Lumbar disc herniation

Long time listener, first time poster.

I’m a 40 year old cycling enthusiast (6-8 hours per week training) and full-time GP (family doctor). I decided to get serious about my training this fall and have been enjoying building a good base over the winter that I hoped would set me up for some endurance events (Vätternrundan in Sweden being my ‘A’ event). I’ve got tight hamstrings, weak core, don’t do enough stretching etc but this winter I genuinely built more S&C work into my plan.

And then disaster struck last week. I’d had some niggling sacro-iliac pain but the pain just suddenly exploded. I lost power in my left leg so went to A&E where they thankfully ruled out cauda equina but confirmed a herniated L4/5 disc. The pain has eased quite dramatically but I’m hobbling around like an 80 year old and a return to fitness looks like a long journey indeed.

I’m planning on getting some specialist physio and throwing everything at it but wondered if anyone on here had overcome a similar injury and returned to their previous level and avoided flare ups. I’ve had lots of patients with similar injuries obviously, but very few athletes and no road cyclists (it’s quite a niche sport in the community I work in).

I know there’s no magic bullet but any tips and inspiration would be welcome. It’s hard to take too much heart from Mathieu van der Poel’s comeback from a disc injury, for example, because we have very little in common anatomically and physiologically (sadly)! Indeed, even he is struggling again now. I know an updated bike fit will be essential when the time comes for example.

Damn, sorry @davidcoleman. I tell my patients to expect 6-9 months for full recovery. Hopefully you can get back to some easy spinning soon. Check out “The Ready State” app by Kelley Starlet if you’re interested in some self physio, mobility, activation work. He has lots of stuff related to back problems. “The Foundation” by Eric Goodman is a good book resource. Good luck, Dr. Rob.

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Dear Dr. Coleman,

In the late summer/early fall of 2020 I herniated the disc at L4/L5. At first, I thought that I had hurt my hip and thigh, but quickly realized that this was something different. Once the correct diagnosis was made I was given three possible tracks:

  1. Complete conservative treatment including medication, rehab, and time.
  2. An Epidural Steroid Injection at L4/5 to help take pressure off of the nerve then followed with rehab and time.
  3. Surgical Decompression.

My symptoms improved some on their own with rest, initial rehab and time, but like you, I had residual weakness in my right leg. I was limping around like a man twice my age. (I’m 50.)

The MD I was working with and I settled on trying one Epidural Injection before resorting to surgical intervention. I was lucky. The injection didn’t make everything 100%, but it got me functional which allowed me to rehab more aggressively. Ultimately I was able to avoid surgical intervention.

As far as the bike went, I spent nearly 5 weeks completely off the bike. When I restarted, it was on the trainer only with my position completely upright. The slight forward flexion actually took pressure off my nerve and made me feel better.

The progression back to good was certainly not linear. As an MD yourself, you have watched many patients go through this pattern. I did have, and still do occasionally, have some flare ups. I manage the flare ups with rest, meds and a refocus on the same rehab exercises that helped my recovery.

As far as my level goes, I am VERY close to my pre-injury performance. I’ve discovered patience with myself and my own body. Not because I’m all zen, but because I had to.

I’m a nurse here in the United States and my friends and family know that I’m better at my job and a better dad/spouse when I can ride. I can imagine that your situation could be similar. It’s not an easy time to be in health care, though I can’t actually remember a time when it was ever easy. Lol.

Stay with it. You will get better.

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Thank you both for those kind messages. I had that sort of time frame in mind Rob so that’s reassuring, although I know everyone is different. I will look at those resources - I have time on my hands after all!

Like you William I also thought it was something else - deep gluteal/piriformis syndrome - at first. It wasn’t until I developed numbness and the weakness became more pronounced that it appeared more disc related.

I’m very much hoping to avoid a surgical path and will do everything I can to improve conservatively - fingers crossed on that.

And you’re right - riding isn’t just a hobby, it’s precious time to decompress (excuse the pun) and relax. It makes me a better person to be around too.

Thanks for the support guys. I will keep catching up on the podcasts and reading posts on here in preparation for my eventual return!


@davidcoleman, do you have a L4/5 foot drop? Do you need a brace? I wonder if physiatry could figure out a specific one for cycling?

I have a fairly good going weakness - not sure I’d call it a genuine foot drop but maybe that’s just because I don’t like the sound of that level of impairment! I can Dorsiflex the ankle (weakly), but with slightly reduced range of movement. I don’t have the power to do a single leg heel raise on the affected side, but I was weaker on that side before the injury (I had a short bout of sciatica last year which in hindsight was likely the same disc but that settled after 4-6 weeks)

Balance is ok, gait isn’t too severely affected and sensory loss in L5 dermatome is starting to improve distally. The neuropathic pain has eased and I’m managing on paracetamol and ibuprofen now, with just a little dose of amitriptyline at night.

A brace may help if I return to spinning though to avoid asymmetry further up the chain. I’m mindful the weakness could create further knee, pelvic or back issues without any modifications. Maybe an interim fit would be useful.

Hi David,
Really sorry to hear that you’ve suffered this injury.

There are a large number of factors in helping one to return from a lower back injury, as every back injury is unique. It’s a process to herniate a disc, and what you had been doing leading up to the “sudden explosion” will help to tell the story.

The treatment of lower back injuries in the general medical community tend to try to fit individuals into “bins”, as opposed to taking the time to dive into the specific injury of that one person, and to understand the mechanisms and tissues involved.

A great resource is Dr. Stuart McGill’s website, and his book “Back Mechanic”.

Hope this helps, and that you feel better soon.

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My advice following a cervical disc herniation last year is to stay positive as these sort of set backs can feel like a challenge to your identity as a cyclist. Also based on personal experience try to ignore the forum posts that you will find via random Google searches advising you to get a recumbent. :slight_smile:

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Thanks both. I’ve picked up a copy of that book actually and started reading - I haven’t got to the remedy section but it’s helped me reflect on the reasons behind this - as you said, it’s a journey rather than an isolated event. I’m very right side dominant after previous sciatica (sometimes 58:42 according to my Favero pedals) so there are a lot of repetitive asymmetric forces going on there.

I think I was also a bit overzealous with the weights and maybe not having the best form.

I’ll keep plugging on and staying positive. Pain is better and I managed a short walk today. Progress will be non linear and I’m anticipating setbacks. But as McGill says, it’s about good habits and movements for the next ten years - not just until the pain settles.

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Glad to hear you’re on the right track here, and have a good mentality on the process here.
I’m here if you find you need help beyond Back Mechanic’s guidelines.