Frederick A. Davis M.D. Southern California Permanente Group
PM&R/Pain Management Symposium August 1, 2009
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Outline Overview Anatomy and Biomechanics Clinical Evaluation
History Physical Examination Specific Injuries Sport Specific
Football Gymnastics Running Golf Baseball Tennis Bowling
Basketball
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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
owneven without treatment! So why do they need us????
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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.
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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.
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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).
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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. 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
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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.
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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 Keenes 1989 study, a little
more than 50% of these injuries were acute in nature (Keene JS,
1989).
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Epidemiology Catastrophic spine injuries account for less than
1% of all sports injuries and usually involves the cervical
spine.
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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
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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
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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.
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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.
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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.
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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.
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Anatomy
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Specific Anatomic Points Intervertebral Disc 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 heart-
shaped compared with the more oval form seen in the lumbar
spine.
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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.
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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.
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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.
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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.
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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.
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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.
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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)
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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)
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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
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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
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Biomechanics Muscles Flexors Rectus abdominus, internal and
external obliques, transverse abdominus and psoas Extensors Erector
spinae, multifidus, and intertransversarii Rotation and lateral
bending When right and left side flexor and extensor muscles
contract asymmetrically lateral bending or twisting of the spine is
produced (Andersson, GBJ, 1997).
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Biomechanics During the first 50-60 degrees of unloaded flexion
range of 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)
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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 (flexion-
relaxation phenomenon).
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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)
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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.
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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.
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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.
Reduces the muscle energy exertion Tilting the pelvis forward
increases the sacral angle and lumbar lordosis increases and a
compensatory increase in kyphosis occurs
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Biomechanics
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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
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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.
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Biomechanics Intra-abdominal pressure (IAP) The pressure
created by coordinated contraction of the diaphram and abdominal
and pelvic floor muscles. 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).
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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.
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Clinical Evaluation Goals Resolution of problem Return to play
at the pre-injury level Prevention of future injury
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History On the field/at the event Mechanism of injury Any loss
or increase in neurologic function What is a Stinger or burner?
Character of the pain Sharp, stabbing, burning, tingling, throbbing
Location of the pain Midline vs lateral Does the pain radiate?
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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 over- immobilizing the injured athlete than by attempting to
move him or her in a hurry to allow completion of the athletic
event.
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Physical Examination On the field ABCs Brief neurologic
evaluation Movement of fingers or toes where appropriate Testing of
sensation
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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
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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.
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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
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Physical Examination Observation Body type Ectomorphthin body
build Mesomorphmuscular or study body build Endomorphheavy, body
build Gait Spinal Posture View anterior, posterior and
lateral.
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Physical Examination ROM Look for limitations in active ROM
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
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Physical Examination Neurologic Examination Check sensation
both light touch and pin prick Reflex testing Motor strength Check
for clonus
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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
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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.
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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
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Physical Examination Hamstring flexibility Obers Test Thomas
Test Piriformis Stretch Test Stork Test Check peripheral
pulses
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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.
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Soft Tissue Injuries
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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.
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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 Possibly
because of their youthful and supple ligamentous composition The
more viscous nature of the disc The lower likelihood of a
free-fragment herniation.
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Radiology
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Radiology-Stenosis
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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.
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Disc Herniation Treatment decisions are more complicated in the
elite athlete, because 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.
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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 pre- injury
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.
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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.
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Pars Defects-Spondylolysis and Spondylolisthesis Not uncommon
lumbar spine injuries in athletes, and usually occur at L-5 (L5S1)
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).
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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
(PhalenDickson sign). In cases of severe slippage, a slip may be
palpable; otherwise, the physical examination may reveal tight
hamstrings and lumbar muscle spasm.
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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.
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Pars Defects-Spondylolysis and Spondylolisthesis The goals of
management in the athlete with pars defects are 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.
Slide 73
Pars Defects-Spondylolysis and Spondylolisthesis Plain x-ray
films should show healing of the defect by 3 months; a 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.
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Radiology
Slide 75
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.
Slide 76
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.
Slide 77
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.
Slide 78
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 15- 20
years ago. Even more force is generated during participation in the
sport and while training
Slide 79
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
Slide 80
Football Squats Military Press Flys Clean and Jerk Bench
Press
Slide 81
Gymnastics The most commonly mentioned sport in reference to
lower back pain. Female gymnasts have an incidence of spondylolysis
of 11%.
Slide 82
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 athletes sport, and the
experience of the treating surgeon.
Slide 83
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.
Slide 84
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 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
Slide 87
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
Slide 88
Golf Top of the backswing Beginning of co- contraction of the
internal and external obliques on both the right and left
sides.
Slide 89
Golf Impact Beginning of co- contraction of the internal and
external obliques on both the right and left sides.
Slide 90
Golf Follow through Deceleration
Slide 91
Golf Return to Play Symptomatic Limit practice time Limit
aspects of the game that are practiced at one time Winter rules or
preferred lies.
Slide 92
GolfThrough 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
Slide 93
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
Slide 94
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
Slide 95
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
Slide 96
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 counter- rotates the
shoulders towards a side-on position early in the action.
Slide 97
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
Slide 98
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 ADLs
can prolong an athletes recovery and return to play.
Slide 99
Thank You
Slide 100
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Slide 101
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Slide 102
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Slide 103
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Slide 104
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Slide 105
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Slide 106
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Slide 107
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Slide 108
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