Lumbar disc herniation

Lumbar disc herniation

Mitsutoshi Hayashi

Mitsutoshi Hayashi

Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association

Lumbar disc herniation

Concept of disease

Lumbar disc herniation is the most severe cause of lower back pain. It may cause serious problems such as nerve palsies if left untreated. It occurs mainly in young people (in their 20s and 30s), but it also occurs in younger people (in their 10s) and middle-aged people (in their 40s). Be careful when numbness in the legs and sciatica have appeared severe lower back pain. Because this condition could lead to career-ending injury and differential diagnosis from other lower back pains when appearing first, the athletes should always seek medical attention.

Cause and mechanism of onset

With the application of stress to the intervertebral disk by the sport, the intervertebral disk raptures and the nucleus pulposus protrudes posteriorly from the middle.
In most cases, the annulus fibrosus of the fourth or fifth lumbar spine disc degenerates, and the nucleus pulposus may protrude behind the lumbar spine, and compresses the fourth lumbar nerve (L4), the 5th lumbar nerve (L5), and the 1st sacral nerve (root) (S1). Consequently, a variety of symptoms may develop, depending on the location of compression. The symptoms of the lower extremity are often unilateral because only either one nerve of left and right nerve of roots is often compressed. A herniation is a displacement of the nucleus pulposus from the normal position (intervertebral disc) or a lumbar disc herniation in the lower back.



Low back pain, pain during exercise (forward flexion of the trunk), numbness of the lower extremity (mainly on one side), sensory disturbances in the affected leg, and motor nerve palsies. In severe cases, dysuria and muscle atrophy of the thigh and leg may also appear with a prolonged duration.

Characteristics of pain

It is characterized by lower back and buttock pain in growth period and lower extremity pain in adults. Particularly, pain during exercise is more likely to occur during trunk anteflexion. It is more severe in lumbar spinal muscles, and the physiologic lordosis of the lumbar spine disappears and anteroposterior flexion of the trunk is limited. Differential diagnosis of lumbar spoindylolysis is characterized primarily by pain on backward bending of the trunk.

Clinical testing

The SLR test* (sciatic nerve extension) sees leg elevation to 90 degrees (Photo 1). In addition, check the area of perceptual disturbance (region, bilateral difference and level), and manual muscle testing (MMT) to check bilateral difference in strength of anterior tibial muscle (L4), extensor hallucis longus (L5), and gastrocnemius (S1) muscles, and see if there is sciatica in the buttocks.
* SLR test means Straight Leg Raising test. It is a test that the person lies supine and raises the feet upward to see if the pain is induced.

Photo 1: SLR test at a 90 degrees. It is the easiest check for sciatica, but it is necessary to distinguish athletes who simply has stiff hamstrings


Currently, MRI (Photo 2) is the least invasive method and provides an easy way to determine the location and extent of herniation. Other procedures include plain X-ray, myelography, radiculography, contrast-enhanced CT and electromyography.

Disc herniation MRI

Photo 2: MRI shows lumbar spine degeneration of the fourth and fifth disc with darkening and prominent mild posterior herniation

Treatment and rehabilitation


Conservative treatment is the first choice. During the acute phase, rest is maintained and anti-inflammatory analgesics are administered. When the angle of the SLR is restored to 90 degrees, the patient stretches in the anteflexion position of the trunk with trunk rotation stretching with holding the knees. In addition, pelvic traction and electrotherapy could be done, and furthermore, nerve root blocks or epidural blocks could be done to inject anesthetic into the nerve if these treatments do not relieve symptoms. Surgery is indicated in severe cases that the symptoms are not relieved after at least 3 weeks of the above conservative treatment would have done. Surgery may include a Love procedure, in which the lumbar spine’s laminae are opened from the back to make hernia removed directly, and percutaneous nucleus pulposus extraction would apply these days. In younger patient with mild cases, laser burning of the nucleus pulposus may be performed.


Rehabilitation begins with trunk stretching with holding the knees after the SLR angle has returned to 90 degrees, and lower back pain has decreased. However, pain in the lower extremity may not improve with rest. Especially because the hamstrings are stiff, perform the SLR stretching of the lower extremity with the knee flexed while avoiding developing sciatica in early rehabilitation. Restarting abdominal and back exercises should not be maximized initially, and make sure to do gradually while decreasing the frequency and avoiding painful posture. Long-term running should be done with caution because the trunk swaying may irritate nerves and worsen symptoms. At the beginning of rehabilitation, it is desirable to use a support for lower back pain (Photo 3), and take rehabilitation period for three months as one cycle. Not surprisingly, it is important that t prompt restoration measures are more likely leads to recurrence.

Lumbar supporters

Photo 3: Support for lower back pain: Combined application of the support (corset) to protect the lumbar spine reassures when starting rehabilitation or returning to competition.

Typical example

A 26-year-old man was selected for a member of the national volleyball team in Japan after 4 months of league matches. However, strong lower back pain, right inferior limb pain, SLR of 45 degrees, minus 40 cm in standing position bending forward and a limitation in range of motion of the trunk were observed obviously at the medical check. There was decreased sensation of the lateral side of the right leg, with weakness of the extensor hallucis longus (Manual Muscle Testing 4, called MMT4). MRI showed a change (blackening) due to degeneration of the lumbar spine of the fourth and fifth intervertebral disc and slight herniation protrusion. Rest with conservative treatment (with above rehabilitation) was immediately started, and the patient was able to return to the competition about 4 months later.

Yoshizumi Iwasaki

Yoshizumi Iwasaki

NATA certified athletic trainers, certified athletic trainers from the Japan Physical Education Association, and chairman of the Japan Core Conditioning Association (JCCA)

Trainer’s Edition


The advent of MRI has completely changed diagnostic approach of disc herniation (see Table 1). There used to be many sports instructors who had decided prematurely that their athletes must have had “hernia” or “sciatica” if they had had lower back pain and were unable to perform supine SLR test. In fact, in the era when MMT (manual muscle test) was the mainstream method of initial diagnosis, it is true that hernia was hard to diagnose and therefore heavily dependent on the doctor’s intuition. There seem to be cases in which some instructors decide prematurely that it must be hernia based on their past experiences.

Table 1: Typical complaints

In addition, some advisors believe that a hernia that really jumps out (without discriminating between a protruding and a prolapsing type) should only be treated by surgery. However, conservative treatment (treatment without surgery) has recently resulted in many cures. In some cases, large hernias have been reported to be better absorbed and healed. Refer to the Medical Edition for more information.
The mechanism by which disk herniation occurs is understood, but why some people do not get it is not well understood. Some athletes with severe symptoms may be forced to retire. Be sure to maintain your body so that you do not accumulate fatigue. Be sure to eat and sleep, as well as perform after-exercise care. A delicate balance of exercise, nutrition, and rest is essential to creating a tough, smooth body.

On-site evaluation and first aid

As a rule, all suspect sports situations should be reported to a team doctor or transferred to a medical institution, especially all injuries that include deformities, swelling, discoloration, warmth, and severe pain. However, people with low back pain should seek medical attention if they have extreme limitations or numbness.


Some parts of conservative treatment include physical therapy, but the type of reconditioning that is commonly used in the process of return after low back pain, such as disc herniation, includes the items listed in Table 3.
If any type is used incorrectly, there is a risk of recurrence. If this is done, consult with a specialist, PT, trainer, etc. if it is to be used instead of relying on the patient's symptoms.

Table 3 Reconditioning types

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