Most of the time he just felt his lower back “wasn’t right” – that he was only able to give 90% at work. Occasionally he’d have a flare up and end up flat on his back for 2 weeks, until he was able to resume his normal work-load. This had continued on and off for half the season – half the rugby season. The patient I’m talking about was a 6 foot 7 inch Scottish international second row rugby player. The flare-ups were always caused by being dropped in the line-out (incase you don’t know, second-row players are boosted high up into the air by their supporting players and usually guided back down to earth, but sometimes it doesn’t quite work out and they are “dropped” from a great height, while being bashed about by the opposition, meaning they can land in all sorts of damaging ways).
Aside from a few weeks in the season, he trained for – and played in – top level club rugby and international rugby. He felt he wasn’t able to sprint flat out, but nobody else seemed to have noticed, so he carried on being selected. Although he seemed to improve with treatment, the flare-ups kept happening, so I sent him off for an MRI of his lower back (not easy to get back in those days)… The radiologist reported “two large central disc prolapses” – one at L4L5 and the other at L5S1. That was a bit of a surprise! Here I had someone playing international rugby with just the odd inconvenient acute pain, otherwise feeling pretty good, but wandering around with two large disc prolapses which – from all my training – I’d have expected to have been been causing incapacitating pain. What was going on? At the time, he was a bit of a puzzle.
Jump forward 15 years of pain research and we know much better what was going on. It turns out that of all 45 year olds who have no lower back pain or sciatica, 60% of them have disc prolapses, herniations, or degenerative changes (as seen on MRI). So, you can definitely have a disc prolapse without pain. It’s still a subject of controversy, but some researchers maintain that the disc itself has no sensory nerve supply – so it’s possible to damage it and feel nothing.
But when you damage a disc it pushes on an adjacent nerve, doesn’t it? Not always. If there’s a big spinal canal (the tunnel the nerves pass through), it may be able to accommodate the nerves as well as a bit of prolapsed disc.
What about inflammation? Yes, when you damage a disc it usually becomes inflamed, and it may be that when this guy was dropped in the line out the disc became inflamed and that then irritated the area, resulting in protective muscle spasm – keeping him out of action for a few days. But if it was inflamed, wouldn’t the inflammation have irritated his spinal nerves, causing true sciatica? I’d have thought so!
So perhaps his acute episodes of pain had nothing to do directly with his disc prolapses. But what about his inability to sprint flat out? Could that have been due to the disc problems? Perhaps his body was acting to protect him in some way – just not put too much strain on the discs? It’s likely that his high level of physical fitness helped to stabilise and protect his lower back – one of the biggest predictors of lower back pain is low levels of fitness.
And the fact that he enjoyed his job could only have been a good thing – “work-related stress” is closely linked to higher levels of pain. His high levels of physical activity would also be producing frequent bursts of endorphins – the body’s natural painkillers. And having experienced lots of trauma as a kid – through rugby – is shown to reduce reports of pain in adults.
I recommended he change some of his training – especially going easy on the heavier weight training that could further compress and damage his discs – and suggested he ensure he had the best possible relationship with the players that were meant to guide him back down to earth. ;-)
His acute episodes resolved and he was happy to report that his full sprinting power returned within a few weeks.
What can you learn from this story? How about…
If you want to “cope” better with disc problems and lower back pain, you should
- experience plenty of physical trauma from an early age
- exercise like a professional sports person
- enjoy your job
- make sure the people around you are supportive!
If you’d like help puzzling out your own diagnosis, and the things making your back pain or sciatica worse, give me a ring / drop me an email.