Spine injuries

Mechanical defects of spine causing LBP

-Caused mainly by faulty posture, obesity, or faulty body mechanics -Minor injuries can develop into chronic and recurrent conditions -Maintaining the body's proper segmental alignment during standing, sitting, lying, running, jumping and throwing is of utmost importance for keeping body in good condition

Recurrent & chronic LBP

-Repeated strains/sprains may cause supporting tissues to lose their ability to stabilize the spine, producing laxity -Possible causes: malalignment of vertebral facets, discogenic disease, or nerve root compression -Incidence of this condition increases significantly with age

Back trauma causing LBP

Field officials, coaches, and athletic trainers must use discretion, exercise good judgment, and be able to identify certain gross indications of serious spine involvement

LB muscle spasms

-Etiology: 1) sudden extension contraction on an overloaded or unprepared spine (usually also with trunk rotation); 2) chronic strain (commonly associated with faulty posture that involves excessive lumbar lordosis)' ---Flatback posture or scoliosis may also predispose athlete to strain -Signs/Symptoms: discomfort (localized or diffuse), pain on active extension and passive flexion, no radiating pain further than buttocks or thigh, no neurological involvement -Management: acutely, RICE to decrease muscle spasm (*compress). Graduated program of stretching and strengthening (concentrate on extension strengthening, flex/ext stretching)

Acute Torticollis (wryneck)

-Etiology: athlete usually complains of pain on one side of neck upon awakening. Usually occurs when a small piece of synovial membrane lining joint capsule is impinged or trapped within a facet joint in cervical vertebrae -Signs/Symptoms: palpable point tenderness, muscle spasm, head movement restricted to the side opposite the irritation with marked muscle guarding -Management: modalities to break pain-spasm cycle; joint mobilizations; cervical collar for comfort; muscle guarding typically lasts 2-3 days

Cervical fx

-Etiology: incidence is relatively low (spinal cord protected by bony canal, sheath, fat & fluid cushioning). ---Axial loading of cervical vertebrae combined with neck flexion - anterior compression fx or dislocationC4, C5, C6 most commonly fx ---If head is rotated when contact is made, a dislocation may occur May occur with forced hyperextension of the neck -Signs/Symptoms: neck point tenderness and restricted movement, cervical muscle spasm, cervical pain and pain in the chest and extremities, numbness in trunk and/or limbs, weakness or paralysis, loss of bladder/bowel control -Management: extreme caution must be used in moving an unconscious athlete (can sustain a catastrophic spine injury from improper handling and transportation)

Sciatica

-Etiology: inflammatory condition of the sciatic nerve that can accompany recurrent/chronic low back pain. Commonly associated with nerve root compression from intervertebral disk protrusion, structural irregularities within intervertebral foramina, or tightness of the piriformis muscle. Particularly vulnerable to torsion or direct blows that tend to impose abnormal stretching and pressure (emerges from spine) -Signs/Symptoms: sharp shooting pain that follows posterior and medial thigh; tingling and numbness; may be extremely sensitive to palpation; SLRing usually intensifies pain -Management: rest is essential; treat cause (stretching, traction). Oral anti-inflammatory medication

Scheuermann's disease (dorsolumbar kyphosis)

-Etiology: kyphosis that results from wedge fractures of 5 degrees or greater in 3 or more consecutive vertebral bodies with associated disk space abnormalities and irregularity of epiphyseal endplates ---Accentuation of the kyphotic curve and backache in the young athlete ---Adolescents engaging in sports like gymnastics & swimming (butterfly) are prone to this condition ---Multiple minor injuries to vertebral epiphyses disrupt circulation to the epiphyseal endplate, causing avascular necrosis -Signs/Symptoms: initially - kyphosis and lordosis without back pain. Later - point tenderness over spinous processes, backache at the end of a very physically active day. Hamstring muscles are usually tight. -Management: major goal is to prevent progressive kyphosis. Extension exercises, postural education, bracing, rest, and anti-inflammatory medications; athlete may stay active but should avoid aggravating movements

Cervical cord & nerve root injuries

-Etiology: may be injured via 4 different mechanisms ---LACERATION: usually produced by combined dislocation & fx (jagged edges cut nerve roots or spinal cord & cause varying degrees of paralysis below the injury site) ---HEMORRHAGE: develops from all vertebral fractures & most dislocations, also strains and sprains. Hemorrhage within cord itself may cause damage (okay in muscles or within arachnoid space) ---CONTUSION: may result from sudden displacement of a vertebra that compresses the cord and then returns to its normal position (edematous swelling, resulting in degrees of temporary/permanent damage) ---CERVICAL CORD NEUROPRAXIA: transient paralysis followed by ability to move limbs freely and no other symptoms other than a sore neck; caused by cervical spine stenosis ---SPINAL CORD SHOCK: usually occurs with severe trauma to spinal cord; immediate loss of function below level of lesion, limbs are flaccid (later spasticity). Total loss of deep tendon reflexes, with later development of hyperreflexia -Signs/Symptoms: complete cord lesions at or above C3 will impair respiration & result in death; lesions below C4 will allow for some return of nerve root functionIncomplete lesions can result in ---:Central cord syndrome: caused by hemorrhage or ischemia in central portion of cord, -----results in complete quadriplegia with nonspecific sensory loss, sexual & bowel-bladder dysfunction ---Brown-Sequard syndrome: caused by injury to one side of spinal cord -----results in loss of motor function, touch, vibration, and position sense on one side of the body, and loss of pain and temperature sensation on other side ---Anterior cord syndrome: caused by an injury to the anterior 2/3 of the cord -----results in loss of motor function and pain & temperature sensation; normal sexual and bladder-bowel function ---Posterior cord syndrome: caused by injury to posterior cord (rare) -----Motor function is completely intact -Management: handle with extreme caution; minimize additional trauma to cord if paralysis present

SI sprain

-Etiology: may result from twisting with both feet on ground, stumbling forward, falling backward, stepping too far down and landing heavily on one leg; or bending forward with knees locked during lifting; also downhill running or repetitive unilateral activities - irritation & stretching of sacrotuberous or sacrospinous ligaments ---May also cause unilateral pelvic tilt; as healing occurs, join on injured side may become hypermobile -Signs/Symptoms: palpable pain and tenderness (inferior and medial to PSIS) with associated muscle guarding, radiating pain and possibly groin pain, pain increased with unilateral stance, movement from sitting to standing creates pain, ASIS and/or PSIS may be asymmetrical, possible measurable leg length difference, SLR increases pain after 45° -Management: modalities to reduce pain, supportive bracing, correction of any asymmetry, strengthening

Acute Strain of neck & upper back

-Etiology: mechanism is usually a sudden turn of the head or forced flexion, extension, or rotation. Muscles involved are typically the upper trapezius, sternocleidomastoid, scalenes, and splenius capitis and cervicis -Signs/Symptoms: localized pain, point tenderness, restricted motion; muscle guarding from pain -Management: RICE, cervical collar; ROM, isometrics, progress to full-range isotonics

Lumbar Sprains

-Etiology: most common sprain involves lumbar facet joints (occurs when athlete bends forward and twists while lifting or moving some object). May be acute or chronic -Signs/Symptoms: pain localized just lateral to spinous process; pain becomes sharper with certain movements; passive anteroposterior or rotational movements will increase pain -Management: RICE, joint mobilizations, abdominals & back extensors strengthening, brace/support

Congenital abnormalities causing LBP

-Most common cases: excessively long transverse process of L5, incomplete closure of neural arch (spina bifida occulta), nonconformities of the spinous processes, atypical lumbosacral angles or articular facets, and incomplete closures of the vertebral laminae -Abnormalities may produce mechanical weaknesses that make back prone to injury

Herniated Lumbar Disk

-Etiology: most often L4-L5 disk, secondly L5-S1 disk ---MOI: forward bending and twisting that places strain on lumbar region ---Prolapsed: nucleus moves completely through annulus ---Extruded: nucleus moves into spinal canal and comes in contact with a nerve root ---Sequestrated: material of the nucleus separates from the disk and begins to migrate -Signs/Symptoms: sharp, centrally located pain that radiates unilaterally in a dermatomal pattern to the buttocks and down the back of the leg, or pain that spreads across the back. Possible weakness in lower limb ---Symptoms worse in morning with axial loading; forward bending and sitting increases pain, backward bending decreases pain. Side bending towards side of pain is limited and increases pain ---SLR to 30° increases pain; tendon reflexes diminished; Valsalva maneuver increases pain -Management: pain-reducing modalities, manual traction (goal is to reduce protrusion and restore normal posture)

Cervical spine stenosis

-Etiology: narrowing of the spinal canal in the cervical region that can impingement spinal cord. ---Caused by a congenital variation or from some change in vertebrae (bone spurs, osteophytes, disks) ---Torg ratio: <0.8 (spinal canal diameter divided by vertebral body diameter) ---Space available for cord (SAC): subtract spinal cord diameter from spinal canal diameter -Signs/Symptoms: transient quadriplegia may occur from axial loading, hyperflexion or hyperextension. Symptoms may be purely sensory or may have a motor component. Complete recovery normally occurs within 10-15 minutes; following recovery, full neck ROM is possible -Management: diagnostic tests to determine cause of problem; contact sport athletes should be advised of the potential risks of continued participation in that sport

Cervical dislocation

-Etiology: occur more frequently than fractures; most injuries happen in pool diving accidents ---Cervical vertebrae are more easily dislocated due to their horizontally arranged articular facets ---Most often occur in C4, C5, or C6 -Signs/Symptoms: pain, numbness, muscle weakness/paralysisUnilateral dislocation causes neck to be tilted towards dislocated side with muscle tightness on elongated side -Management: greater likelihood of causing damage to spinal cord - even greater care required in moving patient

Coccyx injuries

-Etiology: occur primarily from direct impact (forcibly sitting down, falling, being kicked). Injuries include sprains, subluxations, and fractures; with healing, SC joint may become hypermobile & restrict passive motion -Signs/Symptoms: x-ray and rectal examination. Prolonged and chronic pain in coccygeal region -Management: analgesics, ring seat to relieve pressure on coccyx when sitting. Pain from a fractured coccyx may last for many months.

Lumbar vertebrae Fx & dislocations

-Etiology: only pose danger when related to spinal cord injury. ---Compression fx: falling from a height or hyperflexion of trunk -----Most commonly compressed: vertebrae in dorsolumbar curves (usually anteriorly) -----Crushed vertebra may spread out fragments and protrude into the spinal canal ---Transverse and spinous processes fx: often result from kicks or other direct impacts to back -----Fx produce extensive soft-tissue injury (surrounded by large muscles) -Signs/Symptoms: recognition is difficult without x-ray; evaluate through history and through point tenderness over affected vertebrae. Fx of transverse/spinous processes may be directly palpable (swelling, guarding) -Management: x-ray, transport on a spine board to minimize movement of fractured segment

Back contusions

-Etiology: quite vulnerable due to large surface area; contusion must be distinguished from vertebral fracture -Signs/Symptoms: local pain, muscle spasm, point tenderness; possibly a swollen discolored area -Management: cold and pressure, ice massage with gradual stretching, ultrasound

Myofascial pain syndrome

-Etiology: regional pain with referred pain to a specific area that occurs with pressure or palpation of tender spots or trigger points within a specific muscle. Possibly restricted ROM due to pain. Most often develop due to some sort of mechanical stress to the muscle (acute strain or static position that produced constant tension in muscle) ---Usually occur in neck, upper and lower back (also piriformis and quadratus lumborum) -Signs/Symptoms: ---Piriformis: palpation refers pain to posterior sacroiliac region, to buttocks, and occasionally down posterior or posterolateral thigh. Pain is a deep ache that increases with exercise or prolonged sitting with hip ADD, flexion & IR. ---Quadratus lumborum: sharp, aching pain in lateral lower back or flank. Pain may be referred to upper buttocks and posterior sacroiliac region and sometimes abdominal wall. Pain increases with long periods of standing, moving from sitting to standing, or coughing/sneezing. Painful SB toward TP side. -Management: stretching and strengthening of involved muscle. Combo technique (e-stim & US)

Brachial Plexus Neuropraxia

-Etiology: transient neuropraxia resulting from stretching or compression of brachial plexus is the most common of all cervical neurological injuries in the athlete. ---Neuropraxia causes disruption in normal function of a peripheral nerve without any degenerative changes. ---Often occurs when neck is forced laterally to opposite side while shoulder is depressed -----When neck is extended, compressed, and rotated towards affective side -Signs/Symptoms: pain and numbness radiating into fingers of the hand (includes roots C6, C7, C8) ---If there is associated weakness, it is limited to deltoid & biceps/brachialis (indicating C5 involvement) ---Burning sensation, numbness and tingling, pain from shoulder down to hand, some loss of function of arm and hand that lasts for several minutes -Management: once symptoms resolve, athlete can return to activity. Athlete should begin strengthening and stretching exercises for neck musculature; shoulder pads and cervical neck roll to limit motion during impact

Cervical disk injuries

-Etiology: usually develops from an extruded posterolateral disk fragment or from degeneration of the disk. Primary mechanism involves sustained repetitive cervical loading during contact sports -Signs/Symptoms: neck pain with some restriction in neck motion, radicular pain (nerve root) in UE with associated motor weakness or sensory changes -Management: rest and immobilization of neck to decrease discomfort. Neck mobilizations to regain ROM, cervical traction to relieve pain.

Cervical sprain (whiplash)

-Etiology: usually results form a violent snapping motion. Frequently muscle strains occur along with ligamentous sprains. Sprain affects anterior & posterior longitudinal ligaments, interspinous & superspinous ligaments -Signs/Symptoms: signs of a strained neck, but they persist for longer; may be tenderness over transverse and spinous processes; pain from inflammation of injured tissue and protective muscle spasm -Management: rule out fx, dislocation, or disk injury; cervical collar to reduce muscle spasm; RICE; cryotherapy, heat and massage; mechanical traction

Spondylolisthesis

-commonly begins unilaterally; if it extends bilaterally, may be some slippage of one vertebra on the one below it; considered to be a complication of spondylolysis that often results in hypermobility of a vertebral segment (step deformity). ---Highest incidence with L5 slipping on S1; incidence of slippage is higher in girls ---Will usually have a lumbar hyperlordosis postural impairment ---Direct blow or sudden twist or chronic low back strain may cause defective vertebra to displace forward -Signs/Symptoms: mild to moderate aching or stiffness with increased pain after physical activity. Complaint that low back fatigues easily. Athlete feels the need to change positions frequently to reduce pain. At extreme ranges held for 30 seconds, an aching pain develops. Feels weak when straightening from forward bending. Segmental hypermobility may be present (and possibly accompanying neurological signs) -Management: bracing and bed rest to reduce pain; major focus should be directed toward exercises that control of stabilize the hypermobile segment; trunk strengthening, dynamic core stabilization

Spondyloysis

-degeneration of the vertebrae and a defect in the pars interarticularis of the articular processes of the vertebrae; defect occurs as a stress fx, more common among boys, congenital origins. May produce no symptoms unless disk herniation occurs or sudden trauma occurs (hyperextension). Sport movements that characteristically hyperextend the spine are most likely to cause this condition -Signs/Symptoms: mild to moderate aching or stiffness with increased pain after physical activity. Complaint that low back fatigues easily. Athlete feels the need to change positions frequently to reduce pain. At extreme ranges held for 30 seconds, an aching pain develops. Feels weak when straightening from forward bending. Segmental hypermobility may be present (and possibly accompanying neurological signs) -Management: bracing and bed rest to reduce pain; major focus should be directed toward exercises that control of stabilize the hypermobile segment; trunk strengthening, dynamic core stabilization