Unsure about the deadlift

[Stuffed Olive]

Hello Mr Rippetoe,
I think I?ll start by saying thanks for your books. They?re hugely informative and taught me a lot about barbell training and effective exercise in general. I?m eager to start your program, and would do so tomorrow, gallon of milk and all, were it not for my concern over deadlifting and a persistent lower-back strain. I have bought all the equipment you list necessary in your book and have some Ironwork IIIs lined up too so I can begin training on SS.

I picked up the injury a couple of months back in the gym and it has improved dramatically since then; it?s far more flexible and I can play fairly rigorous sport with little to no problems. In fact I find it far better to be up and doing things as opposed to sitting which makes it feel quite uncomfortable. As far as diagnosis goes I?ve seen a doctor several times and am attending physiotherapy and they think it is simply a muscle strain (postural muscles in particular I think). I think it?s safe to rule out a
significant spinal injury (having read about herniated discs for example).

As I say I am worried about deadlifts and to a lesser extent the power cleans. I think I can press and bench press til my heart?s content, and squatting (admittedly light weights) feels fine. However there is still some pain in the lower of my back, slightly and noticeably to the left side. It almost feels like a ?pull?, being connected to my left leg that hurts when, for example I am seated and stretch out my left leg totally straight. This is strange because initially the injury did not seem limited to one area. Here is where I?d say it is on a diagram:

http://img26.imageshack.us/my.php?image=lowerback.jpg

On the whole I think I?ve recovered about 90-95%. This problem is persistent but it doesn?t seem massively serious (the pain is not and never was really bad, never enough for me to take pain killer) but I don?t want to run the risk of re-injury. At the same time I feel the problem may correct itself if I train. Given the information do you think I should go ahead and do your program and do the deadlifts? Should I just start them light (say around 140lbs) and just build up slowly and let pain (if there is any) be the judge, whilst doing the rest to the letter (being careful and cautious)? Or should I wait it out, keep working on rehab exercise, until I feel '100%'?

Thank you

[Mark Rippetoe]

This is pretty typical SI-joint (sacro-iliac articulation) pain. It will probably get better when you start to pull and squat, and most people report that this happens. But I'm afraid that once the thing is loose it is prone to re-injury no matter how careful you are. This is part of the fun of training, and even more a part of the fun of being a biped. Sorry. You'll learn to manage it like the rest of us have.

[Tuesday]

It might be SI joint pain, true, but it might also be pain from a tight piriformis. An easy fix for the later is to feel around in the middle of the area where it hurts for a place that's painfully sensitive to pressure. Massage or hold firm pressure on that tender spot with a knuckle, tennis ball, or your girlfriend's elbow every day for a few minutes a couple times a day until the pain subsides.

[Mark Rippetoe]

But what if it's a tight obturator? Or one of the gemellus muscles? Piriformis is one of these diagnoses that get made by PTs and orthopods after a CME exposure to the idea that it explains weird hip pain. I have seen 4 or 5 "cases" of piriformis syndrome within a couple of weeks out of the same doctor's office here in The Falls. I am, uh, suspect of this diagnosis in most cases.

[Tuesday]

I may be wrong, but doesn't piriformis syndrome involve the piriformis irritating the sciatic nerve, usually from the pretty common situation where part of the sciatic nerve passes through the piriformis? And doesn't it usually present as leg pain or numbness for that reason? If that's what piriformis syndrome is, piriformis syndrome is not at all what I intended to suggest.

You're right, there is a bunch of muscles in that area with a similar insertion and function, but the piriformis' origin is right where Stuffed Olive's pain is, and not only do the gemellus muscles and the obturator internus originate more laterally, they also don't really overlap other muscles or share their attachments, plus their innervation seems to be pretty clean (obturator internus and gemellus superior together, quadratus femoris and gemellus inferor together, and piriformis on its own). If the problem were the lateral rotators you mentioned, I think the pain would be more local to the muscles themselves--i.e. toward the other end of the piriformis--but it certainly couldn't hurt to check them as well since they're pretty accessible there along the edge of the glute max, especially if the leg is rotated medially.

Even so, it might not be any of the lateral rotators and could still be muscular. Glute max tightness could cause a pain pattern a little more diffuse than what Stuffed Olive reported, but in the same place, since that muscle's origin is much more broad, and the tender spot would probably be a little inferior and lateral to the tender spot for the piriformis.

Anyway, I figure the ART/MFR/trigger point/self-massage stuff is one of those "can't hurt to try" things since, if you do it yourself, it doesn't cost anything, takes next to no time to do, and shows improvement immediately if the problem is muscular (and if you find the right spot). And if it works, I think it's far better than the alternative of simply accepting that you'll be in pain. The problem seems to be that because, like chiropractic, though it works for some stuff, the science behind it isn't all that great, and so some people think they can hang all sorts of hippie crystal gripping nonsense on it.

[TravisRussellDC]

From a purely biomechanical standpoint, it's virtually impossible to have an SI joint problem without piriformis involvement. After all, the piriformis originates from the anterior surface of the sacrum. With the sacrum being half of the SI joint, it stands to reason that there will be either stretching or shortening of the muscles which attach to it. However, that doesn't mean that the piriformis is the cause of the problem. Could it be a pain generator? Sure. But I doubt it's the root cause of the problem.

Also, in the picture where you circled the area of pain, what muscles are there? The lumbar fascia comes up out of the ilium and the glutes will attach superior and lateral to the circled area. But there aren't any muscles that cross the SI joint itself. And it's worth mentioning that the SI joint ligaments are the strongest ligaments in the body. Cadaver testing used axial compression in an attempt to tear the ligaments and the result was that the sacral ala fractured first. The point: SI joint sprain/strain is extremely rare and unless you're a pregnant woman with extra relaxin hormone floating around your system, or unless you demonstrate significant joint hypermobility, I would seriously question the diagnosis of a muscle strain.

More often than not, SI joint pain is a symptom of joint fixation as a compensation for abnormal sacral rotation and motion. Many times, correct training of movement patterns will resolve the problem (about 80% of the time). And sometimes the joints need a little help. Being a chiropractor by trade, I would suggest an exam on the area with some adjustment of the sacrum, ilium and associated lumbar areas, and train the area properly/bilaterally (this includes deadlifts, don't try and get out of them).

[Stuffed Olive]

Thank you very much for your replies but a few things have occured over the past few days.

Wednesday this week the problem seemed to escalate, completely unexpectedly, with pains down the left leg. I have a friend who suffers from sciatica so I know of the symptoms and that's what it seemed like (although not very serious, pain quite mild).

Naturally being worried (and having been making what seemed to be successful recovery from injury for over a month) I booked to see a chiropractic today. He said I have a very visible imbalance towards the right side and that he thinks I may have a disc bulge, although minor. He said no sport for 6-8 weeks but I should recover fully, and I go back twice next week.

This has been quite unexpected as the pain there felt simply like a stretch and I could run and play sport without any serious problems, and my doctor advised me to do so saying 'back problems last longer the more you think about them.' In retrospect this seems like bad advice - but I can't pinpoint anything in the past week or two that caused this (no sudden debilitating pain), with exception to soccer on the weekend (sun+sat), although I felt fine on monday.

If this is a herniated disc then I am glad it is only minor - and 2/3 months wouldn't be too terrible a price to pay. I wasn't surprised to hear that my chiropractic advised against squats and deadlifts permanently saying they are 'stupid exercises' ' - most medical professionals seem to condemn them so. I said with correct form surely they are effective and he did seem to agree - just saying they are 'unnecessary' because of the risk.

I've not had a scan but the pains in the left leg do suggest sciatica, and there doesnt seem to be anything else that could cause the pain except a disc. Could an SI-joint problem also cause this? I read it can cause pain in the leg mistaken for sciatica. At the moment the pain is mostly in the hamstrings and is fairly uncomfortable - but nothing debilitating (like 3/4 out of 10 on pain scale - I've heard it can be quite terrible).

I'm still keen to lift in the future and that includes squats and deadlifts - but it seems I'm going to have to wait a while if this is a disc injury. And I think thanks to poor diagnosis initially this problem has arisen.

Sorry for the long-winded post. Any thoughts or maybe words of encouragement? (I'm gonna need 'em)

[TravisRussellDC]

If you are simply experiencing pain down the back of the hamstring then I doubt it is true sciatica. The more common presentation of sciatic nerve impingement is a sharp, shooting, lightning like pain down the back of the hamstring, crossing the knee, down the calf and sometimes into the foot. Numbness and tingling, or the feeling of your leg falling asleep is also textbook of nerve impingement.

Tell me, do you experience pain while performing the Valsalva maneuver? How about when you cough or sneeze? When you increase the intra thecal pressure the disc is compressed. So if there is a disc herniation then an exacerbation of symptoms is likely. Just because there is antalgic posutre (leaning aways from the pain) doesn't always mean there is disc involvement.

Think about this, the hamstrings connect to the sacrotuberous ligament which connects the sacrum to the ischial tuberosity of the pelvis. The sacrum articulates with the ilium in the area where you circled your pain in the diagram.

Without more information from the physical exam, and using only what you've written here, it does not sound like a disc issue. I'm not saying that it's not. There is way too much information missing in your description to say for sure. But, SI joint dysfunction caused by a rotation of the sacrum with change the resting length of the hamstrings. SI joint syndrom can sometimes mimic sciatica if it is not properly investigated.

As far as what caused it, if you're imprperly loading the hamstrings due to dysfunction in the SI joint, then you're going to experience pain. Also keep in mind that the most pain experienced from acute inflammation is on the 2nd-3rd day. So if you played soccer on the weekend, you may not have noticed a great deal of pain until Tuesday or Wednesday.

Good luck with your treatment.

[Stuffed Olive]

Thank you for your replies! I posted my last reply before I saw the last two posts (Travis and Tuesday's). I did read them yesterday but did not have a chance to make a full response.

So originally Mark thought it could be SI-joint pain, but Tuesday and Travis also think that it could be from the piriformis, or a combination of the two? And my chiropractic now seems to think it is a disc bulge. Obviously he has inspected the injury (albeit no scan and he never said he was 100% sure, just that he doesn't see anything else causing the symptoms) - so is there a case for a joint/muscular problem?

Tuesday says that piriformis syndrome can 'involve the piriformis irritating the sciatic nerve' which would account for the mild sciatica I am experiencing. And as Travis says, SI-joint problems come hand in hand with piriformis problems. I've taken a picture of my lower back this time to try and give a better idea of where the pain is originating from (apologies for the shot, kinda had to lower pants to get a full picture):

http://img8.imageshack.us/my.php?ima...rbackpoint.jpg
http://img8.imageshack.us/my.php?ima...ckcircledp.jpg

I have read about piriformis syndrome and am unsure what to make of it – I don’t want to try stretches to self-diagnose and make the problem worse, and I don’t know if I could trust my judgement in any case. One of the major aspects seems to be pain in the buttock, and I think there is certainly an element of that in my case.

I'm still very puzzled as to how I could have damaged a disc. If it was the original injury quite some time ago, would it not have been evident (I never had any sciatica before wednesday this week - although I read disc injuries do not always cause it); the original injury itself was not something sudden, it was more a gradual thing over 2 or 3 days. Or could the original injury have caused some minor trauma to the disc? If so would it have taken so long to start bulging into a nerve, as a result of wear and tear from playing sports and the excessive stretching condoned by a doctor? This is considering I had been exercising (but no weights) for quite a while before the events of wednesday, the only problem being a 'stretch' in the left hand side just above the buttock that I originally complained about – I had been conscious of some sort of problem in the left hand side for some time.

Again this wednesday there was no sudden pain in the back - I woke up and something did not feel quite right, and by the middle of the day I had clear signs of sciatica in the left leg. Is it more likely I have aggravated the piriformis which is resulting in my symptoms? I think this really culminates in whether I should question the chiropractic’s judgement. Could he have got it wrong or am I being too idealistic that it's not a disc?

I see the chiropractic this coming tuesday – should I ask him about this condition and perhaps request a scan? Although I hear scans are often not very clear cut. As for my sciatica it has been getting rather painful, but when I woke up this morning I didn't feel it - and I have just lied down for about half an hour now and currently sitting, it feels fine.

Thank you hugely for your responses

[Jay Cohen]

To the OP;

You're getting some great high quality advice, most of which is way over my head. My only two cents would be to suggest an MRI, IF you have health coverage, as they are pricey.

I was having some radiating pain(down the leg) a few years ago, did twelve weeks of therapy for Quad/Ham imbalance, end of sessions, pain still there. Went to another Ortho Pod, who couldn't believe the therapy prescribed, sent me for an MRI of lower back, showed "slight" compresson of L 3 4 5, prescribed Celebrex (only 4 weeks), which reduced the inflamation, I also worked on some decompression excersises, 6 weeks later-No Pain- and that was three years ago.

I do try to get a quality Deep Tissue massage every other month and catch a yoga class every so often, plus I gave up LSD running(that shit will kill ya).

Good luck, hope everything works out for you.