This is the third installment of our series on the ‘care and feeding’ of the injured lumbar disc. In Part 1 we discussed the structural pathology (the broken stuff) and in Part 2 we started a discussion of the functional pathology (why stuff broke). Today, we’ll continue the functional discussion assuming you’ve done some pre-reading or have an understanding of the Joint By Joint Approach. If you don’t, follow the link and brush up. Also, these approaches and the exercises associated with each stage of the rehab process are represented in the library of detailed functional rehab exercise here at MyRehabExercise.com. You can’t use them to help teach your patients and clients unless you’re a member. Membership is inexpensive ($19.99/mo), 30 day trial for $1 and you can discontinue service anytime. Follow the links to the right to sign up.
If you don’t have an office set up to instruct your clients or patients in rehab exercise, or if you just don’t feel comfortable customizing the exercise Rx yet for disc injury, check out FixYourOwnBack.com. There, you can just refer your patients or clients with disc injury, disc bulge, herniation, sciatica and for $9.99/mo they can receive the self-help education and rehab Rx that is being discussed in this blog series re: management of the lumbar disc injury.
The Plan–“Plan the work, then work The Plan”
Once we have an injured lumbar disc, The Plan (as it’s referred to on FixYourOwnBack.com) is as follows:
- Stop faulty movements and postures that “pull the scab off” of the healing disc
- Learn disc “First Aid” using McKenzie methods to assist in healing and control pain
- Use McGill’s Big 3 and DNS methods to stabilize the lumbar spine
- Improve mobility in the T-spine and hips to spare the spine
- Use FMS-based corrections to integrate stability and mobility achieved in #3 and 4 above into long term sustainable movement patterns
- Improve strength in the muscles necessary to perform #5 above
- Improve agility in those sustainable movement patterns to help with resilience when life throws a curve
- Incorporate sport specific skills to help manage disc injury and recurrence
The Stiff Upper Back
The Creaky Hips
As the shortened flexors’ insertion onto the lesser trochanter persists, the femur shifts anteriorly in the acetabulum. When that individual squats deeply, the acetabular labrum gets munched and sometimes the repetitive loading of this imbalanced hip into deep flexion can result in bony changes now referred to as femoral acetabular impingement (FAI). For more info on FAI, check out this link to Craig Liebenson’s blog. Learning how to test for this is helpful, as an Xray can point to whether that patient should be in an orthopedist’s office. However, all anterior hip pain is NOT FAI, and the condition starts as a soft tissue issue. Catching it early in the progression means you can head off not only a hip replacement years later but also the well-meaning FAI surgery!
Charles Scott Sherrington’s Law of Reciprocal Innervation won him a Nobel Prize in 1932 for describing the neurological relationships between agonist and antagonist muscle groups. Stated simply, when a muscle contracts, its antagonist on the other side of the joint is reflexively relaxed to allow joint movement to occur. Several decades later, Czech neurologist Vladimir Janda coined a corollary to Sherrington’s Law which states that when a muscle’s resting length has been shortened, it’s antagonist will be reflexively inhibited. Around the hip joint, the tight hip flexors inhibit the large muscles of the buttock…the glute max and the glute med. This condition in the hips has been referred to in Janda circles as part of the Lower Cross Syndrome, and years later by Stu McGill as ‘gluteal amnesia’.
- In single leg stance, pull one knee to the chest and release.
- Observe for failure in ability to maintain >90 degrees of hip flexion for 15 sec.
- Is there cramping in the TFL?
- Observe for posterior lean, rounding in the spine or lateral tilt of the pelvis