Introduction and Anatomy
Cause And Diagnosis
Healing A Herniated Disc Section 1: Ergonomics, Posture and Traction
Healing A Herniated Disc Section 2: Exercises And Mobility
Healing A Herniated Disc Section 3: Nutrition And Supplementation
How Long Will It Take To Heal?
Ice And Heat
Electrical Muscle Stimulation
Introduction and Anatomy
Our lumbar spine consists of 5 vertebrae, with discs sitting in between each one acting as a shock absorber. Intervertebral discs are firmly held in place between each vertebra, and are composed of a nucleus (toothpaste-like substance in the center) surrounded by fibrous rings made of cartilage, known as the annular fibers (anulus fibrosus). These annular fibers are very tough, and the direction of the rings are designed in such a way that makes them incredibly strong.Along the entire spine is a very long, tough ligament known as the Posterior Longitudinal Ligament (PLL). It attaches to each vertebrae and serves the purpose of a) protecting the spinal cord and b) limiting the amount of spinal flexion that we can perform, essentially stopping us from bending ‘too far forward’ and causing an injury.
Terms such as bulging, herniated and slipped discs are thrown around so interchangeably that it’s hard to differentiate between them. One radiologist may use a different term to another radiologist. For the purposes of this article, let’s simplify the terminology and define the differences between different types of disc injuries that can occur.
Occurs when the disc material has gone beyond it’s normal anatomical range. In some cases, a bulging disc is actually completely normal and the person may have had a bulging disc since birth.
Occurs when the disc material has gone beyond it’s normal anatomical range, and is also accompanied with a tear in the anulus fibrosis.
A tear in the anulus fibrosus.
You may also hear a myriad of other terms such as extrusion, sequestration, rupture, protrusion, broad-based and focal, and others. We will not delve into the specific terminology here, but focus on the basic principles.
Cause And Diagnosis
Disc injuries are often caused by the following:
Constantly bending forward or slouching when seated gradually pushes the lumbar discs posteriorly until the disc is damaged. Disc injuries can also be caused by the lower back rounding so far forward that the discs cannot handle the pressure and herniate.
Just like bending too far forward can cause a disc herniation, so can bending too far backward, especially combined with a compressive load (e.g. an overhead press). This type of action can cause the vertebra to “pinch” the disc and cause a tear in the anulus.
Massive Compressive Force/Trauma
The spine, when in a neutral position, can handle a huge amount of compression. However massive compressive/kinetic forces, such as those that occur in a car accident, or a weight too great for the spine to handle can cause a disc herniation.
Twisting is one of the most deleterious activities for the spine, and in general the spine cannot handle a large amount of rotation.
Before beginning a rehabilitation program for a herniated disc, it’s important to get a diagnosis of the exact injury. Unfortunately, the only way to get an exact diagnosis is with expensive imaging techniques. Pain from a disc can be confused with a lumbar strain, and common tests such as the “straight-leg test” are not that useful – pain from a herniated disc does not always radiate into the legs (sciatica). In fact, a herniated disc may produce no pain at all (even enormous herniations)! If you suspect a disc injury, the best way to determine the exact diagnosis is to have an MRI or CT scan of the lumbar spine.
Healing A Herniated Disc Section 1: Ergonomics, Posture And Traction
• Avoid sitting for long periods and change your seated posture often and use a standing desk. Do not try and sit in a fixed “perfect posture” for hours and hours. There is no best posture for sitting down. Research suggests that constantly changing the position you sit, even with bad posture is better than trying to sit in a stiff, rigid position with good posture.
• Interrupt sitting with breaks to walk and move around.
• Avoid badly designed chairs such as managerial office chairs and car seats. These seats are designed for comfort, not health.
• Sit on an ergonomic chair such as a Herman Miller Aeron Chair that allows the height, back angle and hip angle to be adjusted. Research is beginning to show that while seated, the closer you are to being in a “lying down” position, the less stress on your discs.
• Lay down if possible (but don’t forget to move around). New workspaces are available that allow a user to lay down while they work.
Your body is constantly healing your disc injury and remodeling and replacing new cells in your body every day. If you have had a disc injury for months or years and the pain is not getting better, it is not because your body has “forgotten” about the injury; it is because the disc is being continually damaged and is not being allowed to heal. In most cases, simple lifestyle adjustments such as having correct posture are all that is needed to heal a disc injury.
• Always have a neutral spine. A quick guide to position you into neutral is to squeeze your glutes, lift your chest and then brace your abdominal muscles. Your disc injury will heal faster if you keep your spine in neutral, since the disc is not being continually damaged.
• Keep your abs braced (with about 10 percent tension) throughout the day. It will take pressure off your spine and promote better posture. Your abs may be sore for the first few days but you will quickly adapt.
• Lose excess body fat. The more body fat you have, the more compression there is on your spine. Think of excess body fat as an anchor attached to your body – fat is mainly useless tissue (except for some necessary fat needed around certain organs to survive).
Remain active as much as possible. Click here to read about the importance of movement with a herniated disc.
Traction will reduce the pressure on the intervertebral discs for a short period of time and may bring the bulging disc back into its natural position over time. If you can afford it, an inversion table is the most effective way to perform traction at-home. However, traction can also be performed by hanging on a bar or by laying over a swiss ball.
Spinal Decompression Machines
It’s unknown whether expensive spinal decompression treatments are more effective than regular traction. Most promoters of these machines have a vested interest towards patients using them. The studies behind their effectiveness are usually biased and thus hard to draw objective conclusions from.
Healing A Herniated Disc Section 2: Exercises And Mobility
In order to cure a herniated disc, the goal is to build as much muscle and strength as possible in our legs, abdomen and spinal erectors. This is why athletes tend to recover better from these types of injuries. By building more and more strength and muscle over time, there is less and less stress placed on the discs which allow them to heal completely. Some fields of athletics require specific training to prevent lower back pain. Take the spine-unfriendly sport of cycling, as an example. Professional cyclists are specifically instructed to strengthen the lower back and abdomen in addition to their training, as they need strong muscles to protect their spine from spending so much time in flexion. Olympic weightlifters also spend vast amounts of time strengthening their lower back in order to improve performance, prevent low back pain and safeguard their back against any spinal injuries.
The deadlift will build up your spinal erector muscles like no other. The spinal erectors (erector spinae) have a function of protecting the spine and strengthening them is key in resolving herniated discs and many other cases of back pain. This muscle group is so vitally important that it is almost always engaged and always supporting the spinal column. Executing a deadlift correctly will also teach you how to use a hip hinge and improve movement patterns for everyday life. If you have a set of strong spinal erectors, you will never have to worry about “throwing your back out” when picking up something off of the ground. It is important to use progressive overload to slowly build up your lower back strength over time to prevent further injury.
There is discussion over the fact that the deadlift causes too much compression of the spine and is harmful. Yes, it does compress the spine however this is a good type of compression – over time your body will adapt by thickening your bones and increasing your bone mineral density to accommodate for the increased stress on your body. If need be, the spine can always be decompressed with traction techniques afterwards.
Do not fear deadlifts! A deadlift performed with correct form, movement mechanics and a weight you can handle will be the most important exercise in rehabilitating your disc injury. The good news is that the low back responds very well to resistance training, and you may feel a lot better after just one session. The important thing to remember is to not start off with relatively heavy weights. Start light and then progress. The kettlebell deadlift should be used in the beginning stages, as the conventional barbell deadlift requires at least two large plates on either side to hold the bar up.
Read more about the deadlift and it’s role in lower back pain prevention and herniated disc treatment.
Russian Kettlebell Swing
The kettlebell swing will build muscular endurance in your lower back, glutes and hamstrings. The kettlebell swing is an excellent exercise as it can be performed with light weights and still be very effective. Ensure you are using power from your hips – you should not consciously be moving your arms to bring the kettlebell up and down.
The reverse hyperextension will build muscle in your lower back, glutes and hamstrings as well as provide a ‘pump’ to the intervertebral discs.
The weighted plank will build muscle and strength in your rectus abdominis muscles and teach you how to engage your abs isometrically. This is important as it carries over to the deadlift and everyday life. Weight plates are the ideal method of adding resistance to this exercise, and they should be placed on the lower back. Aim to hold your plank position for 30 – 60 seconds and slowly increase weight over time.
The suitcase carry will build up strength and muscle in your obliques. This movement is very simple and safe, as the spine remains in neutral.
Squats are known as the king of all exercises as they will build tremendous amounts of muscle in your legs and teach you how to squat using correct movement patterns. Like the deadlift, many people have criticized the squat for causing too much compression on the spine. By training the barbell squat and using progressive overload, the muscles involved with squatting will become stronger. Furthermore, it will train you to use correct squatting mechanics.
Make sure form is excellent, and you have very good flexibility. Progress very slowly in weight. Begin with bodyweight squats, before moving on to weighted goblet squats and then barbell squats. Different pelvic and hip bone structures means some people may be able to handle a deep squat below parallel without lower back rounding, others may be able to only go parallel. If possible, be coached by a professional weightlifting coach with herniated disc experience. Do not do quarter-squats or half-squats! If you are unable to squat deep with a weight, it means your back is not strong enough to support the load. Lower the weight until you can squat deep with no pelvis tuck.
The simple pullup will build strength in your latissimus dorsi, lower back and core.
Walking will ensure your cardiovascular system is in good condition and deliver nutrients to your injured disc faster. It will also build up endurance in your lower back muscles.
What about the transverse abdominis, mulitifidus and swiss ball exercises?
The exercises listed above allow consistent progressive overload. Exercises such as stomach vacuums and bird-dogs may help in the initial stages to build a small amount of core muscle, however they will quickly become useless and progress will stall. Focus on exercises that will consistently challenge you and build more strength. The deadlift will target the multifidus better than any bodyweight exercise. Swiss ball exercises such as swiss ball jack-knifes and swiss ball hip thrusts can, however, be a good warmup for weighted exercises.
Can I add other ab exercises?
Feel free to add other ab exercises to build core strength, however weighted planks are sufficient. You will be able to add more and more weight over time. The weighted plank allows you to keep your spine neutral, and will carry over to real world applications. A plank will teach you to contract your abs hard for a long period of time and can help tremendously with lifts such as the deadlift and squat. Weighted crunches should be avoided – they cause the lower back to round and do not carry over as well to other exercises.
Swiss ball exercises and exercises such as stomach vacuums to target the transverse abdominis (TVA) have become overrated in relation to lower back pain treatment. The TVA isn’t even attached to the spine (unlike the erector spinae and hip flexors which are worked with the above exercises), and the studies of swiss ball exercises have shown they’re not that effective at improving ‘stability’.
Aim to foam roll the following areas:
• Hip flexors
• Abductors/IT Band
• Thoracic Spine
– Use a lacrosse ball or hard foam roller to foam roll your glutes, hamstrings and chest, as these areas are dense and require more force than a standard foam roller.
– After several months, areas such as your hip flexors and calves will require more force to loosen the muscle tissue. A barbell can be used to provide an even greater myofascial release.
– Do not foam roll your lower back.
Foam roll using long, slow passes over each muscle group. Keep passing over each area until there is less pain.
Aim to stretch the following areas for 1-2 minutes:
• Hip flexors
Exercises and stretches to avoid
These stretches are a classic stretch prescribed by physical therapists that have been used for decades. Unfortunately, it causes the spine to go in deep flexion, and only masks the pain at the time by releasing feel-good hormones in the low back.
Avoid exercises and stretches that put you into deep flexion. This will push your disc bulge out and make it worse.
Twisting motions put a large amount of pressure on discs and should be avoided.
Healing A Herniated Disc Section 3: Nutrition And Supplementation
Drinking enough water is crucial. Water will help deliver nutrients to your body and aid in the healing of your disc injury.
There seems to be minimal evidence suggesting glucosamine and chondroitin may speed up the healing of a herniated disc. Since there are little to no known side effects associated with using these supplements, it is worth trying.
Fish oil is a natural anti-inflammatory and may relieve herniated disc pain and bring nutrition to joints, possibly reducing disc cartilage degeneration.
Cissus quadrangularis is a supplement claimed to improve bone healing and may apply to herniated discs. It has appeared relatively recently for commercial use and as such, little to no studies have been performed. It is unknown whether cissus quadrangularis can heal herniated discs faster.
Vitamin C assists in tissue repair and may aid recovery of a herniated disc.
How Long Will It Take To Heal?
There is a lot of misinformation on the internet claiming that bulging and herniated discs can heal fast, the most common giving time ranges anywhere from 1 week to 6 weeks. Sure, in that time frame the pain may go down – however the disc will not be fully healed. A damaged disc is not the same as a broken bone that will heal in 6 weeks. A more realistic time frame is a minimum of three months.
Bulging and herniated discs typically take a long time to heal. The discs have a very poor blood supply, and rely on movement to pump nutrients in and out of the disc.
This is further exacerbated as the person will usually:
1. Stick to old movement patterns such as constantly bending forward.
2. Have a lack of cardiovascular exercise to deliver nutrients more effectively.
3. Reduce their resistance training, causing atrophy of the spinal erectors and core muscles which will put more pressure on the intervertebral discs.
Keep in mind that the size of the herniation does not indicate how well it will heal. Having a small herniated disc does not mean it will heal faster, and there is evidence that large herniations repair faster as the body can “detect” them better.
Healing a damaged disc can be sped up by using the guide above to build strong core muscles, keeping the body’s cardiovascular system in good condition and using better posture and movement in everyday life.
Painkillers should be avoided for the simple reason that, while using them, you will have no idea if your injury is getting better or worse. You may constantly re-injure the area or make it worse without knowing, as the pain will be masked, not to mention the known harmful side effects. This applies to epidural injections as well.
Ice And Heat
There is no evidence that heat or ice speed up recovery with any injury. In fact, it was only recently proven that using ice actually cools down the targeted area! And new evidence suggests that ice may in fact delay recovery as it delays the body’s natural inflammatory response.
It is recommended to avoid using heat or ice, and to let the injury heal naturally. Inflammation is a natural response to provide as much blood and nutrition to the area as soon as possible. While it does hurt, it is necessary.
If you do decide to use heat or ice, it is best to use ice in the initial stages. An ice pack (using real ice) on the low back will relieve symptoms. The issue with heat is – while it will feel good at the time and relax your lower back muscles – will cause the area to become chronically inflamed. Injuries typically follow three stages – inflammation (stage 1), repair (stage 2) and remodelling of new tissue (stage 3). By consistently using heat, you are keeping the area inflamed and not allowing the healing to progress through to later stages.
A better alternative is to alternate heat and ice (ending with either ice or a very short turn of heat) in order to draw nutrients in and out of the area.
Electrical Muscle Stimulation
EMS is not necessary. These machines do activate and contract a muscle, but nowhere near close enough to actually produce any hypertrophy. Their only benefit is if you are bed-ridden and need electrical stimulation to keep your core muscles from atrophying.
Surgery should be considered a last resort, or if your herniated disc is damaging the cauda equina and you are losing bladder control. Surgery for a herniated disc is unnecessarily performed far too often. Doctors typically prescribe painkillers, advise patients to avoid lifting weights (allowing the spinal erectors to deteriorate) and then go ahead with surgery after 6-12 weeks if “things haven’t improved”. If a patient is lucky, they may be prescribed a short course of physiotherapy – which may help slightly at first – however usually falls short after several weeks as they are only performing bodyweight workouts or ineffective bosu ball exercises which doesn’t allow progressive overload. It’s a story seen far too often and isn’t addressing the root cause of the issue.
Also keep in mind that most operations, such as a discectomy, only solve sciatic pain and not back pain. Back pain from a herniated disc is due to inflammation and chemical irritation from the disc and nucleus pulposus. The nucleus pulposus is encased within the disc since birth – it is treated as a foreign substance if it comes into contact with the body.
Herniated discs are common and not as serious as doctors make them out to be. Even massive disc herniations have a good prognosis. Treating herniated discs with a conservative physical therapy approach usually has better outcomes because it teaches the user how to move correctly and build stronger core muscles. Surgery has many complications and is permanent.
Is surgery even effective?
Not really. The poor outcomes of surgery have even led to the terms “Failed Back Surgery Syndrome (FBSS)” and “Failed Back Syndrome (FBS)” due to how common it occurs. Even certain operations have unofficial terms related to their poor outcomes (e.g. Failed Spinal Fusion Surgery Syndrome). In most cases, surgery is only effective if you have an extremely large herniation pressing very hard on a nerve root. The outcome is good in this case since the patient will go from having severe chronic sciatica to having little or no sciatica (back pain will still remain, and in some cases will increase). Surgery for smaller disc herniations or discs that are not pressing on a nerve root typically have poor outcomes – this is because back pain from a herniated disc is caused by chemical irritation and inflammation. For emphasis: surgery on a herniated disc will usually only treat leg pain and sciatica. The main priority of back surgery is to remove pressure off the nerve before there is permanent damage to it.
In a certain percentage of cases, surgery can make things worse. Risks include:
• Permanent nerve damage and paralysis (rare)
• Excessive scar tissue buildup (common). Excessive scar tissue can press on a nerve root and cause more pain than before an operation. In turn this will usually cause permanent chronic sciatica that only risky surgical intervention is able to remove (if a surgeon is willing to operate).
• Increased back pain (common, see below)
• Re-herniation of discs (very common)
• Gradual weakening of other discs (100% certainty, see below)
Any surgery which involves removing a disc or a portion of a disc will create problems for the other intervertebral discs in the lower back. Discs act together as shock absorbers and if a section of a disc is removed, it will have less mass and function and pressure will be transferred to the other discs. It can also cause chronic back pain due to scar tissue buildup and irritation. In turn, this will gradually weaken the other discs which can cause other discs to bulge and herniate. Strengthening the spinal erectors and abdomen is the only way to prevent this occurrence.
Be cautious of surgeons and clinics who claim to have very high success rates with discectomy and other surgical procedures. They may have a high success rate according to diagnostic imaging; that is, a patient may have a better-looking MRI scan than before (regarded as surgical success) however they may be in complete agonizing pain.
The problem with surgery is that it does not address the root issue and does not aim to heal the disc – in fact, the opposite – it is the removal of a portion of the disc (discectomy) to relieve pressure off the nerve root. A fusion removes the entire disc and fuses the vertebrae together, however this limits flexibility, creates stiffness, lowers height and puts pressure on the remaining discs.
Why are doctors advising patients to avoid lifting weights with a herniated disc when its effectiveness has been well proven?
Liability reasons most likely – plain and simple. Doctors can be held responsible if a patients injury is made worse based off of their advice. The politics behind this is the main reason why this information has been lost in relation to the treatment of bulging and herniated discs. There may also be ignorance – doctors do not have the education compared to those in the field of exercise science and human biomechanics. The truth is that additional muscle has been well established to take pressure off of joints and bones, and is a primary treatment with respect to conditions such as arthritis and osteoporosis. It is no different in the case of a bulging or herniated disc – hypertrophy of the spinal erectors and abdominal muscles will reduce pressure on your discs and allow them to heal.
Be aware that chiropractic treatment has severe risks. Short, fast adjustments can make things worse. Many people have had herniated discs caused by chiropractors from badly performed movements and applying too much traction (yes, too much traction can be harmful) to the lumbar area. Other risks include destruction of nerve roots, permanent sciatica, paralysis and blood clotting. There is a real possibility of chronic, permanent pain that can be caused by chiropractic treatment that is unable to heal naturally and not even surgery or advice on this site can fix.
If you decide to go through the chiropractic route, ensure:
1. The chiropractor has a high success rate with disc injuries
2. You have an MRI/CT scan that they can view. Do not let a chiropractor “guess” your injuries – many people have regretted this decision.
• Consult with a medical professional and obtain a correct diagnosis.
• Aim to maintain a neutral spine throughout the day.
• Bend from the hips, rather than rounding your lower back.
• Begin a rehabilitation exercise program to strengthen the muscles surrounding your spine, notably the spinal erectors and muscles in your abdomen.
• Do not allow yourself to become weak due to your disc injury. Use weighted exercises, rather than bodyweight exercises, to continually build strength and muscle as they allow progressive overload.
• Do not neglect your cardiovascular system. Walking several times per week will keep your cardiovascular system in good condition, allowing nutrients to be delivered to your discs faster.
• Eat a healthy diet rich in vitamins and minerals, and drink lots of water.
• Do not stress about your herniated disc. Stress can manifest itself as lower back pain. If you follow this guide, your herniated disc will heal completely.