T Nation

Post-Herniation Hip Misalignment


#1

Could use some help, here, really at the end of my rope after 3 years of incomplete rehab - beware of wall o' text, scroll down for Cliff Notes.

Ever since I've herniated my L4/L5 disc 5 years ago, my posture worsened, leading to my torso slightly leaning to the right and thus my right shoulder sitting lower. This has put an undue amount of stress on my right SCJ (sternoclavicular joint), a symptom I haven't noticed until 6 months post-herniation.

2 years post-herniation, I badly - and partially - tore my right SCJ during a failed deadlift attempt. It's been just 315 lbs on the bar and I used to squat in the 400s for 20+ reps - so, baby weights, really.
That was 2010 - this injury was a total game changer - for the better part of a year, I couldn't even go down on a gal in missionary style let alone carry her. Running is also out of the question on account of the arms and shoulders moving too much and popping my SCJ.
For the past 3 years, I didn't do any heaving lifting, no squats, no deadlifts, no chins, no horizontal/vertical presses, no rowing variations.

For the past 3 years, prolotherapy did a lot to fix my SCJ, but the root cause still remains and is hindering my total rehab. Training my core on a daily basis provides me some temporary postural stability w.r.t. the aforementioned misalignment - which goes a long way in taking stress of my right SCJ.

CLIFF NOTES

2008: disc herniation, L4/L5, right side

since 2009:
- right hip misaligned,
- right oblique tight (re-tightens after release, such as trigger point therapy, extra-corporeal shock wave therapy etc.)
- right shoulder dipped and rolled forward
- right SCJ prominent, right clavicle not sitting correctly in manubrial notch

since 2010:
- partial SCJ tear (anterior and posterior capsules)
- total game changer w.r.t. training / (p)rehab: no squats, deadlifts, rows, chins, pressing movements, no comprehensive core training (abs pull rib cage down, rib cage pulls on SCJ ...), no intense cardio, no running
- no missionary style sex until 2012
- can't carry a gal, anymore, no matter how petite
- right SCJ prominent, right clavicle not sitting correctly in manubrial notch (worsened)
- successful prolotherapy for SCJ, but structural misalignment putting undue stress on right SCJ, interrupting the SCJ healing process time and again
- recurring trigger points in e. spinae @L4/L5
- right hip snaps when anteriorly raising right leg in extended fashion (both in laying and standing positions)
- recurring trigger points in right latissimus dorsi
- recurring trigger points in right teres minor
- my right glute tires noticeably faster than my left glute

I'm really at the end of my rope, here and have spent a lot of time and money on finding the right docs whose 'help' was mostly lackluster - since 2008.

Questions

  1. Could this be caused by some muscular imbalances / weaknesses? I'm thinking somewhere along the lines of the multifidus muscles, seeing how they atrophy scaringly after a back injury.

  2. How could / should I go about identifying the culprits?

Thanks, fellas.


#2

First of all, you get respect points for not posting this under a ghost account. To that, I tip my hat.

Yours is a complex case, to say the least. Brace yourself for the fact that no one single post from anyone will liberate you. I am going to leave a few comments in the hope that we can at least get you on the right path.

I'll put your text in "quotes" and my response below.

"Ever since I've herniated my L4/L5 disc 5 years ago..."

Just so we're on the same page, when you say "herniated L4/L5" are you in fact stating the annulus fibrosis bulged or tore? The terms 'herniated' and 'ruptured' are often used interchangeably (I've been guilty of this in the past).

However, for the sake of clarity, I now define a herniated disc as a bulge - but no tear - in the annulus fibrosis and a rupture as a tearing of the annulus fibrosis and leaking out of the nucleus pulposus.

So is your L4/5 a bulge or a tear?


"This has put an undue amount of stress on my right SCJ (sternoclavicular joint), a symptom I haven't noticed until 6 months post-herniation.

2 years post-herniation, I badly - and partially - tore my right SCJ during a failed deadlift attempt."

Sounds to me you made the all-too-common error of rushing through rehab (if you did them at all) and went straight back to bi-lateral barbell work. That injury to your L4/L5 ALTERED the way you move and inevitably manifested in the scj injury.

If anyone reads your story, hopefully they will have the wisdom to realize that barbell work, even done with good form is not the same as correct rehab. I've said this many times before in the past: just because that barbell is moving in a perfect line, it is no guarantee your body is working in ideal synchronicity.

So the next time you read an article stating that a barbell is more or less all anyone needs and that uni-lateral work is pointless...you have now learned, the hard way, just what a crock of shit this is. So do yourself a favor and ignore those authors, who are little more than bitter old men that pathetically cling to their faulty notions of strength training, as well as any of their sycophants who vomit what these fools write.

This isn't just an I-told-you-so lecture on my part. You have to genuinely accept this if you are ever going to properly rehab.


"For the past 3 years, prolotherapy did a lot to fix my SCJ, but the root cause still remains and is hindering my total rehab."

I'm no expert on prolotheray. From the studies I've read as well as the anecdotal information people have given, it appears to be hit or miss. Nice to hear you belong to the population who got good results from it.

However, you now know as well as I do that, until you resolve the underlying issues, the pain will return - regardless of the treatment protocol. This you can bank on.


"Training my core on a daily basis provides me some temporary postural stability w.r.t. the aforementioned misalignment - which goes a long way in taking stress of my right SCJ."

How do you define core training. In other words, what exercises have you been doing? If you made the common error to performing too many exercises that work on spinal flexion, you are not doing your scj issues any favors.


"...right hip misaligned..."

Have you been actively addressing this? If so, in what manner?


"...right oblique tight (re-tightens after release, such as trigger point therapy, extra-corporeal shock wave therapy etc.)"

"...recurring trigger points in right latissimus dorsi"

"...recurring trigger points in right teres minor"

"...my right glute tires noticeably faster than my left glute"

What is the one common denominator here? All on the right side - the location of the L4/5 injury.

I suspect the right side of your body is working constantly to brace your spine in an effort to prevent re-injury.

The right teres minor is most likely a result of the scj injury but I think you get my point.


I would like to know the current status of your L4/L5. Once we know that, a meticulous program that addresses correct pelvic alignment will be invaluable. Maybe, just maybe, this could be the key.

Of course, once correct pelvic alignment is achieved, you must pro-actively work on maintaining it. From there you can work on the scj issues.

Whether or not you take or leave my advice, one thing is beyond debate: you now have an incredibly small margin of error.

I honestly cannot guarantee if you'll be the same again. It's going to take luck, perseverance, discipline, and a a paradigm shift in what you think is proper and intelligent strength training. Any future re-injury will be even more difficult to recover from. So if you choose to listen to those who preach from the altar of the barbell...well, I've seen too often how such stories end...and you can no longer blame naivete.


#3

56x11, thanks for taking the time to read my post and give a thorough and well thought-out reply. Let me address your questions.

How so? :wink:

I guess it's pretty evident from my lack of training-related posts since 2010 that my once so promising lifting career must've come to a screeching halt. I'm the guy who used to do 220 lbs barbell curls for reps, squat 400+ lbs in very high rep ranges and use 1.75 bw for OHP'ing - at a sub-200 lbs bodyweight.
Who - despite still carrying an appreciable amount of muscle - wasn't able to carry his slim wife over the threshold. Now, even mundane things have become quite the obstacle. I need to kinda plan my movements in advance when getting off the bed or when pleasuring my wife. Yesterday, I went fly and wasp hunting at home and couldn't use my right arm for about 5 hours without excruciating pain. Push-ups? No way.

I'm glad you came to that conclusion: it shows your appreciation of my symptoms and possible causes. Take it from me: a lot of docs I've visited over the years didn't take my condition seriously.

That's a good question. I know for a fact that it's a herniation, at least. But ever since you can palpate something squishy under my skin around L4/L5. Even now, 5 years later.
I've had to contend with pain, leg and foot numbness and - most importantly - a severely changed gait. It appears that my right leg is shorter, but only functionally.

Again, I'm glad we're on the same page.
I haven't been doing barbell exercises for the last 2.5 years and have relied on doing unilateral exercises, only - at least for my upper body. I had also started to do unilateral leg work, albeit relying on machines, only, since I'm lacking the necessary stability to do things like pistol squats or unilateral deadlift variations.

Also, it should be noted that I had ulnar wrist surgery in december 2005 which had me wear a full cast for 4 weeks and a forearm cast for 3 weeks. And, of course, I rushed right back in doing heavy barbell exercises. Come to think of it, I didn't have noticeable structural imbalances until 2007, but ever since coming back from the wrist surgery my right side was never the same, especially strength-endurance-wise.

Prolotherapy just gives you a way to control the wound healing cascade, more specifically to restart and intensify it. Barring any congenital issues with wound healing, everybody should be able to benefit from prolotherapy. Most of the miss cases made one or several of the following mistakes:
- take NSAID and/or fish-oil and other anti-inflammatories during prolotherapy
- bad nutrition
- bad lifestyle habits / lack of sleep
- unmodified training protocol: tissue remodeling during wound healing benefits from loading and training in general, but someone having received prolotherapy for partially torn wrist ligaments shouldn't do olympic weightlifting for at least 3 months after the last prolotherapy injection
- bad injection technique: prolotherapy requires the practicioner to employ a very specific injection pattern, especially w.r.t. to the fibro-osseous junction of ligament tears
- target tissue: ligaments and tendons respond well, ditto fibrous cartilage - joint cargilage, however, not so much

My wrists are almost as good as new.
My wife's ankle, too. And a few other ankles and ACJs of people I've convinced of giving prolotherapy a shot. As I've said: it's a means to control the wound healing cascade to a certain degree and thereby to prolong wound healing which usually shuts down roundabout 6 weeks post-injury - it's no panacea.

Absolutely.

As you're well aware, core training usually puts a lot of stress on the SCJs, so I have to be careful and work into it. Not everything works, either.

Around march 2013, I've found out I couldn't pull my left into my hips in a standing position, i.e. raising my left foot about an inch off the ground, without falling over. Genius that I am, I've finally concluded that I need to address my week core muscles - especially something around my right L4/L5 area - ASAP. Due to my SCJ not having tolerated most core exercises for the better part of 2,5 years, I had neglected core training until 2013.

Here's what I'm doing:

  • pallof press (I wasn't able to do them until the beginning of 2013 - my SCJ hadn't tolerated it until then)

  • FattyFat's Crossover: stand on one leg, brace my abs, try to maintain neutral hips (both horizontally and vertically), flex my trunk to about 80 degrees (as with a bent-over row), raise one arm to the front, raise the contralateral leg to the back: initially, I did this without weights, now I'm able to do it with about 7 lbs. I've also added a chain instead of only using plates to achieve additional stability demands. As expected, this exercise consequently shows my right L4/L5 area (including multifidii and obliques) is weaker than on the left side.

  • FattyFat's hypex, which is a variation of the aforementioned FattyFat's Crossover: I'm using my 45 degree hypex bench, activate my quads, flex my abs and do hyperextensions by coiling and uncoiling my spine. During said uncoiling movement, I'm raising one arm overhead. Originally, I started with 2.5 lbs, not I'm doing like 7 lbs for multiple reps on this one.

  • FattyFat's rotational hypex, which is a variation of the aforementioned FattyFat's hypex, only I'm also twiting my trunk. I wasn't able to do this one until about a month ago.

Also, my spinal erectors and abs have become stronger and thicker since starting this routine.
Additionally, I'm doing my 'real' lifting in unilateral fashion.

  • I'm starting with the aforementioned core protocol

  • unilateral lat rows: these need a tad of explaining, since I've never seen anyone but myself doing them: using the upper pulley/cable attachment, I use a pronated grip (maximum reduction of SCJ as opposed to using a supinated grip), standing about 2 meters from the cable stack and then assume a 80 degree position (relative to my legs) with my trunk. Keeping my arms as close to my body as possible, I pull with my elbows. This is the only back exercise I'm able to do without aggravating my SCJ. It's almost all lats with negligible scapular retraction.

  • unilateral rope curls: rope + chain + plates

  • unilateral tricep push-down (upper cable)

  • unilateral lateral raises in scapular plain with swinging chain

  • unilateral shrugs, pronated grip (<-- has done a lot to keep my SCJ in a good enough position)

  • unilateral leg curls

  • unilateral leg extension

  • treadmill, 20 degree incline, sometimes steady-state cardio, sometimes 'HIIT' with a weight vest - running is no option

Only with my own core protocol. Mind you, I'd been to multiple physicians with this, to no avail.
I've even went so far as to show my wife how to dry needle my e. spinae in the L4/L5 area. She does this once a week and it helps my hip alignment for about a day.

I absolutely concur, dude. I've been knowing this for quite some time but couldn't find a doc noticing this, too.

Thing is: I don't know how to address it.

I'm not sure: my teres minor trigger points automagically vanish after dry needling my right L4/L5 e. spinae.

See above.
There was one doctor who suspects some constant irritation going on in the L4/L5 area. His opinion is that neural therapy / pain management at this area might be worth a try. That's a very recent assessment, though and I wasn't able to go about finding a practicioner for this, yet. Also, I'm sure this is only part of the solution, at best. Hence my starting this thread.

My thinking, exactly. As I've said: I know it's necessary but I don't know how to do it.

There's no need for you to sugar-coat your words, pal: I'm well aware of my incredibly small margin of error and so glad you took the time to address my issues.

I'm willing to do whatever it takes.
To give you an idea: last year, I wanted to come to Vail, Colorado to have a reconstruction surgery done on my SCJs. But both my professional and private lives intervened, let alone the costs involved (I'm living in Germany).
I'm years past any unwillingness to stop doing certain exercises - I'd be happy to be able to carry-fuck my wife, again :wink:

By the by: as much as I love T-Nation, it takes some time for my posts to appear. If it's ok by you, I'd like you to contact me via e-mail (see my profile for contact info).

Thanks, dude.


#4

Brother, I feel your pain. I've had drop foot, sciatica, and now another terrible back injury. I have been attacking myself with a lacrosse ball trying to "find" the problem.

You know your shit. So I'm going to tell you the one secret I learn last week.

Using a LAX ball, start around L3 and work your way up around T7 or so. At each vertebra, do a glute bridge (hip extension). This will stretch spinal erectors and it's kind of an ART-type motion. Keep pressure on the ball. I found a NASTY spot in my back that hurts with even tiny pressure. I bought a dental guard so I don't shatter my teeth! 3 days of doing that, my APT is noticeably better and now I can walk.

T-Nation always stresses attacking the hips with LAX ball. This is true. But DO NOT ignore the erectors. That has been bugging me for years.


#5

Thursdays are hectic for me so I just popped in between sessions to read your post.

Per your request, I'll shoot you an email. The subject line will read 56x11 so you know it's from me. I most likely won't be able to send out an email until tonight or sometime tomorrow.


#6

Email sent. Subject line: 56x11


#7

I realize you mean well. However, the OP, based on the information he provided, already has his wife perform trigger point therapy.

And even if that wasn't the case, I find it questionable if anyone in the OP's state should perform SELF Myofacial Release near a location that has a history of significant trauma. If that ball rolls just an inch (or even less) in the wrong direction and hits the location of the herniation (or rupture - we're not quite sure which), very bad things can happen very quickly.

I do agree that some sort of release work should be done along the erector spinae/multifidus. Indeed, the OP stated that it helps (albeit temporarily). I feel that some type of release work in conjunction with other protocols, which I discussed with the OP in my email, can have a synergistic effect.


#8

What he said.

njrusmc, I appreciate your input, thanks man.
I'm glad to read you've found a way to get yourself back on track, again and hope you'll get back to 100 % further down the road.