Transcript The Lumbar Spine in Sports

Frederick A. Davis M.D.
Southern California Permanente Group
PM&R/Pain Management Symposium
August 1, 2009
Outline
 Overview
 Anatomy and Biomechanics
 Clinical Evaluation
 History
 Physical Examination
 Specific Injuries
 Sport Specific
 Football
 Gymnastics
 Running
 Golf
 Baseball
 Tennis
 Bowling
 Basketball
Lumbar Spine
 Most injuries are relatively minor
 Most injuries occur during practice
 Most athletes are reluctant to document minor injuries
 Most injuries are self limiting and resolve on their
own…even without treatment!
 So why do they need us????
The Problem
 For the recreational athlete (weekend warrior to
advanced amateur)
 Their livelihood is usually obtained through means
other than in the athletic arena
 They may have this as such an integral part of their life,
cessation or even reduction in activity may be extremely
difficult to accept.
 For those who have athletic ties that are intimately
connected to their means of making a living.
The Problem
 For the elite athlete
 Their livelihood IS dependent on unencumbered
physical performance
 Lumbar spine injury is a frightening prospect.
 Excellent functional outcome from treatment to be able
to continue at the same level of performance is essential.
 In either operative or non-operative treatment it is
important to understand that the athlete will continue
to face the same physical stresses and dangers that were
injurious in the first place.
Epidemiology
 Cumulative lifetime prevalence of low back pain is almost
80% with almost 30% of athletes having acute back pain as
it relates to sports (Dreisinger TE, 1996. Kelsey JL, 1980).
 The type of injury varies with age; nearly 70% of lumbar
spine injuries in adolescent athletes in whom forces are
exerted on skeletally immature spines
 Injury often occurs in the posterior elements and muscles
 The majority of low-back injuries in adult athletes are
related to muscle strain and discogenic disease (Micheli LJ,
1995).
Epidemiology
 4790 athletes medical records studied over a 10 year period
and 17 intercollegiate varsity sports with injury rate of 7 per
100 participants (Keene, JS. 1989).
 Injury rates were higher in both gymnastics and football.
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Only 6% of these injuries occurred during competition.
80% occurred during practice
14 % during pre-season conditioning
Injuries divided into 3 categories
 Acute (most common)
 Overuse
 Pre-existing conditions
Epidemiology
 U.S. Air Force Academy injury statistics, collected
during a 1-year period, indicate that 9% of all athletic
injuries are related to the spine.
 Another study looked at 1000 injuries from one
professional football team and found that 6% were
related to the spine (Ryan, AJ. 1965).
 Musculoskeletal injuries sustained by collegiate
wrestlers and female gymnasts and found a 2% and
13% injury rate of the thoracolumbar spine.
Epidemiology
 Athletes who have long trunks and particularly
inflexible lower extremities are more prone to lumbar
spine injury (Fairbank JC, 1984).
 Sports involving repetitive hyperextension, axial
loading (and jumping), twisting, or direct contact
carry higher risks of low-back injuries.
 In Keene’s 1989 study, a little more than 50% of these
injuries were acute in nature (Keene JS, 1989).
Epidemiology
 Catastrophic spine injuries account for less than 1% of
all sports injuries and usually involves the cervical
spine.
Anatomy
 Specific Anatomic Points
 Vertebral bodies are
particularly large and
heavy compared to rest
of spine
 The pedicles of the
lumbar spine are short
and heavy, arising from
the upper part of the
vertebral body
Anatomy
 Specific Anatomic Points
 The lamina are shorter
vertically than the bodies
and causes a gap between
the lamina at each level,
which is bridged only by
ligaments
 The spinous processes are
broader and stronger than
those in the thoracic
spine; they project in a
dorsal direction with little
caudad angulation
Anatomy
 Specific Anatomic Points
 The articulations in the
lumbar spine are the same
three-joint complex.
 The joints are oriented in a
more sagittal plane. This
orientation allows the
lumbar spine to have
relatively more flexion and
extension than its thoracic
counterpart but
significantly less rotation.
 This joint alignment also
allows for lateral flexion in
the lumbar spine.
Anatomy
 Specific Anatomic Points
 The anterior longitudinal
ligament is relatively
thicker in the lumbar
spine.
 The ligamentum flavum is
much stronger than its
thoracic counterpart. This
increased strength is in
part due to the fact that it
serves as a bridge between
adjacent laminae where
there is no bony
overlapping.
Anatomy
 Specific Anatomic Points
 The facet joint capsules of
the lumbar spine are
thicker and stronger in the
lumbar spine, as are the
supraspinous and
infraspinous ligaments.
 The stability of the lumbar
spine is related much
more directly to the
ligamentous structures
than the thoracic spine
because of the loss of
stability added by the rib
articulations and rib cage.
Anatomy
 Specific Anatomic Points
 The musculature of the
lumbar spine is organized
in the same pattern as that
of the thoracic spine.
 As one moves more
caudally into the lumbar
area, the muscles of the
superficial groups tend to
become larger and
stronger.
 The enveloping fascia in
the lumbar spine is thicker
and stronger than its
thoracic counterpart.
Anatomy
Anatomy
 Specific Anatomic Points
 Intervertebral Disc
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Two components
The Annulus (the outer, laminar
fibrous container)
Nucleous pulposus (the inner,
semifluid portion)
The disks make up approximately
one fourth of the height of the
entire spinal column.
Moving from cephalad to caudad,
the disks become thicker when
measured from one vertebral end
plate to the next.
The thoracic disks are heartshaped compared with the more
oval form seen in the lumbar
spine.
Anatomy
 The nucleus pulposus
 Occupies a concentric
position within the confines
of the anulus. Its major
function is that of a shock
absorber.
 The nucleus pulposus
exhibits viscoelastic
properties under applied
pressure, responding with
elastic rebound.
 There is no definite
structural interface between
the nucleus and the anulus.
The two tissues blend
imperceptibly.
Anatomy
 Specific Anatomic Points
 The blood supply and nutrition of the intervertebral
disk is achieved primarily by diffusion from the adjacent
vertebral end plates.
 The annulus is penetrated by capillaries for only a few
millimeters.
 The normal disk tissue has a high rate of metabolic
turnover.
 The disk itself has no direct inervation. Sensory fibers
are abundant, however, in the adjacent longitudinal
ligaments.
Biomechanics
 Flexion
 Requires an anterior compression
of the intervertebral disk, along
with a gliding separation of the
articular facets .
 Limited by the posterior ligament
complex and the dorsal
musculature.
 Extension
 More limited motion, producing
posterior compression of the disk
along with gliding motion of the
zygo-apophyseal joint.
 Limited by the anterior
longitudinal ligament as well as
the ventral musculature. The
lamina and spinous processes
limit extension by direct
opposition.
Biomechanics
 Lateral flexion
 Lateral compression of the intervertebral disk, along
with a sliding separation of the facet joint on the convex
side, whereas an overriding of this joint occurs on the
concave side.
 Limited by the intertransverse ligament as well as the
extension of the ribs.
Biomechanics
 Rotation
 Related most directly to the thickness of the
intervertebral disk.
 Compression of the annulus fibrosus fibers.
 Limited directly by the geometry of the facet joints.
 Limits rotation by resistance to compression in the
annulus.
Biomechanics
 The center of gravity is anterior to the lumbar spinal
column which places much of the resistive force on:
 The erector spinae muscles
 Lumbodorsal fascia
 Gluteus maximus.
 The instantaneous axis of rotation or the effective pivot
point, is near the center of the disc in normal lordosis and
moves posterolaterally in extension (Pearcy MJ, 1988)
 When combined together the annulus, disc, and posterior
elements bear significant combinations of tensile stress
and compressive and shear force, respectively whereas the
posterior soft tissues bear considerable resistive stress.
Biomechanics
 During flexion
 The most strain is on the interspinous ligaments >
capsular ligaments > ligamentum flavum.
 During extension
 The most strain is on the anterior longitudinal ligament
 During lateral flexion
 The most strain is on the contralateral transfers
ligament > ligamentum flavum and capuslar ligaments
 During rotation
 The most strain is on the capsular ligaments of the facet
joints (Panjabi, MM, 1982)
Biomechanics
 Range of motion is due to a combination of the motion
segments throughout the spine.
 Flexion
 4 degrees in each of the upper thoracic motion segments
 6 degrees in the mid-thoracic region
 12 degrees in the lower thoracic region
 Increases in the lumbar motion segments with a
maximum of 20 degrees at the lumbosacral junction
(White, AA and Panjabi, MM 1978)
Biomechanics
 Lateral flexion
 6 degrees in the upper thoracic segments
 8-9 degrees in each of the lower thoracic segments.
 6 degrees in each of the lumbar segments
 Exception is the lumbosacral segment which shows only
3 degrees.
 Rotation
 9 degrees in the upper thoracic segments
 2 degrees in the lower lumbar segments
 5 degrees in the lumbosacral junction
Biomechanics
 Range of motion is age dependent (McGill, SM 1999)
 Decreases by 30% from youth to old age
 Loss of range of motion occurs in flexion and lateral
bending while axial rotation is maintained with
increased coupled motion.
 Range of motion has gender differences (Biering-
Sorensen, F., 1984 and Moll JMH, et al, 1971)
 Men have greater mobility in flexion and extension
 Women have more mobility in lateral flexion
Biomechanics
 Muscles
 Flexors
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Rectus abdominus, internal and external obliques, transverse
abdominus and psoas
 Extensors
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Erector spinae, multifidus, and intertransversarii
 Rotation and lateral bending
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When right and left side flexor and extensor muscles contract
asymmetrically lateral bending or twisting of the spine is
produced (Andersson, GBJ, 1997).
Biomechanics
 During the first 50-60 degrees of unloaded flexion range of
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motion occurs mainly in the lower lumbar motion
segments (Carlsoo, 1961 and Farfan 1975)
Tilting the pelvis forward allows for more flexion.
When lifting and lowering a load this rhythm occurs
simultaneously (Nelson, 1995).
Flexion is initiated by the abdominal muscles and the
vertebral portion of the psoas muscle (Andersson, GBJ,
1997)
The posterior hip muscles control the forward tilting of the
pelvis while flexion of the spine occurs (Carlsoo, 1961)
Biomechanics
 The weight of the upper body is then controlled by the
erector spinae muscles.
 The quadratus lumborum superficial erector spinae muscles
and deep are silent when upright.
 As flexion increases the superficial > deep erector spinae
become active.
 At 90 degrees of flexion the quadratus lumborum and deep
erector spinae are very active with less activity in the
superficial erector spinae.
 With full flexion (ie touching ones toes) the quadratus
lumborum and deep erector spinae muscles are maximally
active and the superficial erector spinae are silent (flexionrelaxation phenomenon).
Biomechanics
 In forced flexion the superficial erector spinae muscles are
activated.
 As one goes from full flexion to being upright the muscle
activity sequence reverses.
 Gluteus maximus and the hamstrings activate early to rotate
the pelvis to initiate the movement and then the erector
spinae are activated until the motion is complete.
 Compressive load of the spine caused by the muscle forces
produced when lowering the trunk with a load or
resistance can approach the spinal tolerance limits (Davis,
KG, 1998)
Biomechanics
 From neutral to hyperextension the extensor muscles
initiate the motion and the abdominal muscles take
over.
 Forced extension (or extremes of extension) requires
extensor activity.
 During axial rotation the back and abdominal muscles
are active on both sides of the spine to produce
controlled movements.
 The SI joints act mainly as shock absorbers to protect
the intervertebral joints.
Biomechanics
 During compression testing the fracture point of the
vertebral body was reached before the intervertebral
disc was damaged (Eie,N ,1966 and Ranu, HS 1990)
 Forces ranged between 5000 and 8000 N.
 The force of Earth's gravity on a human being with a
mass of 70 kg is approximately 687 N.
 A “yield point” was also reached prior to bony damage
when the force was removed but it made the bond more
susceptible to damage when reloaded.
 Extrinsic support of the trunk muscles helps to stabilize
and modify the loads.
Biomechanics
 Sacral angle of inclincation
 Normally the base of sacrum is pointing 30 degrees
forward downward.
 Tilting the pelvis backwards decreases the sacral angle
and lumbar lordosis flattens.
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Reduces the muscle energy exertion
 Tilting the pelvis forward increases the sacral angle and
lumbar lordosis increases and a compensatory increase
in kyphosis occurs
Biomechanics
Biomechanics
 Walking at 4 different speeds (Cappozzo, 1984)
 Compressive loads at the L3-4 motion segment ranged
from 0.2 to 2.5 times body weight.
 Loads maximized at toe-off
 Loads increased linearly with increased walking speed.
 Muscle action was focused in trunk extensors.
 Forward flexion also increased the loads
 Limiting arm swing increased joint loading
Biomechanics
 Erector spinae muscles are intensely activated with lumbar
hyperextension while prone and lessens with elbow support.
 Pillow under the abdomen provides better spinal alignment to resist
the forces.
 Bent knee and straight knee sit ups produce comparable levels of
psoas and abdominal activity and increase spinal loading.
 Curl-ups or “crunches” minimize compressive loading in the lumbar
spine (Axler, CT, 1997)
 Unanchored feet, leg elevation or torso twisting do not significantly
increase abdominal muscle acticity.
 Isometric reverse curls with the buttocks off the table activate the
internal and external obliques and the rectus abdominus and have
less lumbar stress than a sit up.
Biomechanics
 Intra-abdominal pressure (IAP)
 The pressure created by coordinated contraction of the
diaphram and abdominal and pelvic floor muscles.
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Converts the abdomen into a rigid cylinder that greatly increases
stability
 Reduction in extensor moment varies from 10-40 percent.
 Fine wire EMG shows that the transversus abdominus is the
primary muscle for IAP generation.
 Unexpected loading can increase extensor muscle activity by
70% (Marras WS, 1987). The shorter the warning the higher
the increase in extensor muscle force (Lavender SA, 1989).
Biomechanics
 External stabilization
 Inconclusive evidence exists as to whether or not IAP is
increased, if restriction of a motion segment helps
reduce forces in the extensor muscles.
Clinical Evaluation
 Goals
 Resolution of problem
 Return to play at the pre-injury level
 Prevention of future injury
History
 On the field/at the event
 Mechanism of injury
 Any loss or increase in neurologic function
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What is a Stinger or burner?
 Character of the pain
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Sharp, stabbing, burning, tingling, throbbing
 Location of the pain
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Midline vs lateral
Does the pain radiate?
Physical Examination
 On the field/at the event
 If there is any question of a spinal column injury with
neurologic symptoms, it is important to immobilize
the athlete in the position in which he or she was found
and not attempt to move the athlete.
 No attempt should be made to remove equipment, such
as a football helmet or part of the uniform.
 The athlete and the provider are better served by overimmobilizing the injured athlete than by attempting to
move him or her in a hurry to allow completion of the
athletic event.
Physical Examination
 On the field
 ABC’s
 Brief neurologic evaluation
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Movement of fingers or toes where appropriate
Testing of sensation
Stinger or Burner
 2.2 brachial plexus
injuries per 100 players
per year
 at the collegiate level
approximately 50% of
football players have
sustained a stinger
 estimated that 30%
suffered their first injury
while playing high
school football
Stinger or Burner
 Unilateral symptoms
 Does NOT involve the legs
 Look for associated problems (fractures, etc)
 Check proper fit of equipment
 Return to play when strength returns, tingling resolves
and ROM normal.
History
 Obtain a complete history (in the office)
 Onset of the pain
 Mechanism of injury
 Any loss or increase in neurologic function
 Character of the pain
 Location of the pain
 Duration frequency of the pain
 Previous spine injuries
 Factors that exacerbate or reduce pain
Physical Examination
 Observation
 Body type
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Ectomorph—thin body build
Mesomorph—muscular or study body build
Endomorph—heavy, body build
 Gait
 Spinal Posture
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View anterior, posterior and lateral.
Physical Examination
 ROM
 Look for limitations in active ROM
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Flexion 40-60 degrees
Extension 20 degrees
 Standing
 Prone-Sphinx position
Lateral flexion 15-20 degrees
Rotation 3-18 degrees
 Look for limitations in distracted ROM
 Pain with performing certain motions
 Resisted isometric movements
Physical Examination
 Neurologic Examination
 Check sensation both light touch and pin prick
 Reflex testing
 Motor strength
 Check for clonus
Physical Examination
 Straight Leg Raise (SLR)
 Seated and supine
 When seated then lead into Slump Test
 Positive when symptomatic in the 35-70 degree range
with some radicular pain
Physical Examination
 Dynamic Abdominal test
 Normal (5)—hands behind neck until scapula clears
table and 20-30 second hold.
 Good (4)—arms crossed over chest until scapula clears
table and 20-30 second hold.
 Fair (3)—arms straight until scapula clears table (10-15
second hold.
 Poor (2)—arms extended towards knees until top of
scapula lifts from the table and 1-10 second hold.
 Trace (1)—unable to raise more than the head off the
table.
Physical Examination
 Internal/External
Abdominal Oblique Test
 Patient is supine with
knees straight
 Test with hands at the
side (do right then left
side)
 Test with hands across
the chest
 Test with hands behind
the head
Physical Examination
 Hamstring flexibility
 Ober’s Test
 Thomas Test
 Piriformis Stretch Test
 Stork Test
 Check peripheral pulses
Soft Tissue Injuries
 Sprains refers to ligamentous damage.
 Strains represent an injury to a muscle, tendon, or
musculotendinous junction.
 In the lumbar spine region, the symptoms of these types of
injuries
 are similar.
 Local paraspinal tenderness without radiculopathy
 Provoked by bending, twisting, and weight bearing.
 Physical signs may include local bruising; significant contusions
should prompt consideration of underlying transverse process
fracture or renal injury (particularly if hematuria is present)
 Anteroposterior and lateral lumbar spine x-ray films may be
obtained in such patients.
Soft Tissue Injuries
Soft Tissue Injuries
Soft Tissue Injuries
 Treatment is symptomatic with ice and/or heat
 Deep tissue massage may also be helpful
 Improper mechanics and/or poor overall conditioning may
predispose an athlete to soft-tissue injuries
 Appropriate rehabilitation must include mechanical
adjustments and emphasis on improved strengthening of
core musculature, flexibility of the lower extremities, and
overall ROM.
 The athlete with a low-back sprain or strain can return to
unrestricted competition when symptoms subside AND
full ROM is regained.
Disc Herniation
 As in the general population lumbar disc herniations are
more common in older athletes.
 Disc herniations in adolescents, although relatively rare, do
occur with sufficient frequency that this diagnosis must
always be entertained.
 They may present more subtly with only back pain and
spasm, with little or no radicular component
 Athletes in their teens or early 20s also frequently have less
obvious signs of radiculopathy
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Possibly because of their youthful and supple ligamentous
composition
The more viscous nature of the disc
The lower likelihood of a free-fragment herniation.
Radiology
Radiology-Stenosis
Disc Herniation
 In the younger group, imaging studies should be
considered in patients with persistent symptoms, even
though their symptoms are seemingly minor.
 Radiographic workup includes anteroposterior and
lateral films with oblique views to visualize the pars
interarticularis and lateral integrity of the spinal
alignment.
 The MR imaging studies will delineate the anatomy of
the disc and its relation to nerve roots.
Disc Herniation
 Treatment decisions are more complicated in the elite athlete, because
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the pressure to return to play is placed against the well-known success
rates of conservatively managed lumbar disc herniations.
Absolute indications for surgery in the athlete with lumbar disc
herniation include cauda equina syndrome and progressive
neurological deficit.
Relative indications include continued pain and inability to compete in
athletic competition.
The threshold for surgical intervention in the elite athlete is
Lower:
 If lumbar disc herniation is a barrier to competition.
 If pain is considerable and there are inadequate conservative options to
allow the athlete a return to performance in a timely fashion acceptable
to all parties involved, surgery may be considered.
Disc Herniation
 The surgical approach to the herniated lumbar disc is
guided by the tenet that tissue disruption should be
minimized so that the athlete may return to his or her preinjury level of physical performance.
 Bilateral laminectomies should be avoided
 Longer incision
 More extensive muscle dissection
 Can lead to post-operative instability or pain syndromes
 Standard microsurgical discectomy or percutaneous
microendoscopic discectomy are techniques of choice.
 The anulus is subjected to considerable tensile stress once
competition is resumed.
Disc Herniation
 The rehabilitation program is a critical determinant to how soon the athlete can return to
play.
 This is guided by:
 The safety of the athlete is paramount
 The timing of the injury in relation to the athletic calendar
 His or her athletic longevity
 The capabilities that the player will have after his or her athletic career is ended
 A recovery program may differ if the injury is sustained at the end of a season rather than
midway through.
 Aggressive core strengthening and increased flexibility and ROM form the basis of most
programs.
 Athletes may return to play
 After a sufficient time for healing and recovery
 When symptoms are minimal or absent.
 It is preferable that the athlete follow the standard course of rehabilitation after surgery
and that top-level competition only be resumed when all postoperative symptoms
subside and ROM has returned so that the chance for further injury is minimized.
Pars Defects-Spondylolysis and
Spondylolisthesis
 Not uncommon lumbar spine injuries in athletes, and usually
occur at L-5 (L5–S1) in young athletes engaged in sports
involving repetitive hyperextension and axial loading.
 Indeed, nearly 40% of athletes with back pain lasting for more
than 3 months had abnormalities of the pars interarticularis in
the lumbar spine (Jackson DW, 1979).
 Football players, especially offensive and defensive linemen, and
gymnasts are particularly susceptible, because both sports
involve tremendous degrees of hyperextension and vertical
loading.
 Up to 15% of college football players may have spondylolysis
whereas gymnasts may have an 11% incidence of spondylytic
defects (McCarroll JR, 1986).
Pars Defects-Spondylolysis and
Spondylolisthesis
 The presenting symptoms are low-back pain
exacerbated by extension, usually without
radiculopathy.
 Patients may compensate with knee and hip flexion on
ambulation, accompanied by shortened stride
(Phalen–Dickson sign).
 In cases of severe slippage, a slip may be palpable;
otherwise, the physical examination may reveal tight
hamstrings and lumbar muscle spasm.
Pars Defects-Spondylolysis and
Spondylolisthesis
 Imaging should include plain x-ray films and bone
scanning such as SPECT scanning
 The degree of slippage, if any, can be ascertained using
plain x-ray films.
 Computed tomography scanning is the modality of
choice to define the bone architecture of the pars.
 SPECT scanning may enable detection of occult and
acute “stress” fractures if plain x-ray films fail to reveal
a defect.
Pars Defects-Spondylolysis and
Spondylolisthesis
 The goals of management in the athlete with pars defects are
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alleviation of pain and prevention of progression and instability.
Nonsurgical management of symptomatic pars defects depends
on the degree of slippage.
In patients with low-grade slips, some advocate a period of
activity restriction until pain subsides, followed by gradual
resumption of activity (McTimoney CA, 2003).
Should pain resume, a period of lordotic bracing (for example, a
Boston brace) is recommended for between 3 and 6 months or
until pain subsides (Micheli LJ, 1980)
This approach may in some cases be augmented by the addition
of an external bone growth stimulator which may expedite
treatment in difficult cases.
Pars Defects-Spondylolysis and
Spondylolisthesis
 Plain x-ray films should show healing of the defect by 3 months; a
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SPECT scan may help assess the degree of healing if plain radiographs
are ambiguous.
Once pain has subsided, activities focused on core muscle
strengthening, lower-limb flexibility, and ROM can be resumed.
Athletes with low-grade slips can usually return to competition after an
aggressive rehabilitation program.
Athletes with high-grade slips, progressive slips, or symptoms
refractory to conservative management are considered to be candidates
for surgery.
Low-grade slips can be addressed by direct fusion of the pars defect,
with favorable rates for the return of athletes to play in noncontact
sports
Arthrosis of the affected joint is generally performed for higher-grade
spondylolisthesis.
Radiology
Minor Fractures
 Fractures of the transverse processes, spinous
processes, facets, vertebral bodies, and endplates are
uncommon.
 Most individuals with acute fractures present with
back pain immediately after the injury.
 In most cases the neurological examination is normal.
 Managed conservatively because only one column is
injured
 The athlete with a fracture of the transverse and/or
spinous processes can resume full activity when
symptoms have subsided and full ROM has returned.
Minor Fractures
 Mild compression fractures can occur in the anterior aspect of the vertebral
body.
 Exercises like squats or the military press involving repetitive flexion and
compression of lumbar vertebral bodies may lead to endplate fracture, disc
space collapse, or mild vertebral body fracture.
 Once healing occurs, these activities must thereafter be restricted to reduce the
risks of recurrence.
 Fractures of the facet joints are only now becoming a recognizable entity in
sports medicine, and may actually be more common than originally thought.
 Usually present with unilateral pain and pain on extension.
 In young athletes in particular, radicular symptoms may be a manifestation of
an associated epidural hematoma presumably caused by bleeding from the
fracture site.
 The injury is usually treated conservatively and monitored with neuroimaging
for resolution
 As with moststable fractures, athletes may return to vigorous activitywhen
symptoms and compressive radiographic abnormalities are resolved.
Football
 Aside from the trauma in
practice or during the event,
weight and strength training are
the back bone of football
programs.
 Incidence of low back pain in
weight lifters estimated to be
around 40%.
 Incidence of spondylolysis in
weight lifters is estimated to
be around 30% and in these
37% had spondylolisthesis.
 The forces needed to stabilized
the spine given what we know
about the biomechanics are
extremely high.
Football
 Iowa State study found
that 1 out of 10 football
lineman were markedly
overweight
 6 feet tall or under
 Weighing over 300 pounds
 The “kids” are bigger and
much faster than even 1520 years ago.
 Even more force is
generated during
participation in the sport
and while training
Football
 Gatt et al. in a small study (n=5) looked
at 5 division 1A football lineman as they
hit a blocking sled.
 The sled was outfitted with a force plate.
 The average impact force measured at
the blocking sled was 3013 ± 598 N.
 The average peak compression force at
the L4-5 motion segment was 8679 ±
1965 N.
 The average peak anteroposterior shear
force was 3304 ± 1116 N, and the average
peak lateral shear force was 1709 ± 411 N.
 The magnitude of the loads on the L4-5
motion segment during foot ball
blocking exceed those determined
during fatigue studies.
Courtesy of Rob Helfman, www.shawdog.com
Football
 Squats
 Military Press
 Fly’s
 Clean and Jerk
 Bench Press
Gymnastics
 The most commonly
mentioned sport in
reference to lower back
pain.
 Female gymnasts have
an incidence of
spondylolysis of 11%.
Gymnastics-Return to Play
 Return to Play-Spondylolysis
 Immobilization for > 6
months not recommended.
 Painless spinal mobility (Full
ROM)
 No hamstring spasm
 Clinical examination every 6
months
 After surgical fusion of a
spondylolisthesis
 Long-term effects of sporting
activities on the immature
athlete with a lumbar fusion
for spondylolysis and
spondylolisthesis are
unknown.
 Guidelines for return to play
must be made for each
athlete individually, based on
the severity of the
spondylolisthesis, the
surgical outcome, the
demands of the athlete’s
sport, and the experience of
the treating surgeon.
Running
 Distance runners predisposed to isolated abdominal
weakness and imbalances in flexor and extensor
muscles in the trunk as well as the legs.
 Treatment usually involves rigorous stretching
program along with cross training to correct the
muscular imbalances.
 Always check to be sure that proper footware is
maintained.
Golf
 Lower back pain is the number one problem on the
PGA tour and number two on the LPGA tour.
 300 golfers on the PGA tour in 1985 were interviewed
(Callaway and Jobe.
 230 experienced an injury (77%)
 44 % were spine related and 42% were related to the
lumbosacral spine.
 Golf swing
 Some braek the swing down into 6 components, some 7
and some up to 14 components.
Golf
 http://www.youtube.com/watch?v=s50K65PNeBU
Golf
 Address
 Slight flexion at lumbar
spine, hips and knees
 Center of mass is much
more forward than
when standing upright
 Produces increased
muscle forces across the
lumbar spine muscles
Golf
 Backswing
 The goal is to rotate the
shoulders, trunk and
hips while maintaining
abdominal support
 Ameteurs allow for
movement in saggital
plane which causes
increased lumbar
muscle forces
Golf
 Top of the backswing
 Beginning of cocontraction of the
internal and external
obliques on both the
right and left sides.
Golf
 Impact
 Beginning of cocontraction of the
internal and external
obliques on both the
right and left sides.
Golf
 Follow through
 Deceleration
Golf
 Return to Play
 Symptomatic
 Limit practice time
 Limit aspects of the
game that are practiced
at one time
 “Winter rules” or
preferred lies.
Golf…Through the years
 Muscles & Bones
 Sarcopenia

 Strength (LE>UE, proximal>distal)
 Muscle strength decline
 1 to 1.5% decline per day of strict bedrest (Siebens H., Aronow
H., Edwards D, 2000
  connective tissue elasticity

 flexibility
 Nerves and CNS (Kimura, 1989)
  nerve conduction velocity
  motor response
Golf
 As we age
 Decrease in overall strength

Proximal more than distal
 Decrease in flexibility
 Decreased motor response
 Increase in degenerative disc disease
 Advances in equipment technology
Baseball
 Hitting
 Begins with “seeing” the ball properly
 Late recognition of the ball leads to


Rotation of the hips in front of the shoulders
Increased torsional strain of the spine
 Throwing
 Trunk and leg strength generate the velocity for the throw
 Trunk muscle fatigue



Lumbar lordosis increases
Arm is behind in the pitching motion and pitches come up
Can predispose to arm injury
Tennis
 Involves much of what
we previously discussed
with the added aspect of
performing this
rotational motion in
awkward postions with
extremes of:
 Flexion
 Lateral bending
 extension
Bowling
 Three bowling actions for fast
bowlers
 The front-on technique with
hips and shoulders
remaining parallel to the
crease for much of the action
 The side-on technique
whereby the action starts
with the hips and shoulders
pointing down the pitch
 The mixed action whereby
the bowler usually counterrotates the shoulders towards
a side-on position early in
the action.
Basketball
 Applies all of the
principles we have
discussed to this point
 Unexpected loading
 Loading forces from
jumping and running >
2.5x body weight
Courtesy of Rob Helfman, www.shawdog.com
Summary
 Understanding the anatomy involved and
biomechanics
 Understanding the soft tissue response to injury and
how they heal
 Understanding the mentality of the athlete you are
taking care of
 Desire to return to play
 Understand and articulate how simple ADL’s can
prolong an athletes recovery and return to play.
Thank You
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