Inflexible hamstrings due to herniated disk

[David Brinkmann]

Hi! I've recently started a friend of mine on SS. He's squatting, benching and pressing just fine. However he is unable to deadlift.
His hamstrings (especially on the right side) are so inflexible, that he can barely reach the top of his knees with a straight back and slight knee bend. Some years ago he had a lumbar disk herniation and has not gotten surgery. He avoids surgery, because of the possible complications. There was no obvious reason for the injury, he just woke up in pain one morning.
According to the physical therapist, that he went to, the disk puts pressure on the nerves, that connect with the hamstrings. That's supposedly the reason for his flexibility issues.
Our strategy so far is to have him do back extensions and assisted chins after squatting and pressing. The idea is, that the back extensions will improve his flexibility to a point, where he can do rack pulls. Then we will try to lower the pin height over time, until he can pull of the floor.
Is this a viable strategy? Does anyone here have experience with treating such a problem? His range of motion has only increased very slightly over the last three weeks.
He is 22 years old, 6'2", 220 lbs.

[Will Morris]

Hi! I've recently started a friend of mine on SS. He's squatting, benching and pressing just fine. However he is unable to deadlift.
His hamstrings (especially on the right side) are so inflexible, that he can barely reach the top of his knees with a straight back and slight knee bend. Some years ago he had a lumbar disk herniation and has not gotten surgery. He avoids surgery, because of the possible complications. There was no obvious reason for the injury, he just woke up in pain one morning.
According to the physical therapist, that he went to, the disk puts pressure on the nerves, that connect with the hamstrings. That's supposedly the reason for his flexibility issues.
Our strategy so far is to have him do back extensions and assisted chins after squatting and pressing. The idea is, that the back extensions will improve his flexibility to a point, where he can do rack pulls. Then we will try to lower the pin height over time, until he can pull of the floor.
Is this a viable strategy? Does anyone here have experience with treating such a problem? His range of motion has only increased very slightly over the last three weeks.
He is 22 years old, 6'2", 220 lbs.

Why not do slow RDLs and let the Barbell stretch the hamstrings?

[David Brinkmann]

Why not do slow RDLs and let the Barbell stretch the hamstrings?

Well. I never Even thought about RDLs because they generally aren't part of the program. But I can see this working.
The only problem I have with the idea is that the range of motion might be too small to really do anything and the weight for that R.O.M. so high, that he could reinjure. That's also why I don't have him do rack pulls above the knee. Back extensions have a longer range of motion and are by nature so light, that they won't hurt him.
Do you have any thoughts on that?

[Will Morris]

Well. I never Even thought about RDLs because they generally aren't part of the program. But I can see this working.
The only problem I have with the idea is that the range of motion might be too small to really do anything and the weight for that R.O.M. so high, that he could reinjure. That's also why I don't have him do rack pulls above the knee. Back extensions have a longer range of motion and are by nature so light, that they won't hurt him.
Do you have any thoughts on that?

Sorry for the short reply yesterday. I was boarding a plane when i responded and had very little time. Let’s step back a second and let’s think about the explanation given by the PT. Are we okay with that explanation?

[Delaying_the_inevitable]

As someone who had a compression fracture in the lumbar region who is able to deadlift without issues, I would be reluctant to accept the opinion of a physical therapist alone. "If" there is pressure on a nerve for any reason, seeing an orthopedist or neurologist and getting an MRI or CT scan is something he should at least consider.

Many orthopedists are or were competitive athletes themselves and there are entire practices that specialize in sports medicine. A physician who is used to dealing with athletes who want to continue with a sport following an injury may be better able to offer useful advice that one who advises patients to avoid certain activities.

If there is no risk of serious injury, starting with a limited range of motion could be a good option. For deadlifts, rack pulls at progressively lower heights are one approach. Later, you friend could start with the plates of the deadlift bar on top of a couple of plates. Once the bar is lifted, two assistants could remove one plate on each side. When I restarted performing deadlifts, I was nervous about lifting the bar from the ground and I found that starting with the bar on pins or plates and lowering the deadlift bar below the starting point was a reasonable way to begin. If something didn't feel right on the way down, I would have just let go of the bar.

[Will Morris]

As someone who had a compression fracture in the lumbar region who is able to deadlift without issues, I would be reluctant to accept the opinion of a physical therapist alone. "If" there is pressure on a nerve for any reason, seeing an orthopedist or neurologist and getting an MRI or CT scan is something he should at least consider.

Many orthopedists are or were competitive athletes themselves and there are entire practices that specialize in sports medicine. A physician who is used to dealing with athletes who want to continue with a sport following an injury may be better able to offer useful advice that one who advises patients to avoid certain activities.

If there is no risk of serious injury, starting with a limited range of motion could be a good option. For deadlifts, rack pulls at progressively lower heights are one approach. Later, you friend could start with the plates of the deadlift bar on top of a couple of plates. Once the bar is lifted, two assistants could remove one plate on each side. When I restarted performing deadlifts, I was nervous about lifting the bar from the ground and I found that starting with the bar on pins or plates and lowering the deadlift bar below the starting point was a reasonable way to begin. If something didn't feel right on the way down, I would have just let go of the bar.

Appreciate your input, however, I think I am going to have to disagree with some of what you say here.

Without additional information, one cannot even begin to make a determination if a MRI is indicated in this situation. "Pressure on a nerve" is not an indication for an MRI. Progressive neurological deficit or medical red flags related to back pain are an indication for advanced imaging. This has to be determined during a competent exam. There is nothing reported here in the original post that gives us any indication what the actual situation is, therefore, recommending a specialty consult and advanced imaging is WAY beyond the scope of information we should be providing. Please understand, a MRI or CT scan is not for you, the patient....the advanced imaging is for the clinician to make the right decision about your care. As mean as it may sound to hear, but a patient's request for advanced imaging means virtually nothing. The patient does not consider getting a MRI/CT Scan. The physician considers ordering it. That is a big distinction.

I can guarantee you, that as a Physical Therapist, I can perform a physical exam that is on par with most orthopaedic surgeons and neurologists when it comes to assessing this type of condition. I don't have as much on my menu to treat them, but my exam and my "opinion" is actually quite important. In fact, I am consulted by orthopaedic spine surgeons and neurologists with somewhat routine regularity.

I don't think you have any data to support your assertion that a greater number of orthopaedic surgeons were / are competitive athletes. It certainly seems to have face validity, however, I know just as many, if not more, orthopaedic surgeons who never played a sport in their lives. History of competitive sports gets your nowhere near an ortho residency. Superior GPA and Step 1 scores get you to an ortho residency.

You are exactly right, though, about physicians with a knowledge base in activities will almost certainly provide more well-rounded guidance for someone who wishes to return to higher level function post-injury.

I don't disagree with you in principle about modifying range of motion, if needed, however, I think the idea of having friends remove plates directly under a loaded bar invites the risk that said person with back pain drops the bar and crushes someone's hand.

[Delaying_the_inevitable]

Appreciate your input, however, I think I am going to have to disagree with some of what you say here.

Without additional information, one cannot even begin to make a determination if a MRI is indicated in this situation. "Pressure on a nerve" is not an indication for an MRI. Progressive neurological deficit or medical red flags related to back pain are an indication for advanced imaging. This has to be determined during a competent exam. There is nothing reported here in the original post that gives us any indication what the actual situation is, therefore, recommending a specialty consult and advanced imaging is WAY beyond the scope of information we should be providing. Please understand, a MRI or CT scan is not for you, the patient....the advanced imaging is for the clinician to make the right decision about your care. As mean as it may sound to hear, but a patient's request for advanced imaging means virtually nothing. The patient does not consider getting a MRI/CT Scan. The physician considers ordering it. That is a big distinction.

I can guarantee you, that as a Physical Therapist, I can perform a physical exam that is on par with most orthopaedic surgeons and neurologists when it comes to assessing this type of condition. I don't have as much on my menu to treat them, but my exam and my "opinion" is actually quite important. In fact, I am consulted by orthopaedic spine surgeons and neurologists with somewhat routine regularity.

I don't think you have any data to support your assertion that a greater number of orthopaedic surgeons were / are competitive athletes. It certainly seems to have face validity, however, I know just as many, if not more, orthopaedic surgeons who never played a sport in their lives. History of competitive sports gets your nowhere near an ortho residency. Superior GPA and Step 1 scores get you to an ortho residency.

You are exactly right, though, about physicians with a knowledge base in activities will almost certainly provide more well-rounded guidance for someone who wishes to return to higher level function post-injury.

I don't disagree with you in principle about modifying range of motion, if needed, however, I think the idea of having friends remove plates directly under a loaded bar invites the risk that said person with back pain drops the bar and crushes someone's hand.

All very valid points. Some of the things I mentioned could have been stated differently. My suggestion should have been more clear that I wasn't offering an opinion about what decisions a specialist might have about the possible need for advanced imaging and was merely mentioning that it might be a possibility.

I wasn't trying to diminish the role of a physical therapist who can assessments judgments about certain types of injuries that are comparable to those of a specialist. Still, whenever there are even minimal risks of a further spinal injury, I would want as much information as possible before proceeding. I had a neck injury the extent of which was not apparent without an MRI. A massage or some types of physical therapy could have caused a debilitating injury. Please don't take my comments as diminishing the benefits that physical therapy can provide.

The plates only have a small surface area and the small ones below them only need to be pushed a couple of inches away. Obviously, if the lifter is uncertain about the weight this is a dangerous approach. I used a very low rack position when I was starting deadlifts instead of starting on a flat surface. Once I was able to handle more than a couple of hundred pounds, I decided to discontinue walking backwards with a loaded bar held in my hands.

I believe I used the words that many orthopedists have a sports background instead of most. My family has more than one national champion and some of us have tried to compete after suffering serious injuries. Just my observation, but we have had better results with those providers that recognize that each of us wanted to return as quickly as possible and didn't simply tell us to stop training. It might be a coincidence but former athletes who are still training seem to have more suggestions for how to continue training without undue risks.

[Delaying_the_inevitable]

I reread my earlier posts once I got home and I wanted to clarify one more comment. When I said that seeing a specialist or getting imaging done "is something he should at least consider," I meant just that. In other words, I didn't state that he definitely should or shouldn't do so. Perhaps I am more sensitive to this because of the stories I have heard from physicians in my family and my own realization that the injury to my neck could have led to paralysis. Without the MRI, which my orthopedist ordered, the infrequent nerve pain might that I suffered from might have led to severe complications.

Since one or more anecdotes doesn't make data, my experience doesn't imply anything about the original poster's friend's condition. Please excuse my cautious approach to back injuries. Also, i appreciate the time that you and others take to answer individual questions.

[Will Morris]

All very valid points. Some of the things I mentioned could have been stated differently. My suggestion should have been more clear that I wasn't offering an opinion about what decisions a specialist might have about the possible need for advanced imaging and was merely mentioning that it might be a possibility. I completely understand, although I may suggest that most medical providers who would be seen for such a complaint already know the indications for imaging, and, suggesting advanced imaging to them is almost completely unnecessary.

I wasn't trying to diminish the role of a physical therapist who can assessments judgments about certain types of injuries that are comparable to those of a specialist. Still, whenever there are even minimal risks of a further spinal injury, I would want as much information as possible before proceeding. I think this comment is being based off an assumption that medical providers that are outside of the surgical specialties do not know how to safely screen a patient prior to treating them. I'd wonder, what classifies as "minimal risks of further spinal injury"?I had a neck injury the extent of which was not apparent without an MRI. A massage or some types of physical therapy could have caused a debilitating injury. If you had a fracture in your neck, you almost certainly would have met the Canadian C-Spine Rules and every single Physical Therapist would be bound to knowing and recognizing the presentation of this. For any neck pain patient I have referred to my clinic, I spend about 5+ minutes performing a cervical spine clearing exam before I ever initiate any treatment. This does not count the routine physical exam which requires I perform ROM testing, a neurological screening, etc. If you happened to fall into the hands of a provider who does not know this, they should not have a license in the first place. Please don't take my comments as diminishing the benefits that physical therapy can provide.I do understand, and thank you for stating that. I do, however, believe that some of the original language used is a bit alarmist and may not necessarily be helpful. Medical professionals have a big enough problem with inducing fear and unnecessary disability in patients by the way we speak to them.

The plates only have a small surface area and the small ones below them only need to be pushed a couple of inches away. Obviously, if the lifter is uncertain about the weight this is a dangerous approach. I used a very low rack position when I was starting deadlifts instead of starting on a flat surface. Once I was able to handle more than a couple of hundred pounds, I decided to discontinue walking backwards with a loaded bar held in my hands.

I believe I used the words that many orthopedists have a sports background instead of most. My family has more than one national champion and some of us have tried to compete after suffering serious injuries. Just my observation, but we have had better results with those providers that recognize that each of us wanted to return as quickly as possible and didn't simply tell us to stop training. It might be a coincidence but former athletes who are still training seem to have more suggestions for how to continue training without undue risks.I'm by no means a national champion in anything, but I do have a fairly extensive, albeit a completely below average athletic history and it absolutely feeds into my practice patterns. There are very few instances where the medical advice, "stop training" is appropriate. But, that brings us back to the issue medical providers have with inducing harm to our patients by the words we choose to use.

We may not agree on everything, but I certainly appreciate your participation. I thoroughly enjoy having well-reasoned discussions on here. Thank you.

[Delaying_the_inevitable]

We may not agree on everything, but I certainly appreciate your participation. I thoroughly enjoy having well-reasoned discussions on here. Thank you.

Thank you so much for the detailed explanation. I always appreciate when someone takes to the time to provide not only useful advice but does so in a polite and professional manner. I would rather be told that I am wrong by someone who knows more than I do, than to continue to think I am right when I may not be.

I never realized that I had a serious neck injury until long after it happened. My guess is that it happened when I was a linebacker. At various times, something would cause intense pain for several days and the pain would go away. The only time I had a massage, I was incapacitated for several days. I was only of those people who only went to see a doctor for flu shots and a physical every few years. Since my neck never hurt when I went for a physical, the issues with my neck went undiagnosed for a very long time.

After a discussion with a family member, who is an orthopedic surgeon, I went to see a local provider. He recommended an MRI and referred me to a neurologist. The neurologist recommended never lifting weights over my head and I decided to quit squatting. The injury is high enough on the cervical spine that I later found that I could low bar squat and I can overhead press as long as I don't perform some contorted move trying to get one more rep. Obviously, I need to be very careful with this and a visit to a neurologist is now an annual event, like flu shots and a physical.

You are clearly quite thorough with your screening of new clients and IIRC you are also quite strong. If I ever need PT again, I hope I can find someone as capable.