LOW BACK INJURIES

LOW BACK

Sarah Burkart

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INTRODUCTION

Back pain is the third most common reason that people go to the doctor’s office, and approximately 80-90% of people in their lifetime will have at least one episode of low back pain that disrupts work, sports, or everyday activities.

The following presentation is to provide useful information on low back pain, its relation to sports, and links to other sources. It should in no way be used to diagnose a problem, or be a substitute for a visit to your health care provider.


ANATOMY OF THE SPINE

vcolm.gif (32586 bytes)The spine, a bony column in the middle of the back, provides support for the body and1.jpg (62267 bytes) flexibility for the trunk. These bones surround the spinal cord, the bundle of nerves that allow us to feel sensation and to move. This is all held together by a system of muscles and ligaments, and forms an "S" shape naturally. The lower portion of this "S" is the low back, or lumbar spine.

The lumbar spine is made of 5 bones called vertebrae, named L1-L5. These bones are separated by intervertebral disks (or discs), that cushion the vertebrae and allow for movements of the back like bending. These intervertebral disks are similar to cushions of a gel-like material between the bones. Nerve fibers going to and from the spinal cord and the body also pass at each vertebra, or spinal level.


LOW BACK PAIN (LBP) SYMPTOMS

Most people do not suddenly injure their backs and feel pain; it is usually a gradual process that reflects degenerative changes in the spine over the years. In other words, our backs become worn as we age. Twisting and bending produces a great deal of stress on the back, which adds up over time.

LBP can be divided into 2 types: Mechanical and compressive.

1. Mechanical pain is due to injury of the vertebrae, disk, ligaments, or muscles of the back. It usually causes soreness like a pulled muscle in the low back that may radiate, or be felt in, the buttocks and thighs. The great majority of sudden low back injury and pain (such as due to a sport) is from the twisting and straining of the muscles in the back. But direct blows to the spine can fracture, or break, vertebrae. Continuous strain on the back can lead to inflammation and destruction of the intervertebral disks, called herniated disks or annular tears.

2. Compressive pain is due to the pinching of the nerves going to and from the spine. This pain is different in every person, but the earliest sign of a pinched nerve is that the area near it on the back may go numb. There is a large nerve, the sciatic, that runs out of the lumber spine and down each leg. If the sciatic nerve is pinched, it can produce severe, shooting pain in the back, hip, buttocks, and all the way down the leg. Long- term compression of a nerve going to muscle can also result in the weakening of that muscle.

*********WARNING*********

If you are experiencing compression-type nerve pain in your lower back, and you have suddenly lost bowel and bladder control, contact your physician or go to the ER immediately! THIS IS AN EMERGENCY called cauda equina syndrome.

In all back injuries, the history is extremely important to figure out a cause and determine treatment. Some questions your health care provider will ask include the following: How long you have had back pain? Where exactly is the pain located and what does it feel like? Did any one event cause the back pain? Have you had pain in the past? Does anything relieve the pain or make it worse?

After a thorough physical examination, you may get imaging studies and tests done so that any problem may be visualized. These include X-ray, MRI, CT Scan, Myelogram, Discogram, Electromyogram, and bone scan. The MRI is most commonly used to look at the spine. Many changes and injuries to the spine can be seen by one of these methods and, together with history and physical, can help determine the best treatment plan.

There is such a wide range of back injury, no one treatment plan is right for everyone. The majority of simple back strains will resolve on their own in a matter of weeks, and require nothing more than a day or two of rest, followed by back-strengthening exercises and stretches. On the other hand, large disk herniations, especially with sciatic pain, require more aggressive treatment, and possibly surgery.

The goals of any treatment plan for LBP are:

1. to relieve the pain

2. to get back to pre-injury activities

3. to prevent future injury

Some general things you can do are: use warm or cold compresses to ease sore muscles, take aspirin or ibuprofen for the pain, do back strengthening exercises, and modify any activities that cause the pain. Being active and stretching will also help. Overweight people may find some benefit in losing weight to help their low back pain. Water therapy in a pool is another great way to exercise and soothe a sore back.

The links section of this page will connect you to some great resources for exercise programs and tell about treatments for specific back problems.


SPORTS AND LOW BACK PAIN

Injuries to the lumbar spine are the most common injuries in gymnastics, football, weightlifting, wrestling, dance, rowing, swimming and golf. Back injuries are also significant in many other sports. The following information on individual sports can be found in: The Low Back Pain Handbook, "The Lumbar Spine and Sports" by A.J. Cole et al. (see references).

Baseball

Lumbar pain is most common in infielders, from constant bending. There is also severe stress on the lower back during the twisting motions involved in pitching and hitting. Prone to muscle and ligament strain and sprain, disk and facet injuries. Strengthen abdominal and back muscles through trunk exercises. Hitters may need to adjust swing to keep the back happy.


Basketball

Centers are most prone to low back injury, especially strains and sprains, but also vertebral fractures from contact in the paint. Strengthening the back and stretching will help.


Bicycling

Prone to back strains and facet pain, as well as increased incidence of sciatic pain, mostly due to the position of the body on the bicycle. The best thing to do is correctly position yourself:

-if you rock side-to-side, lower your seat

-if one leg is longer than the other, build up the pedal on the shorter leg

-if the lumbar spine is too flexed, (bent over), raise the handlebar

Also, ride a good quality bike with properly inflated tires and a suspension system.


Dance/Aerobics

Low back pain is common in all types of dance and aerobics, but is most common in ballet. Dancers are prone to disk and facet pain due to hyperextension common in dance moves and lifts. Maintain proper posture, concentrate on flexibility, emphasize abdominal strength and cut down on arabesque-type movements to protect the back.


Football

About 30% of players lose playing time to a low back injury. Most of these are due to a direct blow, or a single instant of overload on the spine, like diving in for a touchdown. Direct hits often cause fractures of the parts of the vertebrae, such as the transverse process. This happens to quarterbacks and receivers, who may be blind-sided or hit in the air. Linemen are prone to spondylolysis, and need to practice flexing in the hips and knees, not the back, while blocking to decrease injury. Football players have a peculiar problem in that most already have well-developed trunk and upper body muscles, which can become inflamed and spasm following injury, interfering in the healing process. The way around this is careful back stabilization during rehabilitation and weight lifting supervised by a trainer or therapist.


Golf

Low back injury usually occurs with the downswing of the club. Prone to disk and facet injury. Strengthen trunk muscles and do postural and balance exercises. May need to revise golf swing to be more "back friendly".


Gymnastics

Most low back pain is due to overuse and repeated hyperextension during exercises like handsprings and walkovers. Most episodes will go away on their own in 6 weeks. Prone to facet joint injury, spondylolysis and herniated disk. Try to stabilize the spine during stretching and dismount to reduce stress on the back, and don’t forget to smile during the floor exercises!


Racquet sports

Most injury occurs during the serve and overhead hits, so be sure to use the knees and the hips, not the back, for these motions. Also, keep shoulders square with the hips during backhands and forehands to reduce twisting of the spine.


Rowing

Crew members are very prone to low back strains, disk herniation, and spondylolysis, especially during sprint training. The best way to decrease this risk is common sense: strengthen the back through specific exercises, take it easy if pain is present, and follow the directions of a trainer or therapist.


Running

Lumbar spine pain is most common in long-distance runners, but jogging can make previous back pain worse due to the increased stress, primarily on the disks. Back problems are very common in a runner with a leg-length difference of at least 0.5-inch; try correcting this with an orthopedic insole. Running on hilly terrain is also more stressful on the spine, especially facet joints; use a cushioned track if possible, or try trail running to reduce the impact from concrete. Always stretch well before and after a run. Run with head up, spine straight, and shoulders back. And wear quality, not-too-worn-out running shoes! (I also recommend the special socks for runners... they are great!)


Soccer

Lumbar spine pain in as many as 14% of soccer players. Long-distance kicks, fast direction changes (while dribbling), chest traps and throw-ins are tough on the back. During these motions, practice using the knees and hips, not the back, to absorb the shock.


Swimming

Overuse and repetitive small injuries during training give swimmers low back pain. Those who swim butterfly and breaststroke are prone to facet pain, while freestylers and backstrokers are at risk of annular and disk injury. Flip turns are also stressful on intervertebral disks. Use good stroke mechanics, keeping the hips in line with the shoulders to decrease injury. A trainer or therapist can place tape across the back during training for extra support.


Volleyball

Players are prone to low back strains and disk injury in almost any movement of the game. Digging the ball puts a player at risk of vertebral fracture as they hit a hard floor. Athletes must strengthen the abs and back and stretch well. (Sand volleyball may be a good alternative to hard court for those who play recreationally and want to reduce stress on the back.)


Weight Lifting

Most low back injuries are chronic, with a gradual onset. Prone to all sorts of back problems, as this sport places a large load on the back. Injuries can be minimized by catching problems like spondylolysis early and by maintaining proper lifting techniques...lift with the legs, do not round the back, emphasize a smooth motion. Always have a spotter and wear proper back support (belts).


Wrestling

Wrestlers have about a 30% chance of low back injury in their careers, but these are almost always sprains or strains. Most spine injuries are to the neck in this sport, and that can be serious. So, wrestlers, be conscious of the way the spine is supposed to move vs. the way you are moving!


TERMS DEFINED

 

Annular tear: The intervertebral disk is made up of a gel-like core, the nucleus pulposus, surrounded by a ring of fibrocartilage and fibrous tissue called the anulus fibrosis. An annular tear is an actual rip in this layer of the disk. This often causes pain and may lead to disk herniation.

Cauda Equina Syndrome: The cauda equina is essentially the "tail" of the spinal cord. It contains all the spinal nerves below L1. When a huge herniated disk or other obstruction is able to completely compress the cauda euina, this is extremely bad and a medical emergency requiring immediate surgery. The symptoms include: low back pain that may have been present for some time with associated "pinched nerve" pain, loss of sensation or movement in both legs, and the sudden loss of bowel and bladder control or urinary retention.

 

Degenerative spine changes: The deterioration, or worsening condition, of the parts of the spine resulting in decreased function and movement, soreness or pain, and possible nerve injury. The vertebrae and the discs are most affected. Degenerative changes are due to normal aging and the use of the back over time, repetitive small injury or stress, or a degenerative disease affecting the spine such as osteoarthritis or osteoporosis.

 

Facet injury: The facets are the places on the vertebra that articulate, or form a joint with, the next vertebra in the spinal column. A great deal of back pain, especially chronic pain, is blamed on the facets, but no one really knows how or why they cause pain. The symptoms of facet pain may be in the back or in the legs, and the diagnosis is one of exclusion. That is, you rule out every other common cause of pain first.

 

Herniated disc: This means that the "gel core" of the intervertebral disc, the nucleus pulposa, has come out through the disc covering, or anulus, and is now in the spinal canal itself. Here it can compress nerves and cause a great deal of pain and loss of sensation. Disc herniation is most common in those aged 30-40, and almost always involves the disc between L4 and L5 or between L5 and S1 (the sacrum or tailbone). 3/4 of these herniations will go away on their own within 6 months with activity modification and exercise. The typical course of a disc herniation is as follows:

-begins with repeated episodes of low back pain over time

-these pain episodes get worse and come more often

-pain and a tingling sensation may start going down one leg

However, disc herniation may have very mild or no symptoms.

On the other hand, very severe disc herniation can sciatica or even cauda equina syndrome.

 

Imaging studies

1. Bone scan: a view of the bone using radioactive isotopes (nuclear medicine)

2. CT Scan: a type of x-ray that allows the body to be seen in thin cross-sections

3. Discogram: controversial imaging technique using x-ray and injections to see the anatomy of

intervertebral disks

4. Electromyogram (EMG): nerve conduction studies involving the electrical stimulation of a

particular nerve or muscle in order to see if it is injured

5. Myelogram: Previously the standard to evaluate nerve compression in the spine, but MRI is now

done more often for this purpose. This technique uses contrast (dye) injected in the area of

the spinal column to outline nerves

6. MRI (Magnetic Resonance Imaging): uses a magnet (not x-ray) to see the body’s internal structures

from many different angles. Good imaging for joint, tendon and vertebral soft tissue problems.

7. X-ray: Used mostly to see bony structures, like the vertebrae.

 

Sciatic Nerve/ Sciatica: The sciatic nerve is actually a bundle of nerves that run from the lower spinal cord to the hip and buttocks area and down the leg, one on each side. Sciatica occurs when a lumbar disk herniates and crowds the spinal canal, pressing down on the nerve bundle. In addition, chemicals released by the damaged disk irritate the nerve. The nerve roots of L5 and S1 are the most common areas where this occurs. Symptoms include pain in the low back that radiates to the buttock and down one leg. This pain may begin very suddenly, and can be very severe. It usually begins as a bad leg cramp that lasts for weeks to months, and activities like sitting or coughing can make it worse. You may also feel weakness in the affected leg, a tingling or numb sensation over the affected area, or a burning sensation down the leg.

Sciatica occurs in about 1 in every 50 people, usually between the ages of 30 and 50. The onset of pain may be from a recent back injury, like straining your back shoveling snow, but more often it is a gradual process of wear and tear. Typically, a person with sciatic pain will have had short episodes of mild to moderate back pain over many years in the past, and they cannot recall one recent back injury that brought on the pain.

The majority of people with sciatica get better over time, without surgery, with exercises, stretching, and anti-inflammatory medications like ibuprofen or aspirin.

Spasm: a sudden, involuntary muscle contraction (a cramp)

Spondylolysis: Degeneration of a portion of the vertebra. Can result in spondylolisthesis, which is the slipping forward of one lumbar vertebra onto the one below it.

Sprain: an injury to a ligament from excessive force

Strain: to overuse or push beyond limits; usually a muscle

LINKS

http://www.orthospine.com/index.htm

http://www.wfubmc.drkoop.com/conditions/low_back_pain/

http://www.vh.org/Providers/Clin Guide/Back Physician/Back Physiscian.html

http://www.nlm.gov/medlineplus/sportsinjuries.html

http://www.physsportsmed.com/issues/1997/01jan/back_pa.html

http://www.medinfo.co.uk/conditions/low back pain.html

http://www.orthinfo.aaos.org


REFERENCES (books)

Cole, A.J, MD and Herring, S.A., MD et al. The Low Back Pain Handbook. Hanley and Belfus, Inc.,

Philadelphia, PA, 1997.

Watkins, R.G., MD et al. The Spine in Sports. Mosby-Year Books, Inc., St. Louis, MO, 1996.


Questions on weg page content matters - email Sarah @ samcdona@ufl.edu

Questions on weg page technical matters - email Mike @ florthopa@yahoo.com

 

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