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Low Back Pain Introduction (Part 2 of 3)

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Sports such as football and skiing involve high compressive forces via collision impact or ground reaction.  This excessive loading of the spine under high velocity combined with a forward bent posture can cause vertebral endplate lesions or anterior intravertebral disk herniation (Rachbauer, 2001).  Forward bending greatly increases intradiskal pressure, causing fracture of the normal vertebral endplate.  In baseball and golf, athletes perform forward bending and rotation while swinging, which applies shear stresses to the spine that can lead to annular tears of the intervertebral disks.  In gymnastics and dance, vigorous lumbar flexion and extension movements produce tensile stresses on the spine, which can strain the surrounding lumbodorsal fascia, muscles, or ligaments.  In addition, repetitive hyperextension of the low back, which is common in numerous sports (football, gymnastics, diving, figure skating) can lead to the development of spondylolysis – stress fractures of the pars interarticularis (Jagadish, 2013).  With the various movements (flexion, extension, rotation) involved in sports combined with external loading, the lumbar spine can be damaged due to a combination of compression, shear, and tensile stresses.  It is important to take all of this into account when providing exercise prescription for each athlete’s respective sport.

 

ASP athlete and founder, Jack Cooney, understands, implements and practices first hand, the programming necessary, across all sports, to strengthen the posterior chain and involved structures that support the spine.  

 

Interestingly, a study on surfers’ low back pain, reported CT scans that showed no fractures or disk herniation and MRI studies that showed no spinal cord compression, acute disk changes, or ligamentous injury (Chang et al., 2012). This non-traumatic spinal cord injury is known as surfer’s myelopathy. The hypothesis is that the low back pain is associated with lumbar hyperextension and ischemia (lack of blood flow) resulting in tissue death of the great anterior radicular artery which provides the blood supply to the lumbar and sacral cord.  Lying prone on a surfboard in a hyperextended position with simultaneous paddling and maneuvering requires well-developed back musculature (Shuster, 2011).  Therefore, novice surfers may exert considerable forces on the spine if insufficiently trained muscles cannot protect the back.

 

At ASP we make sure that every one of our athletes is fully aware of their required posture for each exercise and the implications on the spine through positioning, breathe, and their individual bony structure.

 

Similarly as in sport, daily life, prolonged sitting and slouched posture can increase compressive forces on the lumbar spine exposing it to injury.  Sitting has been shown to increase intradisk pressure by approximately 40% when compared to standing (Howell, 2012).  Slouching results in backward rotation of the sacrum, causing dorsal widening of the L5-S1 disk and strain on the iliolumbar ligaments.  Both activities produce extended loading of the spine, decreasing disk hydration and separation between vertebra.

 

Lastly, certain body types are predisposed to injury such as flat back or scoliosis (congenital or functional), where the lumbar spine is in an unfavorable postural position.  The lumbar lordosis curve is necessary to evenly distribute the center of body weight load.  Studies have shown correlation between decreased lumbar lordosis and increased spinal nerve compression.  Using thermographic imaging, reports show less lordosis resulting in higher temperatures in the lumbar region, as nerve muscle stimulation was transmitted to the skin (Gong, 2011).  Also, sitting with a straightened back shows increased intradisk pressure by approximately 10% (Howell, 2012).

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Low Back Pain Introduction (Part 3 of 3)

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Rehabilitation Plan

 

The initial stage of the rehab program will focus on alleviating pain while encouraging pain-free range of motion and maintaining spinal segment stability. Eventually, the athlete will progress to more advanced exercises, maximizing core strength and stability. At ASP, we take back pain on a case by case basis with the appreciation that the exact location of the nerve impingement or another injury will not be the same for every athlete, therefore their pain and symptoms will all vary. A detailed assessment will help determine the location of impingement, but an MRI or CT scan will provide a higher degree of accuracy. When developing the rehab program, a trial and error approach will be necessary in finding the right combination of exercises and modalities that prove most effective.

 

Getting on the Right Track

 

Symptoms can be exasperated by natural splinting. One of the early corrective exercises that we have the athlete perform are various postural, diaphragmatic breathing exercises in order to provide traction of the lumbar spine, which enhances the nourishment of the disk and leads to decreased pain and increased function (Prentice, 2004).  The purpose of traction is to draw apart the lumbar vertebrae enough to create a subatmospheric pressure, which tends to pull the disk protrusion back to its original position (Kolar, 2005).  90-90 wall breathing and crocodile breathing focuses on breathing into the belly by utilizing the diaphragm and contracting the transversus abdominis to stabilize the spine. It is important to not lift the rib cage or shoulders while inhaling in order to get the desired effect. Eventually, the athlete can progress and test how they respond to further traction modalities, either by using a physioball or inversion table.

 

See Diaphragmatic Breathing Description in One of our Previous Posts.

 

Decrease Neuro Symptoms and Pain; Increase Flexibility and Relaxation

 

Once posture, pain, and segmental spinal control return to normal, the athlete may progress to include core stabilization exercises (Prentice, 2004). It has been found that disc herniation is associated with lumbar instability and core muscle weakness (Bakhtiarya et al, 2005). Lumbar and core stabilization exercises may improve activities of daily life and control and limit the free movement of one vertebra on another.  The active straight leg raise is more commonly used to monitor and track pain free range of motion, and diagnose lumbar dysfunction as muscular or neurological.  Although we use it for such purpose as well, we also use it as an exercise to develop core strength, provide kinesthetic awareness of keeping a neutral spine and pelvis, as well as help improve/track hamstring flexibility and relaxation.

 

The athlete begins the exercise by placing their back flat against the ground and maintaining a neutral pelvis and pain free position. By having the athlete find this position, we are reinforcing the kinesthetic awareness that this is the safest and most stable position.  The actual leg raise will induce a lever arm that challenges the stability of the spine, while also providing us with a day to day record of pain free ROM gains.  It can also be deduced that the increased stability of adjacent vertebra in the spinal column may accelerate the recovery process of the herniated disk. We introduce several variations that may include just body weight, a resistance band, or the assistance of a wall depending on the progress of each case.

 

Reintegrate Muscle Activation and Mobility of the Splinting Muscles.

 

The next progression of the rehab program is to include more functional exercises such as a squat. At this point in the rehab program, it is important to avoid axial loading on the intervertebral disk. A squat is beneficial because it has the athlete practice moving while keeping a neutral spine, and proper breathe. In addition, the athlete is developing hip mobility as they challenge depth.  The goal is anti-flexion/extension by incorporating an anterior/lateral resistance challenging the erector spinae and transversospinalis muscle groups . Together they work to stabilize, and slow down flexion and lateral flexion

 

Another possible addition is the drop lunge at wall (anterior stabilization). In this exercise the athlete reaches their non-supporting leg medially (across the midline) and posteriorly while at the same time bending at the knee on the support leg. Although this is a seemingly simple exercise, it is reserved for the later part of rehab because there is room for incorrect execution which may cause further pain. For example, if the athlete excessively rotates or flexes laterally, there may be further compression on the nerve or shearing force. Additionally, the goal in stretching the ER of the hip may also impinge the nerve distally. This exercise has an emphasis on balance and anti-rotation, thus lumbar stability is challenged once again.  The wall reinforces postural awareness while avoiding the aforementioned flexion rotation combination that many athletes experience in their sport.

 

As these options are just a  piece of the puzzle structuring the road to recovery, the anterior and lateral structures of the torso and hip are addressed  just as well.

 

Return to Play

 

Before the athlete can make a full return to sport, the athlete should have regained centralization, normal flexibility and strength to lower extremities. It is essential that the athlete understand and performs proper mechanics in order to avoid re-injury.  While these exercises can be construed by some as purely rehab exercises it is important to understand the underlying science and it’s affect on exercise prescription and how it impacts each athlete’s sport and career longevity.

 

Again, every athlete will respond differently to every exercise or modality of treatment depending on how and where the nerve impingement is occurring. Exercise selection and progression should be monitored throughout the rehab program in order to provide safe and effective recovery.

 

References

 

Bakhtiary AH, Farokhi ZS, Rezasoltani A.  Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation.  Journal of Back and Musculoskeletal Rehabilitation 2005.

 

Finn C.  Rehabilitation of Low Back Pain in Golfers: From Diagnosis to Return to Sport.  Sports Health: A Multidisciplinary Approach Jul2013, Vol. 5 Issue 4, p313 7p.

 

Gong W.  Correlation between the Lumbar Lordosis Curve and the Temperature Differences of the Lower Extremity Regions in Patients Lumbar Herniated Pulposus.  Journal of Physical Therapy Science 2011.

 

Herniated Disk in the Low Back.  American Academy of Orthopaedic Surgeons, November 2012.

 

Howell ER.  Conservative management of a 31 year old male with left sided low back and leg pain: a case report.  Journal of the Canadian Chiropractic Association 2012.

 

Jagadish A.  Spinal Interventions – The Role in the Athlete.  Operative Techniques in Sports Medicine 2013.

 

Kolar K.  Lumbar-Disk Herniations: Conservative Clinical Applications.  Athletic Therapy Today, September 2005.

 

Moore, K. L., Dalley, A. F., & Agur, A. M. (2005). Clinically oriented anatomy. Lippincott Williams & Wilkins

 

P.C. Vroomen, M.C. De Krom, J.T. Wilmink, A.D. Kester and J.A. Knottnerus. Lack of effectiveness of bed rest for sciatica. The New England Journal of Medicine. 1999. 340 418–423.

 

Prentice, William. (2004). Rehabilitation Techniques for Sports Medicine and Athletic Training (4th ed.). New York, NY: McGraw-Hill Companies, Inc.

 

Rachbauer F.  Radiographic abnormalities in the thoracolumbar spine of young elite skiers.  American Journal of Sports Medicine July/Aug 2001: Vol. 29 Issue 4. p. 446-449 4p.

 

Shuster, A.  Surfer’s myelopathy-an unusual cause of acute spinal cord ischemia: a case report and review of the literature.  Emergency Radiology 18.1 (2011): 57-60.

 

Skytte, Lene;  May, Stephen; Petersen, Peter. Centralization: Its Prognostic Value in Patients With Referred Symptoms and Sciatica. SPINE Volume 30, Number 11, pp E293–E299 2005
Watkins, RG.  Lumbar disc injury in the athlete.  Clinics in Sports Medicine Jan 2002: Vol. 21 Issue 1. p. 147-165 19p.

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Overcoming Injury: The Mental Edge

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Many athletes experience injury during the course of their careers.

 

And recent research by Ardern, C., Taylor, N., Feller, J., & Webster, K. (2012) suggests that negative behavioral changes can occur from anxiety of re-injury during and post-recovery, including:

 

-impinged performance manifesting as hesitation
-reduced maximal effort
-a wariness in the athlete of both unfamiliar and familiar movement patterns similar to that from which the injury occurred.

 

This cycle of events, in some cases, can actually increase the risk of re-injury and lead to a vicious cycle of physical and mental uncertainty regarding performance.

 

Accelerate Sports Performance’s extensive physical and mental assessment and programming takes into consideration not only the physical demands of rehabilitation, but also the mental rigors of returning to competition, recreational exercise, and functional daily activity. ASP’s clients, once recovered, often perform more efficiently than prior to their injury.

 

In the next blog post, we’ll take a data-driven look at the progress of Kayla Coloyan, a high school basketball point guard, who is 6 months post-op from ACL surgery and looking to return to play stronger than before.

 

ASP_WebPhotos-29

 

Full Citation

 

Ardern, C., Taylor, N., Feller, J., & Webster, K. (2012). Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery. Journal of Science and Medicine in Sport, 15 (6), 488-495.

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ASP Intern In the News

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HSU kinesiology major Alex Pili said he learned something new every day during his time at Accelerate Sports Performance in San Francisco.

“There are no textbooks, just the ability to apply what I’ve learned in the real world,” Pili said.

Intern, Alex Pili, getting hands on experience.

http://www.times-standard.com/localnews/ci_25474267/real-world-humboldt-state-university-internship-program-helps?source=rss

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Post Activation Potentiation (PAP) For Athletic Power

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BROAD JUMP

 

Stack has increased his broad jump measuring from an 8’10” in week 1 to 9’2” in week 2 to 9”6 in week 5 to 9’11” in week 7 and in week 9 hit 10’6.5” While putting on 7lbs of lean muscle. Not bad for the NFL, except he’s still in high school.

DEAD HANG

 

David Stack is performing a dead hang, constituting an important part of this complex pair which involves combining high load strength movements with biomechanically similar plyometric/ballistic movements as a means of taking advantage of Post Activation Potentiation (PAP), a phenomenon that refers to enhancement of muscle function as a result of its contractile history for short term and long term muscle function. This method of exercise application and development of athletic power has proven to be far more effective to either resistance training or plyometric training alone.

Stack harnesses the enhanced muscular and neuromuscular functional adaptations associated with PAP.

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THE BASICS OF THE STRETCH-SHORTENING CYCLE AND INCREASING POWER PRODUCTION IN ATHLETES

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The stretch-shortening cycle is incredibly important to all athletes, occurring when a muscle or muscle group is rapidly stretched. In powerful movements and plyometric exercise, muscles go through three different phases of the stretch-shortening cycle: (1) eccentric, (2) ammortization, and (3) concentric.

 

The faster an athlete can switch from an eccentric load to a concentric contraction in their training, the more powerful and explosive the athlete ultimately will be during their competition.

 

Let’s dive deeper into understanding the science behind this important cycle.

 

ECCENTRIC PHASE

 

In a jump squat with counter movement, the eccentric phase occurs as the athlete lowers their hips back into a squatting position.  During that lowering motion, the body is stretching and preloading the agonist muscle groups, (glutes, hamstrings, calves) storing elastic energy to be used on a subsequent concentric muscle action, and stimulating muscle spindles.

 

The stronger we become in the eccentric loading phase, the more proficient those muscle spindles become at muscle fiber recruitment for the explosive concentric phase.

 

This is also why we focus so much on the loading technique at ASP.  If an athlete is using poor technique in the loading phase of the Jump Squat, then the wrong muscle groups are being stretched or the primary movers are not working as efficiently which will lead to a sub-optimal concentric contraction and jump, dissipated stored muscle energy, and the increased possibility of  injury.  One of the many ways that we train this eccentric phase is by implementing various lower body eccentric stability and relaxation exercises during the lower body elasticity portion of the workout.

 

By improving the loading technique and capability, we look to improve power from the following concentric action. During the stretch that occurs during the eccentric phase, muscle spindles fibers send feedback to the central nervous system telling the muscles to contract as a protective response to prevent tissue damage from further stretching. This means due to the reflexive response of the agonist muscles, the greater the stretch rate=the greater the muscle recruitment  (Kramer et.al., 2012)(Baechle et.al., 2000).

 

AMMORTIZATION PHASE

 

This is the transition phase between the eccentric muscle action and the concentric muscle action.  The ammortization phase is when motor neurons transmit to the agonist muscles telling them to contract.  This may be the most crucial phase in power production.  The quicker an athlete can switch from an eccentric contraction to a concentric contraction, the more power they will be able to produce.

 

If it takes too long for the muscle or muscle groups to transfer the eccentric force to a concentric force, the energy stored will dissipate and be lost.

 

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CONCENTRIC PHASE

 

The final phase of the stretch-shortening cycle is the concentric phase, where the agonist muscles use the stretch reflex and stored elastic energy to contract and produce power.  This is often the simplest phase and the easiest to train.  Staying with the squat jump with counter movement example from earlier, this is where the agonist muscles that were stretched during the eccentric loading phase fire to apply force into the ground and ascend into a jump.

 

CONCLUSION

 

We always take a very controlled approach to training the stretch-shortening cycle through in every ASP athlete because:

 

(a) it is significant in power production

 

(b) it’s also very easy to load into an incorrect and/or dangerous loading pattern if the force or load is too great or improperly variable.

 

At the beginning of every workout we include the lower body elasticity section, starting with very basic loading positions, in order to not only gain eccentric strength but to remind our athletes physically and neurologically the correct position to be in.  This will aid in kinesthetic awareness, strength, and increased comfort when they progress to more dynamic movements in their training and in their athletic competition.

 

1.) Kraemer, W., Looney, D. Underlying Mechanisms and physiology of Muscle Power. Strength and Conditioning Journal. 2012, 34, 6, 13-19.
2.) Baechle, T., Earle, R. 2000. Essentials of Strength Training and Conditioning. 2nd edition. National Strength and Conditioning Association. 428-430 p.

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Flat Feet – Symptoms, Structures, and Management

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With rising numbers of lower leg injuries, and the growing number of amateur runners both recreationally, and semi-competitively in marathons and triathlons, we decided to enlighten those interested with an introduction to a few simple structures, deficiencies, and rehab tools use with both our professional and amateur athlete populations.

 

Flat feet are a lowering or collapse of the medial longitudinal arch.  Left untreated, this structural condition can lead to pronation at the ankle joint.  Excessive pronation can cause pain and stress to several structures, including musculature and ligaments (Prentice, 2004).  Today’s blog will outline the visual symptoms, associated structures, and a management plan for flat feet.

Figure 1 displays a posterior view of the left foot and ankle.  On the right side, a collapse of the medial arch is shown indicating flat feet.  On the left side, there is a sign of “too many toes” which is associated with mid-foot abduction.  Also displayed in Figure 1, but not labeled, is an eversion of the calcaneus and a medial bulge of the talar head.  With repeated pronation during weight-bearing activities (standing, walking, running), increased stress will be placed along the medial aspect of the ankle.  As a result, Figure 2 shows swelling and edema posterior to the medial malleolus of the right foot.  These are all visual symptoms of flat feet or ankle pronation.

A common tendon injury associated with flat feet is the tibialis posterior tendon (Yuill, 2010).  The tibialis posterior originates at the adjacent margins of the tibia and fibula and runs posterior to the medial malleolus, then inserts at the navicular, medial cuneiform, and the 2nd-4th metatarsals (middle/inside of the foot).  With flat feet and ankle pronation, strain is placed on the tendon (as shown in Figure 3) and stress occurs on the deltoid  ligament of the medial ankle as displayed in Figure 4.  Both the tibialis posterior and the deltoid ligaments serve to protect the ankle from excess eversion.

 

There are a variety of ways to manage pain and prevent injuries.  On the path back to performance training or incorporated into performance training:

 

(1) The first step is to support the flattened arch through the use of orthotics.

 

(2) Next, we want incorporate a stretching program to ensure full range of motion in all planes.

 

(3) After an adequate level of range of motion has been established, a strength program can be added.

 

(4) Finally, proprioception and balance exercises will be trained to enhance neuromuscular control.

 

A primary aspect that we try to focus on is having the athlete train with a stable medial longitudinal arch. Although three distinct arches function to support the foot, the medial longitudinal arch has been found to be the arch of clinical significance in preventing injury due to flat feet (Franco, 1987).

ORTHOTICS

 

One way to manage flat feet is by using orthotics. The main function of an orthotic is to provide a combination of neuromuscular reeducation and a change in body mechanics in an attempt to readjust the foot into a more ideal weight baring position (Franco, 1987). A proper fitting orthotic provides mechanical support to the flattened medial longitudinal arch and prevents further tendon lengthening or ligament stress. The muscles that are constantly being stressed and lengthened are then, finally relaxed and shortened.

 

EXERCISES

 

While the orthotic passively creates an arch for the athlete and may help prevent overuse injuries, it is also important for the athlete to actively train and strengthen muscles that are underactive during over pronation. A program that incorporates the strengthening of the anterior and posterior tibialis is important because they help maintain a proper arch. Without the use of an orthotic, the athlete can work towards biomechanical betterment by practicing “bilateral short foot position.”

 

https://www.youtube.com/watch?v=oxU9uC5FHF4#t=7

 

Other exercises that should be incorporated into the athlete’s program to build strength in the ankle and lower leg include isometric exercises against all planes of motion. After that, the athlete can progress to concentric and eccentric movements using tubing or resistance bands and onward.

 

Kinesthetic awareness can be regained through multiple balance training exercises. One balance exercise that we may incorporate into the rehab training is a single leg RDL. While a main objective of this exercise is to strengthen the posterior chain, performing an RDL on one leg also forces the athlete to focus on balance, thus improving neuromuscular control at the ankle, lower leg, hip, and torso. Another way we improve balance is by having the athlete stand on a soft, unstable pad while throwing a ball for them to catch. When the athlete reacts to catch the ball, they must stabilize the foot and lower leg.

 

While these are general exercises for ankle and lower leg rehabilitation, athletes respond to treatment and exercises differently, so modifications should be made accordingly.

 

In the next blog post, we will talk about the effects of over pronation up the kinetic chain.

References

  1. Howitt S, Jung S, Hammonds N. Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report. Journal of the Canadian Chiropractic Association Mar2009, Vol. 53 Issue 1, p23 9p.
  2. Yuill E, MacIntyre I. Posterior tibialis tendonopathy in an adolescent soccer player: a case report. Journal of the Canadian Chiropractic Association Dec2010, Vol. 54 Issue 4, p293 8p.
  3. Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. Physical Therapy Jan2009, Vol. 89 Issue 1, p26 12p.
  4. Mattacola, Carl & Dwyer, Maureen. Rehabilitation of the ankle after acute sprain or chronic instability. Journal of Athletic Training. 2002 Oct.; 37 (4); 413-429.
  5. Prentice W. Rehabilitation Techniques for Sports Medicine and Athletic Training Fourth Edition 2004.
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An Emotional Return Back to Play

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ASP athlete and Sacred Heart Cathedral Varsity Basketball player Kayla Coloyan recently returned from an ACL injury to help win an emotional 47 – 39 victory over St. Ignatius.

 

With four steals and leading an early 10-3 run in the third with a three-point play, “Kayla gave us a big boost,” basketball coach LyRyan Russell said. “She always gives us instant energy.”

 

Please read more about Kayla and her team’s success in the SF Chronicle.

 

Congrats Kayla! We couldn’t be more proud of you returning back to play stronger than ever.

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