Member Case Study: Annular Disk Tear and Ironman Training

author : AMSSM

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I know that annular tears mean there is a risk for a bigger disc blow-out. How do I continue to train and compete without putting myself at risk for worsening of my injury?

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Member question from bmcquinn
 

I'm two weeks out from an overuse bike injury that my ART therapist thinks may be an annular disc tear. After a 200K ride event (on a recently fitted road bike), my back was uncomfortable during the car ride home. It remained uncomfortable but tolerable during a 45 mile hilly ride the next day. The following week, I did my usual hilly bike commute (20 miles round trip) to work (though my commute bike has never been professionally fit), and since then my back started getting progressively more achy after 3 days. I took 2 rest days, and 6 days total off the bike (no pain with running but I learned that swimming butterfly was a no-no).

The symptoms were improving, so I attempted my bike commute one more time. My back was pretty stiff by the end, and that night I developed pretty severe stiffness and pain, especially with sitting or car rides. Three days after this, I ran slowly for 5 minutes and it felt OK. Then I saw the therapist, who suspected a disc injury, so it's been just swimming and aquajogging since.

So far, I have no leg symptoms except an occasional sandpaper sensation in my left toes in the morning. The stiffness is improving, and I'm good by the end of the day, though my back is still stiff in the morning. I am 52, normal weight, female and training for my 6th Ironman.

So after all that background, here's my question:

I know that annular tears mean there is a risk for a bigger disc blow-out, something I definitely want to avoid. Since running didn't hurt 4 days after the injury (I know cycling is out for awhile), how soon is it safe to return to running slowly on soft ground? I want to make sure the tear is healed, obviously, but I'd like to get back to some kind of weight-bearing exercise. My therapist just says if stuff doesn't hurt I can do it, but that's not very specific, and I certainly don't want bigger disc issues!
 

Answer from Dr. David Liddle
University of Utah Internal Medicine

Member AMSSM

First off, congratulations on your 6th Ironman - that is impressive!!!

As for your question, in addition to the “how soon can I run” question, the other question you seem to be asking is, “how do I continue to train and compete without putting myself at risk for worsening of my injury?”

Unfortunately there is little evidence to guide us. The number of people who have annular tears who later go on to disc herniation is unknown. Many people who have annular disc tears are asymptomatic. In one study, 37% of healthy, asymptomatic volunteers had an annular tear on MRI. Therefore, if someone is found to have a disc herniation, it is difficult to know if they had a precipitating annular tear or not. And it may not matter since exactly what factors increase the risk of progression to full disc herniation is still under investigation.

We do know that, in the vast majority of cases, aggressive conservative therapy is superior to surgery for most types of back pain, including annular tears. We also know that core strength and spine flexibility are key to rehabilitation and injury prevention.

Aggressive conservative therapy for your injury should include:

1. Control of pain.

2. The restoration of range of motion with emphasis on lumbar spine extension exercises.

3. Muscle strengthening and endurance with progression from isometric to isotonic exercises with emphasis on concentric strengthening.

4. Coordination retraining to improve posture, muscle control, and spine stability. Your therapist can guide you through the specifics.

Core strength and improved range of motion will help you in all aspects of your triathlons and is the conservative therapy of choice, with the most and highest quality data, for the treatment and prevention of back injuries.

Therefore, for treatment of your back injury, focus on core strength and spine flexibility. From there, let pain guide you as you work toward your triathlon stage specific training and weight bearing exercise.

I hope that is helpful. I wish you the best of luck with your back pain and in the Ironman.

Dr. David Liddle
University of Utah Internal Medicine
 

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date: June 22, 2009