Herniated disc and Ironman?

author : AMSSM

comments : 1

Is it too big of a risk to train for iron distance while managing a spinal injury?

Member question from alexandriava:

I have had back pain since a bad episode in April this year and have recently been diagnosed with a "large" disc herniation at l4-l5. I have tried some physical therapy and am currently beginning to receive epidural steroid injections. My goal for 2016 is Ironman in October and am wondering if am being too ambitious. This year I was able to complete several tris up to a 70.3 while managing the injury. My plan would be to heal as much as possible and be healthy April 1. Am I risking significant further injury while continuing to compete?

Answer from Deanne Eccles-Rotar, M.D.
Member AMSSM

Having a large disc herniation and trying to train through it is a challenge.  I do think there are things you can do to help you progress your training and avoid surgical intervention for the disc herniation.  The lumbar discs are composed of an annulus and a nucleus.  A visual analogy is to picture a jelly filled donut where the annulus is the outer crust and the nucleus is the inner jelly.  The annulus is composed of a fibrous ring of tissue that tries to keep the inner gel-like nucleus from squishing out from between the vertebral bone.  The purpose of having the inner gel like nucleus is to allow movement between the vertebral bodies.  There are typically 5 lumbar vertebrae and the lumbar area of the spine allows most of the movement in the spine because the upper thoracic movement is restricted somewhat by the rib cage.  When the annular ring sustains a tear in the fibers it is possible for the nucleus to push out beyond the edge of the vertebral bone where it can come into contact with exiting nerve roots.  Annular tearing usually occurs from forceful flexion of the spine with a rotation in combination with inadequate abdominal and paraspinal muscle bracing at the time of the flexion.  If the fibers of the nucleus only stretch the disc may bulge; this is fairly common with aging.  In this case the disc may not actually contact exiting nerve roots but can extend past the edge of the vertebral body.  When the nucleus herniates it pushes through the fibers of the annulus and can migrate up or down into the central spinal canal or recess and contact the exiting nerve root at that level.  In your case this would most likely be either the L4 or L5 nerve root.  The nucleus material is very irritating to the nerve root and when it contacts the nerve you feel pain radiating down into the leg.

The initial treatment for a disc herniation should involve physical therapy.  The most accepted type of exercises for lumbar disc herniations are called McKenzie exercises and are based on the theory that using lumbar extension (backward bending) will create forces on the spine that help get the disc to resorb.  This is because forward bending usually puts forces on the anterior aspect of the disc and will push the nucleus towards the spinal canal and could potentially worsen disc herniations.  With lumbar extension the forces are on the posterior vertebral body and may facilitate resorption of the disc.  So if you can I would advise doing lumbar extension exercises several times daily.  In addition to the extension exercises you should avoid any lifting while flexing (forward bending) as this could worsen the herniation.  Traditionally larger disc herniations have the most likelihood of being resorbed.

With triathlon training the most likely stress to the herniation would be biking because the spine is flexed during this activity.  To continue biking you should pay close attention to spine posture and try to get flexion in the hips while maintaining as neutral a spine position as you can to minimize stress to the disc.  You could consider a bike fitting to find a bike setting that allows you maximum power output with minimal lumbar flexion.  With running the spine posture is usually in extension; as is walking.  Running creates stress due to impact so try to run so that you are light on your feet with a mid foot strike instead of a heel strike.  Swimming usually does not create stress to the discs unless you do a flip turn.  If you feel pain radiating into the gluteal area during flip turns then consider doing open turns or open water swimming to help lessen this.  Any activity that causes pain to radiate into the gluteal area or distally into the leg is causing the disc to pressure the nerve.  So pay attention to your posture, your pain level and your pain location and try to centralize all pain into the low back.  This can usually be achieved by changing lumbar posture into neutral or slight extension.

Lumbar epidural steroid injections can help by reducing pain and inflammation.  This helps you progress your physical therapy and can also facilitate the disc resorption.  Sometimes providers will do more than one steroid injection which may have additive effects on reducing the pain and inflammation.  If the epidural steroid injections are not effective in helping control symptoms sometimes providers will order a nerve block.  This is when the steroid is placed in the neural foraminal area of the spine where the nerve exits.  For lateral disc herniations this type of steroid injection works very well and has the same benefit of reducing pain and inflammation as the epidural steroid injections do.

Disc herniations are challenging to work through because they require a lot of patience and activity management to allow the disc to heal.  It is important to continue with the extension exercises and also work on core strength once the nerve pain has improved.  Once the disc has herniated it is no longer normal and you are likely to develop degenerative disc disease so keep up smart training with attention to spine position.  Heavy lifting should try to by done close to the body with strong abdominal/gluteal support to avoid re-injuring the low back.  If conservative treatment fails then surgical treatment is usually successful in relieving nerve symptoms but may not resolve low back pain and does carry a risk of infection and scar tissue development.  I would encourage you to try conservative management for the problem for 6-12 months before considering surgery if you can manage the symptoms and are not having any weakness in the leg.  If weakness develops or you lose control of bowel or bladder then surgical management would be recommended.

Good luck with rehabilitation and training!

Deanne Eccles-Rotar MD
Dean Janesville East Clinic
Janesville, WI

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date: March 31, 2016