RESTARTING EXERCISE
RESTARTING EXERCISE
A graded return to exercise is well-supported for patients with L5 HNP. Guidelines strongly recommend structured, progressive exercise programs including both aerobic and strengthening components for LBP with radiculopathy.
[1-2]
The proposed approach of 50% upper body and 25% lower body loading is a reasonable starting framework, though no specific percentage-based protocol exists in the literature — the key principle is symptom-guided progression.
[2]
Upper Body (starting at 50% baseline)
This is generally safe, as most upper body lifts impose relatively low axial load on the lumbar spine. Seated exercises with back support (e.g., seated press, rows) are preferable initially over standing overhead movements.
Avoid Valsalva maneuvers and heavy loads that increase intradiscal pressure. Progress by ~10% per week as tolerated without worsening radicular symptoms.
Lower Body / Lumbar Loading (starting at 25% baseline)
This is appropriately conservative. Exercises that increase lumbar flexion under load (e.g., conventional deadlifts, barbell back squats) carry the highest risk of symptom exacerbation and should be reintroduced last.
Safer starting options include leg press, hip bridges, bodyweight squats, and hip hinge patterns with minimal load. Stabilization exercises targeting the lumbar/abdominal/hip musculature ("core") are recommended as a foundation.
[2]
Progress based on pain response: a modest, temporary increase in back pain during exercise is acceptable, but worsening or new radicular symptoms (leg pain, numbness, weakness) should prompt load reduction.
[2]
Regarding Calisthenics
Bodyweight exercises are appropriate and align with guideline recommendations for motor control and stabilization training.
[1-2]
Specific guidance:
Recommended: Bird-dogs, planks (front and side), glute bridges, bodyweight squats, wall sits, modified push-ups. These develop spine stability with low compressive load.
Use caution with: Sit-ups/crunches (high intradiscal pressure in flexion), burpees, and any explosive plyometric movement that loads the spine dynamically.
Avoid initially: Full range-of-motion lumbar flexion movements (e.g., toe touches, V-ups), heavy jumping, and loaded rotational movements.
General Principles
A progressive walking program (45 min, 4x/week at ~60% max HR) should be a cornerstone of the rehabilitation.
[2]
Directional preference exercises (often McKenzie extension) should be incorporated if they centralize or abolish pain.
[2]
Outcomes for lumbar disc herniation with conservative management including active rehabilitation are excellent, with 90% good-to-excellent results.
[3]
A modest increase in LBP during activity does not indicate damage and can be expected. The key red flags requiring reassessment are progressive neurological deficits or worsening radicular symptoms.
[2]
1.
Diagnosis and Treatment of Low Back Pain (LBP) (2022).
Department of Veterans Affairs. 2022. Maj Danielle Anderson DPT DSc OCS FAAOMPT, Thiru M. Annaswamy MD MA, LTC Adam J. Bevevino MD, et alGuideline
2.
Non-Invasive and Minimally Invasive Management of Low Back Disorders.
Journal of Occupational and Environmental Medicine. 2020. Hegmann KT, Travis R, Andersson GBJ, et al.Guideline
3.
Muscle & Nerve. 2020. Dillingham TR, Annaswamy TM, Plastaras CT.Review
For all four sports, a foundational cervical rehab program should precede sport-specific training: deep cervical flexor activation, cervico-scapulothoracic strengthening/stabilization, and progressive ROM exercises have moderate evidence for improving pain and function in cervical radiculopathy.
[1-2]
Combined cervical and core stability training improves trunk endurance and reduces kinesiophobia in cervical disc herniation patients.
[2]
Return to high-level activity is typically recommended no sooner than 3 months, with prerequisites including pain-free ROM, normal neurologic exam, and stable spine.
[3-4]
Pickleball: Begin with isometric cervical stabilization in neutral, progressing to dynamic neck control during simulated paddle strokes. Lateral shuffling and quick directional changes impose cervical shear forces, so cervico-scapulothoracic endurance training (rowing movements, scapular retraction with elastic bands) should be established before court agility drills.
[1][5]
Overhead dinking/smash motions require pain-free cervical extension; progress from below-shoulder strokes to overhead only after confirming no radicular symptom provocation.
Golf: The rotational swing generates significant cervical torque. Rehab should emphasize cervical rotation against elastic band resistance in upright posture and thoracic mobility to offload the cervical spine.
[1][5]
Begin with putting and chipping (minimal cervical rotation), progress to partial swings with short irons, and advance to full driver swings only with pain-free end-range cervical rotation. Sustained downward gaze posture during address requires cervical flexor endurance conditioning.
[2]
Basketball: High-impact collisions, rebounding, and rapid head movements make this a high-impact/high-frequency sport — one of the more challenging return scenarios for cervical disc patients.
[4][6]
Rehab should include eye-neck coordination/proprioceptive exercises to restore oculomotor control during fast-break play, progressing from controlled layup drills to contested play.
[1][5]
Neck isometric strengthening in all planes protects against contact forces. Clear return-to-play criteria include normal strength, painless ROM, and adequate canal space for neural elements.
[4][7]
Soccer: Heading is the primary cervical concern — it generates repetitive axial loading and extension forces. Rehab should progress through cervical isometric strengthening (flexion, extension, lateral flexion) before introducing controlled heading drills.
[5]
Begin with non-heading technical skills (passing, dribbling), then introduce light headers from short tosses with coached neck bracing technique before progressing to aerial challenges. Consideration should be given to permanent heading restrictions depending on herniation severity and residual stenosis.
[4][8]