

Written by jason reynolds

Low back pain is the number 1 cause of doctor visits in the U.S. aside from the common cold. Low back pain is an epidemic and it will affect 85% of us at some stage of our life and to varying degrees. Low back pain however, is a garbage can term; it is both ambiguous and useless if we do not define the specific pathophysiology that would manifest the label of “back pain.” Now one thing that needs clarification is that the chronicity of low back pain seen in the average American, is often different than the acutely episodic low back pain an athlete may encounter. Some of the same anatomical, physiological and biomechanical principals are true of all lumbopelvic injuries or “back pain,” still it remains that the etiology and prognosis will vary from your athlete to your, relatively speaking, unfit individual. A perfect working example of this is the recently inured yet fast healing patient and colleague, Chad Smith the Juggernaut. This 3-part article serves as a journey and case study into the cause, management and prognosis of “back pain,” the often elusive, multifaceted, number 1 cause of disability in the US. Hopefully we can unravel some truths about the causation, progression and appropriate therapies in dealing with such a menace to our society.

The text came through on June 6th, about 1 week prior to the initial incident, and it was at that moment that I decided an MRI was necessary because the symptoms had worsened over a weeks time. Also, my pull of the trigger to order imaging was greatly influenced by seeing Chad at his wits end with something. Complaining and inability are not 2 things common to this man, so we needed to see what I inevitably knew would be present on the MRI: Multi level herniations both central and foramenal. The largest was 7mm and it served as conclusive evidence to support the neurologic and orthopedic exams (performed serially over the last 7 days). Now we had our diagnosis! We know what is causing the “back pain” or do we? Here are some concepts that often need explaining to many of my patients that have back pain, or any pain for that matter. Most times the CAUSE of the pain is not the CAUSE of the pain. No typo there. Let me explain. When our body afferently transmits pain signals to our brain, in this case from Chad’s L5/S1 posterolateral disc tissue and nerve root sheath, we call this the pain generator, there is a pathophysiologic change to the tissue either structurally or chemically and now our body is alerted in hopes of protecting itself from further damage and degradation. Than we have the cause of the pain. All injuries whether chronic or acute have some type of biomechanical, anatomical or physiological dysfunction (not directly the pain generator), the only exception is external force trauma, example: Joe Theismann’s Tibia/fibula fracture. So what CAUSED this bout of disc tissue failure, there was not much I can think of especially from a guy who for the 4 years I have known him has been lifting, pushing and pulling ungodly amount of weight. If over 900 pounds sitting on your back as you squat your ass past your knees isn’t enough to make tissues fail, I don’t know what is.

In studies searching for the proverbial holy grail of back pain causation, there are many indicators that functional integrity is at the root cause of most of the chronic or non-traumatic acute incidences. This functional integrity is more of an epidemic than overt morbidities such as neoplasms (cancers), autoimmune disorders (RA), and the normal degenerative process of spinal arthritis. Surely in a case like Chad’s, functional integrity is the only factor of his low back pathology. The question still begs, how does a person of herculean strength suddenly have an injury that absolutely floors them. 3 words, General Physical Preparedness. This is a word often used in the training and sporting arenas. You wouldn’t typically hear a doctor speak of it and surely not attribute it to the cause of lumbar disc pathology with radiculopathy. Just a few weeks prior to this injury, Chad had begun doing an exercise called an Ox deadlift, most of you know what that is and if you do not (as I did not) Chad has a video of him doing them, HERE. Nevertheless this exercise is an absolute genius strategy to train portions of ones deadlift and all at the same time a nightmare come true for the lumbopelvic region of the body. Once I actually saw a video of this exercise being performed I knew immediately that this was a big piece of the problem Chad was experiencing. The exercise itself is not one that I would recommend however the manner in which the exercise was being done was the straw that broke the camels (or Juggernauts) back. We have all heard that old adage, and possibly experienced something similar, a paralyzing sensation that floors you into spasms and all you were attempting to do was pick up something off the floor, or maybe it was getting out of bed, or doing a seemingly routine tempo type training session. Whatever the “straw,” it was probably not the force or activity you thought would put you in the ER or into an MR machine. The same with Chad, how did this “straw” of an exercise do him in? It’s quite simple; his body was not prepared for the repetition with such a foreign exercise.

As I began to explain, Functional integrity is a major underlying cause for lumbar spine pathology. What does that even mean you ask? I do not entirely like the use of the word functional because it is a very ambiguous term and can be used out of context, however it is the best way I can describe what happened or does happen to an individual’s spine when it fails. The best example of a this is to imagine what would happen to a rubber band if you continued to stretch it to its submaximal limit over and over again over days and months and years, or a paperclip bent in half and then again in half the other way and so forth. Our tissues will respond the same way to stresses. Some stresses we can adapt to and get stronger and more resilient from, some our body cannot adapt to and failure occurs. This is functional integrity; it is a specific tissues physiologic resiliency to stress. It is made up of both anatomic considerations and neurologic considerations. Take a lumbar disc for example in this scenario with Chad; clearly the anatomic structural resiliency to heavy loads with both high frequency and volume was not a question. What Chad was missing and what most pathologic failures of lumbar tissue are missing is the neurologic component. Proprioception and mechanoreception, the ability of a muscle, tendon, joint and fascia to know where it is relative to gravity, an external load and the adjacent tissue/joint, (I will talk more about proprioception and mechanoreception in the rehab portion of this 3 part article). Too many times we allow our bodies to do an activity or movement that it is not ready to do, or has not trained to do. This happens all the time with athletes who experience overuse injuries early in a season, too much too soon and no general physical preparation before beginning the meat and potatoes of the training. The truth of the matter is that if we had taken an MRI of Chad’s Lumbar Spine just a few hours before he started to have his symptoms we would have likely seen bone marrow changes, potential herniations, and other structural abnormalities that were not pathologic enough to manifest pain or dysfunction. However, the introduction of a new exercise, activity (Ox deadlifts) or even the repetition of an action that is detrimental to specific tissue (bending from the lumbar spine instead of utilizing a hip hinge), will eventually wear down perfectly normal tissue to failure and mainly due to neurologically inept tissue.

There are many diagnoses that can elicit the label of “back pain,” the etiology of the pain is usually a no brainer if you are given imaging and a solid orthopedic and neurologic work up is done. The challenge is to know if what those symptoms and diagnosis portray is the issue you address or is it simply the pain generator that has an even deeper causation. The answer is almost always yes, there is another causative factor. Functional integrity and general physical preparedness are cornerstone pieces for the formulation of how to correctly diagnose an injury and more importantly how to treat and manage the injury so that optimal recovery can ensue. Next article we will look at the passive care arsenal that was implemented to keep Chad away from the knife and Cortisone and have him back to loaded squatting and pulling in just 4 weeks.

Related Articles: Lumbar Spine Rehab-Part 2 by Dr. Jason Reynolds

Lumbar Spine Rehab-Part 3 by Dr. Jason Reynolds