Initial Discoveries & Treatment

So, there I was, in the summer of 2013, having just been diagnosed with an isthmic spondylolisthesis at L5-S1, wondering what that meant for me - how would I treat it, what would I would be able to do going forward, what were the risks for me, etc.?

My sports med doc said that though this was obviously a serious diagnosis, that it was a "stable" spondy (I had flexion/extension x-rays done to confirm it was "stable" and not experiencing excessive segmental motion) and that much of the research shows that spondy's don't tend to increase in slippage without a major trauma, so I didn't necessarily need to worry too much at this point. Now, every case is unique, and obviously the nerve was pretty compressed, but he didn't think that the nerve pain and numbness would necessarily progress unless there was a major trauma.  He thought that ultimately I should be able to return to doing the kinds of activities that I like to do assuming I could get the nerve pain calmed down.  He suggested some initial rest and some PT to see if we could calm down the nerve pain.  This seemed like a reasonable approach to take, so I stopped CrossFitting at the end of July, and went ahead and scheduled PT to begin in August.

Of course, being a research nerd and a CrossFitter, after my diagnosis and during my rest, I started scouring the net for information on the condition and what the best course of action would be beyond PT.  I wanted to know about the risks of doing CrossFit, lifting, playing sports, etc. with a spondy and degenerative disc, and whether I would make things worse.  It was (and is) hard to find great info on spondy and weightlifting, Crossfit, etc. but I did find a few posts here and there, some conflicting and some in agreement.  Mark Rippetoe, of Starting Strength fame, seems to suggest that lifting can be very helpful for those with spondy in terms of maintaining core and overall strength (obviously while maintaining strict form), and Kelly Starrett also suggests that those with spondy can continue to lift, assuming they stay primarily to "stable" category 1 movements (squats, deadlifts, push ups, pullups, etc.) as well.  So, there was some encouraging news there, but obviously disappointing in the fact that going hard with Oly movements might not be the best idea going forward.

Throughout my searches, I kept coming across info by Stuart McGill, a PhD from Waterloo, Canada, who is regarded as an expert in the field of spinal research.  He has conducted dozens of experiments to determine the effects of various types of loading on the structure of the spine and his conclusions and recommendations for improving core/spinal stiffness have been used and shared widely.  In short, McGill is a big proponent of maintaining spinal stiffness (i.e. no relative lumbar motion) in athletic endeavors (which CrossFit also prescribes in pretty much all movements) and doesn't like movements that emphasize spinal power, especially loaded flexion (think rounded back deadlifts) or repetitive flexion/extension movements like sit-ups, back extensions, toes-to-bar, knees-to-elbows, etc. due to risk of disc damage.  Now, how much of that repetitive motion disc damage applies to those with spondy is a question I don't have an answer to, but I've taken McGill's notion of spinal stiffness to heart with a vengeance, since it seems to minimize risk of further damage, and I try to apply it to all of my movements.  Indeed, I had found that many of the sit-up and back extension movements were irritating to the nerve in my case so I've stopped doing those.

As far as sports go, I did come across a few folks who have reported continuing to play their sports with spondy (most notably, Steve Nash of NBA fame) so that seemed reasonable as long as I could get the pain under control and maintain core stiffness.

With all this in mind, I moved into August of 2013 determined to decrease the pain and build up the necessary strength and skills needed to ensure that I could go back to doing what I wanted.  I began August by resting completely for a couple of weeks, and then began a formal PT program.  PT at first involved some massage and mobilization of the lower back muscles, pelvis, quadriceps and hamstrings, as well as some attempts at mobilization of the nerve itself using "flossing" technique (as described by McGill), and then we progressed into core strengthening work including bird-dogs, glute bridges, clamshells, etc.  I discovered some core weaknesses that I had despite CrossFitting 4-5 days/week (especially in the gluteus medius), and got an opportunity to really work on those.  Unfortunately, though I initially saw a bit of decrease in pain levels, it wasn't a major improvement, and I was beginning to get a bit discouraged by the lack of progress.  I continued on the path for another 5-6 weeks hoping that things would get better.

Up next: After PT

#crossfit #weightlifting #spondylolisthesis

Background & Initial Diagnosis

Hello, world.  This is my first post to this blog, and my hope in starting it is to provide some useful info to others who are in a similar situation - (aging) athletes still trying to hang on to glory despite some significant back issues.  Over the last year and a half, since I discovered I have a lumbar spondylolisthesis, I have been searching for info online about how to navigate CrossFit, weightlifting, sports and other strenuous activities with this condition, and the info has been pretty limited.  So, my hope is that those who are looking for this kind of info in the future will find this a helpful resource.

First, a little background.  I am a 40-something professional with a wonderful  family and a full-time job, and I have been active all my life.  Growing up I always played and participated in various sports - soccer, baseball, basketball, lacrosse, tennis, skiing, etc., and started lifting weights in high school.  After college, as my career interests took off, my athletic endeavors were put by the wayside a bit, but I always tried to continue training and lifting weights to maintain a base of strength and conditioning that would allow me to continue to participate in whatever physical pursuits I wanted, and also just to not suck at life in general (and, probably, so I could eat more too...but that's a separate discussion).  This waxed and waned over the years a bit, depending on what was going on in my life at the time (work, grad school, new puppy, new baby, etc.) but I have never strayed too far from some sort of athletic pursuit.

About 9 years ago, my yearning to return to competitive sports grew big enough that I could no longer ignore it, and I started playing lacrosse again in a very competitive post-collegiate club league, mostly with guys 10 years younger than me.  In order to keep up, I began training hard - lifting, running, sprinting, agility work, etc. - and it began to pay off for me.  My play improved and I got in some of the best shape of my life.  Around 2007, while searching for training info online, I accidentally discovered CrossFit, and started experimenting with it on my own.  I soon became hooked and began building my own basement and garage gym - barbell, bumper plates, rower, jump rope, squat rack, etc.  - so I could do the WOD's from the main page, and from various CrossFit affiliates who posted their WOD's online.  I mostly trained on my own, learning from countless videos and Journal articles, and supplemented my knowledge and experience with drop-ins to various boxes on my work travels.  In 2012, a new box opened up right near me, and since that time, my wife and I have become regulars in the box as we have jointly come to know the great sense of community and friendly competition that a box brings (in addition to greater levels of fitness, PR's, etc.)  I became an L1 in January of 2013 and began coaching at our box shortly thereafter.

Following the completion of the 2013 CrossFit Open and my first taste of CrossFit competition, I began to participate in the competitor training program at my box and began to increase the workload (and wear and tear on my body).  My weights increased, I hit some new PR's, and my metcons improved further.  I was enjoying the heck out of it, aside from the increased soreness.  Within a few weeks of starting the program, however, I began to experience some occasional pain and tingling down my left glute, hamstring and lower leg following my training sessions, and with extended periods of standing and walking.  Initially I thought it had to be something relatively routine - muscle strain, ligament strain, piriformis syndrome, etc. and tried various stretching and massage to alleviate the pain.  Nothing really made much difference, but since it was intermittent and I could still work out without any weakness, I plowed ahead in my training.  As the next few months wore on, the pain got increasingly worse and I began to experience numbness and tingling, and walking for any distance and standing still for more than a few minutes became painful.

After a visit with a local chiro (mainly for another orthopedic issue) and his mention that I might have a bulging disc, I began to do some research online and came across some sites like Fix Your Own Back and others, and began to try McKenzie press-ups and other exercises to see if perhaps a disc was indeed my issue.  After a couple of weeks of trying the press-ups with no change in my pain,  I figured it was probably time to get it checked out by a doc.

Following an exam, my sports medicine doc ordered up some imaging to see what was going on in my spine, and in addition to severe disc degeneration at my L5-S1 level, what the X-ray and MRI also showed was a bit unexpected:

"Bilateral spondylolysis at L5-S1 with grade 1/2 anterolisthesis of

L5 on S1 causing severe left and moderate right neural foraminal
narrowing."

In layman's terms, at some point in my life, the back half of my L5 vertebra cracked at the connection to the front half (spondylolysis) and separated from the front half, causing the front half to slip forward some 25-30% (spondylolisthesis) .  Since the disc between L5 and S1 is the only thing holding the segments together, it takes a lot of abuse and has been pretty worn down over the years.  The decrease in disc height and slip of the vertebra had resulted in a lot less space for the nerve roots that run down the legs to exit the spine.  In other words, a severely pinched L5 nerve root.  Ouch.

I was pretty surprised to see these findings on my MRI, especially since, aside from a couple of back tweaks/spasms over the years, I had never had any other back or leg symptoms and couldn't recall any big traumatic events that would have created such a break.  According to the doc, I've probably had the spondylolisthesis since I was a kid and just didn't know it.  But all kinds of questions began to flood my mind - was I only now suffering symptoms due to years of sports, CrossFit, weight lifting, etc.?  Could I have prevented it?  Would I be able to continue with CrossFit and my other activities?  What kind of treatment will I need?  Will I need surgery?

The reality is that I'll never know what caused the spondy specifically, but it's not likely I could have prevented it in any meaningful way at least in my youth.  Has weight lifting and increased levels of training made it worse?  That's hard to say.  I do believe that I probably have accelerated the wear and tear on my discs from weight training, but on the flip side, the training has made me much stronger overall and thus better able to function even with degenerative changes in my back.  Not to mention that imaging results don't always correspond exactly to symptoms, so the degeneration may not have meant much absent the spondy finding.

I have come to believe that there are mechanical aspects of movement, especially in weight lifting, that can be focused on and improved to minimize chances of causing a spondy, especially the overemphasis on lumbar (hyper)extension when setting up for lifts, and perhaps if I had known some of this earlier, I might have minimized the damage, though it's really hard to say for sure.  I don't think I hyperextended when I lifted prior to this, but since I don't have much video evidence to review it's all speculation at this point.  Anyway, it may have been invevitable in my case.  (By the way, cues such as Posterior-Pelvic Tilt, as suggested by Tony Gentlicore, and Kelly Starrett, can help address the hyperextension issue and could potentially reduce the risk of injury over the long haul.  No guarantees, but it likely couldn't hurt.)

In my next post I'll go into my initial discoveries and experiences after being diagnosed.

#crossfit #weightlifting #spondylolisthesis