Journal of Fractures and Sprains

Diagnosis, Treatment, and Rehabilitation of a Lumbar Herniated Disk in a Cross-Country Skier: A Case Report

Case Report | Open Access | Volume 1 | Issue 1

  • 1. Department of Exercise Sciences, Brigham Young University, USA
+ Show More - Show Less
Corresponding Authors
David O. Draper, Department of Exercise Sciences, Brigham Young University, SFH 106, Provo, UT 84602, USA, Tel: 801-995-9102

A 47-year old cross-country skier experienced continuous low back pain. It started after several years of skate skiing, an advanced technique used by cross-country skiers. It was determined that his form was less than ideal, which led to the lumbar pain. An MRI revealed a herniated disk between L3 and L4, and a bulging disk between L5 and S1. For 1 year his back was treated conservatively with core stability exercises, McKenzie extension exercises, thermal ultrasound, shortwave diathermy, TENS, massage, ice, heat, traction, epidural injections and opioid pain prescriptions. The most pain relief came from opioid medication and inversion table traction. After 1 year of using these treatments, his pain was still present. He and his physician decided to try surgery. A partial discectomy was performed to remove the herniated nucleus pulposa and take pressure off the sciatic nerve. The treatment was a success and the patient has been pain free for 12 years. He still has the bulging disk between L5 and S1, but it is asymptomatic.


Draper DO (2017) Diagnosis, Treatment, and Rehabilitation of a Lumbar Herniated Disk in a Cross-Country Skier: A Case Report. J Fract Sprains 1(1): 1002.


As we get older, degenerative changes occur in the spine. Our intervertebral disks become thinner and lose elasticity, while calcium deposits, called osteophytes, form on the vertebrae. These changes often put pressure on nerve endings, resulting in low back pain [1].

Approximately 80% of the population will experience lumbar pain at some time in their lives; of these, 90% will resolve in 2-4 weeks, but 60-80% will recur within 1 year [2]. In the workplace, low back pain is the leading cause of employee morbidity, disability, and lost productivity. Medical care is sought by 15- 20% of those with low back pain, making it the second most common reason for physician visits [3].

This paper deals with my personal experience of developing a lumbar disk herniation from using improper form while crosscountry skiing (skate style). The mechanism of injury, diagnosis, treatment and surgery are discussed.


When I was 45, I had episodes of low back pain. The pain started mid-season of the cross-country skiing season. The pain would last about 2 weeks then disappear, for 2-3 weeks, then reappear. After 13 months of dealing with the pain, an MRI was performed (Figure 1).

This MRI revealed a herniated disk between L3 and L4 and a bulging  disk between L5 and S1.

Figure 1 This MRI revealed a herniated disk between L3 and L4 and a bulging disk between L5 and S1.

The MRI revealed a herniated disk between L3 and L4 and a bulging disk between L5 and S1. These irregularities explained the buttocks pain that radiated down my right leg. Since I was asymptomatic until skiing season, I determined that the cause of the injury was improper mechanics during cross-country skiing--nothing else led to this injury.

A course of exercises, therapeutic modalities, injections and pain medicine was followed for 1 year. The exercises mainly consisted of core stability and back extension exercises, which provided only minimal pain relief. I was also instructed in correct posture techniques. Pain was most severe when sitting. To counteract this, an office chair was replaced by a Swiss ball to sit on. This required core stability and provided only minimal relief.

The therapeutic modalities consisted of ice, heat, TENS, thermal ultrasound, thermal pulsed shortwave diathermy (PSWD), massage and traction. These provided minimal relief, except for traction which provided moderate relief. Also a regimen of 3 epidural injections; separated by me month was followed. These provided moderate pain relief, however, it was short lived (would only last about 24 hours). Pain medication (opioids) was used as needed for pain, which provided only moderate relief.

After 1 year of adhering to all these treatments, I returned to my physician. It was determined that a partial discectomy would be performed. This invasive surgery involved removing the part of the disk (between L3 and L4), that was putting pressure on the sciatic nerve. Prior to the surgery, pain as an “8” on a numerical rating scale of “0” = no pain, and “10” being the worst imaginal pain. The procedure was remarkable, and resulted in complete loss of pain (a rating of “0”). I returned to full recreational activities consisting of running, biking and cross-country skiing.


The lumbar spine consists of 5 vertebrae. These vertebrae are the major support of the low back and are the largest and thickest of the vertebrae, with large spinous and transverse processes. The superior articular processes face medially, while the inferior processes face laterally. The articular processes of the superior vertebrae articulate with the articular processes of the inferior vertebrae. Movement occurs in all the lumbar vertebrae; however there is much less extension than flexion [4].

Between each of our vertebrae is an intervertebral disk that functions to resist compressive forces provide flexibility and provide adequate space between the vertebrae. The outer layer of the disk is the annulus fibrosis, a series of interlacing cross-fibers that are attached to adjacent vertebral bodies. The inner layer is the nucleus pulposus, a protein gel between the cartilaginous end plates of the vertebrae and the annulus fibrosis [1]. The nucleus pulposus is watery, and as we age, it loses fluid (from 85-90% at birth to 70% by age 70) and its normal fullness. Another cause for a disk to lose its full size and normal shape is injury. The stretched or weakened annular fibers (annulus fibrosis) can protrude from the pressure of a bulging nucleus pulpous [1].

The physician and I were pleased with the outcome, but puzzled as to the cause of the herniation. Was it normal deterioration or a recreational injury? I determined that it was improper technique during skate style cross-country skiing that caused the injury.

Cross-country skiing uses 2 main techniques, classic and skating [5] (Figure 2).

Cross-country skiing uses 2 main techniques, classic (left) and skate  (right).

Figure 2 Cross-country skiing uses 2 main techniques, classic (left) and skate (right).

Most people are familiar with the classic technique that involves keeping the skis straight and pushing off the lead leg. This technique is like running, and the poles go in the ground as the arms move in unison with the legs. Classic skiing can be performed on a groomed or non-groomed trail. A groomed trail will have 2 grooves, about 6 inches apart that are the same width as the skis. This is the most common technique. Skate skiing involves turning the tips of the skis out and pushing off the lead leg. The skier leans to the right when pushing off the right leg, and to the left when pushing off the left leg. Typically, the skier uses both poles as he or she pushes off the involved leg. Skate skiing, can only be performed on a groomed trail. The skier does not put his skis in the grooves, but skates on the smooth trail that has been groomed. Those who use both techniques state that skate skiing is not only more fun, but a harder workout than classic skiing [5].

When skate skiing, it takes a lot of skill to alternately push off the right side and then push off the left side repeatedly. I had trouble pushing off the left side, so I only skied by pushing off the right side. I was warned that if I continued to do this, back injury might result. In fact, several times, after I finished skiing, moderate low back pain would occur (about a 5-6 on the numerical rating scale). I rarely skied using the classic technique, but would use the skate technique most of the time when skiing (5-6 times per week, for 45-60 minutes each time).

It was determined that skate skiing caused the injury due to fluid-dynamic principles [1,4]. For example, if the disk is damaged, and you move in a weight-bearing position, the nucleus pulposis will shift. If tears develop in the annular fibers, the nucleus will tend to take the path of least resistance and move in this direction (Figure 3).

Representation of a herniated disk and how it moves according to the  weight-bearing forces placed upon it

Figure 3 Representation of a herniated disk and how it moves according to the weight-bearing forces placed upon it

This squeezing of the vertebrae on the disk caused it to protrude and put pressure on the sciatic nerve.

Because the disks receive no blood supply, they must rely on changes in pressure and body position to produce a pumping action that brings in nutrients and flushes out metabolic waste products with an influx and out flux of fluid. Because maintaining a fixed body position curtails this pumping action, sitting in one position for an extended period of time can negatively affect disk health [6]. This might be why some pain relief occurred when the office chair was replaced with a Swiss ball. The round shape of the ball required moving of the hips and feet to remain on the ball. This movement may also have moved the disk slightly enough that the disk did not press on the sciatic nerve, leading to some mild pain relief.

Forces acting on the spine include body weight, tension in the spinal ligaments and paraspinal muscles, intra-abdominal pressure, and any applied external loads. When the body is upright, the major form of loading on the spine is axial, and the lumbar spine supports the weight of the body segments above it. Although most of the axial compression load on the spine is borne by the vertebral bodies and disks, the facet joints, when the spine is in hyperextension, may be as much as 30% of the load. Under significant compressive loading, such as during a heavy lifting task, (or pulling yourself up a hill while skate skiing) increases in intra-abdominal pressure that may help to stiffen the trunk to prevent the spine from buckling [7]. When the paraspinal muscles are fatigued, there are increased levels of co-contraction, which also helps to stiffen the spine and increase spinal stability.

Strengthening of the back muscles is imperative to stabilize the spinal column. Exercises to strengthen the low back area should involve back extension, lateral flexion, and rotation. In addition, it is important to strengthen the abdominal muscles to maintain appropriate postural alignment. Normal range of motion (ROM) also is essential in stabilizing the spine and preventing injury. If warranted, stretching exercises should be used to promote and maintain normal ROM. In particular, it is advantageous to ensure maximal motion in lateral flexion, forward flexion, and rotation [8]. All of these exercises were performed with only mild pain relief.

Other than pain medicine, the thing that provided the most pain relief was inversion traction (Figure 4).

The patient found that the inversion table traction device was an  inexpensive ($150-$200), effective way to moderately relieve pain.

Figure 4 The patient found that the inversion table traction device was an inexpensive ($150-$200), effective way to moderately relieve pain.

Inversion table traction is an inexpensive ($150-$250) effective way to gain the benefits of traction. The patient is suspended upside down or at various angles by the ankles or thighs. This position allows the weight of the upper body to act as a traction force. Because it causes significant increases in blood pressure, this technique is contraindicated by someone with hypertension. Also it increases pressure on the eyes, so patients with glaucoma should not use inversion traction. Guvenol et al, [9]. Reported no difference between inversion traction and mechanical traction in alleviating symptoms of herniated lumbar disk patients. I, however; found inversion traction to be far superior to mechanical traction. This was probably due to extending the back while prone, by laying on a wedge immediately after the inversion traction regimen (Figure 5).

As soon as the inversion table traction therapy session ended, the  patient would lay prone on a wedge. It was thought that this position helped to  relieve pressure off the sciatic nerve

Figure 5 As soon as the inversion table traction therapy session ended, the patient would lay prone on a wedge. It was thought that this position helped to relieve pressure off the sciatic nerve


Though not that common, lumbar pain can occur during cross-country skiing, especially when the skier uses an improper technique. In my case exercise, pain medication, injections and modalities provided only minimal or moderate pain relief. Surgery, involved removing the affected part of the disk that was pressing on the sciatic nerve. This resulted in complete eradication of pain. There is still a bulging disk between L5 and S1, but it is asymptomatic.

Draper DO (2017) Diagnosis, Treatment, and Rehabilitation of a Lumbar Herniated Disk in a Cross-Country Skier: A Case Report. J Fract Sprains 1(1): 1002.

Received : 02 Feb 2017
Accepted : 02 Apr 2017
Published : 04 Apr 2017
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X