I get a lot of PMs about people with back pain ( upper, mid and lower). So i figured id make a short post that might give people some direction.
First, you have to know what is wrong. Im not about to try to use some magical abilities and figure out what is wrong and how bad. Some people can have severe spinal stenosis and barely have symptoms and others can have a small focal protrusion rubbing up on a nerve and they are in severe pain. Physical exam is not a really good indicator....well unless you have loss of bowel and bladder function then thats just bad...
GET AN MRI.
It should be a noncontrast MRI on a high field 1.5 of 3t magnet. DO NOT opt for an open magnet unless ur like 330lbs and cant fit in a 3t bore. The MRI will guide managment. Stop guessing...its pointless to say you have backpain so it must be a disc. An xray is not that helpful..get the MRI
COMMON ISSUES FOR BODYBUILDERS
The most common things i see in bodybuilders are disc issues, facet arthrosis, spinal stenosis and compression fractures.
Disc issues: Years of axial loading take its toll. Sometimes the disc will protrude straight back into the canal, off to one side a bit or into the neural foramen. We need to know where it is and what its doing before trying to treat. The mri report will describe it. Sometimes is a small buldge that can get smaller overtime ( natural progression) or sometimes its just completely extruded and your effed and its unlikely to decrease too much in size but sometimes it can a bit.
Facets: those things in the back that allow you to bend. Susceptible to repetitive motion and to a lesser degree axial loading. This often will cause more focal back pain with motion and less likely to cause radicular symptoms BUT THEY CAN! The facet is the back part of your neural foramen and make up part of our lateral recess so it can bang into nerve when it gets enlarged and inflammed. Sometimes perifacet cysts form and project into the canal compression nerves.
Spinal stenosis: Could be caused by many things such as a disc, facet, ligamentum flavum or epidural fat. Sometimes its even congenital. With respect to epidural fat...i bet ya didnt know that being overweight can cause spinal stenosis! Look up epidural lipamotosis.... look how narrow that canal gets from being overweight and insulin resistance.
Compression fractures: The human body can only physically support so much weight. Suddenly overcoming those limits either via trauma or sudden increase in axial loading can cause a fracture..even in young healthy guys. That can be not too significant or very bad. That why its important to know what is causing your back pain. A guy on another board had bad pain and thought it was a disc. he showed me his MRI before he saw his doctor and he had a bad T12 compresssion fracture!
Ok...GG you are boring us again...can we get to some treatments.
Rest: WTF how is that a treatment option??! Well after you have a disc herniation sometimes you get an annular tear and fluid leaks out. THis can cause a lot of pain but often over time as the disc loses hydration it will get smaller and have less mass effect on the nerves its hitting. Ok...in laymans terms... a lot of the time if you do nothing it will get better!! Guys take all types of supplements...do traction...bracing..voodoo... whatever and they think they got better because of that when many times its just the natural disc dessication and the disc got smaller on its own.
Anti-inflam meds
NSAIDS: I like aleve as a general good option. 440mg PO 2x daily with food is a good option. THis is better then advil
Selective cox2 inhib like celebrex and etoricoxib are great. Etoricoxib is my personal Nsaid of choice but its not available in the usa because of the vioxx isssues around 2004. Selective cox2 inhibs dont cause gastric issues like advil does. 60mg etoricoxib daily> 2000mg advil with respect to pain relief.
Toradol : Yea buddy! now we are getting into the fun stuff. 40mg PO x 5 days works nice for acute pain. but dont use for more then 5 days.
Oral Corticosteroids:
Things like prednisone, dexamethasone etc. These are gonna work on the very first part of the inflammatory cascade so its gonna knock out a lot of inflammation but they have sides. Dont stay on for too long...if anything just use for a few days then stop. Longer term issues can occur not just with ACTH suppression but can lead to things like avascular necrosis of the hips etc.
Injections:
Ok so you know what is wrong with your back and its not responding to oral treatments and you want to step up your game a bit... lets talk epidural
Epidurals allow for greater concentration of corticosteroids to be applied more directly to the inflammed nerve roots rather then everything going systemic, but keep in mind the meds do go systemic a bit.
If you get an injection DO NOT EVER let someone inject you blinding. I dont care how good they claim they are or what there google reviews are. You must have it done with either fluoro or ct guidance. Most pain docs use fluoro as they dont have access CT and thats fine.
Cspine: Options are interlaminar or transforaminal injection.
Interlaminar : You get injected in the back and with interlaminar the meds get everywhere about 2-3 segements above and below. The meds as you can imagine get a bit diluted because they are coating everything within a few inches. The good thing about interlaminar in the neck is you can use depo-medrol ( a particulate) and less risk of injecting into a vessel that could cause a minor side effect like paralysis and death...
Yea...im sure you can find some studies showing comparable efficacy of particulate vs non but from many people experience the particulates give great longer term effects due to delayed release
Transforaminal/peri-isthmic approach: This is basically coming in from the side-ish and putting the meds directly next to which ever nerve has the issues. you get high local concentration and often gets better results then interlaminar. But the risk here is the vessels so you cant use a particulate and instead have to use dexa or betamethasone
Lumbar:
You have interlaminar, transforaminal and caudal injections here. less risk with the transforaminal in the lumbar then cervical spine and the interlaminar approach is a layup because there is more epidural fat her. If its my back id probably opt for like 80mg depo medrol interlaminar approach first and if that didnt give adequate relief then id go transforaminal.
If the pain you have is mostly inflammatory from a disc hitting it but you dont have severe stenosis then a steroid injection could help you until the disc dessicates and therefore you could have almost perminant relief ( because disc became smaller and is no longer hitting nerve). If the disc continue to hit the nerve but there is still space then the epidural could easily give a year plus of relief and some guys get a few years if there is still space. BUT if there isnt much space and theres constant contact then you are looking at maybe 3-6 months of relief.
Traction:
It may help in some situations where its a small bulge. If is extruded or there is a large facet/lig flav component its not gonna help. That is why its important to know what is wrong first. I personally use the Saunders neck traction unit for some relief of my disc issues in my neck. Im not against it but know that my MRI has never improved from using it...only temporary relief.
Percussive massage:
Good for muscle spasms associated with nerve root irritation and not gonna fix your disc
AAS/peptides etc:
Big old NOPE. Sorry pal..whatever peptide you wanna name isnt gonna fix that big old herniated disc. And no deca isnt gonna hydrate your discs and have you grow taller.
Surgery:
Last resort but be smart...if you need it you need it. Given the conditions bodybuilder usually have the best options usually are discectomy and interbody fusion. If the posterior elements are playing a significant role then you will need a laminectomy and posterior fusion to go with it. I will personally be getting an ACDF on my cspine but right now im managing with epidural and etoricoxib but when the times comes ill get it done.
First, you have to know what is wrong. Im not about to try to use some magical abilities and figure out what is wrong and how bad. Some people can have severe spinal stenosis and barely have symptoms and others can have a small focal protrusion rubbing up on a nerve and they are in severe pain. Physical exam is not a really good indicator....well unless you have loss of bowel and bladder function then thats just bad...
GET AN MRI.
It should be a noncontrast MRI on a high field 1.5 of 3t magnet. DO NOT opt for an open magnet unless ur like 330lbs and cant fit in a 3t bore. The MRI will guide managment. Stop guessing...its pointless to say you have backpain so it must be a disc. An xray is not that helpful..get the MRI
COMMON ISSUES FOR BODYBUILDERS
The most common things i see in bodybuilders are disc issues, facet arthrosis, spinal stenosis and compression fractures.
Disc issues: Years of axial loading take its toll. Sometimes the disc will protrude straight back into the canal, off to one side a bit or into the neural foramen. We need to know where it is and what its doing before trying to treat. The mri report will describe it. Sometimes is a small buldge that can get smaller overtime ( natural progression) or sometimes its just completely extruded and your effed and its unlikely to decrease too much in size but sometimes it can a bit.
Facets: those things in the back that allow you to bend. Susceptible to repetitive motion and to a lesser degree axial loading. This often will cause more focal back pain with motion and less likely to cause radicular symptoms BUT THEY CAN! The facet is the back part of your neural foramen and make up part of our lateral recess so it can bang into nerve when it gets enlarged and inflammed. Sometimes perifacet cysts form and project into the canal compression nerves.
Spinal stenosis: Could be caused by many things such as a disc, facet, ligamentum flavum or epidural fat. Sometimes its even congenital. With respect to epidural fat...i bet ya didnt know that being overweight can cause spinal stenosis! Look up epidural lipamotosis.... look how narrow that canal gets from being overweight and insulin resistance.
Compression fractures: The human body can only physically support so much weight. Suddenly overcoming those limits either via trauma or sudden increase in axial loading can cause a fracture..even in young healthy guys. That can be not too significant or very bad. That why its important to know what is causing your back pain. A guy on another board had bad pain and thought it was a disc. he showed me his MRI before he saw his doctor and he had a bad T12 compresssion fracture!
Ok...GG you are boring us again...can we get to some treatments.
Rest: WTF how is that a treatment option??! Well after you have a disc herniation sometimes you get an annular tear and fluid leaks out. THis can cause a lot of pain but often over time as the disc loses hydration it will get smaller and have less mass effect on the nerves its hitting. Ok...in laymans terms... a lot of the time if you do nothing it will get better!! Guys take all types of supplements...do traction...bracing..voodoo... whatever and they think they got better because of that when many times its just the natural disc dessication and the disc got smaller on its own.
Anti-inflam meds
NSAIDS: I like aleve as a general good option. 440mg PO 2x daily with food is a good option. THis is better then advil
Selective cox2 inhib like celebrex and etoricoxib are great. Etoricoxib is my personal Nsaid of choice but its not available in the usa because of the vioxx isssues around 2004. Selective cox2 inhibs dont cause gastric issues like advil does. 60mg etoricoxib daily> 2000mg advil with respect to pain relief.
Toradol : Yea buddy! now we are getting into the fun stuff. 40mg PO x 5 days works nice for acute pain. but dont use for more then 5 days.
Oral Corticosteroids:
Things like prednisone, dexamethasone etc. These are gonna work on the very first part of the inflammatory cascade so its gonna knock out a lot of inflammation but they have sides. Dont stay on for too long...if anything just use for a few days then stop. Longer term issues can occur not just with ACTH suppression but can lead to things like avascular necrosis of the hips etc.
Injections:
Ok so you know what is wrong with your back and its not responding to oral treatments and you want to step up your game a bit... lets talk epidural
Epidurals allow for greater concentration of corticosteroids to be applied more directly to the inflammed nerve roots rather then everything going systemic, but keep in mind the meds do go systemic a bit.
If you get an injection DO NOT EVER let someone inject you blinding. I dont care how good they claim they are or what there google reviews are. You must have it done with either fluoro or ct guidance. Most pain docs use fluoro as they dont have access CT and thats fine.
Cspine: Options are interlaminar or transforaminal injection.
Interlaminar : You get injected in the back and with interlaminar the meds get everywhere about 2-3 segements above and below. The meds as you can imagine get a bit diluted because they are coating everything within a few inches. The good thing about interlaminar in the neck is you can use depo-medrol ( a particulate) and less risk of injecting into a vessel that could cause a minor side effect like paralysis and death...
Yea...im sure you can find some studies showing comparable efficacy of particulate vs non but from many people experience the particulates give great longer term effects due to delayed release
Transforaminal/peri-isthmic approach: This is basically coming in from the side-ish and putting the meds directly next to which ever nerve has the issues. you get high local concentration and often gets better results then interlaminar. But the risk here is the vessels so you cant use a particulate and instead have to use dexa or betamethasone
Lumbar:
You have interlaminar, transforaminal and caudal injections here. less risk with the transforaminal in the lumbar then cervical spine and the interlaminar approach is a layup because there is more epidural fat her. If its my back id probably opt for like 80mg depo medrol interlaminar approach first and if that didnt give adequate relief then id go transforaminal.
If the pain you have is mostly inflammatory from a disc hitting it but you dont have severe stenosis then a steroid injection could help you until the disc dessicates and therefore you could have almost perminant relief ( because disc became smaller and is no longer hitting nerve). If the disc continue to hit the nerve but there is still space then the epidural could easily give a year plus of relief and some guys get a few years if there is still space. BUT if there isnt much space and theres constant contact then you are looking at maybe 3-6 months of relief.
Traction:
It may help in some situations where its a small bulge. If is extruded or there is a large facet/lig flav component its not gonna help. That is why its important to know what is wrong first. I personally use the Saunders neck traction unit for some relief of my disc issues in my neck. Im not against it but know that my MRI has never improved from using it...only temporary relief.
Percussive massage:
Good for muscle spasms associated with nerve root irritation and not gonna fix your disc
AAS/peptides etc:
Big old NOPE. Sorry pal..whatever peptide you wanna name isnt gonna fix that big old herniated disc. And no deca isnt gonna hydrate your discs and have you grow taller.
Surgery:
Last resort but be smart...if you need it you need it. Given the conditions bodybuilder usually have the best options usually are discectomy and interbody fusion. If the posterior elements are playing a significant role then you will need a laminectomy and posterior fusion to go with it. I will personally be getting an ACDF on my cspine but right now im managing with epidural and etoricoxib but when the times comes ill get it done.