When your back “goes out”

I’m guessing that it went something like this:

You reached or twisted quickly.
You went to pick something light off the ground.
You lifted a heavy couch, sack of birdseed, or barbell, with or without good form.

Immediately or shortly thereafter, you experienced a dagger in or just below the spine. The pain went from nothing to searing. You held your breath. You swore that a bone or muscle must have cracked right in two. You didn’t want to think about moving.

You, my friend, as they technically say, have thrown your back out. I’ve been there. On more than one occasion. What exactly is going on in there? It’s difficult to say exactly what tissue is at fault. But we can make a few basic assumptions with some degree of confidence.

First let’s try to define what kind of injury we are dealing with:

-There was a relatively abrupt onset of symptoms.
-The quality of the pain was sharp and intense.
-There was no numbness, pain, or weakness down either leg.

When this is the case, we are most likely dealing with one of three things:

-Strained muscle, tendon, or ligament. With these you can almost always palpate (touch or point out) the site of injury. The pain is very consistent, just like when you pull a hamstring or hip flexor after sprinting in the cold. Maintaining a rigid brace of the spine when you move often increases the pain because this places demands on the stabilizing muscles that are in question.

-Stress fracture. This is fairly rare but it happens. This pain is also very consistent, increasing with almost all loaded movements (standing on your feet). Almost all unloaded movements (laying down and sitting) cause minimal pain, though transitions back to sitting and standing will be difficult.

Lumbar stress fractures are seldom related to forward bending activities. They occur more commonly from extension overload, over arching, where the spine repetitively or traumatically undergoes compression with backward rotation (as when running, jumping, and tackling with a weak anterior core and/or tight hip flexor muscles).

–Disc derangement. As the years roll by and I manage hundreds of people with lower back pain, I’m certain this is the most likely culprit for backs that “go out” during and after flexion based activities. Keep in mind that not all disc herniations cause referred pain or numbness to the lower extremities. It is well known that tears within the disc, with or without an actual “slipping” of the disc, may produce a sharp or intense pain without pressing on the nerves that go into the legs.

The pain is almost always increased with forward bending and prolonged sitting because you are reproducing the mechanism of injury. But otherwise, the condition is fairly inconsistent. Sometimes there’s no pain at all and you’re like, “whew, smooth sailing!” Then, just when you let your guard down and go to put the milk back in the refrigerator, **BAM** you’re shot by the lumbar sniper.

With all things considered, here’s the ironic kicker. Whether your abrupt, severe, lower back pain is due to a disc injury or a muscle/tendon/ligament injury, you should treat it nearly the same way.

The absolute best things to do in the short term are as follows:

1. REST. Lay off it already! No, literally, lay flat on your stomach or on either side and take it easy. One way or another, you literally have injured tissue. There’s no manipulation or particular exercise that’s going to make it heal faster in the short term. Again, seriously, stop running for the manipulations and wiggling around when what’s most likely needed is REST. Try not to sit for prolonged periods. You can try some gentle press-ups and ice. Massage and modalities like electric “stim” and ultrasound may alleviate muscle pain for a short while. But the main thing you need to do is quit nagging it and give it a chance to heal.

Press-ups are often indicated in the instance of acute, flexion-based back injury. The mullet is not necessary.	.

 

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2. Ice is usually best in the first few days. But truly, with back pain there are no hard and fast rules. When I experienced acute lower back pain, ice made me feel stiff and a hot shower was almost miraculous. If you tolerate anti-inflammatory medications, take them. Nobody is impressed with anti-medication heroics. Taking a moderate dose of Advil for a few days is usually worthwhile.

3. Avoid flexion/bending activities. I have found that in the acute phase of lower back pain, most people underestimate the importance of staying away from the type of movement that stirred up the issue in the first place. Avoiding slumped sitting and the recliner chair posture is critical. If you feel significantly shifted to one side, and it’s hard to straighten up, try laying on the floor and getting straightened out. Shift your hips to the side that leaves you in line with your shoulders, and simply lie there for a while then try to stand upright, without the lateral shift.
   This type of lateral shift needs to be corrected ASAP.
To be clear, avoiding flexion means NOT standing and reaching to your toes. It means NOT kneeling and pushing your chest to the floor. It means NOT laying on your back and pulling your knees toward your chest. All of these stretches cause lumbar flexion and you should not do them! I’m amazed at how many people strain their lower back while bending forward or lifting, and then continue to stretch it by bending forward.

Yes, the bending forward movements do indeed stretch tight muscles. But it also reproduces the mechanism that got you into trouble in the first place! The relief of stretching those muscles will be temporary at best. At worst you will further aggravate or progress a disc problem to a full herniation.

So technically, these three things “to do” when your back goes out are actually non-doing things. And in the immediate short-term, that’s exactly what the doctor ordered to allow time for healing. But after 3 to 5 days, you need to get moving. You need to DO some things and still be careful to avoid doing others.

Prognosis?

By the numbers, you probably will get better with this simple advice. You will naturally take it easy, partly because you can’t go hard, partly because you will be more cautious. For a while. But did you know, also by the numbers, that chances are that after you improve and get back to what you like to do, you will experience a more severe episode of similar or progressive symptoms in the future? The last I read on this topic, there is a 90% chance that symptoms will return, and they are usually progressive in nature. What once was a disc tear will have progressed to a full blown disc herniation with sciatica, and you won’t be trying to call that a simple muscle strain.

Above all else…

Given the grim statistics on the natural progression of acute, localized lower back pain, let your personal episode of misery serve as a warning. Once you rest and ice and be very careful to avoid forward bending movements, it’s time to get active. There are plenty of things you should be doing to mitigate or altogether avoid the natural progression. But that’s another essay!