Tiger Woods Low Back Pain Was Destined To Return
I predicted it HERE, just after his remarkable first round at the British Open. The 3 main reasons for this are:
- A lumbar micro-discectomy does not solve the problem of low back pain.
- Healing of a lumbar disc, the most likely source of his pain, is very slow and at best incomplete. This is true even if adequate time for healing was allowed, which it was NOT.
- His lumbar disc is unable to withstand the torque and force placed upon it by his aggressive swing. In fact, his back surgery probably rendered the lumbar disc even less mechanically stable than it was prior to surgery.
Stay with me and you will understand all that you need to know about Tiger Woods’ micro-discectomy and why his pain returned. The information will also benefit anyone who is experiencing problems with back pain and sciatica.
Lumbar Micro-Discectomy: What Does It Do?
Lumbar micro-discectomy is a relatively straight forward procedure that is designed to accomplish 3 things.
- Use a small incision and microscopic instrumentation to minimize damage to the low back’s supporting structures. (Muscles, joints, ligaments, bone)
- Remove the disc herniation compressing the spinal nerve.
- Provide relief for sciatic (leg) symptoms such as pain, numbness and/or weakness.
It is also important to understand what lumbar micro-discectomy is NOT.
- It is NOT a treatment for low back pain.
- It is NOT even a guaranteed cure for sciatic pain.
- It will NOT heal a damaged lumbar disc, and may actually make it weaker and more susceptible to further degeneration.
- Scientific studies have NOT proven lumbar microdiscectomy to be superior to surgical procedures preceding it.
- It MAY NOT even be better than time and conservative care. Many, if not most, lumbar disc herniations will heal on their own. Possibly even more completely.
So....What are the Results After Having a Lumbar Micro-discectomy?
Research looking at athletes who have suffered a lumbar disc herniations show similar trends:
- Most, but not all, athletes return to competition.
- Typically, there is a decline in performance and a shortened career.
- Those who chose non-surgical treatment had outcomes very similar to those who had chosen to have a lumbar micro-discectomy.
A review of these studies, that I had published in a prior post, is shown below:
- The Spine Journal (March 2011) reported that 81% of the athletes returned to their sport for an average of 3.3 years post surgery. This study also stated that there was no difference in return to play rates between those having surgery versus those who chose to have their disc herniation treated conservatively.
- Clinical Orthopedics (July 2014) performed a review of all related studies on lumbar discectomy in elite athletes noting that at least 75% of the athletes returned to play reaching a performance level of at least 64% of pre-surgical capacity.
- A study of professional hockey players (Am J. Sports Med, 2013) looked at 87 players suffering lumbar disc herniation noting no difference in return to play between those treated surgically versus conservatively. Perhaps more important, however, is that they found a significant decrease in performance, after return to play, in all athletes suffering this injury.
As you can see, the results are acceptable, but not perfect. But, the sciatica that Tiger Woods had experienced, and that the micro-discectomy was designed to correct, is the least of his current problems.
Understand the Disc and You Understand Tiger's Dilemma
A normal lumbar disc is made up of 2 main components.
- An inner core, called the nucleus pulposus that has a very high water content and is pre-pressurized.
- An outer restraining network, called the annulus fibrosus, that is tough, compact, and somewhat more elastic than the inner core.
When each of these 2 components are healthy and doing what they were designed to do:
- The pressure from the inside of the disc (nucleus pulposus) is transferred to the outer (annular fibers). The distribution of pressure is relatively equal throughout the disc.
- The outer fibers (annulus fibrosus) tighten as the pressure is distributed. Healthy outer fibers resist buckling and provide adequate restraint of the pressure that is applied against them.
This combination of equal pressure distribution, and tightening of the outer fibers leads to the multi-directional stability that is necessary for most activities, but especially for dynamic and forceful movement.
The lumbar disc also has its own rich supply of nerves as shown on the left. These nerves completely encircle the disc and when activated signal pain. Activation of these nerves occurs in 2 ways:
- Abnormal stretch, tension, or load bearing placed upon the disc.
- Through the release of inflammatory chemicals resulting from local disc structural injury.
In most cases, these 2 mechanisms work together often resulting in a disc that is sensitized to even normal load bearing stresses. This is why postures that increase disc pressure, such as sitting, can become painful when they had never been painful before.
Tiger's Low Back: One Disc But 2 Problems
When Tiger Woods first began experiencing significant low back problems, his lumbar disc probably looked like this. It is an example of an annular tear.
- Notice the separation in the outer (annular fibers) that are supposed to be tight and compact. Their laxity leads to excessive strain.
- It is also very likely that the internal part of the disc (nucleus pulposus), discussed previously, has lost some of it’s water content. This leads to abnormal distribution of forces and pressure.
- You will also recall that inflammatory substances are released in areas of localized structural damage.
Because of these changes, a disc like this becomes sensitized to even normal loads and loses the structural integrity necessary for spinal stability. With Tiger Woods, this is compounded by the force of an elite golf swing that has been estimated to put up to 8-10 G forces upon the low back.
Once a disc has lost its water content and annular tears have developed, progressive structural changes can occur because of the asymmetry in how spinal forces are distributed. It is important to know that these can initially be asymptomatic or cause only minimal low back pain.
The diagram on the left illustrates the progressive nature of a lumbar disc injury.
- The initial stage of damage (Grade 1 and 2) is more towards the center of the disc. This is usually not painful because it has not yet reached the pain transmitting nerves (discussed earlier) that are on the outer part of the disc.
- As the annular fibers continue to weaken (Grade 3 and 4), the inner disc material migrates towards the outer part of the disc causing mechanical strain and inflammatory stimulation to the disc’s pain fibers. At this stage, back pain is the most common symptom because the larger nerves (forming the sciatic nerve) have not been compressed.
- Grade 5 damage is a complete disruption of the annular fibers. The inner disc material now compresses the spinal nerve. Sciatica is often severe. It is not uncommon at this point for the intensity of low back pain to be reduced. This is where Tiger Woods was when he had his surgery.
So, now that I’ve discussed the stages of lumbar disc injury, let me review how Tiger’s one lumbar disc causes to 2 distinct, but inter-related problems.
- Low back pain is due to the internal weakening of the lumbar disc causing abnormal load and pressure distribution, stretch and tension on pain sensitive structures and magnified by the inflammatory chemicals that are produced.
- Sciatic pain occurs when the disc has weakened to the point where a disc herniation develops and causes compression on major spinal nerves.
You will recall that the purpose of Tiger Woods’ lumbar micro-discectomy was to take the pressure off of his spinal nerve and relieve sciatic pain. This appeared to be initially successful but… what about the rest of the disc and the “other” problem of back pain?
Tiger Didn't Tank but His Low Back Did and Will Again
The physical reasons for Tiger Woods’ withdrawal from the Bridgestone Invitational were REAL and related to back pain that I had anticipated would return.
It is ridiculous to hear some pundits questioning the validity of his pain and the necessity of him withdrawing from the tournament.
But, equally ridiculous is to have surgeons and other medical experts opine that his lumbar micro-discectomy would “cure” his problem and all would be well when they should know better. Here are the straight forward reasons why.
The graphic on the right illustrates the type of lumbar disc herniation, for which Tiger Woods underwent a lumbar micro-discectomy.
- The lumbar disc “fragment” or material compressing the nerve was removed.
- This likely led to a great reduction in his sciatic pain.
- But, removing this piece of material also removed substance that is necessary to the inherent stability of the disc.
- It is also important to note that the annular tears, through which the disc extruded, are NOT repaired by this surgical procedure nor is the hydration that was lost replaced.
Recall from our above discussion that hydration, pressurization, and a strong supporting external restraining system are necessary for adequate lumbar disc stability.
To a large extent, lumbar discs and tires are very similar. (except for the hydration part)
- Each require adequate internal pressurization.
- Normal internal “pressure” can become problematic if the external support system is defective.
- Any changes in pressure distribution, level of pressurization (especially if low), or in the external support network will lead to a rough ride.
“Trimming” the outer defect on this tire may allow for temporarily smoother travel. How long it lasts depends on the health of the remaining structure and the demands of the ride.
It really isn’t that much different with a lumbar disc.
Tiger has had, and will have, a rough ride. His low back pain will remain problematic.