Herniated Lumbar Discs: A Guide to Prevention and Rehabilitation

Written By Rich DeAngelo

Unless you’ve spent your life living in a van down by the river (Chris Farley), than either you have or you know somebody who has experienced lower back pain (LBP). Personally I’ve taken an interest in preventing LBP because I have experienced a handful of issues over the course of my own athletic career. I am not a doctor, this guide is not meant to be medical advice, however it should give the reader some insight into what their rehab protocol, and prevention should look like, and some things they can expect. The purpose of this guide is to educate athletes on the causes of HLD, how to prevent it, and how to return to competition if athlete develops HLD. Lower back injuries and more specifically herniated lumbar discs (HLD) are one of the most common injuries that can sideline athletes from competing and training. The best form of treatment is to prevent a HLD from happening in the first place, however preventative measures don’t always guarantee that you won’t get a HLD.

Let’s start off with what causes the onset of HLD, “…the primary cause of herniation is repeated flexion or sustained flexed posturing… many athletes even at the elite level lack the capacity to dissociate hip flexion from lumbar flexion whether due to lack of motor control or lack of available ROM, thus potentially leading to their training methods contributing to the cause of their HLD…” (VanGelder). According to VanGelder, and other researchers, the primary cause of disc herniation is repeated flexion of the lumbar spine under a load due to instability in the vertebrae, and the athlete having poor motor control and or poor range of motion forcing them to “hip-hinge” using the lumbar spine rather than the hips. Most commonly herniation’s happen at the L4/L5, L5/S1 and L3/L4 intervertebral discs. Symptoms of HLD last on average around 4.5 weeks, however if left untreated can last indefinitely, 79% of athletes who experienced HLD, rehabbed using non operative treatment, for 4.8 months on average before returning to sport. (Iwamoto.).

So how do we prevent athletes from getting HLD? “Mechanical stability of the spine is necessary in order to permit and control movement, carry loads, and protect the spine and the nerve roots… Herniation of the intervertebral disc is associated with repeated compressive loads (1,000+ repetitions) that occur in fully flexed or bent postures.35 Work by Adams & Hutton appears to indicate that the spinal segment must be flexed to its full end ROM in order for the disc to herniate.36 Finally, it appears that axial rotation combined with flexion encourages radial lesions of the annulus, while axial rotation alone does not… addressing the Janda Pelvic Crossed Syndrome, gluteal weakness, pelvic floor and diaphragm… The classic pelvic crossed syndrome is a described imbalance between tight and short hip flexors and lumbar erectors spinae and weak or inhibited gluteal and abdominal muscles.71 Evidence for decreased hip flexor extensibility is evident in individuals with a history of LBP…Although the role of the gluteus maximus and hip extension in the HLD and LBP population is unknown at this time, decreased hip abduction and external rotation strength, have been implicated as a predictors of back and lower extremity injury.. Latissimus dorsi contribution to tension development in thoracolumbar fascia (TLF) does produce an extension moment at L5/S1, theoretically making it useful in resisting flexion in the most common location for disc herniation… Postural education should be coordinated with the athlete's coach in order to determine the appropriate balance between a protective posture and optimal sport performance. In most sports, a neutral spine posture will be beneficial, but in some sports such as rowing or cycling, a true neutral spine position is not possible. In these cases, inadequate hip mobility or lack of thoracolumbar extension may compound the risk placed on their lumbar discs in their sport position. Therefore, the best attempt toward improving hip mobility and thoracolumbar extension should be made, but recognize that years of sport specific tissue adaptation may prevent the athlete from achieving the “optimal” neutral spine in their sport position.”(VanGelder). According to the literature, we can prevent HLD in athletes by increasing musculoskeletal stability of the lumbar spine, avoid compressive loads in flexed and bent postures, avoid rotation while flexed, correct the athletes pelvic cross syndrome(anterior or posterior pelvic tilt) by lengthening the hip flexors and strengthening the abdominal muscles to the ideal length necessary for a neutral spine, strengthen the gluteal muscles, pelvic floor muscles and address proper diaphragmatic breathing, strengthen the Latissimus Dorsi, educate the athlete on proper posture to find a balance between safe posture and optimal performance which usually results in a neutral spine for most sports, and finally to address the athletes hip mobility and thoracic extension.

What to do if the athlete follows every preventative measure listed above and all else fails and they still end up with a herniated lumbar disc? This is when a proper return to performance rehabilitation plan comes into play. “Phase I: Non-Rotational/Non-Flexion Phase (Acute Inflammatory Phase), Phase II: Counter rotation/Flexion Phase (Repair Phase), Phase III: Rotational Phase/Power development (Remodeling Phase), and Phase IV: Full return to sport.”(VanGelder). These are the four phases of the rehabilitation protocol designed by VanGelder.

Phase I: the Non-Rotational/Non-Flexion Phase (Acute Inflammatory Phase), or the Protective Phase, the main focus of this phase of rehabilitation is to minimize inflammation by chemical means, eliminate mechanical stress on the disc by practicing proper body positioning on movements within a pain free range of motion. “Aggressive repeated movements applied to the spine during the inflammation stage may delay healing or cause additional injury. Therefore during phase I of this protocol the objective is to eliminate excessive mechanical stresses on the spinal segment in order to prevent further exacerbation and provide a safe healing environment.”(VanGelder). In addition to protecting the disc from further injury, a sub-goal of this phase is to begin introducing therapeutic intervention such as the McKenzie Method also known as Mechanical Diagnosis Therapy, to help restore disc health. “The McKenzie method exists of 3 steps: evaluation, treatment and prevention. The evaluation is received using repeated movements and sustained positions. With the aim to elicit a pattern of pain responses, called centralization, the symptoms of the lower limbs and lower back are classified into 3 subgroups: derangement syndrome, dysfunction syndrome and postural syndrome. The choice of exercises in the McKenzie method is based upon the direction (flexion, extension or lateral shift of the spine). The aims of the therapy are: reducing pain, centralization of symptoms (symptoms migrating into the middle line of the body) and the complete recovery of pain. The prevention step consists of educating and encouraging the patient to exercise regularly and self-care.”(Machado). Phase I will focus directly on movements in the sagittal plane to help control symptoms of HLD. An emphasis on lumbar spine musculoskeletal stabilization exercises as well as strengthening the hip extensor muscles, will work synergistically with the McKenzie protocol. “Early use of stabilization training exercises has demonstrated improvements in symptom management for the lumbar HLD patient.”(VanGelder). In addition gluteal weakness needs to be addressed during this stage because it will provide needed strength and endurance to perform a proper hip hinge. “Hip hinging involves developing a motor strategy in which flexion of the torso occurs primarily through flexing at the hips rather than throughout the lumbar spine. Flexing at the hips promotes maintenance of lumbar lordosis by means of a slight anterior pelvic tilt throughout the range of motion of forward bending.”(VanGelder). Teaching and reinforcing the proper motor pattern of a hip hinge to the athlete with HLD should be emphasized to prevent any further injury in the future, and this should be practiced throughout daily living activities, not just in sport or training.

Phase II: Counter Rotation/Flexion Phase, or Repair Phase, this phase should focus on unilateral exercises using isometric contractions to resist frontal and transversal plane loads. These exercises should be performed with enough tension to stimulate fibroblast repair, but also protective enough of the spinal segment as to not cause further injury.

Phase III: Rotational Phase/Power Development, or Remodeling Phase. To graduate from this phase, full reintroduction of transverse plane movement must occur. “Continued progression of movement and loads in dynamic activities will aid in the alignment, organization, and cross-linking of collagen fibers.53, 54 Progress to full dynamic rotation rather than simple isometric tensile forces as were utilized in the counter rotation phase is needed in order to fully stress the entire range of the collagen fibers and restore normal intervertebral disc function.”(VanGelder). Conservative progressions and if necessary regressions, must be made as deemed necessary. Practicing controlled rotation has been shown that it may reduce excessive scar tissue formation in the annulus, which in turn will prevent annular cell death and allow adaptive cell reorientation to occur. During this phase, exercises which emphasize protective mechanics of HLD should be performed with low intensity loads, should begin being performed by the athlete to start developing muscular power to prepare the athlete for the rate of force development necessary to compete in their sport and or strength and conditioning program.

Phase IV: Full Return to Sport. During the entire duration of the rehab process, an attempt should be made to practice sport specific technique and conditioning performed within the guidelines listed from phases I through III, within reason to avoid further injury and promote healing as long as the athlete is far enough graduated from the acute phase, that they can participate in daily living activities. To shut down an athlete completely, will result in deconditioning and may increase the risk of further injury. In order to return to sport, the athlete must be able to “freely move in all three planes of motion with adequate mobility, motor control, efficiency, and power. In the transition from Phase III to Phase IV, the athlete must be participating in every facet of their respective sport to some degree. This must be graded appropriately, but all of the athlete's specific movement skills must be occurring at this time. Gradual decrease in emphasis on abdominal bracing should be performed with emphasis switching to stable and controlled mobility throughout the ROM demands of sport activity. However, abdominal bracing should still be reinforced during strength training, in particular with heavier lifting.”(VanGelder). Education must be provided to the athlete in terms of proper posture both for injury prevention and optimal sport performance. For most sports, with few exceptions a neutral spine is best. “. In these cases, inadequate hip mobility or lack of thoracolumbar extension may compound the risk placed on their lumbar discs in their sport position. Therefore, the best attempt toward improving hip mobility and thoracolumbar extension should be made, but recognize that years of sport specific tissue adaptation may prevent the athlete from achieving the “optimal” neutral spine in their sport position.”(VanGelder). In addition, the athlete should be educated on how to maximize muscular stiffness to increase spine stability.

Now that we know the guidelines to follow during the four stages of rehab, here are some example exercises that can be used in each respective phase:

  • Phase I:

    • Abdominal hollowing and bracing

    • Hip Hinging or Romanian Deadlift

    • Hook lying hollowing with foam roller adduction and pelvic floor recruitment

    • Side lying abduction

    • Glute Bridge/Hip Thrust

    • Plank Progressions

    • Lunge Progressions

    • Lat Pulldown/Pullup/Chin-up Progressions

    • Inverted Row Progressions

  • Phase II:

    • Bodyweight Squatting with Latissimus Activation

    • Goblet Squat

    • Turkish Getup

    • Suitcase lift

    • Stability ball curlups

    • Rack pull/block pull deadlifts- progress to full range of motion once tolerated

    • Unilateral Romanian Deadlift

    • Unilateral Squat

  • Phase III:

    • Lunge with a twist

    • Supine stability ball twists

    • Chops and Lifts

    • Kettle bell swings and snatch

    • Hang Clean

  • Phase IV: once full return to sport is achieved, the athlete should still be performing some of these exercises as a lumbar spine maintenance program to prevent re-injury.

     

     

     

     

     

     

     

    Works Cited:

    VanGelder, L. H., Hoogenboom, B. J., & Vaughn, D. W. (2013). A PHASED REHABILITATION PROTOCOL FOR ATHLETES WITH LUMBAR INTERVERTEBRAL DISC HERNIATION. International Journal of Sports Physical Therapy, 8(4), 482–516.

    Iwamoto, J., Sato, Y., Takeda, T., & Matsumoto, H. (2011). Return to play after conservative treatment in athletes with symptomatic lumbar disc herniation: a practice-based observational study. Open Access Journal of Sports Medicine, 2, 25–31. http://doi.org/10.2147/OAJSM.S17523

Machado L. A. C. et al, The McKenzie Method for Low Back Pain: A Systematic Review of the Literature With a Meta-Analysis Approach, SPINE Volume 31, Number 9, pp E25