Rehabilitation Case

Presentation
Marissa Robles

History of Injury
Reoccurring injury
5 years earlier, L4-L5 and L5-S1 herniation
Both retracted

Description of Injury
Caused by repetitive overuse
Pitcher

Herniated disc on the right side

L5-S1

Began as back strain

Then hamstring strain
Sciatica
Unable to ADL
Inability to fully extend knees and it began to hurt to
walk, we referred

Description of injury
Injured Tissues:
Fibrocartilage
Indirectly injured: Skeletal striated muscle and
nervous tissue

Indirectly affected tissues:

Weak Core
Tight hamstrings
Tight back muscles
Sciatic
Numbness, tingling, sharp shooting pain

MRI showed herniated disc at L5-S1

Pre-disposing Factors
History of 2 previous herniated disc
Immediate family Hx. of disc herniation

Genetics
Ectomorph: lean body build

ADL
Excessive weight lifting
Repetitive motion

About herniated disc

Populations commonly affected
35-55 Years old
More men than Women
Usually Lower back
Top 3 Causes
Weight
Aging
Heavy lifting

Top 3 Pre-disposing Factors

Genetics
Weight
Occupation

Mechanism Of Injury
Not ONE specific Mechanism
Caused by overuse
Pitching motion: Trunk flexion
Weights: Heavy Lifting
Axial load causing repeated stress to the lumbosacral joint

5 Years ago

MRI

L4-L5 and L5-S1 herniation

Current

L4-L5 retracted
L5-S1 herniation worse

Dermatomes cause sensation to

radiating areas.
L5-S1
Patient said he could feel a pulling
under his butt and pulling in his
hamstring
Can be seen that this would be an
accurate radiating area for pain.

Non-Surgical Methods
Epidural Steroid Injection
Out patient procedure
Medication is injected in the epidural space
Corticosteroid and anesthetic numbing agent

Pt. has had 2 epidurals

First: relieved pain until the herniated disc retracted
Second: Took about 2-3 days to completely numb the pain and
only lasted about 4 weeks

Epidural Injection Animation

Response Phase
(Inflammatory)

Modalities
Decrease inflammation
Hivamat, NormaTec, Manual massage

Pharmacological Interventions
NSAIDS

Precautions
Based off of patients pain scale

Contraindications
Axial Load
Squats and Lunges
Hip and Knee Full Extension

Response Phase
(Continued)

List 3 general goals for this phase

1. Remove from baseball practice and games

2. Core Exercises
Ex: Hip Dips, Bridges, Physioball exercises
No leg extensions
Focus on strengthening Serratus Anterior

3. Lower body stretch (Increasing ROM)

Prevent Sciatica
Floss

Repair Phase
(Fibroblastic)

Modalities
Repair strained tissues
Ex: Cryo/thermo stim

Pharmacological Interventions
NSAIDs
Dose pack/ Additional Epidural if needed

Precautions
Sciatica
Hamstring Pulling
Pain Management

Contraindications
Axial loading
Heavy weights

Repair Phase
(Continued)

List general goals for this phase

1. Leg Extension, Full ROM
Ex: weight bearing lunges & squats

2. Core exercise
Ex: med ball exercises, ankle weights with leg extension

3. Begin jogging
Ex: pool workouts

4. Begin throwing
Ex: progressive throwing program

Remodeling Phase
(Maturation)

Modalities
Warm up
Ex: Bike
Pain management Feel good
NormaTec
Pharmacological Interventions
Dose pack/ epidural if needed
NSAID
Precautions
Sciatic
Hamstring Pulling
Reoccurring pain
Contraindications
Excessive Weight Lifting
Excessive Axial Loading
Cleans, dead lifts, overhead squats

Remodeling Phase
(Maturation)

List 3 general goals for this phase

1. Running
Ability to run/ sprint on all terrains
2. ADL
Ability to walk, work & sit for long periods of time
without Sciatica

3. Pitching
4. Being healthy long-term

Evidence Based Rehabilitation

Findings
A inexpensive and timely way to provide traction for lumbar
disc herniation with a simple pull up bar (Khani 2015)
Osteopathic manipulative medicine shows as a promising
initial treatment for chronic back pain due to disc herniation
(Bixby 2015)
Epidural injections provide long-term improvement in back
and lower extremity pain for patients with lumbar discogenic
pain (Laxmaiah 2015)
Low back pain assessment, evaluation prognosis and
management for lumbar disc herniation/ bulge protocol
(Delitto 2012)
Epidural steroid injection is a significant option for back pain
treatment arising from disc herniation (Bulent 2105)
Lumbar herniated disc the cause of radicular nerve pain
(Spiker 2014)

References
Bixby, C., Credaroli, E., Mitchell, M., Shepard, S., Merritt, E., & Bilsky, E. (2015). PreOperative Treatment For Disc Herniation: A Case Study Of Chronic Pain.
Delitto A, George SZ, Van Dillen L. Low back pain: Clinical guidelines linked to the
international classification of functioning, disability, and health from the
orthopaedic section of the American Physical Therapy Association. J Orthop Sports
Phys Ther. 2012; 42(4): A1-A57.
Khani, M., & Jahanbin, S. (2015). A Randomized Controlled Trial on the Effect of Repeated
Lumbar Traction By A Door-mounted Pull-up Bar on the Size and Symptoms of
Herniated Lumbar Disk. Neurosurgery Quarterly.
Kl, B. (2015). Lumbar Disc Herniation. Advances in Environmental Biology, 9(2), 44-49.
Manchikanti, L., Staats, P. S., Nampiaparampil, D. E., & Hirsch, J. A. (2015). What is the Role
of Epidural Injections in the Treatment of Lumbar Discogenic Pain: A Systematic
Review of Comparative Analysis with Fusion. The Korean Journal of Pain, 28(2),
75-87.
Spiker, W. R., & Lawrence, B. D. (2014). Lumbar Disc Herniation. In Spine Surgery Basics (pp. 203-214).
Springer Berlin Heidelberg.