A little knowledge can be a dangerous thing…

As a physiotherapist with 15 years experience I know most back pain is nothing serious (ref). I know that severity and intensity of back pain is poorly correlated with the amount of pathology (ref). I know that most back pain resolves spontaneously regardless of the treatments and interventions used (ref). I know that imaging for back pain is not necessary for the majority and may even be harmful for some (ref). 

Yet despite knowing all of this I want to share with you how flipping scary and frightening an episode of back pain can be, and how it can screw with your mind and convince you that there is something really, really wrong even when you should know better.

This is my own personal story of an episode of severe back pain I had a few years ago. I was reminded of this recently after discussing the difficulty we have trying to reassure patients there is nothing seriously wrong when they are in pain and distress.

So a few years ago I was training in the gym as usual and had just finished my deadlift and squat session. All was going well and I thought I would finish off with a few rapid kettle bell swings. However, during the third set of these I was struck, hit, hammered with sudden, searing, stabbing pain in the left hand side of my lower back with a shooting pain flying down the back of my left leg.

I screamed like an actresses in a budget horror movie, and crumpled to the ground like a cheap suit. I lay there for a few seconds in an ugly sweaty mess dazed, confused and wondering what the hell just happened. Had someone just snuck up and stabbed me? Had I been a target of a rogue sniper attack and been shot? No blood anywhere, ok, so can’t be that then. 

So clearing snipers and psychos as a reason for my sudden pain I attempted to stand up, but WHAM immediately I was struck by another bolt of hot, sickly searing pain in my back and down my leg, I let out another squeal and down I went again. 

This happened about four or five more times before I finally managed to get to my feet, and hobbled out of the gym bent over like the hunch back of Notre Dame, whimpering and whincing with every painful step, trying as best as I could to put on a brave face in front of the other gym users looking on in a mixture of confusion and amusement.

I attempted to get into my car to drive home but try as much as I could I could just not sit in the seat and drive. I eventually had to call my wife to come and pick me up, much to her annoyance.

Once home still doubled over, still whimpering and now cursing and swearing like a drunken sailor, I spent the next few hours trying to get myself straight.

But no matter how much I tried to do this, lying on my back, front, side, getting my wife to push and pull me in all directions I just could not, the pain was all consuming and unbearably excruciating. 

Eventually I calmed myself down a little, put my physio head back on and did a self evaluation. Lumbar movement grossly restricted and painful into extension, lateral flexion, and rotation bilaterally, flexion eased symptoms. Dermatomes; no loss of sensation in lower leg. Myotomes; no loss of power in the leg or foot. Bladder and bowel; no issues. Slump test +ve for pain and restriction on the left, -ve on the right.

With my self check complete what I should have concluded was that I had an acute episode of mechanical low back pain with no sinister signs that would most likely resolve in around six to eight weeks.

However, what my psyche actually concluded was “fuck that” this amount of pain and level of disability means you have clearly suffered a massive lumbar disc herniation. In fact I bet you have probabaly suffered a huge disc explosion and have nucleus pulpous splattered all over your nerve roots like shrapnel from a bomb blast.

Now I am exaggerating a little here for comic effect, but on reflection my thoughts were not too far from this. I thought I simply must have suffered a serious structural lumbar pathology and my guess with a disc herniation.

So long story short, things eased a bit, but after four weeks of debilitating, annoying and worrying pain, and still unable to sit or stand up straight for any length of time, I rather embarrassingly talked myself into getting an MRI which I paid for privately and have shown below.

Now, as you probably guessed you can see that there is absolutely NOTHING wrong with my lumbar spine MRI! In fact its in remarkably good shape for a man my age with my level of previous of activity and life style. 

But I still had severe pain, and still unable to walk or sit for more than 10 minutes, and still had leg and buttock pain. Where was this coming from, what was the reason? I don’t know, I still don’t know. Pain is a confusing complex and worrying bitch. 

Adams Lx MRI

Adam Lx MRI 1

Looking back on this episode I can clearly see that even despite me knowing that pain and pathology are poorly correlated, and even though I had no signs of anything sinister, my thinking was just so focused on the certainty of damage as a cause for my pain, I couldn’t think of or consider anything else, that’s despite knowing what I knew.

When I reflect on how I was thinking and feeling during this time it does make me wonder if I could have been convinced by anybody that I didn’t need a scan, and that everything would be ok in a few weeks. Would I accepted someone telling just to keep moving, and give it time. Absolutely not!

This experience does highlight to me how scary pain can be, even with a good understanding of it and it’s complexities. This experience also makes me realise the incredibly difficult job we have in trying to explain and reassure people in pain that all is ok when they are scared, confused, disabled, and thinking the worst. 

If I was unable to convince myself when in pain, I wonder if I am any better in convincing others?

As always thanks for reading

Adam

PS: As suspected and predicted I made a full recovery in approximately six weeks and have not had any issues since, but I still don’t like kettle bell swings that much! 

19 thoughts on “A little knowledge can be a dangerous thing…

  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!

  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. Pingback: Worry, anxiety, and pain: musings on a flare-up - MyCuppaJo.com

  10. 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/

  11. 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?

  12. 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.

  13. 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

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