Lower back pain: disc injury, facet syndrome and where rehab starts

Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, it's Dr. Sebastian Gonzales with the Performance Place. And this time, we're going over back injuries. And back injuries, we're talking about disc injuries, facet syndrome, generalized low back pain, muscle tightness around the back or low back. And the reason why I'm bringing this up today is because I have this conversation a lot with patients at the office. And I want to make sure that I know it's a little bit high pressure, especially in the beginning when you have an injury.

It's very stressful to absorb all the information that I'm saying and that is being put out at you. So, this podcast is just a nicer, gentler way of going through and just reabsorbing that content. Because understanding an injury, and especially a back injury, is super critical in regards to changing your activities of daily living so you have a chance to heal up as well. And activities of daily living are very simple things. And they're activities like putting on your shoes, getting out of bed, washing dishes. All these things are things that a lot of patients that I've worked with do not think of at all as being triggers for their back condition.

Now, in case you're wondering the rough algorithm that I'm going through at the office when you come in and you start speaking about a back injury, First off, we just have to figure out whether it's going down a leg into the foot, into the knee, into the thigh, or not. Because if it is, we need to make sure that we centralize it first. And centralization is the concept that you can look up on Google. And centralization is mainly that we're trying to get that pain or the symptoms to become more centralized, to become more towards the center of the spine, towards the back, towards the hip, and especially away from being further distal or downward from the knee.

So that is the first number one thing. And the reason for that is because a lot of times surgical procedures are more so revolved around a referred pain like that, or how far it goes down into a limb, and especially if it goes down into both limbs and so on. One question I ask as well, when someone comes in with a possible disc injury, by the way, we're talking about not just disc, but also Pisset syndromes, or also muscle tightness to the low back, is we need to figure out if this is a back injury that has one of these three situations, then it's a medical emergency. All the other conditions that don't have these, there's time to wait.

And I'm not saying that it doesn't hurt, and we don't understand that it hurts, that it's very uncomfortable to you, and that's, I understand. But a lot of times there are rehab cases if they don't have these three things, and here's the three. Number one is saddle anesthesia. And this is numbness or loss of sensation in the shape of a saddle on your butt. And keep in mind that encompasses both sides, not just one. Second thing is what we call foot drop. Foot drop is, imagine, you know, someone walking down a hallway, and you can hear them coming because you hear this slap. And the slap is that the foot is, or the toes of the feet cannot stay elevated, and they're just slapping the ground every time that person is walking down the hallway.

So drop foot is definitely something you need to go see, be seen in the ER for. Last is urinary retention. And urinary retention is where you're trying to go to the bathroom and get it all out, but you can't. So if your doc hasn't asked you about these, you really need to figure them out. And if you have one of these, this is an ER visit, and it's possible emergency surgery. Now, the next thing that I ask people is, does it hurt in one of two directions? And then we can figure out the rest from there. And the two directions, if you haven't listened to the Common Terms podcast yet, are flexion or extension.

I'll explain both of them. Extension, most people can understand because when you extend your elbow, it's going backwards. And this happens the same way with the back. If you were to look back over your head, so you're standing, you're looking back up into the sky, that's neck extension. But also times, a lot of times, the low back will extend as well. So, extension is almost, I guess, like if you imagine, I remember one of those seal postcards or sea lion postcards, where they're on their belly and they're extended up and they're looking to the sky and their tails in the sky as well. This is hyperextension, overextension.

So that's one motion, extension. Flexion is the other direction. It's like you're bending forward to do a forward fold in yoga, or you're bending over to touch your toes. And this doesn't always require the lumbar spine or the low back to move, but oftentimes it does. And when it does, if this sets off or becomes a trigger for your low back condition, a lot of times it is a disc injury. And disc injuries can go to varying degrees. So let's not go into that too much. But for the most part, when we're establishing rehab with a back injury, we need to figure out one thing in regards to program design.

And that is, are you more tolerant to flexion or extension? Okay, I'm going to say that again. Are you more tolerant to flexion or extension? And it's not about if one of them is pain free or not. It's which one is less painful. Okay. And the reason why we're doing this is because the muscles of the back need to be rehabbed. And these stabilizer groups, one of them that they've done a lot of research on in the past is called the multifidus. They're supposed to be stabilizers at the low back and protect the region prior to movements, such as prior to bending down, turning and picking up a pencil.

But a lot of times with injuries such as disc injuries, these muscles become really latent and they fire late. So they're not doing their job. And a lot of times we're just tearing up the back if we don't stabilize and retrain these muscle groups. So the only problem is if we train them while you're in pain or put you into a painful motion such as flexion, in this case, if the disc injury doesn't like flexion, then these muscles are shutting down again. So how are we actually getting them to fire up and do their job? The answer is, is we put you into positions which don't hurt and then we stimulate those muscle groups.

So an example of some exercises which I give people with that are flexion intolerant, such as they can't bend down to tie their shoes, is supermans. Or we might give them bridges, single leg bridges. We might give them McKinsey extension exercises, which more is a means to centralize the disc and create some referred, get some referred pain to go away from the lower limbs. But things we definitely wouldn't do with them are sit-ups or crunches. We probably, we might not have them squat beyond a certain depth because a lot of times the low back will cave and create a slang term called butt winking.

And we do have a video on this as well. Look at our squat video. So there's certain things that we won't have you do, but I want you to realize that some of the methods or some of the movements we're teaching in the office here, they are helpful in regards to limiting flexion of the spine by getting the hips to move better. And I'm going to say that again because there was a patient this week that we talked about this about the second or third time now. And I really, really need you to understand this is that if your hips move well, your low back moves less. Let's think about it in a real life setting.

If you have to bend down to pick up a baby and your hips are arthritic and not working, then you're going to bend over with your back. If your hips work well and your legs are strong, you're probably going to squat down or deadlift down and pick up this baby. Now, the complex lift that we show in the office that are needed through everyday life, everybody needs to learn how to do them well, maybe not with a ton of weight, but they need to learn how to do them well, are deadlifting and squatting. Here's my examples. Okay, squatting. How many times do you squat a day? Well, you're squatting to get into your car.

You squat to get down to a seat while you're working. If you do work in a chair, you're squatting to go to the bathroom. All of these are squatting motions that we might as well get really good at and limit the amount of flexion that you have while doing it. Because I can tell you, I have patients that they cannot tie their shoes in the morning because they're getting flexion of the lumbar spine. And so part of our job here is to teach you guys how to limit flexion while you're doing some of these daily activities. Now, deadlifting is one that people argue with me to the blue in the face sometimes about.

They're like, why do we have to do this? Why would I have to deadlift 150 pounds? Well, you don't. But you should probably be able to deadlift at least 65. So, picking up a child, picking up, let's see, a heavy backpack, a log, a table, helping a friend move. These are all motions that require deadlifting. And if you learn how to keep the spine or trunk stable with this, then you should be really good. Now, I had a patient also over the last couple of weeks that he had an epiphany. And it was probably about a fifth or sixth time. And we were doing some deadlifting or hip-binging motions. And he's like, I got it.

And I was like, you got what? And he said, I realize now you don't want me to move my trunk. I said, okay, yeah, yeah. We've been talking about this for a while. He's like, I know, but I finally got it. And again, this is part of the reason for these podcasts is I want you guys to, I want to hammer in what we really, really need you to know. And the goal of the trunk in these rehab settings are to keep it as rigid as possible. And by rigid, I mean robust. And by robust, I mean resistant to deviation from midline. If I were to come up and you were sitting in a chair and you had a disc injury and I pushed you forward and you flexed forward, you wouldn't be happy with me because it probably really hurt.

But if you were ready for that and engaged in the trunk and it came up and you didn't deviate much from midline, your trunk is robust. Robustness is a very, very important thing in regards to stabilization. It doesn't mean that it can't move or it's resistant to movement. It's just resistant to a large amplitude of movement. It doesn't sway a lot. It sways a little bit, but not a lot. And that's how we protect the spine. Now, an analogy which I've gone through in a lot of people with disc injuries, I know we've been talking about disc injuries, not as much with Passett syndromes or things that are extension tolerant.

We will talk about that in a second. So, disc injuries, think of them like a scab. And I cannot stress this enough. Once you get it into your mind that there is a scab on the spine which gets ripped off every time you flex forward, you will stop doing it. And I tell patients over and over again that as soon as you flex forward, you've reset your clock a little bit. Well, when is this going to get better, Doc? I have a snowboarding event I really want to go to. I'm going to go ride this year and so on. I know. I get it. But when you're driving in your car, are you flexing forward? Well, yeah, I am.

I can't drive any more than five minutes. Okay. Look, let's not reset this clock. Understand that when you pick out a scab, it takes longer and longer to heal. So, visualize that. Do not pick the scab off. Limit flexion. Your injury does not tolerate flexion. And if you need to know more about what flexion is, there is a Common Terms podcast. On the intro course that you really, really should listen to. Because we go over a lot more than just flexion. We go over all the motions as well as some of the joint and muscles and so on. Now, with extension tolerant conditions such as facet syndrome, these are ones that I think would be more responsive towards adjustments.

And I know some of you have come in and talked to me about, well, should we be adjusting this disc injury? I personally choose not to. Mainly because there's some flexion and rotation within an adjustment. I'm not saying it doesn't work for other doctors. It's just something that I would not rather dabble with. Now, extension pain, I would. Unless there's a possibility that you have a parse fracture, which is a whole different situation. Now, with extension tolerant, or sorry, sorry, I erased all that. With flexion tolerant, so facet syndrome will be responsive and tolerant towards flexion. So, it will be the direct opposite of a disc injury.

So, you won't be able to extend. So, now we can have you do more things like crunches, squatting, front squatting, and so on. And it's a little bit safer. And facet syndromes are not, by all means, they're not great conditions to have. But they're not as hard to deal with as disc injuries. So, now there are many other conditions at the back. And I know the muscles get tight and so on. But remember this, if you have an area of instability or it's not strong enough to protect itself, and this could be one vertebra upon another, it could be a disc which is injured, it could be a lot of things, a lot of times the muscles will fire up because they are doing what they can to stabilize that area.

And this happens a lot. It happens with shoulder labrums. It happens with a lot of conditions. So, I hope this was really helpful. There will be some videos on exercises you guys can do that we show very commonly in the office. One is the McKinsey Extension Protocol, which is something you might consider doing in the morning, especially if you have a disc injury, not a facet syndrome. If you are flexion intolerant, if you cannot flex, the McKinsey Extension Protocol is usually a great one to start with in the morning because in the morning, the disc is usually more full of fluid because you've been horizontal to gravity the whole night.

So, it fills up a little bit more. And in the morning, as soon as you get out of bed and you start stretching a little bit and go into flexion, it doesn't like it. So, go into extension and give it a chance. Give it a chance to feel good throughout the day. There's no reason to flare it up first thing in the morning. Now, if you guys have other secondary level questions, I really, really invite you to put them down below this podcast. I want to answer the more in-depth questions when they come up because if you're thinking of them, someone else is too. Talk to you guys soon.