Lower Back: Is there a real benefit to getting an MRI?

[lolnickybobby]

Hello All, writing about my back today, but here is some info about me beforehand:

39 years old.
5'10"
190lbs.
SQ: 260
DL: 270
Bench: 195
Press: 130

Those numbers were all a bit higher a few months ago, but my back has not been kind to me and life has been busy, which has prevented me from lifting consistently.

In short, like many of us my lower back sucks. In 2016, when I was 31, I had a discectomy at L4-L5 due to severe sciatic pain. Prior to that I had an MRI: degenerative disc disease, "arthritic changes" in the back, spinal stenosis, hernia at L4-L5, Bulging Disc at L5-S1. Diagnosis: your back is fucked up. Advice: never lift heavy again (yeah right).

These days (and probably as a result of my latest back tweak from picking up a heavy flagstone a couple weeks ago), my back is constantly stiff and sore, especially in the morning. I can't stand up quite straight so I'm a bit hunched over, which is having some cascading impacts on my neck. I'm looking like a broken old man. Walking uphill hurts, putting on pants hurts, bending over the sink to wash my face or brush my teeth hurts. My back feels like it's threatening to seize up at any moment.

Here are a couple questions I have:

• I would love to work with a physio who really knows what they are doing, and I would love to have better insight into what specifically is messing up my back, but it's like I already know that the MRI is going to show a bunch of scary stuff that'll probably come with a bunch of scary advice. If the advice is always "get stronger", then is there any real benefit to put myself through the doom and gloom diagnosis?
  
• In the blue book, you mention that some people shouldn't be deadlifting if their lower back is too messed up. Is there any guideline for determining who falls in that category and who doesn't?
  
• I don't trust my back in terms of pain signaling. I will literally go from being hunched over, completely jacked up, barely able to walk to completely fine in a matter of days - and I just know that's not injuries work. If there was damage there, it would hurt consistently and for longer - no?
  
• If you have a client who comes in with this type of messed up back - what is your typical course of action? Is it simply to lower the weight to something manageable and start deadlifting? What if I can barely bend over/stand up straight?
  
• What are your thoughts on NSAID use to get moving again? E.g., if my back pain responds to NSAIDs, is it a good idea to just take a few Naproxen, wait a couple hours, and hit the gym - or is that irresponsible behaviour?

I appreciate the help in advance. I really want to lift, but I also don't want to make my back worse. It's a tough place to be!

Thanks,
Nic

[Jason Donaldson]

A couple of thoughts, Nic:

The combination of an NSAID + acetaminophen is way more effective than just either on its own. When I use them, I stagger the two, so never on the tail end of both at once. From what I understand, the mechanisms of the two meds are different, and complement each other.

A question for you: How long have you been training, specifically following the SS method?

[Will Morris]

Hello All, writing about my back today, but here is some info about me beforehand:

39 years old.
5'10"
190lbs.
SQ: 260
DL: 270
Bench: 195
Press: 130

Those numbers were all a bit higher a few months ago, but my back has not been kind to me and life has been busy, which has prevented me from lifting consistently.

In short, like many of us my lower back sucks. In 2016, when I was 31, I had a discectomy at L4-L5 due to severe sciatic pain. Prior to that I had an MRI: degenerative disc disease, "arthritic changes" in the back, spinal stenosis, hernia at L4-L5, Bulging Disc at L5-S1. Diagnosis: your back is fucked up. Advice: never lift heavy again (yeah right).

These days (and probably as a result of my latest back tweak from picking up a heavy flagstone a couple weeks ago), my back is constantly stiff and sore, especially in the morning. I can't stand up quite straight so I'm a bit hunched over, which is having some cascading impacts on my neck. I'm looking like a broken old man. Walking uphill hurts, putting on pants hurts, bending over the sink to wash my face or brush my teeth hurts. My back feels like it's threatening to seize up at any moment.

Here are a couple questions I have:

• I would love to work with a physio who really knows what they are doing, and I would love to have better insight into what specifically is messing up my back, but it's like I already know that the MRI is going to show a bunch of scary stuff that'll probably come with a bunch of scary advice. If the advice is always "get stronger", then is there any real benefit to put myself through the doom and gloom diagnosis? I wish you luck in your search for a physio that knows what they are doing when it comes to painful backs and how to approach the painful back in someone who wishes to continue to pursue increasing strength. By in large, what you are likely to find is that you will find a whole bunch of physios that are willing to do dry needling, cupping, manual therapy, treatment based classification system for low back pain, and McGill Big Three.
  
• In the blue book, you mention that some people shouldn't be deadlifting if their lower back is too messed up. Is there any guideline for determining who falls in that category and who doesn't? There is no specific guideline as it really depends on the person. I have seen people with absolutely horrific injuries to their lower back (talking actual diagnosable injury that threatened lifelong disability) get back to very high level lifting. I’ve worked with one lifter, in particular, that Stu McGill, himself, told he should never lift again, and this lifter has gotten back to a > 700# deadlift and has only had a tweak or two in his back in the last five or six years. I’ve also seen some lifters with marginal findings on imaging that are so load sensitive that they were not able to squat or deadlift reliably without having a similar pain response as you reported.
  
• I don't trust my back in terms of pain signaling. I will literally go from being hunched over, completely jacked up, barely able to walk to completely fine in a matter of days - and I just know that's not injuries work. If there was damage there, it would hurt consistently and for longer - no? This is actually a very refreshing level of introspection on such a potentially emotional topic. I think your reasoning here is extremely sound, but the reasoning doesn’t stop your back from being debilitatingly painful. Despite the pain, seeing you not completely catastrophize makes me happy.
  
• If you have a client who comes in with this type of messed up back - what is your typical course of action? Is it simply to lower the weight to something manageable and start deadlifting? What if I can barely bend over/stand up straight? I have them do what they can, and I incrementally load. If that means partial ROM or variations of lifts compounded together, that’s what it is.
  
• What are your thoughts on NSAID use to get moving again? E.g., if my back pain responds to NSAIDs, is it a good idea to just take a few Naproxen, wait a couple hours, and hit the gym - or is that irresponsible behaviour? I think it is only irresponsible when you consider that NSAID abuse is something like the 12th leading cause of death in the US. For PRN (as needed) pain relief, I think that Tylenol is a better, safer option so long as you don’t drink yourself into oblivion on a regular basis. Most of the physicians I have had a longstanding working relationship with seem to have a consensus that NSAID use should be kept to short periods of time (10-14 days) and taken on a schedule.

I appreciate the help in advance. I really want to lift, but I also don't want to make my back worse. It's a tough place to be!

Thanks,
Nic

All this to say, I’d bet there is a relatively simple solution to your lifting troubles.

[lolnickybobby]

A couple of thoughts, Nic:

The combination of an NSAID + acetaminophen is way more effective than just either on its own. When I use them, I stagger the two, so never on the tail end of both at once. From what I understand, the mechanisms of the two meds are different, and complement each other.

A question for you: How long have you been training, specifically following the SS method?

Copy that for the pills. I used that combination when I broke some ribs, and it was definitely helpful.

I've been lifting on and off forever, but I started SS in June 2023. First run was from June 2023 to October 2023, then I took 2 months off because of hunting, but my first very honest NLP where I started working really hard and seeing numbers go up was in January of this year. I stayed on it religiously (including a 4000 calorie/200g protein diet) for 9 weeks until early march. During that time my weight went from 167 to 195, and I added about 100lbs to both my squat and my DL, which is great.

Then life got in the way and the 3x per week of heavy squats and DLs was no longer sustainable for me. I started missing workouts, and I've been struggling to find consistency in both diet and workouts every since, in large part because I keep tweaking and re-tweaking my back. I'm currently on a modified split (provided by an SSC), that has me lifting 2x per week, though I struggle to do that too because my back is hurting on and off, and if we are being honest, because I'm not patient and after I miss a couple weeks of training I'm probably diving back into it too heavy.

I will admit that if nothing else, my back was feeling pretty good when I was lifting consistently. Now I'm in some kind of vicious cycle that I want to break somehow.

I really wish I would have found this program when I was 25!

All this to say, I’d bet there is a relatively simple solution to your lifting troubles.

Thanks so much for taking the time doc!

I do prefer taking acetaminophen over NSAIDs as I was on daily NSAIDs for a very long time while I was waiting for surgery, and all the stories of stomach bleeding and ulcers definitely made me nervous. It was Vimovo though, which from what I understand also has esomeprazole which is supposed to somehow protect your stomach.

It's funny you mention the McGill big 3. I also own "back mechanic" and did the big 3 for a long while after my surgery. I was a big fan until I listened to a podcast episode that had him giving advice to not lift heavy and to walk uphill backwards instead of deadlifting. That's just not my jam. Sometimes life has me lifting heavy things. I live in Canada. We have snow. I hunt. I do my own renos. I can't just be weak and then be surprised that my back is strained after shoveling the driveway.

Knock on wood, I haven't really tweaked my back squatting yet, it's either deadlifting, but even more common - doing random stuff outside of the gym.

I guess I'll start taking tylenol and lifting light until things get more reasonable and then go from there...

Sidenote: do we have any thoughts on Louie Simmons' reverse hyper machine for lower back issues?

thanks again to both of you - much appreciated.

[Will Morris]

One thing that stood out on your initial post was that you had MRI findings that showed spinal stenosis. If you, indeed, have spinal stenosis, you could make a small switch to bracing your spine in a very small amount of flexion, rather than extension (much like you are doing a very small scale crunch) and your back will more than likely be far less irritable to your lifting. True central stenosis eliminates the possibility of being able to brace in extension, so bracing in flexion is a really easy long term solution.

[lolnickybobby]

One thing that stood out on your initial post was that you had MRI findings that showed spinal stenosis. If you, indeed, have spinal stenosis, you could make a small switch to bracing your spine in a very small amount of flexion, rather than extension (much like you are doing a very small scale crunch) and your back will more than likely be far less irritable to your lifting. True central stenosis eliminates the possibility of being able to brace in extension, so bracing in flexion is a really easy long term solution.

This is very useful to know and very good back pocket information for the future, but at this point it seems as though flexion is actually causing (or at least exacerbating) my pain. I've been experiencing stiffness in the morning when doing activities such as bending over the sink to brush my teeth or washing my face, putting on pants/socks, and walking uphill. That tension can quickly lead to my back seizing up. Sitting for extended periods of time also seems to make it worse.

We are only on day 2 of this acute episode and I'm sure it'll resolve itself in a few days as it usually does, but my back has been particularly vulnerable for the past few months - something I'm trying to resolve and get back to being resilient. Again this is all super helpful and I appreciate it.

[Will Morris]

This is very useful to know and very good back pocket information for the future, but at this point it seems as though flexion is actually causing (or at least exacerbating) my pain. I've been experiencing stiffness in the morning when doing activities such as bending over the sink to brush my teeth or washing my face, putting on pants/socks, and walking uphill. That tension can quickly lead to my back seizing up. Sitting for extended periods of time also seems to make it worse.

We are only on day 2 of this acute episode and I'm sure it'll resolve itself in a few days as it usually does, but my back has been particularly vulnerable for the past few months - something I'm trying to resolve and get back to being resilient. Again this is all super helpful and I appreciate it.

Just remember that there is a massive difference between bracing in slight flexion and actually going into demonstrable lumbar flexion.