Back Injury – A Physio’s Experience
As a Physio, I know what to do when I get an injury...theoretically... You see, we are taught how to listen and assess and work out what is wrong. We tell the patient what we have found, what we think is wrong and what needs to be done to make things better. We do our "manual magic", we give appropriate advice and whatever things the patient needs to do at home.
What they don't necessarily teach you is what it is like to be a patient. Even if I saw someone daily, it is still only 30-60mins in 24 hrs...I think too many physios and other health professionals need to think about that more.
I realised this quite a while ago when I had injuries. I have always been quite active so with that comes increased risk of injuries and I have had my fair share. What I want to write for you today is what happened when I strained my back quite badly and how I dealt with the issue. I will discuss what I was thinking and throw some commentary into why I chose what I did and how I made my decisions.
This is post is all about ME, NOT YOU. This is NOT what you should do. You should get assessed for any problems you have. This is about informing you what I was thinking and how I think as a patient and a physio.
Let me set the scene...
I had just been to Melbourne teaching and seeing patients. It was a great weekend and I had worked very hard including flight delays after getting up at 4.30am on a Friday morning meaning I sat for 5hrs in an economy seat, working hard, sleeping in a bed that had a shelf where my feet where to go so I had to curl up all night, and taught on my feet for about 10hrs. I got home late Saturday night, had a fitful sleep as I usually do after teaching, lounged around on Sunday a lot and fell asleep on the couch and didn't do very much - just recovering from teaching and working.
I woke up on Monday and went to training...well, I kinda dragged myself there. I wasn't feeling flash still. I went through the warm up routine... here it is... from CrossFit Creature - The session was looking like a nice one too 🙂
A. Warm Up
2 lengths bear crawl
5 strict burpees
6 weightless turkish get ups
Hip Flow - https://www.youtube.com/watch?v=6qnCHkJ8MgA
C. Deadlift @ 20X1 - 3-2-1 Rest 3 min btw sets (totem test)
Notes: 3 working sets, a triple, a double and a single. As usual form is paramount.
Working to BASE build on last week doing 3 sets of 5 reps working on form.
Rest 30 sec transition to
D. Pull Ups - 60 sec max reps x 3 sets: Rest 2 min btw sets
Gymnastics W2B-Totem 1
Ring Rows 60 sec max reps x 3 sets: Rest 2 min btw sets
5 min AMRAP
DU’s must be in UB sets of 25
Rest as needed
500m row time trial.
Anyway, I wasn't feeling flash. I had just set a 1RM deadlift of 210kg a couple of weeks earlier and I had thought I would be able to do 180 for a triple, 190 for a double and 200 for a single and sneak one more try for 211kg... I had warmed up at 100kg to start and didn't feel really good. I put 140kg on and still didn't feel flash...I was technically fine but not 100%. I told the coach "mate, I'm just not feeling it today, I am going to do my triple at 160kg" - he was fine with that...he had watched me and thought I looked ok and I thought my form was ok too...
The First Working Set
So the first working set was for a triple. I was to stand it up fast, 1sec rest at the top, 2secs eccentric lower, no rest at the bottom (that's what 20X1 means: ecc-rest-concentric-rest). I had 160kg on the bar.
And this set was the problem...
...it was E A S Y. I kept the tempo no problem, it felt easier than the 140kg I had warmed up on. I thought to myself "oh, I just needed more time. I feel good now".
Now a sane, sensible, cautious person would not push their luck. They also don't have much fun in their life...I am sensible. I REALLY FELT GOOD. So, stupidly, I loaded 190kg onto the bar.
The Injury - Monday
So, with 190kg on the bar, I am feeling positive - absolutely no doubt in my mind.
If you feel any doubts at all, take that as a warning and drop the weight. Listen to your mind (within reason). I had no doubt I could do a double at 190kg. 2 weeks earlier in Brunei, I had worked hard the day before, got up early and worked all day and started lifting at 9pm after being up for around 15hrs teaching and talking and waiting for that bloody chicken and meat to cook!
I set my grip, set my position, set my breath and lifted.
From memory, there wasn't anything wrong with my technique. It felt ok, it didn't feel heavy and I stood it up ok. For those that haven't heard me speak, I recommend that people move the bar around a bit to give the brain an idea of how heavy the bar is.
About where the bar passes my knees, I felt something "pop" and my body shifted. It felt like something gave way. I thought it was my L5/S1 or my left SIJ based on where I felt it go. I stood the bar up without pain, just a bit of shock.
This bit was a bit in slow motion... I had a fight in my mind! I was standing there with 190kg and it felt like it came up like it should have. So one part of my brain said "time to go 2 secs eccentric". Another part of my brain was still thinking "what the hell was that pop and why did my body shift". It then became ridiculous. "You need to go", "No, pay attention, that was an injury", "Stuff that, it's ok", "Ah, no it's not", "I wanna hit 211kg today", "I don't think so idiot", "Maybe see how the eccentric goes", "NO!!!".
In the end, I rationalised to myself. I said "OK, lets see what it is. If it is nothing, you can build back up and sacrifice the pullups and go for the deadlift." - I was standing there for maybe 2-3secs arguing with myself but it felt a lot longer. In the end, I just dropped the bar.
Straight away, I started to assess my movement. Knowing that I had just done an injury seconds ago, I wanted to see how quickly my movement degraded. I leaned backwards first. I was standing and if for some really ridiculous reason I had pinched/locked my back into extension, it would show up pretty quickly. Extension with combined movements of lateral flexion and rotations were negative. Something wasn't right but extension was ok at the moment.
I bent over. It felt crooked. It felt like I could move on the right but the left hip and leg felt high and I felt twisted towards the left. Ok, I had movement restriction but no real pain.
Side bending was ok to the right but to the left was restricted.
Nothing really hurt...for now.
I should note here that the coach had noticed and asked me if I was ok. I told him I wasn't sure yet and I will let him know. He had a whole class to coach and we were friends. He wouldn't let me continue without making sure I was ok to go on...
The next 5 mins
So I immediately went down onto my hands and knees and started do some cat and lion movements. The idea was to preserve what motion I had and since I had no pain yet, I wanted to take advantage of that knowing that pain was probably going to come along with some swelling. My joint didn't feel stuck - it felt like muscle restriction so I assumed I had sprained a ligament in the back. Contraction of muscles during my movements didn't hurt so I didn't think I strained a muscle.
During this 5mins, I fought hard to maintain the movement in my low back. The swelling had started and the ache was following shortly after. It wasn't looking good.
After spending 5mins on the ground trying to keep it loose, I decided it wasn't going to happen. That was the end of the session for me.
The Next Hour
Realising that this was not going to go away quickly, and I was getting stiffer in all directions, I immediately took 100mg of Voltaren. THIS IS NOT RECOMMENDED. There are all sorts of conditions that could interact with NSAIDs. There is some discussion that NSAIDs can result in delayed healing or lower quality of healing. However, for me, I was worried about the PAIN. I have had this pain before which helps but my back has never "popped" like that before during lifting.
Over the years, I have seen people post-surgically go from getting "suck it up" advice to the modern "control pain early and often and the result is better". So I went with that. No need to be a hero. I know that uncontrolled pain takes longer to get over and can lead to chronic pain. I have enough chronic problems including pain, I didn't need chronic back pain to be a problem for me as well.
So I took those 2 Voltarens knowing the pros and cons of such an action...just because I did it doesn't mean you should! I know my body and conditions and the risks...make sure you take medications as prescribed by your health professional.
After popping the pills, I had to fight my brain. The fear! The negative thoughts! The worry! It all adds up. "Am I going to be able to lift again? Did I do any nerve damage? Will there be a latent effect and the pain be worse tomorrow? Dammit, that was stupid to go up 30kg in a deadlift like that! etc etc etc".
Don't forget, I have seen some pretty bad pain in my career. I have had patients with decades of back pain. I see people who have hurt themselves lifting in the gym or at work.
So I set to working out what was going on...and eating lunch...100mg of Voltaren on an empty stomach is not smart so I got some food into me and then assessed myself again - it was all worse than initially. I was getting worse! The only good thing was that the pain was localised and I had no apparent nerve damage - no pins and needles, no numbness, no altered sensation, no peripheralizing of pain, no weakness and no referred pain.
I was getting stiffer and stiffer and more and more pain and I had a full day ahead of me seeing patients...
The Rest of Day 1
I made it through work. It was tough and I had to apologize to my patients but luckily things weren't too bad and I was able to manage with all my manual technique and my brain was still working so I was able to still assess, diagnose, teach and correct movement...I just couldn't move well!
The pain got to the point that moving the wrong way would take my breath away. So I made sure I took Voltaren every 4hrs after that first double dose. I must have taken 4 times the amount of Voltaren that is recommended but it was a risk I was willing to take. It wasn't going to be forever, it was only going to be for a few days...at least I hoped so!
I didn't try to get any treatment because, in my mind, nothing was jammed up...I just had protective muscle spasm from a flexion-based strain.
I made finished work, made it home, told the wife, had a shower hoping it would help...it didn't, I took my meds and went to bed hoping it wouldn't be so bad in the morning...
The Next Day (Day 2) - Tuesday
When I woke up through the night, it was PAINFUL. I had to go to the toilet and I was stiff and in pain. Just getting out of bed was painful and so was walking. I felt twisted and even a little cough (hey, I am a physio 24hrs per day) gave me pain. That wasn't a good sign because pain with coughing is often a sign of disc damage...but that didn't add up with me earlier assessment so I just figured that the muscular protection was being strained on coughing.
I made it to work and got through the day. I kept up the Voltaren every 4-6hrs through Day 2.
Thankfully, this day was the worst and the best. The Voltaren started to work and I could tell when it was starting to wear off so I made sure it was topped up.
My biggest fight was with my thoughts. Fear is a powerful thing. You worry if you will be able to do anything again. Even bending over to get changed was painful and I didn't want to be someone who had to get dressed lying down forever! I began to worry about how I could do my job as a physio - could I teach more? Could I find other ways to earn money? Seriously, if you have ever had bad pain, you would know that you even go to irrational thoughts.
I know this is common. I had been educated about the "psychosocial" aspect of pain. It doesn't change the fact that I still had all those thoughts. It is irrational. It is not helpful but it is very common...it becomes a problem if you keep thinking like that.
Seeing patients helped. It kept me focused on what I needed to do. Because I had early and effective pain relief, I was only around a 4/10 pain which shot up to 8/10 pain on certain movements that dropped back down quickly. I can work with that. I resolved to keep work and moving.
Sleeping and getting up was still a problem.
Day 3 - Wednesday
I began to be hopeful. I was still waking up stiff and sore but I was moving better. I began to scale back the Voltaren because the pain wasn't so bad and I didn't want an ulcer! Maybe that is irrational for a short term course of NSAIDs but I was still irrational at that stage.
I usually get up to train before starting work but today didn't feel like I should.
"Hold on" you say...you considered training? Why, of course I did. It is back pain, not quadriplegia. I can move, I can do things and I had decided I had a soft tissue injury. To me, that means that I need to keep moving in a pain free manner trying to restore full range of motion. It's just that on that day (Wednesday), it didn't feel like the right thing to do.
I was moving better at work, less extreme thoughts, less fear, more confidence, less pain, and generally more positive.
Sleep was getting better and getting up at night wasn't so bad anymore.
Day 4 - Thursday
I got up and went to work early but I had crossed off the rest of the day - I was going to try training!!
I don't remember what I did but basically, I kept it simple. No heavy lifting, no pain, simple movements. It felt good to be back at training. I didn't care that I couldn't do what I wanted...I was happy to be there with my friends and moving.
I was back baby!
I started to back off to one Voltaren every 12hrs (which is what has been prescribed to me in the past). The pain was under control.
Now, I knew I had a back injury. I know that it takes 6 weeks to heal to a level that begins to resemble what it was like before with Type III collagen decreasing and more and more of the better Type I collagen. That means I should be careful for the next 6 weeks...and I have. I also know that 50% of people with a significant back injury will get another episode in the next 6-12 months...I still remember that!
But just because I had an injury doesn't mean I can't do things...
Back To Kinda-Normal
I squatted the next day. It wasn't heavy. It probably wasn't deep but it was something that looked like a squat with weight on my back. I was in significantly less pain and happy to try. I still ached but I listened to my body. I kept dynamic movements (jumping, kipping, cleans, snatches, etc) on hold for a while...if I did it, it was light and carefully. Dynamic movements carry more risk than slow, closed-chain movements.
I kept an eye on things and I listened to my body. In a recent workout, my first real deadlift workout since the accident, it was a number of deadlifts at about 130kg but when I was warming up, I felt like 120kg was about right for me so I am still mindful of things 9 weeks later.
I recently PB'd my hang clean to 115kg - my previous best was 105kg. 2 days ago, I finally got under 1.30 for 500m on a rower...it was 1.29.9 and OMG was I praying that I finished before it got to 1.30!! My previous PB was 1.31.7 so I am chuffed with that. It did sort of "twinge" a bit but I think it was a "shadow" of the pain rather than real pain or ache or a warning sign. You know how when you see an accident you can sometimes have a twang of pain, almost like feeling their pain? I think it was like that.
I began to realise I was fearful of deadlifting heavy again. I thought this was unacceptable! Part of me blamed the fact that I didn't "warm up enough" for the reason why I got injured.
Now, I know that this isn't true but the emotions of this belief runs strongly...
...how can I break this belief?
I know! I'll start deadlifting COLD - no warm up.
Over the first part of 2016, I began cold deadlifting starting at 100kg for reps. That is, picking up 100kg for reps without a warm up. Usually this happened on my seminars.
This actually worked well. I remember being in Perth and someone had just done 150kg for a PB 1RM. I was able to do 10 reps and only stopped there because it was too much cardio! Hahaha.
I remember being in Seattle when I did 405lbs (184kg) for a double without a warm up. That felt good, not the least because one of the rare guys on the course wasn't really paying attention to what I was teaching until I did that!
What do you think the biggest mental hurdle of all was? 190kg. I remember being a bit scared actually. That was the weight I got hurt at. I messed with my mind a bit but I was on a course and it was my habit so I did it. And I survived.
I continued with this habit of deadlifting cold on my seminars. I made it all the way up to 205kg with no warm up once...my all time best deadlift 1RM is 211kg...imagine what I could do if I trained! Hahaha.
Why Did I Get Better So Quickly?
I have seen people take a few weeks to get back to training with the same injury. I was able to do so in a few days. I want to tell you why I think I could do that.
1. Maybe the injury was not that bad...maybe. I can normally nearly get my palms to the floor when bending over...I was barely able to touch my knees. I got sharp pain on certain movements. I had trouble moving and working. It was still a significant injury. I have seen patients take weeks with the same injury or even "less serious" incidents...remember, I picked up 190kg. Some people bend over in the shower the wrong way and get the same pain.
2. I took meds really early and made sure I got a dosage that controlled my pain as soon as possible. I then kept that up until my pain was manageable and no longer dominating my thoughts. Make sure you see someone to get medication advice ASAP. Don't be tough - use those meds as directed and control the pain...it REALLY HELPS.
3. I kept movement within pain limits. Lots of people seize up in fear or push their movement too far. I kept the movement reasonable and listened to my body while not aggravating the pain. It helps I know what I am doing. I think a lot of the fear that stops people moving is simply not knowing what to do or how to do it...That's what I do - I teach people what is ok and what isn't and how to progress.
4. I stayed positive and didn't give in to fear or negative thinking. I kept trying to do things and when I failed, I tried again a different way until I did it. Sometimes there was no way to do things without pain so I just did it anyway without making the pain worse.
Treatment That I DID NOT get.
1. I did not get any physio or any other treatment...I could have if I needed to and I had friends on standby if I felt the need but I know muscle spasm exists to protect me in the first week.
2. I did not roll out or use a ball or any "mobility" work. Your body simply reacts to what you do. My back seized up because I strained it. If I tried to break that down, two things would have happened... a. I would have succeeded, been able to move more and possibly reaggravated the injury or b. I would have failed and be bruised trying to make my muscles who were doing their job try to stop doing their job.
3. No Heat creams or rubs while training. A lot of people do this to get rid of aches and pains so they can train "painfree" - Don't do that! Listen to your body!!
4. No massage - see point 2. Getting a massage in the first week of an injury is not wise. It is easier for me to loosen something up than it is to "tighten" something up. I don't mind if you get a bit stiff because I can free you up easily enough. Get too loose or unprotected from a massage and you can be setback in your recovery...I have heard FAR TOO MANY stories of patients who felt good with a massage and then felt worse later. That is because the massage therapist did too good a job and released everything that was protecting you.
5. No internet trawling for information. Apart from the fact that I am supposed to be an expert in this sort of thing, it is tempting to find out as much as you can about things. Don't do it. I personally relied on assessments to determine that it wasn't likely disc or nerve related so things weren't going to be too bad but I was missing movement and things could cascade if I wasn't careful. Get seen early, determine what is wrong, stay off the internet and keep moving gently.
6. I didn't do any specific "Core Stability" retraining. Why? There is no evidence that it helps in the acute stages. I have monitored
What About You?
I have friends and patients who are in pain and the pain doesn't go away easily like mine did. It isn't because they aren't physios. It is simply because their problem was different to mine. If I didn't take action like I did, I probably would still have recovered but taken longer.
If you don't get better in a few days, it doesn't mean you did something wrong, it just means that your problem is different.
Please get an individual assessment by a suitably qualified health care professional. Being biased, I would love for you to see a good physiotherapist (physical therapist) but there are plenty of good people in every profession.
1. Early and effective pain relief, whether it is medication or treatment, is important. Get it ASAP
2. Stay moving within pain limits. Sometimes you need to just rest a few days but whatever you can manage is good for you.
3. Stay positive. Going down the negativity spiral is not helpful.
4. My story is just that - mine. Your story can be different even doing exactly that same thing. Your problem could be worse than mine or you could have other associated problems (they are called co-morbidities) that can be affecting your pain/problems.
5. Lastly, I want practitioners everywhere to remember that a patient lives with their pain 24hrs per day. Make sure your patients know what to do during that time!
Great comment about massaging too soon after an injury. Best to let it settle down and massage when the client gets to the point when the spasm is no longer serving a good purpose.