What is a herniated or ruptured disk?
A herniated or ruptured disk is an intervertebral disk that has bulged out from its proper place in the back. Disks are small, rubbery cushions between the vertebral bodies that keep the spine flexible and act as shock absorbers. The intervertebral disks are made of tough, circular fibers surrounding a jelly-like nucleus.
When disks are damaged, the jelly nucleus may bulge out of place. A herniated disk alone may not cause discomfort, but pain occurs when pressure is put on a nerve root passing by the disk, or on the spinal cord.
If a herniated disk compresses a nerve, symptoms may occur in different parts of the body, depending on the areas innervated by this nerve. It is useful to be familiar with some of the medical terms that your doctor may use when talking to you about back issues. For example, the vertebral bodies are named according to their localization: vertebral bodies of the cervical spine (the delicate top part of the spine) are named “C”, those of the lumbar spine (lower back) are named “L”, and the sacrum (at the base of the spine) is named “S”.
Typical localizations of disk herniations are:
- between C5 and C6 or C6 and C7 in the cervical spine
- between L4 and L5 or L5 and S1 in the lumbar spine
Disk herniations in the upper and middle back (thoracic spine, “TH”) are very rare, accounting for less than 1% of all cases. Pain in the thoracic spine is more likely to be caused by “blocks” of the vertebral bodies and ribs, or by muscle dysfunction.
How can it occur?
A disk herniation usually involves age-related degeneration of the disk. In younger dancers it can be caused by trauma or a sudden strenuous action, such as lifting a heavy weight or twisting violently.
Muscle dysfunction can seriously affect core stabilization and muscle tension in the back and plays an important role with such accidents. A disc herniation would be very unlikely to happen in a totally relaxed back. Cramps of the deep spine muscles and the psoas can put immense pressure on the spine, so that even a healthy disk could rupture with an unlucky movement.
Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with low back issues in dancers. It can affect the lumbar spine in many ways as it connects to four of the lumbar vertebrae in two different planes. Psoas dysfunction will pull the lumbar vertebrae forward, creating hyper lordosis (over arching of the spine) and will exert high pressure on the intervertebral disks and joints. Usually, only one of the two psoas muscles is tight and this will twist and torque both the lumbar spine and the pelvis. As a result, muscle dysfunction will extend toward the trunk (erector spinae muscle, quadratus lumborum muscle) and the lower extremity (rectus femoris muscle, hamstrings), causing severe muscle dysbalance. It is often mutually dependent on a weakness of the abdominal muscles and the glutes. This pattern of imbalance creates joint dysfunction, particularly at the lumbar spine, the si-joints and the hip joint.
What are the typical symptoms of a disk herniation?
Symptoms vary greatly, depending on the localization of the herniated disc. A herniated disc in the neck may cause stiffness and pain in the neck as well as symptoms in the shoulders, arms or chest. A herniated disc in the lower back may cause low back pain but may also cause pain in the buttock and down the leg to the ankle or foot. Numbness, tingling or weaknesses in the arms or legs are symptoms usually related to more severe disk herniations.
How can a herniated disk be diagnosed?
Your doctor will examine your spine and review your symptoms as well as your current training activities. This will include a functional examination of the spine and pelvis to find out about “blocks” in the different areas of the spine and the pelvic joints. He will check for muscle dysfunction of the back muscles and also on the extremies (legs and arms). Some basic neurological tests will be performed to find out if typical reflexes are normal and if any muscle weakness or palsy is present.
Your doctor may order X-rays to get an overview of the anatomy of your spine, especially if you have a scoliosis. X-rays will also be helpful to see deformations and degenerative changes. He may specifically search for osteochondrosis and alignment problems of the vertebral bodies referred to as spondylolisthesis. If any neurological symptoms or a severe radiating pain to the arms or legs is present, he may order an MRI scan. An MRI scan will show all the soft tissues of the back, whereas the intervertebral disks and the spinal nerves will be of particular interest. An MRI could also reveal bony stress reactions of the spine that cannot be seen on X-ray.
This MRI scan of the lumbar spine shows a disk herniation between the fourth and fifth lumbar vertebrae. Liquids appear white in this picture. You can easily notice that the intervertebral disk marked “healthy disk” contains more liquid than the herniated disk, which is plain black.
What treatment options are there?
In most cases, treatment without surgery will be successful. If you have severe or constant back pain or pain radiating to your arms or legs, you should take a break from your ballet training. Ignoring the pain can have serious consequences, as the situation will get more and more complicated the longer you continue your training under pain. First aid of acute back pain includes taking a painkiller and resting in a comfortable position. A pillow under your knees may help when lying down. It is also recommended to apply warmth to the affected area, as it will help to alleviate muscle cramps. If you experience acute pain radiating to your arms or legs, your doctor may consider giving a steroid injection to the affected nerve root to control pain and inflammation. X-ray controlled injections to the spine are a very save option to deposit the steroid at the exact location needed.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine.
Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run. Surgery may be recommended if a herniated disc causes significant pain radiating into the leg, significant leg weakness, or loss of bladder or bowel control.
You have severe or lasting back pain and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.