Squatting Again: My Case Study in Injury Rehab

• Although serious injuries are rare in an exercise/training context (as compared to sports), they can happen and be difficult to manage.
• If an injury is not resolving well on its own, medical imaging may offer insight and give you peace of mind.
• In my situation, rehabilitation for my squat was still needed after imaging and my initial approaches were not very successful.
• After consulting with a physical therapist friend and reflecting on the accumulated knowledge and history of my training, a path forward revealed itself.
• After implementing key modifications I was able to push past my squat barrier of 160 lbs.

Whenever you are engaged in physical activity, injury is always a possibility. The type of injuries common while exercising or training tend to be much more minor compared to injuries sustained while playing sports. In light of this, the recommendation is usually to confirm that there are no signs of very serious injury, rest the injured area a bit until daily activity is once again not a problem, and then go back to training with modifications that allow you to build back up again. For more details on this process, see my previous article here.  

Sometimes, though, an injury can be more serious and present a significant roadblock to training. Such an event happened to me back in 2021 and given that the writing of this article comes at the end of 2025 you have an indication as to just how complicated this situation must have been. Nevertheless, it was a very informative experience, so I decided to record all these details here in this article in the hopes that it may prove helpful to others who are thinking about rehabbing their own injury.

The first question you probably have is: what was the injury and how did it happen? This was actually not something that was initially obvious to me. Some injuries like breaking a bone or tearing a tendon are pretty obvious. In my case, though, there was a gradual increase in lower back pain over time. It was difficult for me to understand this pain as an indicator of injury because 1) pain does not always indicate injury, 2) I had experienced a lot of muscle pulls and strains in the past that were quite painful, 3) I had a pretty high pain tolerance from playing soccer, doing martial arts and getting various bones broken and muscles torn. What I do know is that at one point I started to ignore the pain that was ramping up during my martial arts and lifting sessions. Eventually it got to the point where the lower back pain was radiating from by back and down both of my legs to my calf muscles. When I realized it was uncomfortable to sleep at night with my body straight (I needed to be curled up in a ball), and that standing up straight in the morning was a painful herculean effort, I knew I was dealing with something more serious.

I didn't really have clear red flag symptoms as listed in my above-mentioned article on training while sick, injured or hurt, so things clearly weren't that serious and thus I began with the rehab process listed there. This amounted to several initial weeks of complete rest and then starting back up again slowly. Unfortunately, the several weeks off did not return me to a normal state while doing standard daily activities. I would still have notable pain when leaning backwards. I would also get random, significant pain while simply walking around. Even with the time off, the pain would still radiate down my legs. 

After about a month or so with no improvement I was able to get a reference for an orthopedic surgeon who was a lifter himself. One of the worst things you can do as someone who is serious about training, is see a doctor who has no experience with people who lift, train, or play sports. Such doctors will often tell you that those things ruined you and you need to stop them. Imagine a doctor saying that to a professional football player. Not helpful. So, this doctor was a lifter and after his initial assessment he was pretty sure I had a disc bulge which was causing the radiating leg pain. Given how much lifting I had been doing in my past, he recommended an MRI to make sure there was nothing else going on structurally. For example, there could also have been a fracture and any loose pieces of bone might present more serious issues down the road. So, for peace of mind, I had the MRI. One of the scans is below:

 

The MRI confirmed what the doctor thought: I had two disc bulges in my lumbar spine. However, he noted a few things.

1. The bulges had already started to resorb (go back towards their normal size) and they likely would continue to do so a bit more.
2. My cartilage and vertebrae all looked incredibly healthy. The doctor noted that this is rarely the case for people he sees that lift heavy, so I clearly had great form and knew what I was doing (thank you Starting Strength).
3. I was born with an unusually small spinal canal, particularly in my lumbar region. The spinal canal is the space that holds your nerve fibers as they run down your spine. So, when my nerve fibers compressed down near the lumbar region, they really had no extra room by virtue of the small canal diameter. What this meant was that any pressure on the canal would likely set them off. A disc bulge causes exactly that. If I was born with a slightly larger canal, I likely would have had more "buffer" for a disc bulge to happen and not cause debilitating pain.
4. The bulges were pushing "in" to my body, not out towards the back. So, unlike the typical bulges people fear from having a rounded back as they lift heavy, my bulges were going the other way, as if from excessive arching of my lower back.

In light of everything he saw in the MRI, the surgeon felt that we would have no trouble getting me back to my old self. Indeed, his body had been through much worse (requiring many orthopedic surgeries). He felt that spinal injections to reduce the local information and get the nerves to calm down would do the trick. I gave it a try and after a few weeks, there was still no change. The surgeon was baffled. He offered to do another round of the injections, but my faith in him was now severely eroded. There was no prior indication from him that multiple rounds would be needed and given that there was zero improvement from round 1, I was not inclined to pay thousands of dollars more for a "Hail Mary." I asked him if there were other options and he proposed a dynamic x-ray to see how movements might be triggering the disc pain. I asked him what that information would do in terms of supporting an action or treatments thereafter. He said it would possibly indicate what activities I can and cannot do going forward. I politely declined. A decision to modify training and activity based on what you can and cannot do for an injury like this doesn't need expensive medical tests - it can be worked out on one's own in the gym/dojo/etc.

And so, it was back to rehabbing on my own. The bulge had gotten a bit better and I was able to do some things, but not others. I basically dropped all my weights down again and started from scratch with modifications that didn't cause me pain. For the strict press, I did those seated with an upright bench for back support. For the bench press I used no arch and raised my feet higher on the ground with plates. For the deadlift, simply starting with lighter weights was all that I needed. This lift didn't bother me at all! Interestingly, squatting type movements were a huge problem. Barbell squat, split squats, lunges - these were all no good at anything above body weight. What did work fine were leg machines. So, I cycled in leg presses, leg extensions and hamstring curls. The latter of which had to be seated/upright (the prone version aggravated by back).

So, for quite some time I worked with the above training scheme and each month I would test the barbell squat, gradually increasing weight starting with the empty bar. However, each month, I couldn't get past 160lbs without the radiating pain distracting me so much I had to stop. Although training without the barbell squat enabled me to gain back all the weight I had lost when I couldn't train (as well as some of my strength), it wasn't an ideal situation. I missed squatting (even though I hate squatting) and using only the leg press as a source of heavy squatting stimulus was becoming grindy and rough on my knees.

At this point I decided I wanted a second option from another orthopedic surgeon; a lot of time had passed and the progress was not where I wanted it to be. I still couldn't squat heavy and I still had random pain multiple times a day while just walking around. I began to wonder if maybe something was missed in interpretation during the first round of imaging. I got a referral for yet another doctor who lifts and had him look at my original MRI scan. Over a year had passed, but I just wanted his thoughts on those scans then from back then. He confirmed everything that the prior surgeon had said, except for the part where injections to reduce the inflammation would take care of things. I asked him about potential surgical options given the scans and he said absolutely not. He said the outcome for spinal surgery for something like this is often worse than the state before surgery. Instead, he recommended some rehabilitation exercises. Since a deep dive into rehabilitation seemed like the only path forward, it was time to reach out to a friend.

I reached out to my friend Jeff who is a physical therapist working out of my gym. Again, he is someone who lifts and understands that people will want to be active in their life in different ways, so he leads his practice with a mindset of support not dissuasion. He was more than happy to help check me out and offer any insight he might have. Since the squat had now become the main issue he took a look at my form for both the low-bar and high bar squat variations. What he observed was that my lower back tended to become slightly more extended as I descended into the bottom of a weighted squat. As expected it was less prominent in the low-bar squat (as I am more leaned over in that version), but it was still there. Given that my disc bulge was an overextension bulge, his suggestion was to work on control of a more braced, less extended, possibly even slightly rounded lower back position as I squat.

I was familiar with the position he was referring to as in gymnastics this is called a hollow position. Jeff said the barbell work would take time and practice, but to supplement in the meantime he gave me a variety of drills that forced me to hold this hollow position while standing, leaned over, and with weight. I was astonished at how hard they were. I was extremely weak in these positions. This immediately reminded me of what gymnast Dave Durante had told me back in my CrossFit days after he gave me a gymnastics assessment. He said my back extension strength was incredibly strong, which made sense given how much I could deadlift (470lbs at the time), but my flexion strength (abdominal contraction, hollow hold, etc.) was significantly lagging behind.

I spent many weeks that followed incorporating the drills that Jeff gave me, doing hollow holds more regularly and practicing bracing modifications with light barbell squats. The result of this was significantly reduced pain during daily life activities. Prior to this I would get pain that would repeatedly cause me to stop walking on the street and stretch out my lower back with my foot on top of a fire hydrant. I must have looked ridiculous. But now that almost never happened. I was very pleased. And yet, I still couldn't' get past that 160lb squat. I did a lot of reflecting and it seemed like the issue was that I just couldn't get a tight enough brace in my lower back position when under a weighted barbell. It was so much easier with the drills. It took some time, but after a lot of reflecting I remembered 3 things in concert. I remembered the pelvic tilt drill we do at Starting Strength seminar camps to see if people can control lumbar flexion and extension. I remembered Dave saying that the abdominal bracing I would typically do was not strong enough. I remembered Jeff saying I lose lower back tightness as I start to descend into a squat. What if addressed these three things together? 

What I tried was the following: After taking the bar out of the rack I would tilt my pelvis (hollow it), I would then brace my abs much harder that I would in the past while trying to "lock" them against my lifting belt. I would then start my lean over a bit slower than normal (almost like a tempo squat) in order to keep my tightness "locked in." It worked! I didn't have any pain at 160lbs and over time I was able to keep building up beyond that (as of this writing I've been able to work up to a squat triple at 225lbs). I did add one more piece and that is after each set was done I would lie on the ground and do a brief hollow hold. I'm not sure how crucial this part is, but it definitely feels good after a heavy set, so I kept it in.

At this point many of you no doubt want to know how the injury happened in the first place. Given I have a PhD in orthopedics, am an avid lifter and coach people in how to do the barbell lifts, I realize an answer is almost required. So here we go. As noted earlier my injury wasn't a traumatic event that can be directly pointed to and I am now fairly certain it was an accumulation of aggravating incidents over time. When I was young I did not know how to lift properly and definitely did some things that caused lower back pain. Once I did know what I was doing I still had some instances where I was careless with my form (pulling a heavy clean off the ground without getting properly tight, descending into the bottom of a heavy squat while forgetting to take a breath and brace). In all these cases I experienced brief but significant lower back pain. Then of course there was martial arts where it is common to do a standing "back stretch" at the start of class. I was doing this stretch, aggressively extending my back, for years until I realized it was actually supposed to be a quad stretch where you bend at your knees. Add all of this to heavy squats where I wasn't bracing as well as I could have been plus my 6' 3" frame and narrower than normal spinal canal and, well, I there you have it. 

Final Thoughts

There is a lot that one can unpack from this article. In part this article is a cautionary tale highlighting the importance of listening to your body as pain worsens over time. It's also a reminder that humans may have individual anatomical differences that may make certain things not great for us (even though they may be fine for others). But this article is also a reminder that the rehabilitation process can take a very long time and a solution may present itself much father down the line than you would expect or want. And finally, remember that a solution might require insight from many different people and that nobody can know your body in quite the way you can, so you must remain the conductor of the process.

 

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