Back pain; Pro-Am Sports Injury Clinic

Back Pain - Lumbago

Back Anatomy *Intervertabral injury * Facet joint injury * Acute nerve route compression/sciatica * Posture * Exercise rehabilitation * Other Injuries * Treatment *

"80% of the population will suffer from low back pain at some time in their life".

Back and neck pains can be caused suddenly by a specific injury such as lifting a load awkwardly or it may come on gradually. This is normally due to an accumulation of several minor factors. This could include poor sitting posture at a computer or driving, poor physical fitness and having weak muscles that support the spine. If you leave your problem untreated these muscles will become even weaker and the spine becomes more stiff and painful. The problem then will become chronic and recurrent. Therefore it is important to get your spine checked over as soon as possible, even if you have a minor twinge, if you want to prevent long-term problems. A lot of people avoid early treatment as their problems are intermittent but research shows that early intervention is the most successful way to resolve back and neck pains.

Back anatomy

The back is made up of 24 building blocks called vertebrae which support the body. There are seven cervical vertebrae, twelve thoracic vertebrae, and five lumber vertebrae. The majority of the problems stem from the lower lumber vertebrae where we see most of our problems. The vertebrae sit on top of each other separated by the spinal disc. On the back of each vertebrae there are two joints on each side called facet joints. Half the weight of the body goes through the body of the vertebrae and the disc while the other half of the bodies weight goes through the two facet joints.

The spine has three healthy natural curves. This allows the spine to acts as a shock absorber. As a load is placed upon the spine the curves bend to dissipate the force. If for any reason these curves are lost then there is a dramatic increase of force through the individual vertebrae and disc.

The facet joints are true joints very similar to the joints in your fingers. They allow the back to bend forward and backward as well as rotate from side to side. They are placed under the most stress when the back is bent backward especially with some rotation. Like any joint it is easily sprained and because there is so much stress through these small joints they are more prone to degenerate.

The most talked about structure in the back is the spinal discs. These shock absorbing disc sit between each vertebrae. They are made up of a softer centre and a realatively hard outer shell. They also provide a lot of stability to the lumber spine. Problems usually start when the outer annulus breaks down from injury and aging.

The muscles and ligaments around the spine are crucially important. There is a long ligament that runs down both the front and back of the spine. They stabilize the spine and like any ligament around any joint in the body they can be sprained and cause problems short and long term. The back muscles are important to support the spine and the abdominal muscles are also connected to the lumbar back tissue and have a very important role in the health of your back. It is these muscles and ligaments which we can have the most effect on to ensure a healthy back.

The messages from the brain to the body are carried in the spinal cord. The spinal cord runs down through and is protected by the vertebrae. At each vertebrae there exits a spinal nerve. Often the spinal nerve is injured or irritated as it leaves the vertebrae. The spine is a very complex structure which can easily have problems. Now we know the anatomy we will discuss what can go wrong in the next column.

The back is a very complex structure, many structures within the back can be causing pain. While we can often be very specific about what exactly is causing your back discomfort, more often than not we can not. After taking a careful history of your problem and a thorough examination we usually have a good idea about your back problem but NOT a definitive diagnosis

Back pain can be causing symptoms locally in the back and buttock region or it can cause referred symptoms into the leg and as far as the foot. It can be a dull vague feeling or a very direct shooting pain down the leg. Other complaints include pins and needles, numbness, muscle weakness and general stiffness. Abnormalities of joints, muscles and neural structures may contribute significantly to back pain.

Recent onset of back pain is usually from the joints. In long standing cases of low back pain there maybe associated muscle and neural involvement. Chronic low back pain is caused by instability in which there is disc degeneration. This can cause inflammation of the joints. An imbalance of muscles is also usually present showing weakness of the main stabilisers transverse abdominus and multifidius. Poor posture/postural control can result in this muscle imbalance. Muscle strains are rare in the back unless taking part in extreme torsional sports like javelin or bowling in cricket where stress is placed on the quadratus lumborum.

MECHANICAL BACK PAIN Most back pain falls into this category. The pain is vague and not specific to any structure. It is usually do to a dysfunction of the supporting ligaments and muscles. The stress to the back structures causes the pain. The predisposing factors for this pain vary with the age group. As adolescents grow the bones grow faster than the muscles and ligaments. This leads to tightness and weakness of the structures supporting the back. With increased activity such as athletic participation there is increased stress on the back structures and pain ensues. As we get older a different process takes over. The back naturally starts to degenerate after about age 20. If we do not keep the back in shape the muscles get tight and put stress on the back structures. Combine this with the weakness of the muscles supporting the spine and we have a situation where there is either an increase in abnormal movement between the vertebrae or a decrease in the normal functional movement between the vertebrae. Often these two occur at the same time in different parts of the spine.

Techniques have demonstrated that damage to the facet joints and intervertabral disks are the most common causes of pain in the back.

Intervertabral disc/facet joint injuries

Previously only two types of disk injuries were recognised. One was a prolapsed disc or rupture (usually causes a sharp lacerating pain into the foot). The second was degeneration, a narrowing of the disk space (Spinal Stenosis). However the outer third of the disk (anulus fibrosus) is quite sensitive and can be a source of pain without rupture or degeneration.

Excessive rotational or compression forces can lead to these injuries (bending forward and twisting as in lifting).

Differences of pain provoking techniques can help to differentiate between the disc and joint (flexion with disc injuries, extension with joint injuries). Disc injuries usually present as central back pain and unilaterally with joint injuries. However these are used as guides as they can coexist together.

Symptoms of Disc injuries

Some disruption of the lumbar disc or tissue that supports the area of the disc will cause pain that is confined to the lower back, it is usually on one side more than the other.
It may refer into the buttock and lateral hip but no further. It is an aching type of pain with the occasional sharp twinge.
If the disc has protruded you may experience a more predominate leg pain. This will follow the pattern of a particular nerve root.
Flexion is usually the movement affected. Sitting may be uncomfortable. If a large herniation is present a lateral shift will be present (protective scoliosis). Side flexion may cause symptoms but rotation should be pain free but can cause a pulling sensation.

Facet joint injuries - view video about facet joint

What are the Facet (zygapophysial) Joints?

The facet joints are synovial joints which help support the weight and control movement between individual vertebrae of the spine.

The facet joints work together alongside the intervertabral discs to form a functional working unit. The facet joints direct the plane of motion at each vertebral segment which is dependant on their angle and orientation.

Throughout the spine the angles and orientations differ which alters the possible movement allowed in that area. The facets have an articular cartilage and articular capsule which allow movement but provide stability. Facet joints have a nerve supply from two levels, one branch arises from the nerve root at that level and the second from the level above. When functioning correctly, facet joints move freely controlling the movement of the spine.

Facet joint pain may arise directly from the facet joint either from inflammation or nerve impingement

What are the symptoms?

Common symptoms associated with this condition are adjacent muscle spasms which can pull the patient out of alignment, leading to a guarded posture.
Often patients will report “I just bent over to tie my shoe laces and my back went and I couldn't move”. The usual acute attack of back pain involving facet joints occurs suddenly with no warning. It can appear dramatic and patients are in much discomfort and cannot move very well.

This spasm of adjacent muscles is the bodies way of protecting the area and tries to prevent you from moving and incurring more damage. Symptoms can vary greatly and be confused with disc related disorders as its possible for patients to report referred pain into the lower extremities. The traditional facet locking syndrome may lead to such an acute attack but can be resolved successfully by freeing the offending joint and restoring normal function. This should only be attempted by suitably qualified practitioners following the correct diagnosis.

It can be felt locally to the central lumbar region with some pain radiating across the back as it progresses. It can become more noticeable on one side and can be felt in the buttock region.
If more pressure has been applied to the posterior structures the area of symptoms may travel as far as the posterior knee. Walking can be painful and relieved with sitting. But if sitting is held it can cause stiffness.
It mainly effects extension movements, side flexions to one side may be limited especially towards the side that has pain. Rotations may cause stiffness at the end ranges but should be full range and pain free.
This condition is most present in those who have an increased lordosis curve with increased muscle tension in that area.

If you have sustained a strain to the joint, both flexion and extension will be limited with limited side flexion to the affected side and rotation may cause a pulling sensation. Muscle spasm will be present. It can cause a flattening of the lumbar curve. Pain will be felt in the back and will radiate to one side across the iliac crest.

Back pain is more prevalent than the referred symptoms for intervertabral/facet joint injuries. If prolapse has occurred than the radiating leg pain is greater than the back pain (Sciatica). Other symptoms of disc prolapse are muscle weakness, sensory changes (pins and needles, numbness) and diminished reflexes in the lower extremity. If you suffer from all of these and also start to have abnormal bladder function you need to have immediate referral to your gp.

Posture

Looking at someone's spinal curves can say a lot to why someone is suffering from back pain. The main one I see is lordosis followed by flat back. It is also important to look out for scoliosis especially with children. Postural problems are caused by instability and weakness. Other causes include muscle spasm and deformities whilst growing.

What is Lordosis or Hyperlordosis?

Lordosis is an exaggerated lumbar curve in the spine. Or to put it another way, the lower back curves inwards more than it would naturally do.

The spine needs a natural curve to function correctly. This is due to the shape of the individual bones of the spine (vertebrae). If the curve becomes to great then stress is placed on other parts of the spine causing pain.

”normal

What is the cause of Lordosis?

Some muscles around the hip and spine become tight and some become weak and stretched, causing an imbalance. The muscles that are often tight are:

Trunk extensors (erector spinae and quadratus lumborum).
Hip flexors, in particular the iliopsoas muscle.

These muscles require stretching.

The muscles that are often weak and stretched are:

Abdominal muscles (rectus abdominus, internal oblique and external oblique)
Hip extensors (hamstrings and gluteus maximus).

These muscles require strengthening.

A flat back posture is the opposite to this, the vertebra of the back tens to be very stiff with a flat back.

What is scoliosis?

Scoliosis is a sideways curving of the spine that can often result in an 'S' shape or 'C' shape in the spine. If someone runs there fingers down the spine either side of the vertebrae they will leave two red lines. It is often easier to see the curving of the spine in these red lines. Scoliosis is often a result of an imbalance in the muscles caused by one sided activities such as throwing or racket sports. Children can develop scoliosis through carrying heavy bags on one shoulder all day at school.

Other injuries affecting the back

Spinal Stenosis

Spinal stenosis is a condition seen more in older athletes where the spinal canal narrows causing pressure on the nerves with resulting pain and numbness. The lumbar spinal canal is the space in the spine through which nerves pass into the legs. Over time this space can narrow due to bone and tissue thickening (stenosis).

Symptoms of spinal canal stenosis

Low back pain, leg pain or numbness in the legs Weakness or tiredness in the legs.
Symptoms often come up when walking or standing.
Symptoms may be reduced by sitting or lying in the fatal position.
In severe cases bowel or bladder problems may be present.
An X-ray of the spine can confirm the diagnosis.

Causes of spinal stenosis

Wear and tear on the bones and joints of the spine can cause narrowing of the spinal canal.
Arthritis
Trauma such as a fall or accident.

Treatment of spinal canal stenosis

If symptoms are mild then an exercise programme may be the best course of treatment initially.
Core strengthening exercises to improve back muscle strength and posture.
Drugs may be prescribed to reduce pain and swelling in the spine.
In severe cases surgery may be indicated.

Spondylolisthesis

Spondylolisthesis is a back injury involving a forward slipping of one vertebra over another and is most commonly seen in children between the ages of 9 and 14. It is also more common in sports that have a lot of strain on the back for example throwing events, wrestling, weight lifting and gymnastics. The risk of forward slipping in people over the age of twenty five is very small. It is usually the fifth or bottom lumbar vertebrae that is involved by slipping forward over the S1 (top bone of the sacrum).

It is often seen in conjunction with a stress fracture of defect of the pars interarticularis (spondylolysis). Most cases of pars interarticularis defects that are associated with spondylolysis are those where there is a family history of the defect. Stress fractures of the pars interarticularis through over use are though rarely to be the cause of spondylolisthesis.

Spondylolisthesis can be grading depending on how far forward the vertebra has slipped which is measured by an X-ray from the side.

Sacroiliac Joint Injury - coming soon

Acute Nerve Root Compression - disk herniation

Sciatica is pain that starts in the back and radiates down one of the legs. It is quite a common complaint and is caused by pressure on the sciatic nerve which runs down into the leg. The medical term is acute nerve root compression. The cause of pressure can be varied from a prolapsed disk to muscle tension (Piriformis syndrome) or something less common such as a tumours, bony growths and infections.

A prolapsed disc or slipped disc as it is sometimes known is not simply a disc that has 'slipped' out of place. Intervertabral discs separate the bones of the spine (or vertebrae) and their function is to act as shock absorbers or cushioning for the spine and allow movement.

The intervertabral discs are filled with a soft liquid in the middle called nucleus pullouts and when a disc prolapses this liquid squeezes out and puts pressure on the spinal cord compressing the nerve routes and causing pain.

Depending on where the sciatic nerve is pinched will determine where you feel the pain which can radiate to the front of the knee or right down the back of the leg to the foot. The L5-S1 disc is the disc most commonly damaged and the L4-L5 disc the next most commonly damaged. On the illustration opposite, L4 and L5 are the bottom two Lumbar vertebrae at the base of the spine. S1 is the top of the Sacrum.

DEGENERATIVE BACK DISEASE

Degeneration of the lower back is a completely normal process. If we look at ALL backs as they age, there will be evidence of degeneration which will get worse as you get older. Therefore if someone tells you after looking at your X-rays that you have a degenerative back and have to severely limit your activates, get another opinion. Now, after saying that, as your back degenerates it can cause problems and pain. Obviously, it will not function as efficiently as it once did and it will put stresses on the vertebral segments. Ensuring you keep a good posture and strengthen your core this can prevent back problems occuring.

Treatment

MODIFY ACTIVITY Only the severest of back pain patients require complete bed rest, and even then it has been proven to be detrimental to subject yourself to more than a few days of bed rest. It is prudent to modify your activity so as not to aggravate your back problem. What you have to avoid will depend on the exact etiology of your pain. Often for example sitting is hard in patients with disc problems. Therefore these people avoid sitting for long periods of time and certainly must have a good support and posture while sitting. ICE, HEAT, MASSAGE In the acute episode where the back muscles are in spasm, icing for 15-20 minutes every couple of hours can be very beneficial. Remember to always protect your skin from the ice with a paper/tea towel to avoid frostbite. Once the spasm has abated, heat and massage will be better to increase mobility and relieve stress on your back. MEDICATION Medication is often used in the acute phase to reduce the pain and inflammation. This should never be needed on a long term basis. PHYSIOTHERAPY Therapy is perhaps the most important part of the treatment in the early stages. The therapist can help differentiate the cause of the pain and initiate the appropriate treatment. The therapist will then design a long term treatment program for you to avoid further episodes. A good generalized program that you do on your own is the key. The goal is to make you independent where you control your back as opposed to make you dependent on medication or a specific recurrent treatment

Exercise Rehabilitation

To recover from back pain and prevent re-occurrence the basics of the exercises come from pilates. Pilates has been in use for decades with ballet and dance and has now become beneficial in all sports. With athletes you can progress from floor based exercises to more sport related activities. Many back pain sufferers who learn these exercises learn to control there symptoms and have little re-occurrence through keeping the exercises going. It has been found that back pain sufferers have lost the control of their pelvis and activation of the deep abdominals which are vital in back stability.

Here is a list of the sequence followed: -

1. Postural re-education

2. Floor-based exercises and use of the Swiss ball

3. Exercise on Pilates-evolved equipment i.e.. The Reformer, Trapeze, Ladder Barrel, Combo Chair etc.

4. Sports specific exercise on Pilates and other equipment e.g.. Fitter, Sit Fit, swivel plates, medicine balls, trampette etc.

5. Sport-specific exercise programme using bunjees, tubular elastic, wobble boards, floor hurdles, ladders, irregular bouncing balls etc.

Exercise equipment can be adjusted to simulate the sporting environment and a graded programme can be introduced to return the athlete to his or her chosen sport as soon as the back is capable of performing the rigorous demand of their sport.

Re-education of the pelvic tilt and activating the lower abdominals is most important and must be achieved before advancing to sport specific exercises. see the diagrams below: -

coming soon

Once these have been practised in a variety of positions with limb movements you may want to try the following: -