Knowledge can be a dangerous thing…

As a physiotherapist with years of experience I know that most back pain is not serious (ref). I also know that the severity and intensity of back pain is poorly correlated with damage and pathology (ref). And I also know that most back pain resolves spontaneously regardless of the treatments and interventions used (ref). And that imaging for back pain is not necessary for most and may even be detrimental for some (ref).

Yet despite knowing all of this I want to show you how all this information means very little when the low back pain is your own, and how bloody difficult it is to convince anyone with back pain that they don’t need a scan, that things will get better, and that there is nothing serious to worry about.

I also want to show you how sometimes having more information isn’t always better, and how back pain can be as scary as hell and really screw with your mind, convincing you that there is something really, really wrong even when you should know better.

Ninja Assassins?

So my story of low back pain began on a Wednesday evening in May 2012. I was training after work as usual and had just finished my weekly deadlift session. All was going well and I thought I would finish off the session with a few sets of kettlebell hip swings just to fatigue the posterior chain properly.

I did the first two sets and all felt good and I thought I’d do one last set and call it a day. However, about half way through the last set I was suddenly floored with the most severe, searing and stabbing back pain I have ever felt in the left side of my lower back.

Now I’m not proud to admit that I collapsed to the floor like discarded wet rag and lay there crumpled on the ground in an ugly sweaty mess, dazed, confused and wondering what the hell just happened. My first thoughts were I must been stabbed or perhaps a target of a rogue sniper attack, had the elite manual therapists sent the assassins for me? But after a quick check I found no bullets wounds and no ninjas standing over me, so what the hell had just happened?

I finally managed to get to my feet and hobbled out of the gym, wincing and whimpering with every painful step, trying as best as I could to put on a brave face in front of the other gym users now looking on in a mixture of confusion and amusement. Once home I spent the next few hours trying to get myself together, but I was in agony and felt like I couldn’t move at all.

Self-diagnosis?

Eventually I calmed myself down and started to do my own self evaluation. My findings were…

  1. All lumbar movement grossly restricted and painful, but mostly into extension, with flexion being the most comfortable.
  2. I had no distal or neural symptoms
  3. I had no loss of sensation or power anywhere in my leg or saddle area.
  4. I had no bladder or bowel issues nor any other features of severe neural compromise

With my self assessment complete what I should have concluded was that I clearly had an acute episode of low back pain with no serious or sinister signs and that this would most likely resolve in a few days and probably take a few weeks to return back to baseline.

However, what my anxious and worried mind actually concluded was… “this amount of pain clearly means you have suffered a massive lumbar disc herniation”  and my frantic mind was NOT happy with just this oh no, it decided to go further and give me other thoughts as well…  “I bet you’ve probably suffered a massive lumbar disc explosion and now have nucleus pulpous splattered all over your nerve roots like shrapnel from a bomb blast and you will be crippled and weakened forever”

Now I am exaggerating a little here for comic effect, but honestly upon reflection my thoughts were not too far from this. I was thinking due to the severity of my pain that I must have suffered a serious structural lumbar disc pathology even though I knew I didn’t have any of the key clinical signs or symptoms.

After 2 weeks of frustrating and annoying back pain and still feeling convinced of a lumbar disc explosion, I talked myself into paying for a private MRI and consultation with a spinal surgeon for what I was convinced was going to be a surgical lumber discectomy . Even though in hindsight I can now see I was recovering and feeling better during this time, and still had no clear signs or symptoms of neural compromise!

Now thats embarrassing!

Now, the really embarrassing part, as you can see from my MRI images below there is absolutely NOTHING wrong with my lumbar spine at all, no major disc pathology, no herniation, not even a slight bulge, or any other issues, and certainly no disc explosion that I had convinced myself I had suffered.

So here I was an experienced physiotherapist with years of knowledge and training about back pain and its signs and features, its prognosis and its management, now sitting in an surgeons office after an unnecessary MRI anticipating surgery for something I should have known didn’t warrant or need it. Did I feel foolish… you bet I did and I still do!

Adams Lx MRI
Adam Lx MRI 1

However, looking back on this episode I have now learnt a lot from it, and can appreciate how all the knowledge in the world sometimes can’t replace first hand experience. As Einstein said ‘the only source of knowledge is experience’ and as the great philosopher Henry Rollins also once said ‘knowledge without mileage, is bullshit’

There is no doubt that this experience with severe acute back pain has taught me a lot, such as pain tends to cause us worry, concern, and to think the worst. Also how much of an incredibly difficult task us healthcare professionals have in trying to reassure and convince those we see who are in pain that there’s nothing seriously wrong or to worry about. I mean, if I couldn’t convince myself of this, what chance do I have in convincing my patients.

When I think about how I was feeling during this time it does make me wonder if anybody could have convinced me that I didn’t need a scan, and that everything would be ok in a few weeks, and that I just need to keep moving, and give it time. I doubt it!

Dangerous Knowledge!

However, I do also recognise that sometimes too much information can be a dangerous thing, and that perhaps my exposure to many patients over the years with severe disc injuries and issues, plus my awareness of all the worst case scenarios skewed my perception and primed me to expect the worst rather than taking a more calm and calculated look at things.

Anyway, I’m pleased to report that as predicted my back pain improved in a couple of weeks, my activity returned to normal, and I have had no further major issues issues since. Although I will be honest and say that I did associate my back issue with the kettlebell swinging, and rather foolishly I avoided any further kettlebell swings for a good while afterwards.

However, I’m pleased to report that all is now rectified and I am back to swinging those bells happily and comfortably and so far without any other further stealth ninja assassin attacks.

As always thanks for reading

Adam

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  1. Evening Adam,
    Your narrative is very thought provoking. I had a similar event about eight years ago whilst running upstairs three steps at a time and slipping where someone had scraped snow off their shoes. It was horrendous and I consider myself a Yorkshire stoic.
    After about six weeks it had started to ease a little. At 8 weeks I laid 12 cubic metres of concrete in two days and it resolved. How does that work?
    It was one of the best things that ever happened to me regarding my physio career. Learnt more in that time I think than any other.
    Bit disappointed the MRI scans don’t say The Sports Physio on them. Don’t they know who you are.
    Kind regards,
    Adrian

  2. This was fascinating to read! I’ve experienced something on the opposite end of the spectrum. I never had a notable moment of excruciating pain. I just woke up with pain in my calf one morning – 3 days after my last workout. It took several weeks (during which I continued to do modified workouts) and a scan for DVTs before I even realized the leg symptoms were coming from my back. Eventually I got some soreness in my back, but never anything near the crippling pain you experienced. I did, however, have tingling and numbness down my leg into my foot. My doctor diagnosed it as SI joint inflammation. I’ve been perfectly able to go about my daily life, with only occasional sleep disruption and mild pain during workouts or certain static positions. 3 months into this I sought a second opinion and based on assessment was told it was likely a lumbar disc issue. I was in disbelief and frankly, still am. There’s just no way I could have herniated a disc with the minor amount of pain I have. But the McKenzie press-ups and whatnot do seem to have helped as my symptoms are improving steadily, so maybe he’s right? Still very hard to believe.
    To your point on imaging, even though I am well aware that spinal imaging does not help in these cases (and I am also severely claustrophobic and hate MRIs), I *really* want an MRI. Mostly to satisfy my curiosity and know for sure what I’m dealing with. This feeling was strongest around the time I reached 6 months of symptoms and was convinced this was going to be something I’d have to live with forever. Not to mention the notion of nerve damage kind of freaks me out. But now that I’m showing signs of improvement, the urge isn’t so strong. The desire to have a label and solid “evidence” can be quite strong us scientifically minded people 🙂

  3. Hi Adam, Another wonderful blog as always, I feel I can very much sympathise as I myself have been in the exact situation ( same incident dead lifting MrI normal). I agree sometimes knowledge is to much, I use my husband (not physio but an intelligence analyst by trade) to be my logic brain when I spiral into pain. It is very hard to remain what I call objectively logical when your mind has been hijacked.

  4. Adam…I injured my back lifting a 16 kg box from a shopping trolley in the mid 90’s…so no MRI, not even an x ray…and yes, as we know, everything resolves in time, it took nearly 2 years to learn everything… and active rehab works. We will never understand pain….huge subjective melodrama..The experience does help me teach others…Great story! Thanks

  5. Great blog as always Adam.
    In hindsight what would a finding on the MRI have changed? Given that 70% go people who are Asymptomatic have findings, and positive MRI for large herniations can be managed conservatively? You had no apparent red flags, so did the MRI help?
    Similar question to Theresa, a finding of a disc herniation will in no way mean it is a causative factor. By the way it was never SI joint inflammation, calf pain and parasthesia below the knee? How did your MD explain that?

    • You’re right David even if there was something seen on the MRI nothing would have changed in regards to management, so even more reason not to get the scan, but as I said I wasn’t thinking clearly, I just had to know for sure… Looking back on this it makes me realise that I do/did associate the scan with ‘knowing’ for definite which I knew wasn’t the case, just pain really screws with your thinking!

    • David, I believe my doctor at the time said something along the lines of having calf pain and tingling was unusual for SI joint inflammation, but not unlikely because the sciatic nerve passes by it? I can’t remember exactly. And again, at the time I saw her I had almost no back pain, apart from some slight soreness right in the area of the SI joints. Even the calf pain was intermittent. None of the pain was really even enough to take Advil for. If I saw me as a patient, I’d have a hard time diagnosing that as a herniated disc too!

    • Hi Adam, great blog! (I know its a couple years old). Always enjoy reading your stuff!
      What level is the axial slide? With what looks like an obvious L5 annular tear on the saggital I can’t believe that’s L5/S1 on the axial? Out of curiousity can you clarify and if it’s not do you have the L5 axial image?
      Thanks

  6. Really compelling narrative. Had the same myself, refused an MRI out of cowardice, any Rx made it worse, 7 months later no probs. Huge learning experience for me but like you not sure what others would have said that might have made a difference to me.Could that be because I am headstrong and opinionated? There may be others with these characteristics (I couldn’t possibly comment) who react as you and I did. What about ill-informed patients or folk who are (sensibly) open to persuasion? They probably do need guidance and their pain situating. And perhaps, importantly, keeping from harm ( inappropriate beliefs, over treatment , inappropriate surgery etc)
    Great read, as always – Thanks Adam
    PS I always tell ‘disc’ patients who want an MRI – “An MRI tells you what you haven’t got, not what you have!”

    • ??? thanks for your comments Keith, and I can’t possibly think of anyone who fits the headstrong and opinionated description you mention ??
      And I love the flipping of what an MRI tells us! Gonna use that a lot, Thanks

  7. Absolutely love your blog. As a new grad it’s a breath of fresh air and I find myself constantly visiting for advice. Keep it up, we need more PTs like you to mentor younger PTs like me.
    Just wondering, from my very limited knowledge of MRIs it actually does look like you have a minor disk bulge into L5 S1 in that first MRI image no? Not that it takes away from your point.

    • A good spot Scott, a very small bulge but certainly not touching any nerve roots and who knows it that’s been there for 10 years prior to my pain??? A good eye thou mate, but what out searching for pathology on scans! Can find anything if you look hard enough ?

  8. Hahaha. I literally laughed out loud reading this.
    Even if the pain is just in your head (and it is) and we know that (which we do) it doesn’t make it any less umm.. unpleasant. It’s natural to think there’s something wrong as that’s exactly the way our brains are supposed to interpret it. A lifetime of formal education simply has no chance against a couple of billion years of evolution.
    I love your blog by the way. I posted something on our blog here http://blog.physiofirst.ch/post/136310969639/know-pain-know-gain but I feel it lacks the colour and personal experience I need to connect with my readers the way you do 🙂
    Have a great day!!
    Ash

  9. I have suffered a very similar experience in the gym, probably three times in as many years…I have never had an MRI, because I used to always feel it was a lumbar facet that locked up, resulting in muscle spasm and nerve pain……I always feel in clinic the difference between this and moderate to severe disc is that with my condition, the more I move and stretch, the more it gets better, even though at rest it may slip back…with the disc issue movement does not really seem to bring relief…..muscle relaxants and anti-inflammatories taken together can often work wonders in either condition along with a session of treatment(deep tissue massage, dry needling, manipulation etc. Every case that comes in and what can present as a similar case in two separate individuals can have two totally different outcomes after a treatment session. I do agree that the majority of cases seem present tend to come around and get better. Here is a link to a little blog on back pain I did myself. http://www.physiotherapiststralee.ie/back-pain-treatment-options-made-simple/

  10. Love this post. Just wondering if you had a list of possible causes of the pain (considering that we dont really know what happened, other than it being mechanical like you said), what would they be?

  11. HILARIOUS! I had a similar episode like that, but with neck pain. I had pins and needles down the arm and the whole hand got numb during walking. No reflex changes, no muscle changes, no dermatome pattern. Yet I also had an MRI (insurance cover that by the way) and it took me almost 8 weeks and a lot of exercise with elastic bands and with weights at the gym. That was last September, so more than an year and never had any neck, arm, symptoms since. But definitely, spine it is a scary thing. You see someone that has had knee or shoulder pain for years, and don’t care, but if you have anything radiating down the arm or the leg, you became instantly ignorant.
    Cheers ! Nice blog.

  12. Thanks for this post! Very validating for me as a PT knowing that nothing would have convinced you otherwise. Try as I might to talk patients down after a severe flare of pain it is extremely difficult to convince them not to get a scan. Most think, “oh that study is great but my pain is actually real!”
    -Emily

  13. To offer a different perspective, a friend of mine will be buried next week, because GPs and physios told him for 7 months that he should stop dramatising his back pain. Obviously just overworked muscles and he was considered way too young and active to have serious health issues. And when physio did not help, it was suddenly psychosomatic. Nope, bone cancer in his pelvis, which had spread upwards and was incurable by the time someone finally believed him and ordered an MRI. Rare, yes, but even if just 1 in a 100 patients has a serious underlying problem, that 1 person should not be sacrificed, just because the other 99 confuse pain with damage.