expertise in both PT/sports medicine and CrossFit, so it's hard to know what I can and can't do from now on.

Thanks for reading, and for any advice.
-Andy
Hi Andrew, I have had what you have, am a crossfitter and a sportsmedicine surgeon. Bad news first, it took about a year to feel good again, good news I feel better but it has taken a lot of time and patience. Good news for you also is no neurologic injury. Basically tons of stretching, gradual strengthening and avoidance of painful maneuvers, don't try to predict the future and eliminate Crossfit completely, right now there are certain things you shouldn't do and I am sure you know what they are. When you return be cautious, and enjoy it going lighter for a while. Good luck. Sean
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Old 03-14-2012, 06:15 AM   #3
Carline Saintilien
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

Quote:
Originally Posted by Sean Rockett View Post
Hi Andrew, I have had what you have, am a crossfitter and a sportsmedicine surgeon. Bad news first, it took about a year to feel good again, good news I feel better but it has taken a lot of time and patience. Good news for you also is no neurologic injury. Basically tons of stretching, gradual strengthening and avoidance of painful maneuvers, don't try to predict the future and eliminate Crossfit completely, right now there are certain things you shouldn't do and I am sure you know what they are. When you return be cautious, and enjoy it going lighter for a while. Good luck. Sean
Dear Sean,

May I ask if what you had involved any neurological involvement, pain, paresthesias, twitching? Or just pain. Thank you in advance for sharing.
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Old 03-15-2012, 06:16 AM   #4
Megan Zetter
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

You stated your problem in the opening of your original post: bad form and poor mobility. If you have any hope of returning to Crossfit those MUST improve. Disc injuries occur due to flexion/twisting overload. Poor form while lifting heavy weight is a sure fire way to injure a disc. A weak core is another indicator that someone is likely so have back pain/injury.

As Sean stated you need to eliminate any and all movement that flares-up the back. I suspect flexion/sitting/bending over bother you. You also need to work on core stability -- Google Stuart McGill --. When you have core stability nailed, then work of mobility of the hips and thoracic spine. You can do both at the same time, but I find that if patients get the stability nailed first than they are more successful when it comes to mobility.

Have you considered working with a chiropractor? There are many studies that support the use of joint manipulation for low back pain. Also, continued use of pain meds can slow the healing process. I'd stick to natural anti-inflammatories and use Rx's and OTC's as needed.

I love working with people like you. It's a painful and frustrating injury, but I have a lot of success with utilizing proper rehab; retraining of movement patterns, and manual therapies. The healing process can take time, at least a few months in most cases.

Good luck

Edited to add: "Tons of stretching" is probably not what you need. Mobility does not equal flexibility. Mobility means you joints are moving through their full range of motion. Sometimes that means you need to do some stretching, but not always.
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Last edited by Megan Zetter : 03-15-2012 at 06:20 AM.
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Old 03-15-2012, 06:25 AM   #5
John Powell
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

I injured my back in September and it sounds like the same thing. MRI showed a minor bulge at L5/S1 as well as mild DDD. I get a bit if SI pain sometimes, but otherwise the pain is in my leg and butt.

It has been very difficult to stay positive during this, but IT WILL IMPROVE if you are doing/not doing the right things. I still have some days where it is worse, but overall it is improving--very slowly.

I just ordered Stuart McGill's book. I have to yet to find a person (mostly experts) who have any knock against this book.

Good luck
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Old 03-16-2012, 09:18 AM   #6
Drew Leonard
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

Quote:
Originally Posted by Sean Rockett View Post
Hi Andrew, I have had what you have, am a crossfitter and a sportsmedicine surgeon. Bad news first, it took about a year to feel good again, good news I feel better but it has taken a lot of time and patience. Good news for you also is no neurologic injury. Basically tons of stretching, gradual strengthening and avoidance of painful maneuvers, don't try to predict the future and eliminate Crossfit completely, right now there are certain things you shouldn't do and I am sure you know what they are. When you return be cautious, and enjoy it going lighter for a while. Good luck. Sean
Sean, thank you so much for the response. It means a lot to me to hear from someone who has had the same injury, especially someone with your expertise.

If you don't mind, a couple of follow-up questions:

1) Perhaps the most frustrating part is that I still can't figure out what things I should and shouldn't be doing, and because the injury seems to have gotten slowly worse over the past 4 months, I must not be doing the right things. I am avoiding the things I know aggravate it: sitting (which I now avoid at all costs), forward flexion, and obvious pounding of discs (heavy lifting, running, jumping). Beyond that, I can't figure out why it would worsen. I do my prescribed PT stretches, take my prescribed meds, and do light swimming and body weight exercises (that don't require back movement), and yet it just gets slowly worse. Any guesses?

2) As a doctor who has had this injury, do you agree with Megan (above), and many others on this forum, that the prescription anti-inflammatory and muscle relaxer may be slowing the healing process? I have noticed no difference whatsoever on days that I take them or not, and all else equal would prefer not to take them, but would love your advice on this.

Thanks again,
Andrew
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Old 03-16-2012, 09:49 AM   #7
Drew Leonard
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

Quote:
Originally Posted by Megan Zetter View Post
You stated your problem in the opening of your original post: bad form and poor mobility. If you have any hope of returning to Crossfit those MUST improve. Disc injuries occur due to flexion/twisting overload. Poor form while lifting heavy weight is a sure fire way to injure a disc. A weak core is another indicator that someone is likely so have back pain/injury.

As Sean stated you need to eliminate any and all movement that flares-up the back. I suspect flexion/sitting/bending over bother you. You also need to work on core stability -- Google Stuart McGill --. When you have core stability nailed, then work of mobility of the hips and thoracic spine. You can do both at the same time, but I find that if patients get the stability nailed first than they are more successful when it comes to mobility.

Have you considered working with a chiropractor? There are many studies that support the use of joint manipulation for low back pain. Also, continued use of pain meds can slow the healing process. I'd stick to natural anti-inflammatories and use Rx's and OTC's as needed.

I love working with people like you. It's a painful and frustrating injury, but I have a lot of success with utilizing proper rehab; retraining of movement patterns, and manual therapies. The healing process can take time, at least a few months in most cases.

Good luck

Edited to add: "Tons of stretching" is probably not what you need. Mobility does not equal flexibility. Mobility means you joints are moving through their full range of motion. Sometimes that means you need to do some stretching, but not always.
Megan, thanks so much for this thoughtful response, and especially for laying out a suggested plan of action (Core Stability -> Mobility -> Hopefully recovery!). Some quick follow-up comments and questions, if you don't mind:

1) You are absolutely right that the form/mobility issues are what caused this. I wish I knew a year ago what I know now, but alas...

2) I would definitely be willing to try a chiropractor. Would you suggest this in tandem with a physical therapist? I tend to try one thing at a time so that I can try to tell what works and what doesn't, but am open to anything at this point. Also, is chiropractory something that would need to be done in perpetuity, or just until the pain goes away?

3) I wasn't able to get an appointment with the recommended physical therapist until April 10, though I assume he will get me started with the core stability work. In the meantime, could you recommend some specific core stability exercises that won't aggravate my specific injury? I assume planks and plank variations might be too hard on the lower back?

4) Thank you for pointing me to Stuart McGill - I have been reading his website and watching his YouTube videos. Were you specifically recommending one of his books, or just his philosophy of core strengthening (as opposed to striving for back flexibility) and some of the exercises he recommends?

5) Lastly, once the pain has hopefully disappeared, do you think that yoga would be good for my specific issues, or is that contrary to Dr McGill's philosophy of strengthening the core instead of increasing it's flexibility? (If not, I will need to find another plan for drastically improving my hamstring flexibility and mobility before getting back to real workouts).

My apologies for the barrage of questions, and thanks so much for your advice,
Andrew
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Old 03-16-2012, 12:35 PM   #8
John Powell
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

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Originally Posted by Andrew Leonard View Post
I do my prescribed PT stretches,
I know that many doctors (McGill included) are very against lumbar stretching, and there is evidence to suggest that those with very mobile lumbar spines are at an increased risk of back problems.

Are you doing lumbar stretches. I was and I saw improvement when I stopped doing them. I'd love to hear the doctor's perspective on this

Edit: Sorry I'm dumb and didn't realize that you addressed this above and I can't delete it.

Last edited by John Powell : 03-16-2012 at 12:44 PM.
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Old 03-16-2012, 12:50 PM   #9
Drew Leonard
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

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Originally Posted by John Powell View Post
I know that many doctors (McGill included) are very against lumbar stretching, and there is evidence to suggest that those with very mobile lumbar spines are at an increased risk of back problems.

Are you doing lumbar stretches. I was and I saw improvement when I stopped doing them. I'd love to hear the doctor's perspective on this

Edit: Sorry I'm dumb and didn't realize that you addressed this above and I can't delete it.
Hi John,

Yes, I do lumbar stretches (as instructed by a physical therapist) twice a day. They are relatively light stretches and usually make me feel better for a short period of time. But, as I've said, whatever I'm doing doesn't seem to be working as the injury is slowly worsening, so I would also be interested in hearing from any doctors or PTs with an opinion on this!

Thanks,
Andrew
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Old 03-16-2012, 04:55 PM   #10
John Powell
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Re: Bulging/degeneration in L4-L5 and L5-S1 discs

McGill says that most PTs will recommend the lumbar stretches for exactly this reason (feels better right away) but he argues that this causes soft tissue damage that will often make people feel worse a day or 2 later

http://www.backfitpro.com/articles.php (WFS)
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