Training with cervical disc herniation

[Tim W]

42 year old physician here. I had a C6-7 disc herniation about 6 years ago. MRI confirmed. Completely resolved with a steroid dosepak and a month of PT (the cervical traction was the most useful)

Two days ago while squatting (low bar) I had an acute onset of intense pain in right trap/upper back and throughout right shoulder girdle. I assumed a muscle strain, and began taking Flexeril and Advil. By the next AM, I had clear radiculopathy signs with pain and paresthesias down right lateral/dorsal arm, numbness in index and middle finger, and notable tricep weakness. Identical presentation as the prior.
Last night I was aiming for a 140# triple on OHP, but couldn't even press 85!

Two questions to the medical and physiotherapy members of the forum (but I welcome any insight):

1. Mechanism for this to recur while squatting? All I could come up with is that in an effort to cue "look down", I had excessive cervical flexion while loaded.
2. How do I rehab and maintain strength? I cannot press right now due to the tricep weakness, and I'm scared to get under the bar. High reps with whatever load I can safely manage? Take a week off and reassess?

Its funny - 6 years ago all I worried about was missing work for PT appointments and MRIs. Now all I am thinking about is missing training and losing all the hard-fought gains I've made.

I really don't want to undergo a ACDF. Help!

[Jonathon Sullivan]

From the medical perspective, it sounds like you may have pissed that disc off again. Triceps is C7, and your radiculopathy is C7 distribution. I'd put you on another short burst of steroids to get at the swelling at the nerve root (since it worked before), and again refer you to physiotherapy...provided I knew the PT was lifter-friendly. You don't have a neurosurgical emergency (which is the question I spent my career asking myself--and if not, refer!).

How did you do it? Without video, we'll never know for sure, but hypothesis #1 sounds as good as any guess I'd make.

I would take a few days off and let the medrol work, but only a few, and then see what you tolerate.

Mostly, though, I would send you to Will Morris. I've flagged him on this thread.

[Tim W]

Thanks Dr Sullivan. I will try to upload a video later today. I started a standard Medrol pack last night, and RTC Ibuprofen and Cyclobenzaprine. I'll lay low for a week, deload and see what I can work back up to. I can handle the pain, but the weakness is a huge bummer.
I am an anesthesiologist, so have to move children from the OR table to the stretcher all day long. I don't want to drop anyone!

My main concern is how to lose the least amount of pressing strength possible during the layoff. Does disuse atrophy occur in a week, or is most strength maintained?

[Will Morris]

Thanks Dr Sullivan. I will try to upload a video later today. I started a standard Medrol pack last night, and RTC Ibuprofen and Cyclobenzaprine. I'll lay low for a week, deload and see what I can work back up to. I can handle the pain, but the weakness is a huge bummer.
I am an anesthesiologist, so have to move children from the OR table to the stretcher all day long. I don't want to drop anyone!

My main concern is how to lose the least amount of pressing strength possible during the layoff. Does disuse atrophy occur in a week, or is most strength maintained?

There isn't much to add to this right now except for a couple fairly salient points:

1) loads should be very low while on a medrol dosepak or straight dose prednisone. I would not have anyone lift anything "heavy" for them while on that.

2) Medrol has better evidence to support improving function more so than pain. After the course of steroid, you should feel stronger but may still have residual pain. That's okay, and it really is expected.

3) any nerve injury requires heavy loading relative to what is possible, but, VOLUME has to be very low. I highly recommend short burst sets of 2-3 reps and plenty of rest between sets. Alpha motor neurons get real finicky when you work their muscle to fatigue / exhaustion.

4) you should start pressing and bench pressing as soon as pain allows you to. 6x2 reps or 4 x 3 reps. Linear progression as normal. Roll a small towel and place under your head on bench.....place a tennis ball under your chin during press, squats, and deads. This will prevent excessive cervical flexion.

[Tim W]

Thanks Will for the advice. I met with a PT yesterday, and it doesn't seem he has much experience with lifters. He prescribed gentle neck ROM exercises, and Median nerve glides (basically shrugging shoulder up and down while moving wrist from extension to flexion. And the over-the-door cervical traction. On day 4/6 of methylpred without much improvement.

Are there specific PT modalities that are best suited to rehabbing a C6/7 disc? As for maintaining strength, I'm scared to have a BB overhead or over my face with such tricep weakness.

Would it be good to do unilateral tricep pressdowns or kickbacks to isolate that side with whatever load is feasible? Any way to keep the pecs and delts from detraining while my tricep is out (ie, flyes and side lateral raises)? Every other movement I can think of involves elbow extension.

[Will Morris]

Thanks Will for the advice. I met with a PT yesterday, and it doesn't seem he has much experience with lifters. He prescribed gentle neck ROM exercises, and Median nerve glides (basically shrugging shoulder up and down while moving wrist from extension to flexion. And the over-the-door cervical traction. On day 4/6 of methylpred without much improvement.

Are there specific PT modalities that are best suited to rehabbing a C6/7 disc? As for maintaining strength, I'm scared to have a BB overhead or over my face with such tricep weakness.

Would it be good to do unilateral tricep pressdowns or kickbacks to isolate that side with whatever load is feasible? Any way to keep the pecs and delts from detraining while my tricep is out (ie, flyes and side lateral raises)? Every other movement I can think of involves elbow extension.

Dr. Tim W, unfortunately, this tends to be the general "canned" answer from our profession. As a profession, physical therapists almost universally under-dose patients. Maintaining ROM is important, but this is probably better suited by telling and educated man such as yourself that you still have a responsibility to use your neck. Inactivity is injury in this setting. You are performing gentle range of motion exercises when you look to your right and left, looking up and down, turning your head to check your blind spot, etc. If you were to "protect" your neck with immobilization, you will almost certainly lose ROM over time. The efficacy of performing dedicated ROM exercises, as opposed to patient education on the effects of protective posturing, is probably not worth the time investment.

In my practice, I have not had good success with nerve injuries doing unilateral, isolation exercises. I have used them, sparingly, once recovery is well underway, but to start with them might be less than optimal. I completely understand the trepidation with having a bar overhead with this weakness, but there are ways to mitigate this. For one, bench pressing in a squat rack allows you to set the safety arms to a position where you couldn't possibly drop the bar on yourself. Lowering the weight to the safety arms, setting it down, then pressing the bar from the pins would be a good early training technique. Doing the same thing with press is another good option. We call those press lockouts, or you can perform the shoulder press with rings as illustrated on Rip's shoulder rehab video. That has been, easily, the most effective training option I have found for rehabbing shoulders and cervical disk injuries. Isolation work, albeit seemingly intuitive, does not force the affected musculature to work in concert with the surrounding musculature and, the low weights typically utilized for isolation exercises, lead one to be able to work to fatigue....or, at the very least, if the individual sticks to the short burst sets, the resistance is not enough to produce a physiological adaptation. I have found it to be a far better option to adapt the exercise to a suitable configuration rather than adapt my training.

It needs to be considered that the triceps is not the only effected muscle with a moderate to severe C7 radiculopathy. You will certainly start to have issues with your pec, lat, triceps, and forearms. These all need to be prophylactically trained as well.

[Tim W]

Thanks for the training advice. That was excellent. I did find a local physiotherapist who is also a coach and powerlifter, so I’m hoping he can show me some methods to keep training. Appreciate the help!!

[Will Morris]

Thanks for the training advice. That was excellent. I did find a local physiotherapist who is also a coach and powerlifter, so I’m hoping he can show me some methods to keep training. Appreciate the help!!

How are things coming along Doctor?

[Tim W]

Not good. No improvement after oral and epidural steroids, two weeks of PT, and home cervical traction to 25#.
Repeat MRI worsened since 2012, with now severe neuroforaminal stenosis at C6-7. Likely going to get a discectomy and artificial disc. Neurosurgeon thought with being young and having 1 level disease we could avoid a ACDF.
I AM DYING TO GET BACK UNDER THE BAR, but tricep weakness is precluding that.

I’ll need help postop. Probably start an LP again.

[Mark Rippetoe]

I had the same diagnosis in 1999, got the surgery, and and have had absolutely no trouble since. Get it done.