Transcript Role of the Lumbar Spine:

Role of the Lumbar Spine:
The most important region as it relates
to performance, treatment and
prevention of soft tissue injuries.
The relation of the spine to
somatoautonomic and
somatosomatic components have
recently been “discovered” by the
medical profession
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Key to performance:
As it relates to the shoulder
 Villanova swimmers 75%
 As it relates to Lower Extremity injuries
 As it relates to injuries of the upper
extremity
 As it relates to performance
 2nd most common injury in sports

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Running Kinesiology
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Low Back Injuries:
Sprain! Strain
 Pars Fractures
 Soft Tissue injuries
 Disc injuries

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Golf Swing Sequence
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Lumbar Sprain

Flexion: Tearing capsular ligaments,
Supraspinous Ligament, possible disc
injury.

Extension: Compression facet Joint.
Possible Pars fracture.
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Examination
Observation
 Inspection: A
 Palpation: T
 Range of Motion: R
 Provocative Tests
 Neurology
 Imaging

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Diagnostic Tests
Kemps
 Adams
 Sitting Bechterew
 SLR
 Braggards
 SotoHall
 Golthwaits

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Diagnostic Tests
Stork Test
 Gaenslens
 Obers
 Thomas
 Yeomans
 Nachlas
 Elys

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Neurology
Lower extremity neurology
 DTR’s
 Manual Muscle tests
 Pin Wheel
 Vascular: Dorsal pedis/Tibial
 Pathological Reflexes

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Treatment
If within 24-48 hours deal with the acute
tissue response
 A. Ice, lazer,HVG, Kinesiotaping. Cyriax
 After 48 hours: Cyriax Cross Fiber,
Muscle energy, Impulse Adjusting.
 Modalities to promote circulation,
midrange exercise..Adjustments to fixated
joints.
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Pars Injuries
Active Spondylo:
 Inactive Spondylo:
 Pending Spondylo:

Chapter 5: Dr Terry Yochum
 Illustration: Steven Soffer MD. FICS
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Epidemiology
Gymnasts: Female Adolescent
 Long Jumpers, Triple Jumpers.
 Weight Lifters
 Female volleyball, basketball
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Athletes that do repetitive hyperextension
activities.
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
History of repetitive hyperextension
activities or extreme vertical stress.

Positive Stork

Positive Kemps.
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Holding our Breath
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Cruising
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Pars Fracture MRI
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Radiological Evidence of pars
Defect
Perform spec If positive:
bone scan or Boston
stir MRI
overlap
brace: min 2
mo.
No: make
alternate
diagnosis
Does the
athlete
perform rep
hyperextensio
n activities
If no the make 60% have SI
alternative
Sub. SP/ST
diag:
Iliolumbar
ligament
Perform spec
or stir MRI
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Treat
Play no play
conservativel decision??
y as per
below
30% have
facet
syndrome
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Spondylolysis

There has never been a baby born with a
pars defect.
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Stress fracture:
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Pars defect Axial View
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Bilateral Pars Defect
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Scotty Dog
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Active Spondylo
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Active or Pending
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Treatment
HF 27 US .02 w/cm2 15 min.
 Laser/light 360 seconds
 Boston overlap: Minimum 2 months redo
spec bone scan or MRI
 Once FX is healed: CMT, RMT,
progressive resistance exercises as per
Wolfes Law.
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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Rehab
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The Sacroiliac Joint
Normal function as it relates to
performance
 Dysfunction as it relates to injury
 A. IT Band
 B. Patellofemoral syndrome
 C. Medial Shear at knee
 D. Hamstring Injuries
 F. Pronation
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Normal SI Structure/Function
Sits at a 55 degree angle to the sagital
plane and 30 degree to the frontal plane
 Nutates in both the saggital and frontal
plane
 Shearing forces ie: long jumping,
rebounding can subluxate the sacrum on
the ilium spraining the iliolumbar and
sacroiliac ligaments.

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Findings
History of shearing force or lifting and
twisting
 Palpatory exam: Iliolumbar, lumbosacral
and sacroiliac ligament
 Gaenslens Test
 Yeomans
 Nachlas

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AP SI Joints
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Anterior Inferior Sacrum
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SI ( continued )
Injury involves the quad femoris muscle
 Magines Syndrome. Marc Heller DC
 Very prominent in the female athlete
 Usually involves 5th lumbar facet
 Iliopsoas Muscle

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Pyriformis
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Pyriformis
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Lumbar Plexus
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Sciatic/Pyriformis relationship
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Iliopsoas
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Iliopsoas-Adductors
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SI Joint Treatment
Modalities as per presentation
 Adjustment: Long axis
 A. Does the Innominate rotate or does the
sacrum shear?
 B. Cyriax on Iliolumbar Ligament
 C. Check the kinetic chain including the
Head of the fibula, talus, navicular
 F. M.E on the pyriformis. IT band.

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Cervical Spine Injuries:
Diagnosis, treatment, rehabilitation,
prevention.
 On the Field management.
 A. Range of motion, Spurlings, Jacksons,
Cervical Compression
 B. Upper extremity Eval: Strength,
Neurology.
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Cervical Spine Treatment
Modalities as per presentation
 Prone Long Axis Adjustment or Impulse
adjustment
 Muscle Energy Technique
 Rehabilitation exercises
 Protection: Collar

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Head and Neck Injuries

Brain and Spinal Cord
Heal slowly
 Cannot regenerate
 Cannot be replaced
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
Evaluation must be quick and precise
Head and Neck Injuries

Assume any unconscious athlete has a neck
fracture
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Immobilize head and neck
Check airway
Check vitals: Blood pressure, pulse, respiration
Assess state of consciousness
Check pupils for reactivity, reflexes including
Babinski, reactivity
Movement of extremities
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Head and Neck Injuries

Brain Injuries
Compressive
 Tensile
 Shearing


Coup or contra coup
Coup: Head is not accelerated. Injury at the
site of impact
 Contra coup: Head is accelerated. Injury
opposite the site of impact

Head and Neck Injuries

Skull Fractures
Linear: Usually not brain injury.
 Depressed: Most likely to cause brain injury.
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Head and Neck Injuries
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Neck Injuries
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Axial Loading: Most serious. Is caused by flexing the
neck at the point of impact. Can cause a burst injury
to the vertebrae. A 20% neck flexion causes the bone
to absorb the force.
Flexion Sprain: Injury to the posterior soft tissue,
ligaments, capsule, muscles. Most serious.
Extension Sprain: Injury to the anterior soft tissue with
compression of the articular facets.
Cervicle Exam
Inspection
 Observation
 ART
 Cervicle Compression
 Jacksons Comp.
 Spurlings
 SotoHall

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Upper Extremity Neurology
Inspection: Look for Atrophy/Asymetry
 ART
 DTR
 Manual Muscle Testing
 Adsons, Allens , Wrights

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Treatment
Imflammation/Pain
 Restore normal ROM: Adjustment,
Impulse, ME,
 Strengthen/Stabilize
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Concussions:
Evaluation
 Impact Study
 Return to participation
 Repeat Concussions
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Concussions

Def: A complex pathophysiological
complex involving the brain induced by
traumatic biomechanical forces
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Concussions and Depression
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Common features include
1.Maybe caused by a direct blow to the
head, neck or elsewhere in the body which
transmits impulsive forces to the head.
 2.Typically results in in a rapid onset of
short lived impairment of of neurological
impairment that resolves spontaneously
 3.May result in neuropathological changes
but largely functional disturbance rather
than structural
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Common features ( cont.)
Result in a graded set of clinical symptoms
that may or may not involve loss of
consciousness. Resolution of clinical and
cognitive typically follow a sequential
course. In a small percentage post
concussive symptoms may be prolonged
 No abnormality on standard structural
neuroimaging studies is seen in
concussions
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Symptoms
Somatic( headache) cognitive( feeling in a
fog, emotional( lability)
 Physical signs: loss of consciousness,
amnesia
 Behavioral: irritability
 Cognitive: Slowed reaction time
 Sleep disturbance: drowsy
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Evaluation
Exclude Cervical Spine injury first
 Address First Aid Issues
 Physical Exam
 Cognitive
 Note: The player should not be left alone.
Monitor for deterioration
 No RTP on the day of the injury
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Concussions:
Concussions: 20%/year in High school Sports
 Grade 1: No loss of consciousness.
Momentary period of post traumatic amnesia.
 Grade 2: Momentary loss of consciousness
lasting less that 5 minutes. Amnesia longer
than 30 minutes but less than 24 hours.
 Grade 3: Loss of consciousness greater than
5 minutes. Amnesia longer than 24 hours.
Concussions:

Chronic Brain Injury:
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
Traumatic encephalitis
Repeated head injuries.
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Concussions:
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Post Concussion Syndrome:
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Headache
Dizziness
Fatigue
Irritability
Impaired memory and concentration
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Head Injuries
Intracranial Hemorrhage: Leading cause of
death from a head injury
 Epidural
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Fracture of the Temporal bone
Dramatic deterioration in consciousness in 3060 minutes
Subdural hematoma
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Most common fatal athletic head injury.
Unconsciousness at the instant of impact
Rapid deterioration
Head Injuries

Intracerebral hematoma
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Congenital malformation
Aneurism
Arteriovenous malformation
Subarachnoid Hemorrhage



Brain bruise
Aneurism
a/v malformation
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Head Injuries
 Malignant
Brain Edema syndrome
Rapid
deterioration to Coma
Death in a few hours
 Second
Impact Syndrome
Hyperemia
Second
acceleration head injury
Rapid progression to coma.
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Concussion Eval
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Concussion Eval
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Return to Play Protocols
1. No Activity: Complete physical and
cognitive rest. Until abate of symptoms
 2. Light aerobic exercise: Increase HR
 3. Sport Specific Exer: add movement
 4. Non contact drills: exercise,
coordination, cognitive load
 5. Full contact: restore confidience,
assessment of functional skills
 5. RTP

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Neck and Spinal Cord Injuries
 Cervical
Sprain
Damage
to musculo/tendinous/
ligamentous unit
Remove from competition
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Neck and Spinal Cord Injuries
Spinal Cord Concussion
 Violent
impact to the vertebral column
 Transient loss of motor or sensory
function
 Symptoms last less than 24 hours
 If greater than 24 hours may produce
permanent injury
Neck and Spinal Cord Injuries

Central Cord Syndrome
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Greater loss in upper extremity
Hyperextension Cervical
Sprain
Can an adjustment cause a
disc to herniate?
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Neck and Spinal Cord Injuries

Burning Hand Syndrome:

Lateral Pinch( Stinger)



Radiate down arm to thumb
Several minutes duration
Generally if radial in distribution it is the
neck. If ulnar distribution it is the thoracic
outlet.
Direct Trauma
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Thoracic Outlet
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Traction
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Compression
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Evaluation
Range of motion cervical spine
 Range of motion shoulder, elbow, hand
 Deep Tendon Reflexes
 Muscle testing
 Pathological reflexes
 Make transport decision

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Evaluation

Adsons

Allens

Wrights
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Treatment
Ice to effected area
 Laser
 Impulse Adjustments to Scalene Muscles
 Impulse Adjustments to TOS
 Exercises to retract scapula
 Return to competition as symptoms allow.

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Return to competition
decision-making
Concussions:
 Grade 1: 1st concussion: May return if
symptoms clear rapidly at rest and with
exertion.
 Grade 1: 2nd occurrence: Remove from
competition for two weeks. Must then be
asymptomatic for 7 days before return.
 Grade 1: 3rd occurrence: Season over.
No contact for three months.
Return to competition
decision-making
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MRI or EEG
Neuro Psychiatric exam
Grade 2: 1st occurrence: Stabilize the neck.
Asymptomatic for 7 days.
Grade 2: 2nd occurrence: Asymptomatic for 1
month before return
Grade 2: 3rd occurrence: Terminate season
Grade 3: Transport, Remove from competition
for 1 month, asymptomatic for 1 week.
Return to competition
decision-making
Factors to look at to prevent
head and neck injuries
Head
gear
Technique
Neck muscle conditioning
Return to competition after a
neck injury:
Neurological Exam:




Reflexes
Hoffman’s sign
Motor strength
Sensory exam
Return to competition after a
neck injury:
Orthopedic Exam:




Full ROM in Cervical Spine
Negative Spurlings Maneuver.
Strength in all planes of motion in
Cervical Spine
Normal Neuro exam