What causes a lumbar disc herniation?

A lumbar disc herniation rarely results from a single event. It is the result of a cumulative process called disc degeneration, which begins as early as age 30. This process combines progressive degeneration, repeated mechanical stress, and individual risk factors.

This process begins at age 30. Your nucleus pulposus gradually loses water and protein. The reduction in hydration decreases the disc's ability to distribute loads evenly. Localized stress concentrations are created on the annulus fibrosus. Cracks gradually develop in the annulus. They weaken the structural strength. Eventually, mechanical stress causes complete rupture. Even modest stress can be enough. That's why you can hurt your back picking up a pencil.

Mechanical factors play a decisive role. Axial compression occurs when you carry vertical loads. Flexion combined with compression occurs when you lift objects. Rotation combined with flexion occurs during twisting movements under load.⁷ Shear stresses increase intradiscal pressure (pressure inside the disc), which can reach 2-3 times your body weight during daily activities. Prolonged sitting increases intradiscal pressure by 40% compared to standing.⁸

Main risk factors:

• Age: Peak incidence between 35 and 55 years old, a period when the disc deteriorates but you are still very physically active.

• High-risk occupations: Whole-body vibrations (driving heavy vehicles), repeated lifting, and prolonged bending increase the risk by up to three times.

• Smoking: Accelerates disc degeneration by reducing the supply of nutrients to the disc.

• Genetic factors: Influence up to 75% of disc degeneration¹⁰

Lumbar disc herniation shares a complex relationship with degenerative disc disease (DDD, progressive disc deterioration). The two conditions are not synonymous. DDD represents a continuum of changes including dehydration, loss of disc height, and osteophyte formation. Disc herniation represents a focal rupture event. A disc herniation can occur in a relatively healthy disc under extreme stress. More commonly, it occurs as a complication of pre-existing DDD. To distinguish disc herniation from other sources of lumbar pain, see our guide on lumbar sprain, which affects the ligaments, and our article on lumbar osteoarthritis, which affects the facet joints.

How is a lumbar disc herniation diagnosed?

We diagnose lumbar disc herniation through a clinical examination that includes neurological tests (muscle strength, sensitivity, reflexes) and the straight leg raise test (Lasègue test). MRI provides detailed visualization. However, clinical findings determine the functional impact and guide treatment decisions.

Clinical examination forms the basis of diagnosis. Imaging confirms and characterizes the structural abnormality. Structured clinical examination includes a detailed history of symptoms, observation of posture and gait, assessment of lumbar range of motion, palpation of tender areas, and specific neurological and orthopedic tests.¹⁵

Neurological tests assess the functional integrity of potentially compressed nerve roots. Sensory testing evaluates sensitivity to light touch in each dermatome (area of skin innervated by a specific nerve root). The motor examination assesses muscle strength: knee extension for L4, ankle dorsiflexion and toe extension for L5, ankle plantar flexion for S1.¹³ We systematically test tendon reflexes. The abolition or asymmetric decrease of a reflex suggests radiculopathy (compression or irritation of a nerve root) at the corresponding level.

The straight leg raise test is the most sensitive orthopedic test. It detects lumbar disc herniation with nerve compression in patients under 60 years of age. We perform the test in a supine position. Your therapist passively raises your symptomatic leg with your knee fully extended.¹⁶ A positive test reproduces radicular pain at less than 60 degrees of elevation (not just muscle tension). The contralateral test has an even higher specificity.

What imaging tests confirm a herniated disc?

Magnetic resonance imaging (MRI) is the gold standard examination. It visualizes lumbar disc herniations and their effects on neural structures with superior soft tissue resolution, without radiation exposure.¹⁷ T2-weighted sequences show the herniated disc as an intermediate signal area protruding into the spinal canal or intervertebral foramen.

Computed tomography (CT scan) is an acceptable alternative. We use it when MRI is contraindicated (pacemakers, ferromagnetic implants, severe claustrophobia). CT offers excellent resolution of bone structures. Its resolution of soft tissues remains inferior to MRI.¹⁸

Plain radiographs (X-rays) do not directly visualize discs or nerves. They remain useful for ruling out other causes of low back pain: fractures, spondylolisthesis, and major deformities.

Why do some herniated discs cause no symptoms?

A systematic review of 33 studies involving 3,110 asymptomatic subjects reveals surprising data. Thirty percent of 20-year-olds have herniated discs detectable by MRI. This proportion increases to 60% in 50-year-olds. It reaches 84% in 80-year-olds.⁵ These structural changes are extremely common. They are probably part of normal aging.

Several mechanisms explain why a lumbar disc herniation visible on imaging may remain asymptomatic. The position and size of the herniation determine whether it comes into contact with a nerve root. A lateral or foraminal herniation is more likely to compress a root than a central herniation.¹⁹ Periradicular inflammation plays a crucial role in the genesis of pain. Simple mechanical compression without inflammation generally produces few symptoms.²⁰ Individual sensitivity of the nervous system varies considerably. It depends on the state of central sensitization, your psychological state, and your previous experiences of pain.

A lumbar disc herniation identified on MRI becomes clinically significant only when its anatomical location corresponds to the pattern of your symptoms.²¹ In patients over 60 years of age, spinal stenosis is a common cause of similar symptoms. It can coexist with lumbar disc herniation.

How does physical therapy treat a lumbar disc herniation?

We use preferential direction exercises (McKenzie method), neural mobilization, manual therapy, and progressive strengthening. These interventions reduce disc pressure, improve nerve mobility, and restore function. Research shows that 80-90% of patients with lumbar disc herniation can avoid surgery with appropriate rehabilitation.²⁶

We organize physical therapy into three distinct phases. Acute phase lasting 1-2 weeks. Subacute phase lasting 3-6 weeks. Functional restoration phase lasting 6-12 weeks and beyond. We tailor the specific interventions for each phase to your abilities.²²

Physiotherapy treatment phases: The McKenzie Approach is the most widely studied and effective method for lumbar disc herniation with radiculopathy. This approach is based on identifying a preferred direction of movement (the movement that centralizes or reduces your symptoms).¹⁴ For the majority of posterior or posterolateral disc herniations (90% of cases), repeated lumbar extension is the preferred direction. Repeated extension movements mechanically reduce the herniated disc. They move the nucleus pulposus forward and relieve nerve compression. You should perform the exercises in the preferred direction frequently (every 2 hours during the acute phase).

Neural mobilization aims to restore normal nerve gliding in their tissue interfaces. In lumbar disc herniation, the nerve root becomes adherent or hypersensitive. Our physical therapists use specialized nerve treatment techniques with controlled movements. We gradually apply tension to the nervous system. These neural gliding techniques improve nerve mobility while reducing inflammation.²³

Manual therapy complements the active approach by normalizing segmental joint mobility. Our therapists apply precise joint mobilizations and manipulations to reduce protective muscle spasms. Grade I-II spinal mobilizations produce analgesic effects without excessive mechanical stress on the herniated disc.²⁴

Progressive strengthening and lumbar stabilization become priorities once radicular symptoms become centralized. Ourstabilizing muscle exercise program develops endurance and motor control of the deep trunk muscles (the transverse abdominis and multifidi).²⁵ The typical progression begins with low-load static exercises (planks and glute bridges). It advances to moderate-load dynamic exercises (bird-dog and dead bug). It culminates in high-load functional strengthening exercises.

A Cochrane systematic review of 31 randomized controlled trials reveals that 80-90% of patients with lumbar disc herniation and radiculopathy improve significantly with conservative treatment including physical therapy.²⁶ A prospective cohort study following 370 patients with MRI-confirmed disc herniation reports that 73% experience complete or almost complete resolution of symptoms with conservative treatment at 12 weeks.²⁷

What is the natural healing process for herniated discs?

Lumbar disc herniations can resolve naturally over a period of 3 to 12 months. This process involves inflammatory reactions and phagocytosis (elimination of disc material by immune cells). Large herniations (extrusions and sequestrations) show greater resorption than small protrusions.

Serial imaging studies show that the majority of lumbar disc herniations decrease or disappear completely over time. A meta-analysis of 11 studies involving 650 patients with disc herniations documented by MRI reveals that approximately 66% of herniations show a reduction in size on follow-up MRI.²⁸ Forty-three percent show complete or almost complete resolution.

The biological mechanisms of resorption mainly involve inflammatory and immunological processes. When the herniated nucleus pulposus protrudes through the annulus fibrosus, it comes into contact with the vascular and immune systems for the first time. This exposure triggers an inflammatory response. Macrophages, giant cells, and neovascularization infiltrate around the lumbar disc herniation. They gradually phagocytose the herniated disc material.²⁹ Paradoxically, the inflammation that initially causes pain ultimately contributes to the elimination of the herniation.

The timeline for resorption varies depending on the type and size of the lumbar disc herniation. Sequestrations (completely separated disc fragments) show the fastest resorption rates: up to 75-100% in 6-12 months.³ Extrusions resorb in approximately 60-80% of cases over the same period. Protrusions show the lowest rates, approximately 40-50% in 12-24 months.

Several clinical factors influence the rate of resorption. Younger age (under 50) is associated with slightly higher rates of resorption.³⁰ The initial size of the hernia correlates positively with resorption. Smoking can delay resorption. The correlation between radiological resorption and clinical improvement remains imperfect. Some patients improve clinically without significant resorption visible on MRI. Others show significant resorption without corresponding clinical improvement.

The role of physical therapy during the natural resorption process is to manage symptoms, maintain function, and prevent harmful compensatory adaptations during healing. We cannot directly accelerate biological resorption. We improve the biomechanical and neurophysiological context for recovery.³¹

Patients who are informed of the high probability of spontaneous resolution show less anxiety. They adhere better to treatment. They achieve better clinical outcomes.³²

When is surgery considered for a herniated disc?

We consider surgery in cases of progressive neurological deficit (worsening muscle weakness), cauda equina syndrome (surgical emergency with loss of bladder control), or failure of conservative treatment after 6-12 weeks with persistent functional limitations. Approximately 5-10% of cases of lumbar disc herniation require surgery.

Surgical indications are divided into absolute and relative indications:

Cauda equina syndrome is the only true surgical emergency.³³ This syndrome results from a massive central lumbar disc herniation that simultaneously compresses several cauda equina roots. It produces a classic triad of symptoms: saddle anesthesia (loss of sensation in the perineum and around the anus), urinary retention or incontinence, and bilateral weakness in the lower limbs. The syndrome requires surgical decompression within 24-48 hours to minimize the risk of permanent neurological sequelae. Fortunately, this syndrome occurs in less than 1-2% of lumbar disc herniations.³⁴

Progressive motor neurological deficit is a semi-urgent indication for surgery. If you have muscle weakness that objectively worsens over several weeks despite conservative treatment, we should consider surgical decompression within 2–4 weeks.³⁵

Relative indications for surgery mainly include failure of properly conducted conservative treatment. This includes persistent severe and disabling radicular pain after 6-12 weeks of appropriate physical therapy. It also includes major functional limitations that prevent work or essential daily activities.³⁶ The 6-12 week time frame is not arbitrary. The majority of patients who will improve with conservative treatment show signs of improvement within this time frame.

Several surgical procedures can treat lumbar disc herniations. Microdiscectomy is the standard procedure. A small 3-4 cm incision provides access to the spinal canal. The surgeon removes the herniated portion of the disc that is compressing the nerve root under microscopic magnification.³⁷ Endoscopic discectomy uses an endoscope and specialized instruments with an even smaller incision (1-2 cm).

Surgical outcomes are generally favorable in the short term. A meta-analysis of 64 studies involving 13,055 patients reports that 78% of patients achieve good to excellent results after microdiscectomy.³⁸ When comparing surgery and conservative treatment in the long term (2-4 years of follow-up), randomized controlled studies reveal similar functional and pain outcomes between the groups. Surgery mainly offers faster relief, not a superior final outcome.³⁹

Post-surgical physical therapy plays a crucial role in improving outcomes after discectomy. The typical post-operative program progresses through phases similar to conservative treatment: initial protection phase of 2-4 weeks, restoration phase of 4-8 weeks, functional return phase of 8-16 weeks.⁴⁰ Patients who complete a post-surgical rehabilitation program show better functional outcomes. They have lower recurrence rates.

How can you prevent a herniated disc or its recurrence?

Prevention of lumbar disc herniation relies on maintaining spinal flexibility, core strength (deep stabilizing muscles), proper lifting mechanics (load close to the body, use legs, avoid combined flexion-rotation), and correct posture. Regular movement breaks, ergonomic adjustments, and a healthy body weight reduce the risks.

Biomechanical training is the cornerstone of prevention.⁴¹ Safe lifting techniques include several principles. Keep the load close to your body to reduce leverage and lumbar stress. Use your leg muscles primarily. Avoid combined flexion-rotation movements under load. Distribute loads symmetrically. Pre-contract your abdominal muscles before lifting (bracing technique).

General physical conditioning significantly reduces the risk of lumbar disc herniation. A balanced exercise program includes several components. Cardiovascular training maintains nutritional supply to the disc via diffusion. Strengthening the muscles of the trunk and lower limbs increases load capacity. Flexibility stretches maintain normal joint range of motion.⁴² Regular exercise improves disc hydration. Movement creates compression-decompression cycles that pump nutrients into the avascular disc.

Lifestyle changes:

• Healthy body weight: Every kilogram of excess body weight increases the load on the discs during daily activities.

• Smoking cessation: Smoking accelerates disc degeneration, reduces nutritional intake through vasoconstriction, increases enzymes that degrade the disc matrix, and impairs tissue repair.

• Adequate hydration: Supports overall disc health

• Balanced nutrition: Provides nutrients necessary for tissue maintenance

Occupational ergonomic considerations are particularly important for workers in physically demanding jobs. Strategies include several approaches. Reorganize tasks to minimize repetitive lifting. Use mechanical aids (carts, hand trucks). Practice task rotation to vary physical demands. Adjust work height to avoid excessive bending.⁴⁵ For office workers, adjustments include chairs with adjustable lumbar support, correct desk and monitor height, and regular breaks from sitting (short movement breaks every 30-45 minutes).

Secondary prevention after an episode of lumbar disc herniation requires special attention. The recurrence rate can vary from 5-15% in the first two years.⁴⁶ A long-term maintenance program includes lumbar stabilization exercises 2-3 times per week. It maintains continuous biomechanical awareness.

What activities should be modified with a herniated disc?

Temporarily avoid prolonged sitting (can increase intra-disc pressure by 40-90%), heavy lifting (loads greater than 5-10 kg initially), repeated bending, and high-impact activities during acute phases. Gradual return to activities follows centralization of symptoms and improvement in tolerance.

Modifying activities follows a fundamental principle: temporarily avoid or minimize positions and movements that increase intra-disc pressure and exacerbate symptoms. At the same time, maintain as normal a level of general activity as possible. We do not recommend complete bed rest except in the most severe cases. You should limit it to a maximum of 1-2 days. Prolonged rest delays recovery.⁴⁷

Prolonged sitting is the most problematic activity. Sitting, especially with lumbar flexion (slouching), increases intradiscal pressure by 40-90% compared to standing. It pushes the nucleus pulposus backward.⁸ Modification strategies include several approaches. Limit periods of continuous sitting to 20-30 minutes followed by standing or walking breaks. Use lumbar support to maintain natural lumbar lordosis. Adjust chair height to allow knees to be slightly lower than hips. Consider a sit-stand workstation.

Lifting activities require substantial modifications during the acute phase of a lumbar disc herniation. Initially (first 2-4 weeks), completely avoid lifting loads greater than 5-10 kg. Avoid any activity involving simultaneous flexion, rotation, and lifting.⁴⁸ As your symptoms improve, gradually reintroduce lifting. Start with light loads using perfect technique. Gradually increase the weight (10-20% per week) only if your technique remains correct and your symptoms do not worsen.

Sports and recreational activities: Sports to avoid temporarily (acute phase):

• Racquet sports with explosive rotations (tennis, squash)

• Golf

• Contact sports (hockey, football)

• High-impact running

• Lumbar flexion exercises (full sit-ups, abdominal crunch exercises)⁴⁹

Activities that are generally well tolerated:

• Walking (excellent basic exercise)

• Swimming (especially backstroke and crawl; avoid breaststroke if lumbar flexion aggravates the condition)

• Stationary cycling with an upright posture

• Resistance training for upper and lower limbs avoiding heavy axial loads

Ergonomic considerations at work vary depending on the nature of the job. For physically demanding jobs, a gradual return to work improves outcomes. Start with light or modified tasks. Gradually increase the duration and intensity of work over several weeks.⁵⁰

The progression of return to activities should be guided by two key principles. Centralization of symptoms: pain should not progress toward the periphery. Latency: the delay between activity and the onset of symptoms should increase gradually.⁵¹

Ready to treat your herniated disc with expert care?

Our physical therapists at Physioactif specialize in evidence-based treatment for lumbar disc herniations. We can help you avoid surgery and return to your normal activities with personalized rehabilitation programs. Our programs target your specific lumbar disc herniation pattern, symptoms, and functional goals.

Our approach incorporates the most effective techniques validated by scientific research. We use the McKenzie assessment to identify your preferred direction of movement. We apply neural mobilization to restore normal nerve gliding. We practice manual therapy to improve joint mobility. We develop personalized progressive exercise programs to restore strength, endurance, and motor control.

Beyond relieving immediate symptoms, we equip you with the knowledge and skills necessary to manage your condition long term and prevent recurrence. Our educational approach helps you understand the mechanisms of your pain. You will understand the natural healing process of your lumbar disc herniation. You will learn effective self-management strategies and lifestyle changes that protect your spine.

The evidence strongly supports a conservative approach led by physical therapy. Research shows that approximately 80-90% of patients with lumbar disc herniation can avoid surgery with appropriate physical therapy treatment.²⁶ Even among those who undergo surgery, post-operative rehabilitation improves functional outcomes. It helps reduce recurrences.

If you are living with a lumbar disc herniation, know that you don't have to let this condition compromise your quality of life. It doesn't have to affect your ability to work or participate in the activities you enjoy. Contact us today to make an appointment with one of our physiotherapists who specialize in the spine. During your first visit, we will perform a comprehensive assessment including neurological, orthopedic, and movement tests. We will determine the precise nature of your lumbar disc herniation. We will identify your preferred direction of treatment. We will establish realistic and meaningful recovery goals for you.

Make an appointment now and start your journey toward a full and lasting recovery.

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