Lower Back Injuries
Stress Fractures In The Lower Back
What is it?
Often referred to as pars defect and is an incomplete fracture with in rear portion of the vertebral arch. If it occurs on both sides of the vertebrae and the vertebral body ‘slips’ forward it is called a spondylolisthesis (These are graded 1 to 4, depending on severity)
How does it happen?
It usually results from an overuse injury with activities requiring excessive extension (arching) and/or rotation (eg. fast bowling). The rear portion of the vertebra is placed under stress and reacts by increasing bone turn over (replacing the old with new). If this process results in greater re-absorption than new bone formation then an area of weakness develops and a fracture can take place if the bone is continually loaded (stress fracture).
How does it feel?
The condition may cause pain in the low back (typically one sided) with the possible presence of buttock or leg pain. The condition is aggravated by activities involving extension and rotation. As it worsens you may experience pain with prolonged standing and with lying. Pars defects and a spondylolisthesis can be congenital and asymptomatic. These are typically found incidentally on X-rays for varying low back conditions.
How is the diagnosis made?
Diagnosis is made via a thorough history and physical assessment. X-rays, bone scans and/or CT scan can be requested to confirm the diagnosis and stage of healing.
- The assistance of physiotherapist and doctor is important in the successful management of pars defects. Structuring a rehabilitation program that incorporates the constraints of the diagnosis is vital in returning to activities.
- Rest from the pain producing activities. It is particularly important to avoid forceful hyperextension as this may lead to further symptom provocation and condition deterioration.
- Isolated functional strengthening of the deep trunk musculature. There has been a great deal of research performed by physiotherapists across Australia, which supports the very specific sub-maximal re-training of the ‘core muscles’. This work can be incorporated into more general trunk strengthening and specific functional strengthening as your condition improves.
- Review the biomechanics of the aggravating activity. Changing the loading on the bone is vital to limit the recurrence of the injury and technique changes may be needed in your given sport.
Could there be any long-term effects?
It is possible that defects may never heal, and that a spondylolisthesis may remain the same. But despite this, appropriate management can usually return to your desired level of activity.
Contact a Physiotherapy4u Practitioner for More Information.
Spondylolysis And Spondylolisthesis
Spondylolysis is defined as a defect of the vertebral arch. It can be a naturally occurring problem, where the defect develops due to the normal stresses of weight bearing, or it may develop due to excessive sporting activity. Initially the condition may present as stress fracture of the pars inter articularis. The condition may cause pain in the low back with the possible presence of somatic or radicular leg pain. Neurological signs may also be present. It is particularly prevalent in people who subject their back to repetitive and forceful hyperextension, particularly when combined with a degree of rotation in sports such as gymnastics, fast bowlers in cricket, javelin throwing, weight lifting and other similar activities.
The vertebral arch has two sides to it and the defect(s) can occur on one or both sides. If the defect is present on both sides (bilaterally), forward (anterior) “slipping” of the vertebra may result in a spondylolisthesis (Graded from 1 to 4 depending on the severity). Backwards “slippage” (Retrolisthesis) can occur, but is relatively rare.
Diagnosis of both spondylosis and spondylolisthesis is by x-ray and/or CT scan, but the CT scan needs to be a specific angle (Reverse Gantry), and looking for this condition. If the condition is in its early stage, such as a stress fracture, then the diagnosis can also be made by a bone scan.
It should be noted that the presence of a spondylolisthesis on investigation is sometimes a “red herring”, with the cause of the pain in fact not being from area. The pain may be caused by a disc or facet joint and not related to the spondylolysis or Ssondylolisthesis.
Treatment for spondylolysis and spondylolisthesis may involve:
Rest from the pain producing activities.
As with all types of back pain, it is worth counselling the patient about the likely positive outcome and the need to remain active without aggravating the underlying pathology. It is particularly important to avoid forceful bending backwards (hyperextension). Cross-training through this phase is usually possible, with activities such as bike riding easier than swimming as many people drop into lumbar extension when swimming.
Isolated functional strengthening of the deep trunk musculature.
There has been a great deal of research performed by Physiotherapists across other countries which supports the very specific re-training of specific abdominal and back muscles. This work can be incorporated into more general trunk strengthening and specific functional strengthening as the patient’s ability improves.
Review the biomechanics of the aggravating activity.
The principle of fixing the source of the problem by avoiding the combined extension/rotation mechanism is often applied in other problem activities. This should include your Physiotherapist and Coach.
For more information contact us
“Sciatica” has quickly become a broad term that people use to describe any pain at the back of the thigh and is commonly overused.
Even though pain at the back of thigh can be due to the Sciatic nerve, the reality is that pain in this area is often due to a number of other causes such as pain directly from your back, muscle strain of the glutes or hamstrings and even trigger points or muscle tension.
It is therefore important to have your pain thoroughly assessed, to get the correct diagnosis.
“Sciatica” is symptom caused by irritation of the Sciatic nerve. This irritation can be due to stiffness or inflammation at any point along the nerve’s line. Commonly, the irritation is at the roots of the nerve, as they pass out of the lower back.
Symptoms usually consist of:
- Pain along the specific line of the sciatic nerve
- Dull, pulling, heaving sensation along that line
- Occasionally paraesthesia or a “numb” sensation
Sciatic nerve pain can be diagnosed with specific tests performed by your physiotherapist, that assess the nerve’s sensitivity to lengthening and stretching movements. This should be performed in conjunction with a thorough assessment of your lower back and thigh, to formulate a diagnosis as to why you are getting this pain.
Treatment involves treating the area around the nerve to reduce the irritation and reducing the nerve’s sensitivity to stretching. This can involve:
- Specific mobilizations
- Dry needling
- Specific stretches and exercises
- Modifying biomechanics and lifestyle factors
In adolescents bones are still maturing, including the vertebrae of the spine.
Scheuermann’s disease refers to an abnormality in the growth of the vertebrae, where the front of the vertebrae does not grow as quickly as the back leading to wedging of the vertebrae. This usually occurs in the thoracic spine (the upper back) and may have varying degrees of severity.
WHAT DO I LOOK FOR?
- Pain in the upper or mid back especially with sitting
- Stiffness in the back
- Increased curve in the upper back
WHAT CAUSES IT?
- Often unknown
- Sudden growth spurt.
When do you see someone for help?
Your Physiotherapy4u Practitioner will be able to provide an accurate diagnosis and an appropriate management plan. Often this problem can require a Sports Medicine Doctor, Physiotherapist, and/or Podiatrist to assist.
For more information contact us.
Sacroiliac Joint Pain
What is it?
This is the joint between the sacrum and the two hip bones. When this joint is put under excessive stress it can become inflamed and of the ligaments and muscles surrounding this structure can also become painful.
What do I look for?
- Pain and often tenderness to touch in the buttock region
- Pain with walking, sit to stand, getting out of a car and or when using stairs
- Pain radiating into the lower leg and groin regions
What causes it?
- Muscle imbalances around the pelvic/hip region
- Poor control of the pelvic stabilizers
- An injury such as a fall or a car accident
When do I see the physio?
Physiotherapists can assess your condition, use a variety of techniques, correct muscle imbalances and provide you with an appropriate exercise program.
Do I see my doctor?
Your physiotherapist will also advise you when you need to see your doctor
FOR MORE INFORMATION contact us
Lumbar Disc Pathology
Anatomy of the Lumbar Spine
In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad. The disc is a combination of strong connective tissues which hold one vertebra to the next, and acts as a cushion between the vertebrae. The disc is made of a tough outer layer called the “annulus fibrosus” and a gel-like center called the “nucleus pulposus.” As you get older, the center of the disc may start to lose water content, making the disc less elastic and less effective as a cushion.
Nerve roots exit the spinal canal through small passageways between the vertebrae and discs. Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots.
Differential Diagnosis – Degeneration vs Prolapse vs Herniation vs Nerve Compression
Disc Degeneration – Disc Degeneration refers to a syndrome in which a painful disc can cause associated low back pain. The condition generally starts with an injury to the disc space. The injury weakens the disc and creates excessive movement because the disc can no longer hold the vertebrae above and below the disc together as well as it used to. The excessive movement, combined with the inflammatory response irritate the local area, commonly producing symptoms of low back pain (See Stage 1 of picture). Unlike the muscles in the back, the lumbar disc does not have a blood supply and therefore cannot heal itself and the painful symptoms of degenerative disc disease can become chronic and lead to further problems such as herniation and nerve root compression.
It is important to note that disc degeneration is part of the natural process of aging and does not necessarily lead to low back pain. MRI scans have documented that approximately 30% of 30 year olds have signs of disc degeneration on MRI scans even though they have no back pain symptoms. It must therefore be stressed that not all degenerated discs that are seen on MRI scans are pain generators.
Herniated Disc – Herniated discs are often referred to as “slipped discs”, “bulging discs”, or “prolapsed discs”. This term is derived from the action of the nucleus tissue when it is forced from the center of the disc. The disc itself does not slip. However, the nucleus (soft inner layer) tissues located in the center of the disc can be placed under so much pressure that it can cause the annulus (outer tough layer) to herniate or rupture. This can be seen in its varying degrees of severity in the adjacent picture from stages 2-4. The severity of the discs herniation may cause the bulging tissue to compress against one or more of the spinal nerves which can cause local and referred pain, numbness, or weakness in the low back. leg or foot. Approximately 90% of disc herniations will occur at L4- L5 (lumbar segments 4 and 5) or L5- S1 (lumbar segment 5 and sacral segment1), which causes pain in the L5 nerve or S1 nerve, respectively.
Nerve Compression/Sciatica – The sciatic nerve is the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibers to the leg. Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve,. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of movement control in the leg due to interruption of nerve signaling. The condition may also be caused by a tumor, cyst, metastatic disease, or degeneration of the sciatic nerve root.
Signs and Symptoms of Lumbar Disc Injury Lumbar disc pathology can result in a broad spectrum of signs and symptoms with the primary complaint being low back pain. Initial signs and symptoms may include centralized low back pain, early morning stiffness, pinching and catching, muscle spasm, pain on movement (mainly bending and twisting), and reduced range of low back movement. If the condition progresses and the lumbar disc deteriorates further to cause nerve compression symptoms may present as radiating low back pain, shooting pains down the leg and into the foot, numbness, pins and needles, burning, muscle weakness, and further reduced low back range of movement.
What Increases Your Risk?
Factors You Cannot Change
- Advancing age. The process of aging of the discs in the lower back, as well as repeated injury to the discs and spinal muscles, makes a person more likely to have low back problems, which usually begin in mid-life
- Males greater than females
- History of previous back injury
Factors You Can Change
- Your job or other activities that increase the risk of developing a herniated disc, such as long periods of sitting, lifting or pulling heavy objects, frequent bending or twisting of the back, heavy physical exertion, repetitive motions, or exposure to constant vibration (such as driving)
- Not exercising regularly, doing strenuous exercise for a long time, or starting to exercise too strenuously after a long period of inactivity
- Smoking. Nicotine and other toxins can impair spinal discs’ ability to absorb nutrients they need from the blood, making the discs more prone to injury.
- Being overweight. Carrying extra body weight (especially in the stomach area) causes additional strain on the lower back.
- Frequent coughing
In most cases, if a patient’s low back and/or leg pain is going to resolve after a lumbar herniated disc it will do so within about six weeks. While waiting to see if the disc will heal on its own, several conservative treatment options can help reduce the back pain, leg pain and discomfort caused by the herniated disc.
Physiotherapy treatment for a lumbar disc complaint may include ultrasound, electric stimulation, hot packs, cold packs, traction of your lumbar joints, and manual (“hands on”) mobilisations to reduce your pain and muscle spasm, which will make it easier to start an exercise program. Manipulation may provide short-term relief from non-specific low back pain, but should be avoided in most cases of herniated disc to avoid further injury and/or compression. Non Steroidal Anti-inflammatory Medications (NSAIDS) e.g. nurofen and aspirin, may be helpful in alleviating the inflammation associated with low back pain, and stronger therapies, such as oral steroids or epidurals, may be prescribed to treat severe flares.
At first, your physiotherapist may prescribe gentle stretches or posture changes to reduce the back pain or leg symptoms. When you have less pain, more vigorous exercises will be used to improve low back flexibility and strength, core stability, endurance and enable a safe return to full activity. In severe cases where disc degeneration and/or nerve compression does not respond to conservative treatments surgery may be required.
For more information contact us.
Low Back Pain
WHAT IS IT?
A staggering 80-90% of the population experience low back pain at some point during their lifetime.
Back pain can also refer pain into the buttocks, legs and feet, this is known as referred pain. There are many structures that may be affected such as the;
- Facet joint
- Sacro-iliac joint
WHAT DO I LOOK FOR?
- Sharp/catching pain or ache at the base of the spine/ waist area
- Referred pain into the buttocks or the leg and this can even extend as far as your toes
- Difficulty bending over or putting on your pants and shoes
- Pain in your back after sitting at your desk for a prolonged period.
- Your posture plays a pivotal role
WHAT CAUSES IT?
- Poor posture
- Collisions or falls such as with car accidents, horse riding or contact sports
- Poor biomechanics
- Poor technique with sport, lifting or manual tasks
WHEN DO I SEE A PHYSIO?
Physios can provide accurate diagnosis and use a range of techniques to settle down your symptoms. They can correct poor biomechanics and provide you with an appropriate rehabilitation program.
DO I SEE MY DOCTOR?
If symptoms persist, your physiotherapist will advise when you need to see your doctor
FOR MORE INFORMATION contact us.
Lifting And Lower Back Pain
Low back pain is an extremely common complaint in our society today with up to 80% of the population suffering some form of lower back pain in their lifetime.
There are many causes of lower back pain. Just like we can tear or strain a thigh muscle we can also injure the soft tissue in our back. This can occur through direct trauma but more commonly through placing too much stress on these structures.
Incorrect lifting, lifting beyond our physical capacities, repetitive activities causing overuse of joints and ligaments and poor postures greatly contribute to our levels of back pain.
Other problems that can lead to lower back pain are;
Protrusion of the intervertebral disc material which impinges on nerve sensitive structures in the spinal column.
Fractures such as those that occur from falls. More commonly seen in the elderly as their bones are often more brittle.
Stress fractures from overuse. Seen more commonly in sports involving repeated hyperextension such as gymnastics, fast bowling (cricket) throwing sports and tennis.
Spinal canal stenosis (or narrowing). More common in the elderly. Characterised by pain, aggravated by walking and relieved by rest.
Other causes include malignancy (cancer), arthritis and osteoporosis.
In the majority of cases of low back pain the principles of management depend on careful assessment to detect any abnormality then appropriate treatment to correct that abnormality.
Physiotherapy, hydrotherapy and back care education play a big role in managing these low back syndromes of today’s society.
For more information contact us.
Do Discs Heal?
The intervertebral spinal disc remains one of the most intriguing and misunderstood structures in the human body.
The vast majority of the population will at some stage experience some back or neck injury, and a significant proportion of these will involve the intervertebral disc. However, there are still significant misconceptions about these types of injuries.
The intervertebral disc is of course made up of a thick fibrous layered outer coating called the annulus fibrosus, and the centre called the nucleus pulposa. It is fused to the end plates of the vertebra above and below and can move in all directions.
The nucleus itself is liquid in nature up until about the age of 17 in most people. At this stage the nucleus solidifies as part of natural development of the spine. The nucleus itself does not have direct blood supply, and annulus gains its blood supply through the surrounding blood vessels. Damage to the outer coating or end plate that causes bleeding into the nucleus, will result in a significant inflammatory response. Indeed bleeding into this area can in fact liquefy the solid nucleus in adults.
Other misconceptions can include the old adage a ‘slipped disc’. This of course is impossible due to the extremely strong fusion of the disc to the vertebral end plate.
Common injuries that can incur in a disc are a ‘prolapse’ and a ‘bulge’. The prolapse itself involves tearing of the outer coating of the annulus and can also involve the nucleus protruding through this ‘tear’.
A bulging involves tearing of the deeper layers of the annulus but not the outer coating. The analogy of an air bubble in a re-tread tyre on a car can be a useful description.
Damage to these structures causes an inflammatory reaction, and ongoing pain. But it is also the start of the healing process. If this inflammatory reaction is appropriately managed early, then most disc injuries should heal, as with any other structure. If it is poorly managed it can lead to painful restriction to movement, and long-term disability.
Early intensive treatment from the Doctor and Physiotherapist aimed at returning normal movement and function, and controlling the inflammatory response and pain, can have a dramatic impact on the fate of that injury.
For more information contact us.
Beating Back Pain
BEATING BACK PAIN – TRAINING FROM THE INSIDE OUT
At some stage in their lives eighty per cent of the population will experience back pain. To make matters worse, after the first incidence, eighty per cent will suffer a recurrence within twelve months. The good news is: recent research suggests that good control of your back muscles decreases the risk of hurting or re-injuring your back.
What is spinal stability?
Your spine is made up of individual blocks of bone (vertebrae), stacked on top of each other, with flexible discs sitting in between the vertebrae. Joints between the vertebrae are stabilized by the way the bones meet each other, the ligaments that attach to vertebrae, and the surrounding muscular system. The muscles rely on the nerves to control the timing and the force of the muscle contractions.
When your stabilising systems aren’t working well the vertebrae may move too much on each other and cause pain and discomfort. Research, much of which has been conducted by Australian physiotherapists, has shown that joint stability is improved by very specific exercises that train the nerves and muscles around the spine.
Which muscles are important?
Muscles can be classified as either mobility or stability muscles. The stability muscles tend to be small and deep – close to the joints. They don’t produce much force or movement and if you don’t have a sore back they contract automatically just prior to movement commencing to provide stability.
After an injury, pain and swelling cause the stability muscles to be inhibited or “switched off”. Research has shown that these muscles do not automatically regain their stabilisation ability without specific retraining. It follows that for injury prevention, good coordination between the mobility and stability muscles is vital. This is sometimes referred to as core control.
Typically, the stability muscles are deep. Following injury, research has shown that specific exercises are needed initially to facilitate the stability muscles in isolation (very small effort exercises). Other exercises are then required to incorporate them into everyday activities such as sitting and walking. Often it takes time to isolate these muscles, particularly if you have back pain. The conventional sit-up and abdominal crunch do not regain the function of the stability muscles.
The stability muscles form a stable base from which movement can safely occur without damaging the joints. Even if you don’t currently have back pain it may be worth learning some exercises to help prevent future back injuries.
FOR MORE INFORMATION contact us.
Acute Back Pain
Back pain is probably the most widespread, common, and potentially disabling injury in modern society.
It is also one of the most misunderstood.
It is commonly thought that prompt diagnosis and treatment of Sudden Onset (often called Acute) Back pain by well qualified Physiotherapists gives those suffering from Acute Back Pain, the best chance to resolve this problem quickly and avoid longer term problems and re-occurrence.
What you may feel:
– You will have immediate pain that is worse when you move into a certain direction
– You may have:
- Pins and needles/numbness in your hands or legs
- Tightness or referred pain into you gluteal (bottom) muscles
- Pain when breathing deeply or coughing
- Pain at night initially
How does it happen?
– Often back injuries happen when you least expect it and with any movements:
- Bending forward and twisting as you picked something up
- Jumping and landing in an extended position
- Twisting suddenly
What is the cause?
- The joints in your back have ligaments, cartilage and a capsule just like any other joint in your body. And just like you can sprain your ankle or thumb, you can also sprain your back joints.
- This causes the same response, as if you had sprained your ankle – pain and swelling etc.
What should you do?
– Initially you should perform:
- Active Rest: Try to keep your back moving within your pain limits
- Avoid aggravating activities
- Heat: Every hour place a heat pack on the sore area for 10-15 minutes
- Medicine: Paracetomol pain relief straight away
- Massage: Gentle massage is ok, as long as it is not painful
– Make an appointment with your Physiotherapist for Assessment, Treatment and Advice
– You should avoid:
- Prolonged Sitting
- Heavy Lifting
- Complete Rest
Research has shown that Xrays provide little or no help in diagnosis Acute Back pain, and in many cases can provide false and misleading causes of the Pain.
How long before you have recovered?
– It depends on the severity of the injury. A back sprain can last anywhere from a few days to a few weeks. Usually with physiotherapy and a home exercise program you will feel a lot better within a week. You may not be completely free of pain but you will be able to function a lot better and with decreased pain
FOR FURTHER INFORMATION contact us.