Frederick A. Davis M.D. Southern California Permanente Group PM&R/Pain Management Symposium August...

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 owneven 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. 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 Keenes 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

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.

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 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).

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)

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).

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. 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

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. 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 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?

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.

Physical Examination On the field ABCs Brief neurologic evaluation 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 Ectomorphthin body build Mesomorphmuscular or study body build Endomorphheavy, body build Gait Spinal Posture View anterior, posterior and lateral.

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

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 Obers 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

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 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 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 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.

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 (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).

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.

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 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 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 15- 20 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 Flys 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 athletes 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=s50K65PNeBUwww.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 co- contraction of the internal and external obliques on both the right and left sides.

Golf Impact Beginning of co- contraction 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.

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

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 counter- rotates 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 ADLs can prolong an athletes recovery and return to play.

Thank You

References Keene, JS. et al: Back injuries in college athletes. J Spinal Disord. 2:190-195,1989. Ryan AJ: Medical aspects of sports. JAMA 1965; 194:1118-1124. Snook GA: Injuries in women's gymnastics: A 5 year study. Am J Sport Med 1979; 7:242-244. Snook GA: Injuries in intercollegiate wrestling: A 5 year study. Am J Sports Med 1982; 10:140-144.

References Dreisinger TE, Nelson B: Management of back pain in athletes. Sports Med 21:313320, 1996 Kelsey JL, White AA III: Epidemiology and impact of low back pain. Spine 5:133142, 1980 Micheli LJ, Wood R: Back pain in young athletes. Significantdifferences from adults in causes and patterns. Arch Pediatr Adolesc Med 149:1518, 1995 Fairbank JC, Pynsent PB, Van Poortvliet JA, Phillips H: Influence of anthropometric factors and joint laxity in the incidence of adolescent back pain. Spine 9:461 464, 1984.

References Keene JS, Albert MJ, Springer SL, Drummond DS, Clancy WGJr: Back injuries in college athletes. J Spinal Disord 2:190195, 1989 Kelsey JL, White AA III: Epidemiology and impact of low back pain. Spine 5:133142, 1980 Pearcy MJ, Bogduk N: Instantaneous axes of rotation of the lumbar intervertebral joints. Spine 13:10331041, 1988

References Jackson DW: Low back pain in young athletes: evaluation of stress reaction and discogenic problems. Am J Sports Med 7:364366, 1979 McCarroll JR, Miller JM, Ritter MA: Lumbar spondylolysisand spondylolisthesis in college football players. A prospective study. Am J Sports Med 14:404406, 1986 McTimoney CA, Micheli LJ: Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep 2:4146, 2003 Micheli LJ, Hall JE, Miller ME: Use of modified Boston brace for back injuries in athletes. Am J Sports Med 8:351 356, 1980

References Stinson JT: Spine problems in the athlete. Md Med J 45:655658, 1996 Panjabi, MM, et al: Physiologic strains in the lumbar spinal ligaments. An in vitro biomechanical study. Spine, 7:192, 1982. White, AA and Panjabi MM: Clinical Biomechanics of the Spine. Philadelphia, JB Lippincott, 1978. McGill, SM. Et al. Three-dimensional kinematics and trunk muscle myoelectric activity in the elderly spine-a database compared to young people. Clin Biomechanics, 14:389, 1999.

References Biering-Sorensen, F. Physical measurements as risk indicators for low-back trouble over a one year period. Spine 9:106, 1984. Moll, JMH, et al. Normal range of spinal mobility. An objective clinical study. Ann Rheum Dis. 30:381, 1971. Andersson, GBJ, et al. Evaluation of Muscle function in J.W. Frymoyer (Ed). The Adult Spine. Principles and Practice. New York, Lippincott-Raven. 341-380, 1997.

References Carlsoo, S. The static muscle load in different work positions: An electromyographic study. Ergonomics, 4:193, 1961. Farfan, HF. Muscular mechanism of the lumbar spine and the position of power and efficiency. Orthop Clin North Am. 6:135, 1975. Nelson, JM. Et al. Relative lumbar and and pelvic motion during loaded spinal flexion/extension. Spine, 20:199, 1995. Davis, KG et al. Evaluation of spinal loading during lowering and lifting. Clin Biomechanics. 13:141, 1998.

References Eie, N. Load capacity of the low back. J OsloCity Hosp. 16:33, 1966. Ranu, HS. Measurement of pressures in the nucleus and within the annulus of the human spinal disc due to extreme loading. Proc Inst Mech Eng (H)204:141, 1990. Cappozzo, A. Compressive loads in the lumbar vertebral column during normal level walking. J Orthop Res. 1:292, 1984. Axler, CT et al. Low back loads over a variety of abdominal exercises: searching for the safest abdominal challenge. Medicine & Science in Sport and Exercise. 29:204, 1997.

References Lavender, SA. Et al. The effects of preview and task symmetry on trunk muscle response to sudden loading. Human Factors. 31:101, 1989. Marras, WS. Et al. Trunk loading and expectation. Ergonomics. 30: 551, 1987. Gatt, CJ et al. Impact Loading of the Lumbar Spine During Football Blocking. The American Journal of Sports Medicine 25:317-321 (1997) AndersonK,SarwarkJF,ConwayJJ,LogueS, Schafer MF. Quantitative assessment with SPECT imaging of stress injuries of the pars interarticularis and response to bracing. J Pediatr Orthop 2000;20:2833.

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