Herniated Disc – a Runner’s Guide to Diagnosis, Treatment & Prevention

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 Etymology: The correct modern medical term “spinal disc herniation” comes from the Latin denomination of “prolapsus disci intervertebralis.”

Herniated discs can occur to anyone but can be especially induced by a sudden impact or injury.  It most often occurs in the lower back or lumbar region (the L4-L5 and the L5-S1 levels) as this is the part of the spine that carries most of the body’s weight. As we age, the water content and elasticity of our discs decrease and so people who are between 30 and 50 years tend to be affected the most.

As a runner, the repetitive impact on the spine from shifting from foot to foot while in rapid motion could be enough of a trigger to initiate any number of aches and injury, including, a herniated disc. The pain of a herniated disc can be subtle or it can be severe, but in both cases, it is important that the herniation is corrected. Furthermore, the location of the pain can also vary. Pain in the shoulder, arm, or back could be originating from a pinched nerve in the spine caused by the herniated disc. With running, pain in these areas are common as the back and spine take on impact, therefore it can be common to overlook the issue as an artifact of the sport. Special attention must be given to pain that persists and especially pain that worsens with time and increased physical activity.

Terminology

A spinal disc herniation is also called a herniated disc, prolapsed disc, ruptured disc, and slipped disc. Although, the latter two terms are misnomers because they’re describing the injury incorrectly and may cause confusion. Your doctor will be able to identify and diagnose the proper cause of your injury and provide supplementary information.

The intervertebral discs are firmly sandwiched together between two vertebrae to which they are attached, and cannot actually “slip” or get out of place. The disc is connected to the adjacent vertebrae and can be squeezed, stretched, twisted, torn, ripped, herniated, and degenerated, all in small degrees, but it can never “slip.”

Discs allow bending of the spine and function as shock absorbers.

Herniated-Disc-Flexing-Spine

If appropriate, most physicians will recommend non-surgical treatment like physical therapy, epidural injections, or other medication or the first 6-12 weeks. Treatment efficacy may depend on person to person, and may require a combination of approaches. Should the non-surgical approach fail to provide relief from the pain, surgery may be considered.

Surgery may be necessary immediately if the pain is so severe that the patient cannot perform normal, everyday tasks or if neurological symptoms worsen like weakness in the legs and/or numbness occurs.

Definition

A spinal disc herniation is a medical condition in which the spine is affected. More precisely, it involves a tear in the outer ring of an intervertebral disc which enables the central portion to bulge out beyond the damaged outer rings. Think of the vertebral discs like a bike tire, with a tougher outer layer and a softer inner layer. As with tires, if the the outer layer is punctured and compromised, the air escapes and the integrity of the structure is lost. The condition usually results in the release of inflammatory chemicals, which may directly cause severe pain and discomfort even if the nerve root hasn’t been compressed by these fluids.

The damage is almost always posterolaterally (on the back of the sides) mostly because of the presence of the posterior longitudinal ligament located in the spinal canal.

Most disc herniations are a further complication of an existing condition involving disc protrusion in which the outermost layers of the outside portion of the intervertebral disc (annulus fibrosus) are intact, but bulge whenever the disc is under pressure. In contrast to a disc herniation, the central portion doesn’t escape beyond the outer layers.

Herniated-Disc-Hernia-Herniation-Slipped-Disc

Stages of Disc Herniation

  1. Disc Degeneration: chemical and mechanical changes associated with aging causes the discs to weaken, but without a herniation. It is most often called degenerative disc disease and is a natural process of aging. Throughout our lives, the impact we incur on our spines compress the discs, and over time can create small tears that in the outer layer of the disc, weakening it and making it more susceptible to a rupture which is the root cause of the herniated disc.
  2. Prolapse: Also known as a bulge or protrusion, is when the form or position of the disc shifts with some slight impingement into the spinal canal. This can happen when  the harder outer lining of the disc weakens from structural changes due to the natural aging process.
  3. Extrusion: the viscous nucleus pulposus escapes through the tire-like wall (annulus fibrosus) but remains within the disc. Sometimes, a tear can occur in the annulus fibrosis causing the more liquid-like nucleus to leak out of the inner disc and puts pressure on nerves around the spine, causing pain and reduced mobility of the limb.
  4. Sequestration: the nucleus pulposus escapes through the annulus fibrosus, outside the disc in the spinal canal (HNP).

Symptoms

In the case of a herniated disc, symptoms can greatly vary depending on the position of the injury on the spine, the severity, and other health, genetical, and situational factors. Quick onset pain is almost always reported even when no causating action event is identifiable.

  • Pain (radiating, sudden, tolerable, acute)
  • Muscle weakness
  • Breathing/diaphragm problems
  • Headaches, migraines, dizziness
  • Muscle spasms or cramps
  • Numbness, tingliness, cold feet
  • Bladder and bowel incontinence (cauda equina syndrome)

If the disc herniates into the spinal cord area, then myelopathy (spinal cord dysfunction) may manifest itself, inducing sensory disturbances such as numbness, tingliness, balance impairment, bowel and/or bladder dysfunction.

Immediate surgery is required if cauda equina syndrome occurs. If a central disc herniation is serious enough, the symptoms might include bilateral leg pain, loss of perianal (anus) sensation, paralysis of the bladder, and weakness of the anal sphincter.

Herniated-Disc-Lower-Back-Pain-Symptoms

The cauda equina is a cluster of about 10 pairs of nerve roots that resemble a horse’s tail which it’s named after in Latin. The nerves grow past the spinal cord and visually looks like a horse’ tail and continue down the legs. The sciatic nerve is one nerve that is part of the cauda equina. The neurons from this group of nerve endings are responsible for sensory function of the pelvic area, the lower limbs, the bowel and for bladder function. The cauda equina is the bundle of nerve roots associated with the L1-5 and S1-5 vertebrae and therefore is highly susceptible to injuries in the lumbar region, including herniated discs. Due to the extra weight gained from fetal development, pregnant women are increasingly susceptible to cauda equina disorder due to a herniated disc–the risk is higher in older mothers.

Rehabilitation after surgery for cauda equina disorder include physiotherapy, occupational therapy, and weight management if applicable.

Cervical herniated disc symptoms

Pain, numbness, muscle weakness, pinches and tingliness in:

  • Head and neck
  • Diaphragm
  • Deltoids, biceps
  • Wrist extenders
  • Triceps
  • Hand

A cervical herniated disc usually develops in the 30-to-50-year-old age group, from a trauma or neck injury. Symptoms vary, but pain is almost always reported, mostly as a radiating pain alongside multiple parts of the body.

The pain patterns and neurological deficits are largely determined by the location of the herniated disc, but usually, involves the upper part of the body.

The cervical spine discs are smaller than lower disc which means that even a small cervical disc herniation may pressure a nerve, causing significant pain and discomfort.

Seven vertebrae or stacked bony structures constitute the cervical spine, numbered C1 through C7.

All cervical hernias

Herniated-Disc-Cervical Spine

C1-C2

A disk herniation at this level is less common, but reported constantly, nonetheless. Symptoms might include lightheadedness, dizziness, headaches, muscle weakness, pain, numbness, tingliness anywhere in the head, neck, ear, and/or jaw.

C2-C3

An uncommon herniation region as well, but a herniation at this level may induce, muscle weakness, paraesthesia (tingliness), numbness, headaches, radiating nerve pain, diminished sensitivity in the extremities, muscle stiffness, and pain behind the eyes, neck, and/or shoulders.

C3-C4

It’s a fairly uncommon hernia area which may involve the head, base of the neck, extremities, and torso region. The patient might experiment pain, muscle weakness, tingliness, numbness, and diaphragm problems (difficulty in breathing, pain etc.) The shoulders have a higher chance of being affected in this hernia case, especially when elevating (shrugging) the shoulders.

C4-C5

A disc herniation at this level usually causes shoulder, arm, collarbone, and neck pain. Also, muscle weakness in the deltoid, biceps, and outer arm region. It usually doesn’t cause numbness or tingling but they’re not excluded. Diaphragm problems might also appear (difficulty in breathing, pain etc.)

C5-C6

A disc herniation here usually causes weakness in the biceps and wrist extensor muscles. The inner part of the arm, biceps, and shoulders might experience radiating pain or similar symptomatic manifestations.

C6-C7

A disc herniation in this region usually causes muscle weakness in the triceps, upper arm, and can extend to the forearm all the way to the finger extensor muscles. Numbness and tingling are also reported alongside the triceps, down to the middle finger.

C7-C8

In this case, the triceps, the elbow region, the shoulder, and middle arm down to the pinky can manifest radiating pain, numbness, tingling, weakness, stiffness.

C8-T1

This level is positioned at the very bottom of the neck, where the upper back (thoracic) meets the cervical spine.
A disc herniation at this level usually causes weakened hand grip, with numbness and tingling alongside the arm down to the exterior part of the hand.

Thoracic herniated disc symptoms

Pain, numbness, muscle weakness, spasticity, pinches and tingliness in:

  • Chest
  • Abdominal area
  • Extremities

Most commonly in young and middle-aged adults. Symptoms usually occur in the torso area and alongside the arms, shoulders, and back. Pain and discomfort radiate from inside the torso and worsens with certain movements.

Twelve vertebrae or stacked bony structures constitute the thoracic spine, numbered T1 through T12.

All thoracic hernias

Herniated-Disc-thoracic-Spine

T1-T2

A disc hernia at this level is more common and can develop symptoms in the upper body, especially in the chest area, weakness of the intrinsic muscles of the hand, motor impairments, diminished sensation in the armpit (axilla).

T2-T3

At this level, a disc hernia might cause pain in the back, chest, shoulder blades, that usually wraps underneath the arms. Inhaling, exhaling or chest and hand movement might trigger pain and discomfort.

T3-T4

A hernia in this area usually causes pain in the lower part of the shoulder blades, upper chest, armpit (axilla). Upper mid torso is virtually completely affected

T4-T5

This thoracic hernia causes back and chest pain, especially at the breast level. Often described as a belt of pain just bellow the pecs.

T5-T6 to T9-T10

Here, pain might be experienced below the shoulder blades, flanks, between the nipples, mid back, and the belly button. Twisting, turning, extended arm movement usually triggers the symptoms.

T10-T11

The lower thoracic level causes lower back and abdomen pain, especially in the belly button area. Pain seems to radiate from inside the abdominal cavity towards the outside.

T11-T12, T12-L1

A hernia in the upper lumbar area may cause lower back pain, just above the hips. Also, pain might be present in the lower part of the abdomen, just bellow the belly button. Walking might be impossible to some because of acute pain.

Lumbar herniated disc symptoms

Pain, numbness, muscle weakness, pinches and tingliness in:

  • Legs
  • Extremities
  • Buttocks

Another common reported neurological symptom is the so-called foot drop which includes difficulty in lifting the foot when walking or standing on the ball of the foot.

Lower back pain is described as a dull or throbbing pain/discomfort, accompanied by stiffness, muscle rigidity/weakness, and sometimes even muscle spasms. Pain that worsens with movement or sudden movements such as sneezing, laughing, twisting, bending,

Moderate lumbar disc hernias can be treated with conservatory treatments and don’t usually require surgery or any invasive procedures as pain usually eases within six weeks. Severe lumbar disc hernias may require invasive treatments as it can develop into a chronic and/or debilitating injury which may affect the patient’s life.

In some cases, the herniated disc presses against a nearby nerve because of inflammation and can even cause excruciating or debilitating pain, especially alongside the leg (sciatica).

Five vertebrae or stacked bony structures constitute the lumbar spine, numbered L1 through L5.

All lumbar hernias

Herniated-Disc-lumbar-Spine

L1-L2

A hernia in the first disc of the lumbar part of the spine would mean symptoms in the lower back, hip, groin (inguinal region), abductors, adductors, and legs.

L2-L3

A hernia on this disc may cause pain, numbness, tingliness, and other symptoms in the lower leg area, more specifically the thigh and lower hip region. Walking and raising the leg may prove very difficult with such a hernia.

L3-L4

The knee, tight, lower back, inner thigh, and calf areas are usually symptomatic with a hernia at this level. Again, walking and leg movement may trigger acute symptoms.

L4-L5

A hernia in the last level of the lumbar area may induce pain and other symptoms in the lower back and outer leg, mainly, in the outer tight, knee, inner lower leg, and even in the medial part of the foot.

L5-S1
A herniated disc at lumbar segment 5 and sacral segment 1 (L5-S1) usually causes S1 nerve impingement. In addition to sciatica, this type of herniated disc can lead to weakness when standing on the toes. Numbness and pain can radiate down into the sole of the foot and the outside of the foot, as well as in the buttocks, heel, and knee.
All sacral hernias

Sacral herniated disc symptoms

The lower levels of the spine include bladder, bowel, and genitalia control. Meaning that a herniated disc at this level could cause incontinence or erectile dysfunction which have to be immediately addressed with surgery.

Five vertebrae or stacked bony structures constitute the sacral spine, numbered S1 through S5.

All sacral hernias

Herniated-Disc-sacral-Spine

S1-S2

Raising the leg and knee flexion might prove difficult. This level causes pain, numbness, tingliness in the buttocks, tight, lower leg, and foot.

S2-S3 to S5-Coccyx

From this level downwards, the symptoms mainly affect the groin area including the anus and genitalia. Spreading the toes might also prove symptom-inducing.

Causes and Risk Factors

Degenerative Disc Disease (DDD) or Spondylosis

“Disease” could be considered another misnomer because it’s not actually a disease, but rather a normal age-related condition in which some spinal tissues, including the disc, degenerate. The degeneration or wear comes from the dehydration (dissection) of the annulus (rigid outer shell of the disc). The gradual collapse and narrowing of the gap in the spinal column mean more pressure bing put on the nerves. A condition which favors the occurrence of a disc hernia which is largely decided by lifestyle and genetic factors.

Spondylosis is a broader term used to describe degeneration of the spinal column from any cause.

Acute or Chronic Injury

A herniated disc can also occur from single-event injuries as well. A car or sports injury can result in a single or multiple herniated discs. Most commonly encountered in sports like rugby, football, soccer, gymnastics, weightlifting or after prolonged activities such as driving, lifting heavy objects, bending, shoveling etc.

Other

  • sedentary lifestyle
  • being overweight
  • smoking
  • backpacking heavy

Herniated-Disc-overweight-causes

Prognosis

Most minor herniations heal within several weeks. Severe herniations may require surgery and recuperation may take several weeks, months, or years.

In some cases, doctors will have the patient wait for up to six weeks to see if the symptoms go away with conservative treatment, as it does in most cases.

Diagnosis

A trained practitioner will assess your symptoms, medical history, and perform a physical examination, alongside various imaging techniques. Before going to a doctor, write down any relevant information to help the doctor in diagnosing your condition.

  1. Organize your history
  2. Anticipate what the doctor needs to know
  3. Know your medications
  4. Secure your medical records
  5. Request a verbal summary
  6. Prepare questions

Herniated-Disc-back-examination

Physical examination

The physical examination involves palpation and observation of the patient when performing physical tasks. It must be done in person with a trained professional conducting the assessment. It may then be followed up with radiology, either an x-ray or an MRI.

Neurological check

To assess if the patient has a neurological problem, the doctor will search for loss of sensation, numbness, and weakness. Reflexes are also checked because neurological problems usually affect the patient’s responsiveness.

The patient might be asked to walk normally and on tiptoes to check for a gait abnormality named “foot drop” in which the foot muscles are weakened, resulting in a specific dropping of the forefoot due to irritation or damage to the general fibular nerve including the sciatic nerve or due to the muscle paralysis in the anterior area of the lower leg.

Range of motion exams

Various range of motion tests will be deployed check for pain or lack of mobility. Usual exams involve bending forward, backward, side to side, and torso twisting.

Leg raise test

Another common physical exam for a herniated disc is the leg raise or the so-called LaSegue test, in which the patient lies on his back and raises a leg while flexing the foot.

Straight leg raise

Also known as the Lazarevic test, in which the patient sits horizontally on the back and the doctor gently raises one leg at a time to check for pain which can indicate lumbar disc herniation. In the case of a herniated disc, pain is usually felt between a 30 and a 70-degree angle.

Herniated-Disc-leg-raise

If the raising of a leg causes pain in the other one, then it might signal an impinged or irritated nerve root.

Variations of this exam include raising a leg in a seated position or while the legs are crossed. Such physical exams have high sensitivity but a low specificity. And sensitivity diminishes for patients over 60 years old.

Valsalva maneuver

While covering your mouth and nose, gradually exhale to se if there’s any pain when doing so.

Vital signs check

Pulse rate, blood pressure, temperature, and other vital signs can indicate a variety of illnesses such as infections in the spinal region.

Gait and posture monitoring

Your doctor might photograph and videotape you doing various physical task to monitor your movements and posture. Sometimes, the information is passed through a software to aid in observation.

Spine area exam

Visible inflammation, bruising, or tenderness might present itself in the affected area, usually in the lumbar zone. Light palpation is also used to identify pain or discomfort.

If there is inflammation in the lumbar spine, the skin may appear abnormal or sensitive to touch.
If the doctor sees no signs of a serious problem, the pain is not severe, and there has been no traumatic injury, imaging tests may not be necessary at this point. Some doctors prefer to have the patient wait to see whether the symptoms go away within six weeks, as happens for most people.

Imaging techniques

Herniated-Disc-x-ray-imaging

X-ray

This imaging technique involves a form of electromagnetic radiation which passes through the body to form an image. Although plain X-rays have a reduced ability to scan discs, muscles, and nerves, and other soft tissues, they’re still valuable to confirm or dismiss other illnesses such as fractures, tumors, infections etc. If suspicion of a herniated disc is strengthened upon viewing the X-rays, then other imaging techniques may be deployed fo further and more accurate investigation.

CT or CAT scan

A computer assisted tomography scan creates a cross-sectional image from multiple X-rays. It shows the form of the spinal canal, inside of it, and all other structures in the vicinity. Although the imaging is quite precise, the confirmation of a disc herniation ca be rather difficult with just a CT scan.

MRI

A magnetic resonance imaging is a diagnostic test that produces 3D images of the body structures using powerful magnets and computer technology. It shows the spinal cord, nerve roots, and surrounding areas in high detail. Enlargements, degenerations, and tumors are easily observable. An MRI performed with high magnetic fields is usually the most conclusive method for a disc herniation diagnosis. It allows for clear visualization of the protruded disc material in the spinal canal.

Myelogram

This imaging technique utilizes X-rays on top of an injection into the surrounding cerebrospinal fluid spaces for a better color contrast. It’a precise imaging method because it shows the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, space-occupying lesions, or bone spurs.

Electromyogram and Nerve conduction studies (EMG/NCS)

These exams measure the electrical impulse along the nerve roots, peripheral nerves, and muscle tissue, and can assess the level of damage, as well as the level of healing. These tests are usually used to precisely pinpoint the causes of nerve dysfunction distal to the spine.

Transcranial Magnetic Stimulation (TMS)

A neurophysiological test which can assess the severity of myelopathy by measuring the time required for a neural impulse to cross the pyramidal tracts, from the cerebral cortex all the way to the anterior horn cells of the cervical, thoracic or lumbar spinal cord.
This complex exam is useful in situations where more than two injuries may be responsible for myelopathy, such as two or more cervical disc hernias.

Other related injuries

Some illnesses and injuries might present similar symptoms that can result in a false diagnosis if not properly investigated.

  • Disc protrusion
  • Pinched nerves
  • Sciatica
  • Disc disease
  • Disc degeneration
  • Degenerative disc disease
  • Black disc
  • Spondylolisthesis
  • Tumors, metastases
  • Space-occupying lesions
  • Mechanical pain
  • Discogenic pain
  • Myofascial pain
  • Spondylosis/spondylolisthesis
  • Spinal stenosis
  • Abscess
  • Hematoma
  • Discitis/osteomyelitis
  • Mass lesion/malignancy
  • Myocardial infarction
  • Aortic dissection

First Aid

Often times, symptoms manifest themselves suddenly which can lead to partial or complete incapacitation, affecting daily activities. Some symptoms can be temporarily reversed with the help of over-the-counter drugs, orthopedic devices, and ad-hoc medical procedures.

P.R.I.D. (Protection, Rest, Ice, Decompression)

Upon injury realization, it’s advised you protect yourself from any further strenuous physical activity. That means no more lifting, twisting, bending, running etc. You’ll have to move in a way that doesn’t further stress the spine. Rest is also needed both in the long a short term. Ice cubes wrapped in a towel or such can be applied in the general area of the injury to help in decreasing inflammation and pain. Decompression of the spine is recommended as to ease pain and discomfort. Lay on your back with a pillow under your knees or consider using crutches when walking etc.

Medicine

Medications, such as anti-inflammatory drugs will reduce swelling, pain, and inflammation.

Nonsteroidal anti-inflammatory drugs (NSAIDs) of the propionic acid class

  • Ibuprofen aka. Brufen, Advil, Motrin, and Nurofen etc.

Eat a fiber-rich meal beforehand because Ibuprofen can cause, in very rare cases, gastrointestinal bleeding. Carefully read the package insert. Avoid if you suffer from asthma, heart, kidney, and liver problems!

  • Naproxen aka. Aleve, Anaprox, Flanax, Naprelan, Naprosyn etc.

On the other hand, Naproxen can increase the risk of stomach ulcers which is why it’s often taken with a proton-pump inhibitor (a medication that reduces stomach acid production). Carefully read the package insert and avoid if you have gastric or duodenal ulcer.

Spondylolisthesis-medication-treatment-nsaid-ibuprofen-naproxen

Find them here: (Motrin) | (Aleve)

  • Methyl salicylate-based analgesic heat rub gels

Methyl salicylate aka. oil of wintergreen or wintergreen oil is an organic ester, naturally produced by many species of plants, particularly wintergreens. It is also synthetically produced and can be found in different brands such as Ben-gay, Tiger Balm, Heat Rub, IcyHot, Deep Heat, Flexpower, RUB A535 etc.

  • Selective COX-2 inhibitors

COX-2 inhibitors are a type of non-steroidal anti-inflammatory drug (NSAID) that directly targets cyclooxygenase-2 enzyme responsible for inflammation and pain. It also reduces the risk of peptic ulceration. The medicine has the generic name of Celecoxib. Carefully read the package insert as the drugs present an increased risk for patients with heart problems or under treatment for cancer!

  • Muscle relaxants

If the patient experiences muscle spasms, then muscle relaxant drugs can be administered in the recommended dosages. Muscle relaxants decrease the muscle tone and may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. Carefully read the package insert as overdosing is a serious problem which might lead to heart failure and paralysis!

They come in different brand names such as Ativan oral, lorazepam oral, cyclobenzaprine oral, Skelaxin oral, methocarbamol oral, Soma oral, Zanaflex oral etc.

  • Narcotic painkillers (can cause severe addiction!)

Consider administering painkillers only in extreme cases wherever the pain is acute and debilitating. These drugs should only be used if the pain is just too much to handle, as these drugs are extremely powerful and addictive!

  • Epidural corticosteroid injections

The injections are administered into the epidural space around the spinal cord and spinal nerves, relieving inflammation and pain. This invasive procedure acts immediately and gives short and long term benefits.

Other oral and injectible steroids might prove effective in reducing pain and inflammation, talk to your doctor to see if doing a short steroid cycle might be for you.

Physical therapy

Herniated-Disc-physical-therapy-massage

Physical therapy is strongly advised to both aid in rehabilitation and avoid re-injury. It also offers pain and disability relief. Physical therapy is advised both after conservative treatment and surgery. Studies have shown that a combination of different physiotherapy techniques yields the best result. More emphasis should be put on exercise and ergonomic programs rather than ultrasound and low-level laser.

For surgery patients, physical therapy should be started after 4-6 weeks post-surgery.

On top of the guidelines from this article, the patient should obtain from a doctor or a trained physiotherapist a comprehensive, detailed, and personalized rehabilitation program. Furthermore, the patient should receive adequate education on how to conduct himself ergonomically in everyday activities such as how to properly sleep, get out of bed, going to the bathroom etc. The patient has to keep tabs on the position of the affected area as to not further stress the spine.

Stretching

Although stretching has a relatively low efficiency towards healing, it’s advised you do them under professional supervision. Stretching the tensed muscles can provide a benefit in the short and long term, but only do them under medical supervision and only if recommended by your doctor or physiotherapist.

Behavioral graded activity program

As stated before, daily activities have to be done in a controlled manner and increased gradually. In the first weeks after the surgery or conservative treatment, the patient has to be assisted in doing necessary activities such as getting out of bed, going to the bathroom etc. and the patient has to refrain from certain strenuous activities that may put him at risk.

Tender point deep massage

Patients usually regain some mobility with this type of deep tissue massage practiced by trained physiotherapists. Also, overall pain is lowered after a couple of sessions.

Ultrasound and shockwave therapies

Ultrasound therapy penetrates the tissues and transmits heat deep into the tissues, increasing local metabolism, blood circulation, and enhancing the flexibility of connective tissues. It also accelerates tissue regeneration, potentially reducing pain and stiffness.

Shockwave therapy transmits low-frequency vibrations (10, 50, 100, or 250 Hz) into the tissues, causing oscillatory pressure to decrease pain.

Transcutaneous electrical nerve stimulation (TENS)

In this therapy, an electrical current stimulates the muscles, and it’s generally believed to trigger the release of endorphins which are the body’s natural painkillers. It also reduces muscle spasms.

Manipulative treatment

Manipulative treatment therapy appears to be safe, effective, and better than other therapies. It commonly includes kneading, manipulation of muscles, joint mobilization and manipulation.

Aquatic vertical traction

This therapy is done underwater, has great effects on spinal height, and provides pain relief, especially for those with nerve root compression. It can be especially beneficial in the rehabilitation phase.

Inversion tables

Sitting upside down with the help of inversion table might relieve some symptoms.

Hot and cold therapies

Herniated-Disc-Ice-Pack-Therapy

This therapy combines the benefits of both cold and hot temperatures. Coldness decreases inflammation and pain, while hotness increases the blood flow which carries extra oxygen and nutrients. Extra blood flow removes waste byproducts and decreases muscle spasms.

Cryotherapy

Cryotherapy is used to reduce tissue metabolism after joint surgery, leading to a reduction of pain, edema, and post-operative bleeding. It also increases the range of motion.

Traditional Chinese Medicine

Some forms of traditional Chinese medicine such as acupressure, acupuncture, and cupping has been proven to work in reducing pain and disability. Such practices should only be performed by trained professionals with official governmental certifications.

Spinal manipulative and mobilization therapies

Such therapeutic practices have been proven to have the same effect as NSAID drugs. Should only be performed by trained professionals that are fully aware of your health situation.

Dynamic lumbar stabilization exercises

These exercises include techniques such as dynamic abdominal girdle with emphasis on the multifidus and the transversus abdominis muscle. The multifidus has the role of protecting the lumbar region against involuntary movements and torsion forces, helping the spine in maintaining a neutral position. On the other hand, the transversus abdominis acts like a pressure belt around the abdomen, stabilizing the spine.

  • Hamstring Stretch
  • Pelvic Tilt
  • Arm/Leg Raises
  • Exercise Ball Bridges

Herniated-Disc-hamstring-stretch

Strength rehabilitation program

The following program is a general blueprint of what a proper rehabilitation program for muscle strengthening should look like. It must include both isometric and compound exercises while keeping your back in a neutral position.

Start strength exercises a few weeks after the surgery or end of conservative treatment. Ask your doctor just to be safe.

You can do them every day or every other day for about 1h hour a session. Focus on training your abs and back muscles. Execute a 15-minute warmup involving dynamic stretching of back extensors, hip flexors, hamstrings, and Achilles tendon.

The following exercises and relative variations should always be performed:

  • Quadratus exercises
  • Abdominal strengthening
  • Bridging with ball
  • Straightening of external abdominal oblique muscle
  • Lifting one leg in crawling position
  • Lifting crossed arms and legs in crawling position
  • Lunges

Herniated-Disc-lunges

Add more exercises as you see fit, just make sure you keep your back straight. Perform a couple of reps for each exercise until you feel muscle fatigue but don’t go to failure as you may sacrifice form. Stop if you’re experiencing pain!

Aerobic training

Aerobic training (cardio) has been proven to be extremely beneficial towards recuperation. Aerobic training should only be introduced a month after surgery or end of the conservative treatment because aerobic exercises are dynamic and of high impact, which may be contra-productive if the spine has not yet healed. After a month or so, you can gradually introduce cardio exercises. Begin by exercising on a treadmill, stationary bike, and similar. As the patient’s tolerability increases, intensity can be enhanced, as well as introducing different types of exercises such as swimming, shadow boxing etc.

Stabilization exercises for core stability

The abdominal muscles are very important in supporting the spine. the patient should start with isometric exercises and focus on activating the different fibers within the abdominal group muscles. The overall strength of the abdominal muscles is just as important as the endurance of the abs, so focus on that as well.

  • Crunches
  • Obliques crunches
  • Planks
  • Side planks
  • Bridges
  • Hamstring raises
  • Superman
  • Leg raises
  • Hundreds
  • Leg extensions
  • Physioball exercises
  • Tractions (pull ups/chin ups)

Herniated-Disc-side-plank

The back muscles as just as important in supporting the spine as the abdominals, so training them is imperative. Chin ups and pull ups are the most comprehensive exercises you could do for you back muscles, especially in the rehabilitation phase. Even if you could do a chin up or a pull up on your own, don’t! It’s advised you start off gradually by placing a chair or similar underneath the bar and perform tractions with no more than half your body weight. That means you’ll push yourself with your feet equally in force as you’ll pull yourself up to complete a repetition: 50% push and 50% pull to complete a rep.

Overall muscle strengthening

The body acts as a whole, so you can’t neglect any part of your body. After regaining some strength in your abs and back muscles, you can progress to more complex exercises for the other muscles in your body. Growth and repairing factors are released when exercising which will aid tremendously in the recuperation phase. Just avoid pain at all costs and increase the difficulty in a gradual manner!

  • Squats
  • Benchpress
  • Over the head press
  • Deadlifts (caution!)
  • Tractions

Surgical Treatment

If the nonoperative treatment proves ineffective or if there’s evidence of severe neurological deficit (i.e. muscle weakness, numbness), then surgery may be needed to decompress the nerve structures and stabilize the spine.

Types of surgery

Herniated-Disc-Laminectomy

Discectomy

A discectomy or an open discectomy is the surgical removal of the herniated disc fluid pressing on the nerve root or spinal cord. The central portion of a disc, the nucleus pulposus is extracted.

Microdiscectomy, endoscopic discectomy, and laser discectomy

Some cases allow for a smaller incision and a faster extraction with the help of thin precision instruments which leave less scarring.

Laminectomy or spinal cord decompression

This procedure widens the spinal canal by removing the rear part of a vertebra called lamina. It reduces the pressure on the spinal cord. Often times paired with a discectomy. A herniated disc can put pressure on the spinal cord depending on the degree of herniation. In this case, surgery is necessary and immediate. Prolonged pressure on the spinal cord could cause permanent damage.

Spinal fusion

The procedure consists in totally removing one or more discs and replacing them with autografts (bone grafts from your won pelvis), allografts (donated bone grafts), or synthetic discs. Instrumentation such as metal screws, rods, or cages is used permanently or temporarily to stabilize the spine. Reduced mobility post-operation is often reported.

Other surgery techniques include

  • Foraminotomy
  • Foraminoplasty
  • Corpectomy
  • Nucleoplasty
  • Chemonucleolysis
  • Electrothermal methods

In most cases, the patient begins to walk on the same day the surgery is performed. Activity is then gradually increased alongside physical therapy. Some pain might still exist after the surgery.

Diet and lifestyle

Herniated-Disc-Vegan-Diet
Vegan Burger

In the case of disc hernias, diet and lifestyle play a huge role!

To help alleviate symptoms, reduce rehabilitation time, and most importantly, to decrease chances of a disc hernia relapse, a plant-based diet is strongly advised. Better yet, a strict vegan diet is way better because you’ll keep inflammation to an absolute minimum, you’ll fuel your body with readily usable nutrients, and you’ll reduce all-cause mortality risks. A plant-based diet will also help you reach an ideal body weight. All of which will provide tangible improvements.

On top of a plant-based diet, you’ll a proper sleep pattern and adequate hydration. Alongside a reduction of harmful vices such as smoking, drinking etc.

Focus on dark, leafy greens, fruits, legumes, nuts, seeds such as broccoli, brussels sprouts, collards, mustard greens, chickpeas, spinach, tofu, fortified foods etc. You should also monitor your micro and macro nutrients to see if you’re meeting your needs. B12 is especially important on both a vegan and non-vegan diet, so monitor your intake and eat B12-fortified foods.

Calcium
Men and premenopausal women should consume at least 1000 mg of calcium. Postmenopausal women should consume 1200 mg of calcium. Don’t take more than 2000mg of calcium a day, in total. Try to incorporate more calcium rich foods in your diet like raw milk, cooked kale, sardines, yogurt, kefir, broccoli, watercress, and bok choy.

Vitamin D
Men and women should consume between 600 and 800 international units (IU) of vitamin D per day. Don’t take more than 800 IU of vitamin D a day as high doses can be toxic, especially after long periods of time.

B12 in micrograms (μg)
Age                            RDA (μg)
0-6 months……………….0.4
7-12 months……………..0.5
1-3 years…………………..0.9
4-8 years…………………..1.2
9-13 years…………………1.8
14+ years………………….2.4
pregnant women………2.6
lactating women……….2.8

Sleep is also very important for your body to heal, so aim for 7-9 hours of sleep. Sleep time is when the body tends to do a great deal of regeneration including bone growth, skin rejuvenation, and cell growth to name a few. Degenerative disc disease, while a natural progression of age, can do much of its healing during the sleeping hours. Since degenerative disc disease can be a precursor to a herniated disc, it is important to allow the body to rest and heal itself.

Adequate hydration is also very important because the spine fluids and lubricants are mostly made out of water and their synthesis requires water. For proper hydration, remember the 8×8 rule: drink 8 servings of 8 ounces of water a day (a total of 2L of water a day).

Sunlight
Get at least 1 hour of sunlight, every day. Continue maintaining a physically active lifestyle to encourage calcium synthesis in the body. In addition to bone strength, sunlight is known for improving mood and well being, providing a positive mental outlook.

Improving Posture and Ergonomics

Sitting correctly at the desk or lifting heavy weights with perfect form will definitely reduce the chances of developing a hernia. Try to develop a posture-conscious mindset and remind yourself to always straighten yourself. The back should always stay in a neutral position, regardless of the activity.

The concept of the ‘neutral position’ is key for any good ergonomic practice. Neutral position is the position of the spine, limbs, and extremities that occur when standing. For example, sitting for extended periods of time is unnatural to the body because it puts unusual amounts of pressure to the lower back. Furthermore, most of us tend to also tilt our neck downward to look at a computer screen or phone or may even lean forward, causing an unnatural cure to the spine that can cause pain.  Arms and hands also have a neutral position where the extremities should line up in a straight line. Often times, the direction of our hands and the linear direction of our forearms don’t match (e.g. tilting the wrist when typing to reach keys on the keyboard)–this is deviation from the neutral position of the forearms, wrists, and hands. Neutral positions minimize the pressure on muscles, tendons, nerves and bones to optimally leverage the body’s control and ability to exert or take force. The counter term for the neutral position, is the ‘awkward position’ (see examples above). Good ergonomic practice aims to minimize or eliminate awkward positions.

Neutral postures are postures where the body is aligned and balanced while either sitting or standing, placing minimal stress on the body and keeping joints aligned. For those that spend extended periods of time sitting, for example, sitting at a desk working on a computer, ergonomic furniture exist to help keep the body in the neutral position and to relieve pressure in awkward positions. Some employers offer ergonomic assessments of their employee’s work station and can provide resources (e.g. standing desks, ergonomic chairs, etc.) to alleviate strained pressure points.

Conclusion

Spinal disc herniations are very common between vertebra L4-L5, L5-S1, C5-C6, and C6-C7. The injury greatly varies in severeness and usually affects people over 30 years old. Upon injury detection, it’s advised you set up an appointment with your doctor or go to the ER while applying first aid. Mainly, P.R.I.D. (Protection, Rest, Ice, Decompression) and over-the-counter anti-inflammatory, analgesics, and similar medicine.

As a runner, it is particularly important that neck, spine, and back pain be given extra attention and care. While there could be a number of underlying causes to the pain, ruling out a herniated disc or any other condition putting pressure on the spinal cord or nerves is critical to avoid permanent nerve damage. As mentioned above, pain the lower back and lumbar region should be given extra care as it could be an indicator of pressure on the cauda equina–a nerve bundle that includes the sciatic nerve. Extended pressure to this area can cause permanent loss of sensation to the legs, lower back, and bladder.

Follow your doctor’s advice and improve your lifestyle to help the healing process. Get educated on how to avoid re-injury and develop a posture consciousness.

 

Co-written by Marquesa Finch

Curated by Diana Rangaves, PharmD, RPh

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