[MMitchell1]

#28254

Dear Dr. Corenman,
I’m hoping you can offer some advice for my situation. First, some background. I am 29yo male in otherwise good physical condition. I play tennis, football, squash and golf regularly and go to the gym once or twice per week. I have previously suffered from back pain in 2012. Unfortunately, I don’t have the details available but I was told I had a degenerative disc in the lumbar spine and this was treated with two epidural steroid injections, three months apart. This cleared up the pain, until:

– Dec 5th, 2017 The pain began after an overextended kick in a soccer match. I immediately saw an osteopath who diagnosed as a ligament strain and a probable 6-week recovery after rest and stretching.
After the initial inflammation eased, the only noticeable pain was when fully extending my right leg I would feel pain in the center of the lower back.
– Mid-Feb 2018 After two months had passed, mainly with total rest and light stretches, I felt ready to play football again. Almost immediately after starting to play I felt a similar pain as I had two months previous. Upon going back to the osteopath we worked for another six weeks on strengthening core/quads and stretching hamstring/lower back.
– Late March 2018- Despite the rehab work I began to feel that the strengthening exercises were actually making the problem (most noticeable when sitting for long periods and when bending forward) worse. The pain became more constant throughout the day and even when lying down in bed.
– Mid April 2018. Decided to have an MRI scan. Findings as follows:

MRI scan of the lumbar spine.
There is mild loss of the normal lumbar lordosis.
There are degenerative changes seen at L5/S1 with a diffuse disc bulge and mild
extension into the left lateral recess with mild displacement of the left-sided
descending S1 nerve root.
Subtle associated annular tear is seen.
No foraminal narrowing and no involvement of the exiting nerve roots.
The rest of the intervertebral discs are well preserved. No other disc herniation is
seen.
The cord ends at the level of L1 and the visualised portion is normal with
unremarkable appearance of the cauda equina.

Conclusion:
There are degenerative changes seen at L5/S1 causing impingement of the thecal sac
and narrowing of the left lateral recess with mild displacement of the left-sided
descending S1 nerve root. Associated annular tear is seen. No foraminal narrowing is
seen.

– Present: Since the MRI I have seen both my regular osteopath and a physiotherapist who have both prescribed varying core strengthening exercises alongside stretches for hamstrings/quads (osteopath) and glutes (physio). However, I have not felt any benefit of these despite doing at least 30 minutes per day. If anything I feel like there might be a direct correlation between doing the exercises and an increased in discomfort in the region.

-Other: Since March I have tried to play light noncompetitive tennis (twice, for 90 mins each) and golf (twice, 9 holes, 2 hours). In both cases I have managed how I swing/move in an attempt to not cause any damage to the injury. I also go the gym several times weekly where I do some weight work in addition to my prescribed exercises. I have discussed the gym work with my osteopath and avoid any exercises which would load the spine (i mainly do dumbbell curls and bench press – with my legs on the bench to avoid any spinal arching).

I suppose in summary my two questions for you would be:

– Could the very intermittent sports listed above be impeding my recovery process? I don’t really have a major increase in pain after doing them and I’ve been working on the ‘as long as it doesn’t hurt it’s not doing any damage’ adage. If this is incorrect and I need to stop doing them entirely I will, but would appreciate any clarification you can offer?

– Having had the pain for over five months, and based on the MRI findings of one month ago, would you recommend a different method of treatment? The epidural method was effective for me in the past, as mentioned. The pain I am feeling at present is stronger and more consistent than it was in late Jan after I’d had a period of total rest (albeit the injury hadn’t actually healed).

If there’s any more information I can provide which will help you offer advice then please let me know.
Thank you very much for your time and anything at all that you can offer would be greatly appreciated.

Best,
Matt

[Donald Corenman, MD, DC]

#28259

Your disorder; “L5/S1 with a diffuse disc bulge and mild extension into the left lateral recess with mild displacement of the left-sided descending S1 nerve root” could cause lower back pain or could cause nerve pain (left S1) which could cause pain only on the left side of the lower back. Does the pain occur in the central mid-line lower back (axial pain) or does it favor the left lower back?

Your question; “Could the very intermittent sports listed above be impeding my recovery process? I don’t really have a major increase in pain after doing them and I’ve been working on the ‘as long as it doesn’t hurt it’s not doing any damage’ adage” is correct in your case. If it does not hurt while you are doing the activity and you have no “pay for it later pain”, those activities are probably OK.

“Having had the pain for over five months, and based on the MRI findings of one month ago, would you recommend a different method of treatment”? Yes. You need an epidural steroid injection (ESI) to go along with core strengthening. You may eventually be a microdiscectomy candidate.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[MMitchell1]

#28265

Dear Dr Corenman,
Thank you for your prompt and helpful feedback.
In answer to your question the pain occurs primarily (90%) in the central midline lower back. Is this a good or a bad thing, relatively speaking?
Thanks again
Matt Mitchell

[Donald Corenman, MD, DC]

#28271

Midline pain generally means that this is discogenic pain (pain generated from the disc and not the nerve or facet). This pain is somewhat harder to treat. The epidural injection would be my next treatment option.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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