THE SPINE Functional Anatomy of the Spine • Movements of the spine include flexion, extension, right and left lateral flexion and right and left lateral rotation – Minimal movement w/in the thoracic region • Movement of the spine and muscle contributions • Superficial and deep musculature functioning and abdominal muscular functioning – Flexion and extension – Trunk rotation and lateral flexion Prevention of Injuries to the Spine • Cervical Spine – Muscle Strengthening • Muscles of the neck resist hyperflexion, hyperextension and rotational forces • Prior to impact the athlete should brace by “bulling” the neck (isometric contraction of neck and shoulder muscles) • Varied of exercises can be used to strengthen the neck – Range of Motion • Must have full range of motion to prevent injury • Can be improved through stretching – Using Correct Technique • Athletes should be taught and use correct technique to reduce the likelihood of cervical spine injuries • Avoid using head as a weapon, diving into shallow water • Lumbar Spine – Avoid Stress • Avoid unnecessary stresses and strains of daily living • Avoid postures and positions that can cause injury – Correction of Biomechanical Abnormalities • Athletic trainer should establish corrective programs based on athlete’s anomalies • Basic conditioning should emphasize trunk flexibility • Spinal extensor and abdominal musculature strength should be stressed in order to maintain proper alignment – Using Correct Lifting Techniques • Weight lifters can minimize injury of the lumbar spine by using proper technique • Incorporation of appropriate breathing techniques can also help to stabilize the spine • Weight belts can also be useful in providing added stabilization • Use of spotters when lifting – Core Stabilization • Core stabilization, dynamic abdominal bracing and maintaining neutral position can be used to increase lumbopelvic-hip stability • Increased stability helps the athlete maintain the spine and pelvis in a comfortable and acceptable mechanical position (prevents microtrauma) Assessment of the Spine • History – Mechanism of injury (rule out spinal cord injury • What happened? Did you hit someone or did someone hit you? Did you lose consciousness • Pain in your neck? Numbness, tingling, burning? • Can you move your ankles and toes? • Do you have equal strength in both hands – Positive responses to any of these questions will necessitate extreme caution when the athlete is moved – Other general questions • Where is the pain and what kind of pain are you experiencing? • What were you doing when the pain started? • Did the pain begin immediately and how long have you had it? • Positions or movements that increase/decrease pain? • Past history of back pain • Sleep position and patterns, seated positions and postures • Observations – Body type – Postural alignments and asymmetries should be observed from all views – Assess height differences between anatomical landmarks Postural Malalignments • Cervical Spine Evaluation – Assess position of head and neck • Symmetry of shoulders (levels) • Will the athlete move the head and neck freely? • Assess active, passive and resisted range of motion • Thoracic Spine Evaluation – Pain in upper back and scapular region • Cervical disc or trigger points (long thoracic nerve or suprascapular nerve involvement) – Lower thoracic region pain – Facet joint involvement • W/ deep inspiration and chin tucked to chest • Lumbar Spine and Sacroiliac Joint Observations – Coordinated movement of the low back involves the pelvis, lumbar spine and sacrum – Equal levels (shoulders and hip) – Symmetrical soft tissue structures bilaterally – Observe athlete seated, standing, supine, side-lying, and prone (leg position - contractures) • Palpation – Spinous processes • Spaces between processes - ligamentous or disk related tissue – Transverse processes – Sacrum and sacroiliac joint – Abdominal musculature and spinal musculature • Assessing for referred pain – Have athlete perform partial sit-up to determine tone and symmetry – Assess hip musculature and bony landmarks as well • Neurological Exam – Sensation Testing • If there is nerve root compression, sensation can be disrupted – Reflex Testing • Three reflexes in the upper extremity include the biceps, brachioradialis and triceps reflexes – Tests C5, C6, and C7 nerve roots respectively • The two reflexes to be tested in the lower extremity are the patellar tendon and Achilles tendon reflexes – Used to assess the L4 and S1 nerve root respectively Recognition and Management of Specific Injuries and Conditions • Cervical Spine Conditions – Mechanisms of Injury • Cervical Fractures – Etiology • Generally an axial load w/ some degree of cervical flexion – Signs and Symptoms • Neck point tenderness, restricted motion, cervical muscle spasm, cervical pain, pain in the chest and extremities, numbness in the trunk and or limbs, weakness in the trunk and/or limbs, loss of bladder and bowel control – Management • Treat like an unconscious athlete until otherwise rule out use extreme care • Cervical Dislocation – Etiology • Usually the result of violent flexion and rotation of the head – Signs and Symptoms • Considerable pain, numbness, weakness, or paralysis • Unilateral dislocation causes the head to be tilted toward the dislocated side with extreme muscle tightness on the elongated side – Management • Extreme care must be used - more likely to cause spinal cord injury than a fracture • Acute Strains of the Neck and Upper Back – Etiology • Sudden turn of the head, forced flexion, extension or rotation • Generally involves upper traps, scalenes, splenius capitis and cervicis – Signs and Symptoms • Localized pain and point tenderness, restricted motion, reluctance to move the neck in any direction – Management • Rest, ice, compression, elevation and application of a cervical collar • Follow-up care will involve range of motion exercises and isometrics which progress to a full isotonic strengthening program. • Cervical Sprain (Whiplash) – Etiology • Generally the same mechanism as a strain, just move violent • Involves a snapping of the head and neck - compromising the anterior or posterior longitudinal ligament, the interspinous ligament and the supraspinous ligament – Signs and Symptoms • Similar signs and symptoms to a strain - however, they last longer • Tenderness over the transverse and spinous processes • Pain will usually arise the day after the trauma (result of muscle spasm) – Management • Refer to a physician to rule out fracture, dislocation, disk injury or cord injury. Rest, ice, compression and elevation for first 4872 hours, possibly bed rest if severe enough. • Acute Torticollis (Wryneck) – Etiology • Pain on one side of the neck upon wakening • Result of synovial capsule impingement w/in a facet – Signs and Symptoms • Palpable point tenderness and muscle spasm, restricted range of motion and muscle guarding. – Management • Variety of techniques including traction, superficial heat and cold treatments. • Use of a soft collar can be helpful as well • Cervical Cord and Nerve Root Injuries – Etiology • Mechanisms include, lacerations, hemorrhage (hematomyelia), bruising and shock • Can occur separately or together – Signs and Symptoms • Various degrees of paralysis impacting motor and sensory function; the level of injury determines the extent of functional deficits • Cord lesions at or above C3 result in death, while injury below C4 will allow for some return of nerve root function • Incomplete lesions can result in a number of different syndromes and conditions – Management • Handle w/ extreme caution to minimize further spinal cord damage • Cervical Spine Stenosis – Etiology • Syndrome characterized by a narrowing of the spinal canal in the cervical region that impinges on the spinal cord • Result of congenital condition or changes in vertebrae (bone spurs, osteophytes or disk bulges) – Signs and Symptoms • Transient quadriplegia may occur from axial loading, hyperflexion/extension • Neck pain may be absent initially • Sensory and motor deficits occur but generally recover slowly w/in 10-15 minutes – Management • Extreme caution must be used; Diagnostic testing (X-ray, MRI) must be used to determine extent of problem • Participation in sports is generally discouraged • Brachial Plexus Neurapraxia (Burner) – Etiology • Result of stretching or compression of the brachial plexus disrupts peripheral nerve function w/out degenerative changes – Signs and Symptoms • Burning sensation, numbness and tingling as well as pain extending from the shoulder into the hand • Some loss of function of the arm and hand for several minutes • Symptoms rarely persist for several days • Repeated injury can result in inflammation of the nerve, muscular wasting, and permanent damage – Management • Return to activity once signs and symptoms have returned to normal • Strengthening and stretching program • Padding to limit neck range of motion during impact • Cervical Disc Injuries – Etiology • Herniation that develops from an extruded posterolateral disc fragment or from degeneration of the disc • involves sustained repetitive cervical loading – Signs and Symptoms • Neck pain w/ some restricted range of motion • Radicular pain in the upper extremity and associated motor weakness – Management • Rest and immobilization of the neck to decrease discomfort • If conservative treatment is unsuccessful or neurological deficits increase surgery may be needed Thoracic Spine Conditions • Scheuermann’s Disease (Dorsolumbar Kyphosis) – Etiology • Result of wedge fractures of 5 degrees or greater in 3 or more consecutive vertebrae w/ disk space abnormalities and irregular epiphyseal endplates • Can develop into more serious conditions – Signs and Symptoms • Kyphosis of the thoracic spine and lumbar lordosis w/out back pain • Progresses to point tenderness of the spinous processes; young athlete may complain of backache at the end of a very physically active day • Hamstring muscles are characteristically tight – Management • Prevent progressive kyphosis - work on extension exercises and postural education • Bracing and may be helpful • Stay active but avoid aggravating movements Lumbar Spine Conditions • Low Back Pain – Etiology • Congenital anomalies • Mechanical defects of the spine (posture, obesity and body mechanics) • Back trauma • Recurrent and chronic low back pain – Signs and Symptoms • Pain, possible weakness, antalgic gait, propensity to ligamentous sprain, muscle strains and bony defects • Neurological signs and symptoms if it becomes disk related – Management • Correct alignments and body mechanics • Strengthening and stretching to ensure proper segmental mechanics • Lumbar Vertebrae Fracture and Dislocation – Etiology • Compression fractures or fracture of the spinous or transverse processes • Compression fractures are usually the result of trunk hyperflexion or falling from a height • Fractures of the processes are generally the result of a direct blow • Dislocations tend to be rare – Signs and Symptoms • Compression fractures will require X-rays for detection (referral to physician) • Point tenderness over the affected area • Palpable defects over the spinous and transverse processes • Localized swelling and guarding • Management – X-ray and physician referral – Transport with extreme caution and care to minimize movement of the segments • Low Back Muscle Strain – Etiology • Sudden extension contraction overload generally in conjunction w/ some type of rotation • Chronic strain associated with posture and mechanics – Signs and Symptoms • Pain may be diffuse or localized; pain w/ active extension and passive flexion • No radiating pain distal to the buttocks; no neurological involvement – Management • Rest, ice, compression and elevation to decrease spasm; followed by a graduated stretching and strengthening program • Complete bed rest may be necessary if it is severe enough • Myofascial Pain Syndrome – Etiology • Regional pain with referred pain to a specific area that occurs with pressure or palpation of a tender spot or trigger point w/in a muscle – Signs and Symptoms • Piriformis - pain in posterior sacroiliac region, into buttocks and down posterior portion of thigh; deep ache that increases w/ exercise or prolonged sitting w/ hip adduction, flexion and medial rotation • Quadratus lumborum - sharp aching pain in low back, referred to upper buttocks and posterior sacroiliac region and abdominal wall; increased pain with standing, coughing, sneezing and sit to stand motions; pain increases with side bend toward the trigger point – Management • Stretching and strengthening of the involved muscle • Return muscle to normal length • Lumbar Strains – Etiology • Forward bending and twisting can cause injury • Chronic or repetitive in nature – Signs and Symptoms • Localized pain lateral to the spinous process • Pain becomes sharper w/ certain movements or postures • Passive anteroposterior or rotational movements will increase pain – Management • Rest, ice, compression and elevation, strengthening for abdominals, stretching in all directions • Trunk stabilization exercises • Braces should be worn early to provide support • Back Contusions – Etiology • Significant impact or direct blow to the back – Signs and Symptoms • Pain, swelling, muscle spasm and point tenderness – Management • Rest, ice, compression and elevation for the first 72 hours • Ice massage combined with gradual stretching • Recovery generally last 2 days to 2 weeks • Sciatica – Etiology • Inflammatory condition of the sciatic nerve • Nerve root compression from intervertebral disk protrusion, structural irregularities w/in the intervertebral foramina or tightness of the piriformis muscle – Signs and Symptoms • Arises abruptly or gradually; produces sharp shooting pain, tingling and numbness • Sensitive to palpation while straight leg raises intensify the pain – Management • Rest is essential acutely • Treat the cause of inflammation • Herniated Disk – Etiology • Caused by abnormal stresses and degeneration due to use (forward bending and twisting) – Signs and Symptoms • Centrally located pain that radiate unilaterally in dermatomal pattern • Symptoms are worse in the morning • Onset is sudden or gradual, pain may increase after the athlete sits and then tries to resume activity • Forward bending and sitting increase pain, while back extension reduces pain • Straight leg raise to 30 degrees is painful • Decreased muscle strength and tendon reflexes; Valsalva maneuver increases pain – Management • As pain and posture return to normal additional strengthening exercises can be added • If disc is extruded or sequestrated pain modulation is key • Flexion exercise and lying supine in a flexed position may help with comfort • Surgery may be required • Spondylolysis and Spondylolisthesis – Etiology • Spondylolysis refers to degeneration of the vertebrae due to congenital weakness (stress fracture results) • Slipping of one vertebrae above or below another is referred to as spondylolisthesis and is often associated with a spondylolysis – Signs and Symptoms • Spondylolysis begins unilaterally • Pain and persistent aching, low back stiffness with increased pain after activity • Frequent need to change position • Full range of motion with some hesitation in regards to flexion • Localized tenderness and some possible segmental hypermobility – Management – Management • Bracing and occasionally bed rest for 1-3 days will help to reduce pain • Major focus should be on exercises directed as controlling or stabilizing hypermobile segments • Progressive trunk strengthening, dynamic core strengthening, concentration on abdominal work • Braces can also be helpful during high level activities • Increased susceptibility to lumbar strains and sprains and thus vigorous activity may need to be limited Sacroiliac Joint Dysfunction • Sacroiliac Sprain – Etiology • Result of twisting with both feet on the ground, stumbles forward, falls backward, steps too far down, heavy landings on one leg, bends forward with knees locked during lifting • Causes irritation and stretching of sacrotuberous or sacrospinous ligaments and possible anterior or posterior rotation of innominate bones • With pelvic rotation hypomobility is the norm, however, during the healing process hypermobility may result and allow the joint to sublux – Signs and Symptoms • Palpable pain and tenderness over the joint, medial to the PSIS w/ some muscle guarding • Pelvic asymmetries, measurable leg length deformities, blocked normal movement during trunk flexion • Pain after 45 degrees during the straight leg raise and increased pain during side bending when moving toward the painful side • Pain may radiate posteriorly, laterally, or anteriorly down the thigh and may even be vaguely located in the groin • Increased pain w/ unilateral stance • Movement from sit to stand will create pain • Sitting is usually comfortable • Management – Bracing can be helpful in acute sprains – SI joint must be mobilized to correct positioning – Strengthening exercises should be used to stabilize the joints • Coccyx Injuries – Etiology • Generally the result of a direct impact which may be caused by forcibly sitting down, falling, or being kicked by an opponent – Signs and Symptoms • Pain is often prolonged and at times chronic • May even cause irritation to the coccygeal plexus – Management • X-rays and rectal exam may be required to determine the extent of the injury • ring seat to relieve pressure while sitting Pain from a fractured coccyx could last months • May require protective padding to prevent further injury Rehabilitation Techniques for the Neck Flexibility Exercises • Must restore the neck’s normal range of motion • All mobility exercises should be performed pain free • Perform exercises passively and actively (flexion, extension, lateral bending and rotation) • Exercises should be performed 2-3 times daily, 810 reps and held for at least 6 seconds for each stretch Strengthening Exercises • Should be initiated when near normal range has been achieved, and should be performed pain free • Exercises should progress from isometric to isotonic exercises Rehabilitation Techniques for the Low Back • There are a number of philosophical approaches to low back rehab • Initial treatment should focus on modulating pain (ice, rest; avoid aggravating motions or positions) • Progressive relaxation techniques General Body Conditioning • • • • With acute low back pain, the athlete can be limited for some time Activity must be modified during the initial stages Resume activity as pain can be tolerated Aquatic exercise may be useful to maintain fitness levels Flexibility • There are a variety of exercises that can be performed Strengthening Exercises • Should be routinely incorporated into the rehab program • Used to reinforce pain-reducing movements and postures • Extension exercises – Should be used when pain decreasing w/ lying down and increases w/ sitting – Backwards bending is limited but decreases pain -- forward bending increases pain • Flexion Exercise – Used to strengthen abdominals, stretch, extensors and take pressure off nerve roots – Pain increases with lying down and decreases with sitting – Forward bending decreases pain – Lordotic curve does not reverse itself in forward bending • PNF Exercises – Chopping and lifting patterns can be used to strengthen the trunk, re-establish neuromuscular control and proprioception Neuromuscular Control • Must re-educate muscles to contract appropriately • Stabilization exercises can help minimize the cumulative effects of repetitive microtrauma • Core/dynamic stabilization – Control of the pelvis in neutral position – Integration full body movements and lumbar control – Incorporation of abdominal muscle control is key to lumbar stabilization Functional Progressions • Stabilization exercises must be the foundation and should be incorporated into each drill • Progression of stabilization exercises should move from supine activities, to prone activities, to kneeling and eventually to weightbearing activities Return to Activity • Acute sprains and strains of the back take the same amount of time to heal as most extremity injuries • With chronic or recurrent injuries, return to full activity can be frustrating and time consuming • Extensive amounts of time and education concerning skills and techniques of the athlete will be required to achieve a full return to activity Bandaging and Taping    Will contribute to recovery of injuries When applied incorrectly may cause discomfort, wound contamination, hamper healing Must be firmly applied while still allowing circulation     Gauze- sterile pads for wounds, hold dressings in place (roller bandage) or padding for prevention of blisters Cotton cloth- ankle wraps, triangular and cravat bandages Elastic bandages- extensible and very useful with sports; active bandages allowing for movement; can provide support and compression for wound healing Cohesive elastic bandage- exerts constant even pressure; 2 layer bandage that is self adhering;      Gauze, cotton cloth, elastic wrapping Length and width vary and are used according to body part and size Sizes ranges 2, 3, 4, 6 inch width and 6 or 10 yard lengths Should be stored rolled Bandage selected should be free from wrinkles, seams and imperfections that could cause irritation     Hold bandage in preferred hand with loose end extending from bottom of roll Back surface of loose end should lay on skin surface Pressure and tension should be standardized Anchor are created by overlapping wrap ◦ Start anchor at smallest circumference of limb     Body part should be wrapped in position of maximum contraction More turns with moderate tension vs. fewer turns with maximum tension Each turn should overlap by half to prevent separation Circulation should be monitored when limbs are wrapped        Ankle and foot spica Spiral bandage (spica) Groin support Shoulder spica Elbow figure-eight Gauze hand and wrist figure-eight Cloth ankle wrap    Cotton cloth that can be substituted if roller bandages not available First aid device, due to ease and speed of application Primarily used for arm slings ◦ Cervical arm sling ◦ Shoulder arm sling ◦ Sling and swathe   Designed to support forearm, wrist and hand injuries Bandage placed around neck and under bent arm to be supported   Forearm support when a shoulder girdle injury exists Also used when cervical sling is irritating   Combination utilized to stabilize arm Used in instances of shoulder dislocations and fractures    Historically an important part of athletic training Becoming decreasingly important due to questions surfacing concerning effectiveness Utilized in areas of injury care and protection     Retention of wound dressing Stabilization of compression bandages controlling internal and external bleeding Support of recent injuries in an effort to prevent additional trauma Provide stabilization while athlete undergoes rehabilitation Tape- Injury Protection   Used to protect against acute injuries Limits motion or secures special device  Great adaptability due to: ◦ ◦ ◦ ◦    Uniform adhesive mass Adhering qualities Lightness Relative strength Help to hold dressings and provide support and protection to injured areas Come in varied sizes (1”, 1 1/2” , 2”) When purchasing the following should be considered:  Tape Grade  Adhesive Mass ◦ Graded according to longitudinal and vertical fibers per inch ◦ More costly (heavier) contains 85 horizontal and 65 vertical fibers ◦ Should adhere regularly and maintain adhesion with perspiration ◦ Contain few skin irritants ◦ Be easily removable without leaving adhesive residue and removing superficial skin  Winding Tension ◦ Critically important ◦ If applied for protection tension must be even    Used in combination with non-elastic tape Good for small, angular parts due to elasticity. Comes in a variety of widths (1”, 2”, 3”, 4”)     Skin surface should be clean of oil, perspiration and dirt Hair should be removed to prevent skin irritation with tape removal Tape adherent is optional Foam and skin lubricant should be used to minimize blisters    Tape directly to skin Prewrap (roll of thin foam) can be used to protect skin in cases where tape is used daily Prewrap should only be applied one layer thick when taping and should be anchored proximally and distally  Proper taping technique ◦ Tape width used dependent on area ◦ Acute angles = narrower tape  Tearing tape ◦ Various techniques can be used but should always allow athlete to hold on to roll of tape ◦ Do not bend, twist or wrinkle tape ◦ Tearing should result in straight edge with no loose strands ◦ Some tapes may require cutting agents       Tape in the position in which joint must be stabilized Overlap the tape by half Avoid continuous taping Keep tape roll in hand whenever possible Smooth and mold tape as it is laid down on skin Allow tape to follow contours of the skin    Start taping with an anchor piece and finish by applying a locking strip Where maximum support is desired, tape directly to the skin Do not apply tape if skin is hot or cold from treatments  Removing adhesive tape ◦ Removable by hand Always pull tape in direct line with body (one hand pulls tape while other hand presses skin in opposite direction ◦ Aid of tape scissors and cutters may be required Be sure not to aggravate injured area with cutting device ◦ Also removable with chemical solvents        Razor (hair removal) Soap (skin cleaning) Alcohol (oil removal) Adhesive spray Prewrap material Heel and lace pads White non-elastic tape      Elastic adhesive tape Felt and foam padding material Tape scissors Tape cutters Elastic bandages   Routine Non-injury taping Closed Basket Weave ◦ Used for newly sprained or chronically weak ankles  Open Basket Weave ◦ Allows more dorsiflexion and plantar flexion, provides medial and lateral stability and room for swelling ◦ Used in acute sprain situations in conjunction with elastic bandage and cold application    Helps to manage glide, tilt, rotation and anteroposterior orientation of patella Accomplished by passively taping patella into biomechanically correct position Also provides prolonged stretch to soft-tissue structures associated with dysfunction
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