Okay, I know you: the gym is where you live between work and your bed. You pride yourself on ripped abs, thrashed glutes, and cut quads. You could strum your serratus, pound nails with your pecs, break bricks with your biceps — and as the plated bar bends, some people stop to watch the steam come off your chest.
What happens next is all too common: There’s the lift, the sudden loss of balance, the “uh-oh” moment before a “clunk, snap, pop,” and the dropped weight, lightning bolts to the buttocks and thighs, and the mat coming up to meet you. This follows with the writhing spasm, the crawl to the sauna, the stretch, the ice and the Advil. Maybe you borrow someone’s Vicodin, or maybe you had some left over from the last injury. This lasts a day, a week, sometimes even a month. Maybe it’s the first time. Or maybe it’s the third time this year.
So what happened, and how can you avoid it?
Low back pain is one of the most common health problems in society and causes considerable disability, work absenteeism, and use of health services. It is said to affect 50 percent to 80 percent of us in our lifetime, and 15 percent to 30 percent of us at any given time. During any 6-month period, 72 percent of adults in the general population will report lower back pain and 11 percent will report disabling lower back pain. Differentiating between the type of pain that occurs spontaneously and that which follows a sporting injury is sometimes difficult, as not all patients recall a specific event that caused pain.
With the general and extremely common nature of lower back pain, consider that, among patients who frequent the gym, and particularly the weight training sports, certain patterns of complaints emerge. In my practice as a spine surgeon accepting referrals from the community, there are certain weight training maneuvers that generate the majority of injury: deadlifts, squats, and the clean-and-jerk.
These techniques I’ve mentioned include movements with the highest degree of technical difficulty, which, if performed incorrectly, will expose vulnerable lumbar muscles and disks to high strain, shear and axial loading. “I hurt my back trying for personal best on the deadlift” is a comment I hear weekly. I hear similar comments about squats and the clean, too. The underlying commonality is overloading lumbar extensor muscles , the very large muscle groups that work to stand you up from a bent forward position. These injuries are much more likely to occur during high velocity, rapid muscle contractions, and much less likely to occur in isometrics. The latter are low velocity and relatively-static contractions where the joint doesn’t move much — think of planks.
Even with the best coaching and form, the notion that “avoiding a rounded back” or “lifting straight on the rack” will prevent loading of disks is, unfortunately, a stretch (no pun intended). Regardless of the presence of perfect form and execution, loads through a vertebral disk space when lifting over 100 percent of personal body weight can exceed the stress-to-failure strength of disk and tendon collagen. This leads to tears in fibrocartilage and collagen, two structural components that are responsible for anchoring muscles to bone not unlike like tow ropes or cables on a car.
What happened in the scenario above? The explanation is not simple but the essential idea is that the muscles failed under excessive loads. Some animal studies suggest that the earliest injury involves tearing of the sarcomere (muscle unit) cell-wall. Some studies suggest that, contrary to perception, injury is more likely to occur when a muscle is lengthening under load (an eccentric contraction). Perhaps the muscle is over-taxed resulting in buildup of lactic acid and depletion of ATP — the energy molecules that run our muscles and glycogen stores.
At the larger scale, muscle loading combined with injury, a tetanic contraction occurs (the muscle cannot relax) and this results in severe pain all along the muscle fibers and attachments. The muscle injury ranges from a micro cellular disruption at the low end to tendon avulsion injuries or muscle tears at the high end; inflammation ensues. Muscles and tendons become sore, swollen, or sometimes bruised. Pain radiates from the lower back to the legs — muscles cannot hold up body weight and the reflex action of the body is to fall to the ground. This is the acute or sudden muscular injury.
In the athlete with recurring pains, it is thought that chronic disruption of collagen attachments to bone can result in further susceptibility to injury. It may also be that recurring bad habits in training can result in recurring injury. This is the familiar, “I’ve got a muscle that I keep re-injuring,” or “This happens every time I do squats.” Some animal studies have suggested that it takes 9 months for a disrupted knee ligament to return to its pre-injury strength. A hypothesis of chronic back pain: ligament sub-failure injuries lead to muscle control dysfunction. This is to sa y injuries to ligaments that are just below rupture, as with fraying, leads to pain in muscle contraction and then poor muscle coordination.
Although many people will refer to this severe lower back pain as “sciatica” or a “pinched nerve,” this is rarely the case. It’s important to note, as an aside, that the sciatic nerve is rarely compressed in these types of injuries, and pinched nerves occur only when there is documented disk herniation or spinal stenosis (narrowing of the spinal canal). True pinched nerves from a disk herniation cause numbness, tingling and weakness, as well as radiating pain. And this type of injury is often in combination with loss of strength, atrophy, numbness, and limb reflex changes. It can also only be confirmed by an MRI.
Injuries with weight training can occur whether you are a pro in a strongman competition or just an enthusiast (if there is such a thing.) As an example, in an article published in the Journal of Strength & Conditioning Research , 82 percent of strongman athletes reported a smorgasbord of injuries: Lower back (24 percent), shoulder (21 percent), bicep (11 percent), knee (11 percent), and strains and tears of muscle (38 percent) and tendon (23 percent) were the most frequent. And the majority of these (68 percent) were acute and of moderate severity (47 percent).
Strongman athletes used self-treatment (54 percent) or medical professional treatment (41 percent) for their injuries. In fact, 41 percent of the time, strongman athletes injured themselves enough to require medical treatment. Interestingly, stretching regularly and being in shape and training consistently were not necessarily protective. Monitoring form and adherence to a careful training regime was preventative.
Weight training isn’t all bad news. I’ve rarely seen a chronic injury from performing leg lifts, crunches or planks (unless the supports gave way). Abdominal muscle injury can occur with overzealous or excessive weights. These exercises are safer because they are lower velocity, shorter lever arm, and concentric contractions (excepting crunches). Lower lumbar disk pressures are seen with these exercises as well. Isometric plank exercises increase core strength and can also protect against injury.
And if you want to avoid severe lower back pain, prevention, as with most things, is the best medicine. Maintain an appropriate body weight. Lift weights within reason and within prior ability. Advance slowly and methodically. Use excellent form, which can only come from excellent coaching. Most importantly, do not train when injured. If you are, change to aerobics for a week.
Simple therapies, such as initial icing, rest, subsequent heat, stretching and over-the-counter anti-inflammatories work well for acute injuries. Avoiding chronic pain means avoiding chronic re-injury. There is no shame in training at 30 percent of your max for a while if in the end it means you bounce back quicker and possibly stronger than before. That said, if pain lasts more than a week, or if numbness, tingling, weakness occurs, don’t hesitate to seek out a medical evaluation.
Dr. Michael L. Gordon is a spine surgeon at Newport Orthopedic Institute & Hoag Orthopedic Institute in Irvine and Newport Beach, California. He specializes in minimally-invasive surgery of the cervical and lumbar spine in adults. To stay fit, Dr. Gordon tries to balance work with a minimum of 5 hours a week in the gym. He is an avid cycler, skier and ex-runner who’s replaced the pavement with an elliptical as an inevitable compromise with the old ACL injury.