"Cumulative Injury Cycle": Lower back strains repetitively and won't heal

[thatdubstepsound]

Hi there, I have a strain in my lower right back (just above the illiac crest) that won’t heal. It strains anew from everyday activities several times a week: from simple tasks like lifting a small pot of water, or moving a laptop and sitting up from my floor bed setup. I have been dealing with this worsening condition for the last 3 years, but in the last 5 month it has really entered an acute phase. Since 5 months ago I have spent almost my entire day lying on the floor (with a pillow beneath my knees and a rolled towel on lower back) hoping to give my injury rest. But even so I can't go a few days without a new strain or microtear injury in the same area, starting the cycle anew. Each time the threshold for injury lowers, and the pain lasts longer.

I've seen many doctors, had xrays, physical examinations, and ultra sounds. Nothing. We’ve ruled out Sciatica, issues with the SI joint and Spinal issues. There is nothing structurally wrong. However, there seems to be alot of myofasical adhesion in the area. Scar tissue. When touching the problem area (which is approx the size of a finger tip) it feels feels rougher under the skin, and sometimes has a hardened adhesion lump where the tear happens (the tear injuries are usually Grade A to Grade B strains, around 10 - 15% of the muscle/tendon/ligament fibers by my estimate).

The exception was the initial cause, which was a very painful tear in the exact area while deadlifting 11 years ago. However, in the time since I believed the injury has healed, although it did use to ache occasionally on long walks or during exercise. 3 years ago however, it strained again while performing a 45 lb overhead press. The strain was not particularly painful nor did I notice any loss of movement or weakness, but since that day 3 years ago, I have have been stuck in this perpetual "Cumulative Injury Cycle". The myofascial adhesion weakens and tears anew again and again. At first it was weeks between strains. But now it happens every few days. Each time the threshold for a new strain gets lower. About 3 years ago it took a 5k run or lifting ~50 lbs for the problem area to strain. Today it has worsened to the point where a 15 min walk, or lifting ~10 may trigger a new strain. I've long stopped exercising completely, and have cut back my daily activity month by month, until now I am not even able to sit, walk or stand for more than 10 mins without the pain setting in and getting worse for a few hours after. The last five month has been extremely difficult for my mental and emotional health given my near incapacity to move without fear of a new strain, and near constant low level pain.

Please help me break out of this injury cycle and help the soft tissue in the area heal so I can return to a normal life.



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[physiobob]

Hi thatdubstepsound and thanks for your post. Sorry to hear you have recurrent issues with your low back area. Reading between the lines I think we can summarise as follows.

1. The initial injury was due to deadlifting 11 yrs ago. So this may or may not have been muscular or ligamentous in origin. Either way it may have cause some persistent instability in the region and XRays will not show these up. Diagnostic Ultrasounds also not perhaps that useful in this region especially if they were not dynamic scans i.e. scanning while you were moving.
2. It appears the discomfort is positional if lying with a roll under the low back (giving you some lumbar extension) and knees flexed (reduces perhaps any pull on the lumbar spine from the psoas muscle (hip flexor)
3. Overhead pressing is an aggravating factor (many movements in the lumbar area in this activity) suffice to say that the instability makes this movement problematic.
4. Moving from a bent over position, even with body-weight, and returning to an upright position is now causing issue.

The first thing to know is that PAIN is just the brain telling the conscious you that it is not happy with what you are doing. It is not related to actual tissue damage or inflammation. It is the response to signals from that area sent up to the brain saying 'Please deal with this'. If you satisfy the brain you made a change OR if you reduce the stimulus then the PAIN reduces or resolves until you again put the tissues/structures under the same 'duress'. So most commonly there are mechanical and not inflammatory reasons behind it all. And in your case it is possible that the initial injury causes some deep structure to become injured and they are not been able to repair to a point of providing the original structural stability in that location. The result of this is that other muscles and their tendons have to try to compensate and take over more of a stabilising role and once you bend forwards toward 90 degrees these become of little to no help at all. That's just the way the body is designed (it protects some structures under load in forward flexion but then cannot support those same structures under that load).

I suppose I am writing this as if I was thinking out loud and it is saying to me that perhaps you have a chronic underlying instability at a deep level (lumbar spine/ligament/even a floating rib connection). One that is perhaps always going to be there. At times certain movements cause either spasm in the supporting structures or that the support itself at times pulls the unstable area into a less than desired position triggering signals up to the brain and the brain says PAIN!!

And so what to do? Firstly you need a very hands on therapist who can work with you to finding the root cause/region, and even stimulate the aggravating movements to specifically see what is leading the chain of events to the alert signals being generated. It goes without saying that I would think about changing any gym type activity you have done for many years to a new approach. I think stopping all exercise when you are someone who likes to exercise is never a good idea. It might be that swimming, gyrotonic (perhaps especially useful for you), pilates reformer work, some forms of yoga will help you to move in a slightly unloaded fashion where you can explore those movements and directions that are the aggravating ones. And I think that is key, the therapists need to help you to depend your understanding which is not something a scan can do. Once identified you can work together on exercises that feel supportive to the movement, gradually increasing load and difficulty over time. But start small and little load as you need to get the larger muscles to stitch off in order to get the deeper structures to fire up and get working.

I hope you find some of my comments useful, even if a variation on the way you are coming at the problem. It is an issue that is totally normal within the population. 85% of working age people have back pain at some stage albeit at different times and ages.

Let us know any further insights you have along the way as it would be interesting to contribute some more.

regards