Back And Spine

LOW BACK DISORDERS

Injury Description

Back pain is very common in both athletes and non-athletes alike.  It can vary from a nagging, nuisance type of ache to a severe incapacitating pain.  The cause of back pain is complex and varied.  The following are the four main causes of back pain.

Mechanical Low Back Pain

This is the most common type of back problem seen in the sports participant.  It accounts for 70-75% of all back problems.   It is caused by strain or microscopic tears of the muscles and ligaments in the back and is usually the easiest to treat.

Facet Joint Syndrome

The vertebrae in your back are connected by small joints (facet joints).  These joints are about the size of the joints in your finger.  They can become strained and/or inflamed when they undergo extreme forces, as with excessive twisting or arching of the back.  Since you cannot splint these joints, the pain may persist for a long time as they are constantly irritated.  This accounts for 10-15% of back problems in the active person.

Herniated Disc

This is usually the most severe of low back disorders.  Traditionally it is called a "slipped disc."  It occurs commonly in the young (under 50), but can also bother the older participant.  The disc is a soft substance that acts as a shock absorber between the vertebrae.  The inner center of the disc is like the liquid center of a golf ball which can push out at a point of weakness or injury.  This can then press on the nerves causing pain from the back down to the foot.  This condition accounts for 5-10% of back problems.

Degenerated Discs

If the discs lose moister, they may occasionally shrink and cause the facet joints to settle closer together, thus irritating the adjacent nerves.  Some disc degeneration commonly occurs in people over 40 even without specific injury.

The above four conditions encompass the major causes of back pain in the active person, but there are many other possibilities.   The treatment of each individual back problem varies but the principles are the same.

N.B. If your symptoms change, notify your doctor immediately for re-assessment.

Treatment

Rest

In the most severe cases, total bed rest is mandatory.  You must be on a hard surface (firm mattress, floor).  These are the two ideal rest positions:

• Lie on your back with pillows placed under your knees

• Lie on your side with your knees pulled up to your chest.  Place pillows between the knees.

Ice, Heat, & Massage

If your muscles are in spasm, ice and/or massage can help relieve the spasm and the associated pain.  To reduce stiffness, heat can be applied in the form of heating pad, baths, whirlpool, etc.

Medication

Your physician may prescribe pills depending on the nature of your back pain.  The pills will help relieve muscle spasm, decrease inflammation in the joints or ligaments, and help reduce pain.

Physiotherapy

You may need physiotherapy to reduce the muscle spasm and inflammation in your back.  In addition a rehabilitation program to prevent further episodes of back pain should be worked out for you, based primarily on increasing the flexibility and strength of your back.

Brace

Our team may prescribe a brace to help support your back.  If sitting for long periods of time seems to aggravate your back, then special back supports may be helpful to relieve the pain.

Lifestyle

Small adjustments in the way you sit, stand, lean, and sleep can make a remarkable difference to your back.  Your doctor or physiotherapist will discuss these adjustments with you.

Weight Reduction

This is most important.  Often losing 10 pounds can alter your posture enough to relieve some pressure from the back.

Sports

When back pain is severe, all sports are obviously impossible.  When you do return to sporting activity, the best sports are those that keep the back straight and do not involve jarring and twisting movements which aggravate the condition.  Try to maintain your pelvic tilt (see exercises) during your sport.

Good Sports

These sports will be easiest on your back:

• Swimming (especially on your back)

• Cycling (stationary)

• Walking

• Skating

Questionable Sports

These may be alright for some people but bad for others:

• Jogging

• Skiing (downhill and cross-country)

• Baseball

• Hockey

Bad Sports

These sports are particularly hard on your back

• Diving (avoid at all times)

• Racquet sports

• Football

• Volleyball

• Basketball

• Running fast or downhill

Exercises

The conditioning of the stomach muscles is the key to improving your back problem.  The basic back exercise is the pelvic tilt.   It is important that you learn this exercise first, and then try to maintain its position during your sport activities.  Initially, the pelvic tilt may feel awkward, but with practice it can become second nature.

The Pelvic Tilt

Lie flat on your back, knees bent, feet flat on the floor, and body relaxed.  Tighten your abdominal muscles and press the small of your back into the floor while tightening your buttocks muscles and tilting your pelvis up.  Hold 10 seconds and relax.  Repeat 10 times.

A progression of the basic pelvic tilt is the knee raise.  Tilt the pelvis as above and raise right knee up over chest without using your hands.  Now raise your left knee to join the right.  Hold both for 5 seconds and return feet flat to the floor.  Repeat 10 times.

Hamstring Stretch

Sit on the floor with your leg straight, knee locked, and other leg bent in.  With your back straight, bend from the hips and reach down over your leg until you feel the muscles stretch.  Hold and relax.  Repeat 3 times with each leg.  If this exercise causes pain, discontinue.

Sit-ups

Full bent knee sit-ups can be added as pain subsides.  Maintain pelvic tilt.  Sit-ups should be done slowly, with a smooth, non-jerky motion (both up and down).  Start with only a few, and increase the number as your strength improves.

Questions and Answers

Why do I have back pain?
There are many structures in the spine which may become strained, injured, worn, or diseased.  The spinal column is made up of 33 vertebrae, which work together to provide flexibility in motion, protection for the spinal cord, support for the upper body, and force redistribution.  The vertebrae are separated from each other by soft-centered discs.  If these vertebrae become inflamed, get moved out of line, or press too hard on the discs, you may suffer back pain.

The spine is supported by muscles and ligaments, may become strained or weakened.  This can lead to muscle spasm and resulting back pain.  Most back pain can be caused by sprain, muscle weakness, tension, or arthritic conditions.

How does a muscle strain happen?
Muscle strain (stretching beyond normal limits) may result in inflammation of the muscle fibers and spasm of those fibers and adjacent fibers.  Chronic muscle strain may be a result of poor posture or overuse of muscles.  Lifting and turning at the same time, lifting too much weight, or twisting into an awkward position may strain the involved muscle group.  Strains can occur in any area of the body - back, neck, leg, shoulder, etc.
Muscle strain can also be caused by lack of adequate warm-up exercises, certain traumatic conditions, and being overweight.

Why is bed rest recommended?
Bed rest is often recommended in order to allow the injured area to heal without any further stress.  The amount of bed rest prescribed by your doctor will vary according to your condition.  Your physician may also recommend dry or wet heat.  Occasionally, cold, such as ice massage, may be effective in the temporary relief of acute muscle spasm.

What role does exercise play?
Supervised exercise is the most common treatment for muscle strain.   Strong muscles help support your back, and proper tone can improve posture and reduce the chance of muscle strain.

An exercise program should begin once the acute muscle spasm has subsided.   CONSULT YOUR DOCTOR BEFORE ATTEMPTING ANY EXERCISES.  If your doctor recommends an exercise program for you, start slowly and do not overdo it.  Follow your doctor's instructions carefully, and consult your doctor if pain occurs.

Posture and Lifting Techniques to Minimize Back Strain

The way you stand and sit, the way you lift objects can be critical to your health, especially if you have back problems.  Take a look at the "right" and "wrong" shown here.  Make a habit of being "right."  Take it easy on your back

Lifting

Riding

Basic Low Back Syndrome Conditioning Exercises

These exercises are designed to strengthen a back that has been weakened by a strain, defect, disease, or a simple lack of exercise.   CONSULT YOUR DOCTOR BEFORE ATTEMPTING THESE EXERCISES.  If your doctor recommends any of these exercises for you, start them slowly.  Do not overdo it!   Follow your doctor's instructions carefully.  Consult your doctor if pain occurs.

Starting position for all exercises: lying on the floor, knees and hips bent with back flat and neck comfortably supported, arms to the side, and feet flat on the floor.

Bring one knee to the chest; straighten the knee, extending the leg as far as possible; bend the knee and return to original position.   Relax.  Alternate with the opposite leg.  Repeat 5 times.  This exercise is NOT recommended for patients with sciatic pain.

Exercises for Better Back Care

General Instructions

Your best back support is derived from your own back muscles!  Faithful performance of back exercises often avoids the necessity of an external brace or corset.  Back muscles can give you all the support needed if you strengthen them by routine performance of prescribed exercise.

Exercises

Follow the exercise routine prescribed by your doctor.  Gradually increase the frequency of your exercises as your condition improves, but stop when fatigued.  If your muscles are tight, take a warm shower or tub bath before performing your back exercises.  Do not be alarmed if you have mild aching after performing exercises.  This should diminish as your muscles become stronger.

Exercise on a rug or mat.  Put a small pillow under your neck.  Wear loose clothing; no shoes.  Stop doing any exercise that causes pain until you have checked with your doctor.

Helpful Hints for a Healthy Back

Standing and Walking

Try to toe straight ahead when walking; put most of your weight on your heels; hold your chest forward and elevate the front of the pelvis as if walking up an incline.  Avoid wearing high heels.  Stand as if you are trying to touch the ceiling with the top of your head, eyes straight ahead.  All the elements of good posture will flow from these simply maneuvers.

Sitting

Sit in a hard back chair with spine pushed back; try to eliminate the hollow in the lower back.  If possible, elevate the knees higher than hips while sitting in an automobile.  Secretaries should adjust posture chairs accordingly.  Sit all the way back in the chair with your back erect.

Lifting

Bend your knees; squat and lift with your thigh muscles, not your back.  Never bend with your knees straight and lift with the upper torso.  Move slowly and avoid sudden movements.  Try to avoid lifting loads in front of you above the waist line.  Avoid bending over to lift heavy objects from car trunks, as this places strain on low back muscles.

Sleeping

Sleep on a firm mattress; a 3/4 inch plywood bed board is helpful and should be used with all but a very firm orthopedic mattress.   With acute back pain, sleep with a pillow or blanket rolled under the knees and a pillow under the head.  Keep your knees and under the head.  Keep your knees and hips bent when sleeping on your side.

Driving

Use a firm seat with a padded plywood or special seat support.  Sit close to the wheel with knees bent.  On long trips, stop every one to two hours and walk to relieve tension and relax muscles.

Working

Try to avoid fatigue cause by work requiring long standing.  Flex hips and knees by occasionally placing a foot on a stool or bench.  Take exercise breaks from desk work by getting up, moving around, and performing a few back exercises in the standing position.

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NECK INJURY

What is it?

The cervical spine (bones in the neck) allows more motion than other parts of the spine, thus the neck is an extremely flexible part.  The problem with the neck's being so flexible is that because it moves so easily and is less protected than the rest of the spine, it is more prone to injury.  For most people neck pain is something that disappears with time, but for some it requires medical diagnosis and treatment.

Causes

Neck pain can come from a variety of abnormalities including the soft tissues, the muscles, the ligaments, and the nerves.  Neck pain also can come from the ones and joints of the spine.  Prolonged wear and tear causes damage to the soft tissues, and this is the most common reason for neck pain.  In some people neck pain can come from problems in the back or shoulders.  Rarely people will get pain from infections or tumors.

Degenerative diseases that cause neck pain include osteoarthritis and rheumatoid arthritis, osteoarthritis usually occurs in the elderly as a result of wear and tear of the joints between the bones in the neck.  Rheumatoid arthritis causes destruction to the neck joints.  Both are known to cause stiffness and pain.

Cervical disk degeneration can also cause neck pain, because the disk acts like a shock absorber between the bones in the neck.  People usually develop this after the age of 40.  The disk degenerates and the space between the vertebrae narrows.  Also what could happen is the cervical disk could protrude and cause pressure on the spinal cord or nerve roots when the disk weakens (herniated cervical disk).

Because the neck is so flexible and it supports the head, it's very susceptible to injury.  Injury occurs often in motor vehicle accidents, with contact sports, diving accidents, and falls.  Sometimes in car accidents people hyperextend their neck, which is when the neck moves backwards further then the normal limit.  People can do the opposite, which is known as hyperflexion, a forward motion beyond the normal limits.  Fractures or dislocations of the neck can damage the spinal cord and cause paralysis.

Seek Treatment When...

One should seek medical care for neck pain if it occurs after an automobile accident, or following any sort of trauma to the head or neck.  Immediate medical care should be sought if the injury causes pain down the arms and legs.  Also if the pain isn't to bad in the neck, but causes radiating pain down the arms and legs with numbness the emergency care should be taken.  If there hasn't been any injury then medical care should be obtained when neck pain is: continuous and persistent, severe, accompanied by pain down the arms and/or legs, and when pain is accompanied by headaches, numbness, and weakness.

Diagnosis

Often times orthopedic care is used for proper care of neck pain.  They are trained in the workings of the musculoskeletal system, including the muscles, bones, joints, ligaments, and tendons.  The first thing to do in order to treat the pain is to determine the source of the pain, which can be tougher than it may seem.  The doctor will first take a complete history of the problem concerning the neck pain, also the doctor will ask about other medical problems, and if there was any previous treatment for the neck.  Second, the doctor will perform a physical examination, which will include evaluation of some neck movements, neck tenderness, and nerve and muscle functions.  Also, a lot of time x-rays are used to be sure there isn't anything happening with the bones.  If after these test are performed the doctor needs more help, one or more of the following tests will be prescribed:

• MRI (Magnetic Resonance Imaging), which allows evaluation of the spinal cord and nerve roots; it is non x-ray

• Myelogram (injection of a dye or contrast material into the spinal canal), this x-ray allows for very specific evaluation of the nerve roots and spinal canal.

• CT (computed tomography), this specialized x-ray allows evaluation of the bone and spinal canal.

• EMG (electromyogram), this test is used to evaluation nerve and muscle function.

Treatment

Treatment obviously depends on the diagnosis made by the doctor, but most of the time patients are successfully treated with rest, medication, immobilization, physical therapy, exercise, and activity modifications.

Rest is good simply because sometimes people have a tendency to do to much and wind up overusing their muscles which can cause pain.  Medication is often given in the form of anti-inflammatories because people may get swelling from overuse or irritation of the muscles.  Immobilization is again to allow for the body to calm back down and rest before getting back into stressful situations.

Physical therapy can be good to teach various stretches as well as to help people strengthen their muscles, to alleviate pain from overuse.

Surgery is sometimes used to treat neck pain, if the pain persists after all of the other treatments has been applied.  Sometimes surgery is needed to reduce the pressure on the spinal cord or a nerve root, when the pain is caused by a herniated disk or narrowing of the spinal canal.  Surgery is also needed sometimes following an injury, to stabilize the neck and minimize the possibility of paralysis, for example when a fracture results in instability of the neck.

STINGERS

What is it?

Stingers are seen most by football players, more specifically defensive football players, but any athlete can attain a stinger. A stinger, sometimes referred to as the following: burners, hotshots, zingers, and nerve concussions are intensely painful sensory paresthesia that can last from a few seconds up to a few minutes and are accompanied by some sort of upper extremity weakness.

The weakness is of varying severity and can last from 15 minutes to longer depending on the severity. All stingers may start out with the exact same symptoms, but the underlying injury can be quite different in severity and may affect either the brachial plexus or the nerve root.

These symptoms usually indicate an injury no more proximal than the nerve root and are often experienced unilaterally. Simultaneous symptoms in both upper extremities often signals a spinal cord injury, and should be treated extremely cautiously as a medical emergency.

There is a wide spectrum of injury that can result from a stinger, such as the following: a single transient nerve irritation with no residual deficits; those recur as many as 50 times during a season with no residual deficits; complete avulsion of the nerve roots at the level of the spinal cord that results in permanent anatomic and functional deficits to the upper extremity.

The major point is that all stingers are not the same and it is important that clinicians, trainers, coaches, and athletes understand this. They are symptoms of neurologic insult to either the brachial plexus or the nerve root, which must be evaluated systematically so that the appropriate treatment regiment can be delivered. Since recurrent stingers can result in more severe residual injuries, it is imperative that the treatment includes trying to prevent recurrent injuries.

Mechanism and Frequency

As stated before stingers are most seen in tackle football, but they do occur in other sports as well. Some of the other sports include the following: wrestling, backpacking, sledding, skiing, horseback riding, boxing, weight lifting, and mountain climbing. Since most of stingers occur during football, we will delve into these injuries.

The mechanism of stingers usually involved the athlete’s shoulder colliding with another athlete, the ground, or another object and depressing the shoulder at the same time the cervical spine is hyperextended, hyperflexed, or laterally flexed to the opposite side. As a result the angle of the shoulder-neck is pushed beyond its normal range, which stretches the brachial plexus on the side of the contact. From the stretching of the brachial plexus the C5-C6 nerve roots are injured. Almost 50% of some collegiate varsity football teams’ players can suffer this injury in a four year period of time. Up to 10% of these may be serious enough to cause neurologic deficits that last several hours or longer.

Stingers occur a lot more in college and professional athletes than high school , and it is clear that defensive backs, linebackers, and defensive ends are more likely to receive stingers than other players.

Pathophysiologic Basis of Stingers

Severe burning, stinging paresthesia, and anesthesia in one upper extremity radiate from the shoulder distally through the arm as far as the fingers. The burning and accompanying weakness, most often of the shoulder abductors, external rotators, and elbow flexors are from a neural injury and can last from a few seconds to years.

The severity and duration of the symptoms is determined by the extent of damage to the neural elements. The classification that we’ll use is an electrophysiologic method that correlates to Sunderland’s classification system:

• Transient neurapraxia is a transient block of the neural conduction owing to temporary loss of myelin (Schwann Cell) function around the axon. Since it usually takes only a few minutes for this process to be resolved, it is most likely only a mechanical and vascular response of the neural elements with no structural damage. Once myeline function is restored, the player is symptom free, but may still have some soreness and bruising around the shoulder and at the supraclavicular triangle.

• Neurapraxia is a injury to the myelin sufficient to cause the body to actually absorb the injured cells and synthesize new Schwann Cells, which then go through a maturation process to replace the damaged ones. This reparative phase takes varying amounts of time depending on the number of cells needing to be replaced and their location. Most of the neural function is back to normal within 2 to 6 weeks.

• Axonotmesis occurs when the injury is sufficient to cause damage to the axon and the myelin, which results in actual degeneration of the motor unit organization , which causes the clinically detected weakness. The findings in the electrophysiology during this phase should correlate with the findings clinically (weakness). This type of nerve injury usually regenerates to proximal muscles in 5-6 months.

• Neurotmesis is damage of the axon, surrounding myelin, and adjacent connective tissue, sometimes including the epineurium that is so extensive that regeneration is very poor and loss of function is permanent. The problem is that during the regeneration phase, the structures of the involved axons are too severely damaged to allow regeneration . The only increase in strength comes from collateral sprouting of spared axons into the denervated muscle fibers to create larger than normal muscle fibers per motor axon.

Evaluation and Treatment

Stingers are very easy to notice for doctors, trainers, or coaches because an athlete during competition will usually run off the field holding a limp arm to his/her side. Whoever is responsible for the athlete’s care should immediately ask the athlete where it hurts and how the injury was sustained. In order for appropriate inspection the athlete should remove as much protective gear as possible, so that the cervical spine, shoulders, and arms can be examined.

All of the following should be examined: range of motion of the cervical spine and the upper extremities, manual muscle testing of the upper extremities, gross sensation to light, and reflexes. The athlete should be checked repeatedly throughout the remainder of the game. After the game the athlete should be further examined in the locker room, with the previous tests performed and also more tests to get a good feel for the extent of the injury. Participation is withheld until the player is examined by the appropriate professional to ensure that no weakness has developed.

Prevention

Despite the rules being changed in 1979 to prevent the use of the head for spearing or butting in football due to the large number of cervical injuries, still stingers occur. A high-quality shoulder pad is helpful in absorbing the compression forces received in aggressive shoulder tackling. Once a football player or any athlete receives a stinger additional padding to the shoulder and neck can be helpful.

Rehabilitation

Due to the fact that muscles and bones protect the brachial plexus and nerve roots from injury, soreness from strain and contusion of the scalene, trapezius, and levator scapulae muscles is often associated with a stinger. To minimize bruising, ice should be used immediately, followed by heat after the first 72 hours. Strengthening exercises should be used during the season and off season because it has been documented that stingers often recur and recurrence can cause neurologic deficits. Strengthening will decrease the likelihood of recurrence thus it is worthwhile.