5. MOB TCD
Spine
• The strength of the skeletal
column is due to the size and
shape of the vertebrae
• Its flexibility is due to the many
joints that are close together
6. MOB TCD
Vertebral Column
• Lot of stress in variety of sports
• Cervical pathology
• Pain may be referred to upper
limb
• Lumber pathology
• Lower limb
8. MOB TCD
Low Back Pain in Sports
• 70% of population will suffer
from back pain at some time
• 10% - 15% of sports injuries
are spinal injuries
• 0.6% - 1% have neurological
complications
Deyo & Tsui-Wu. Spine 1987;12:264-8
9. MOB TCD
Low Back Pain in Sports
• Majority of sports injuries
to lumbar spine
• Soft tissue and many are
not reported
• Fractures
• Fracture dislocation
• Abrasions, bruising
• Contusions
Tall & De Vault. Clin Sports Med 1993;12:441-8
10. MOB TCD
Low Back Pain in Sports
• Must know the sport
• Must understand the
biomechanics and stresses
involved in the sport
• Must examine the spine
in the appropriate position
11. MOB TCD
Typical Vertebrae
• Basic parts
• Body and neural arch
• Which consists of
pedicles, lamina and spine
• The transverse processes
arise from the pedicles
• Superior and inferior
articular processes
13. MOB TCD
Lumbar Vertebrae
•
•
•
•
•
Body kidney shaped
No articular facets for ribs
Inferior facets face anterolateral
Superior facets face posteromedial
Intervertebral notch increase in
size
• Accessory processes base
of transverse process
• Mammillary process on posterior
aspect of superior articular
process
14. MOB TCD
Lumbar Vertebrae
• Body is convex anteriorly
• Foramina on the posterior
aspect are for the basic
vertebral veins, which drain
into the internal vertebral
plexus
• The walls of the veins,
which are valve less, have
afferent nerve fibers
• Secondaries can spread
from pelvis, prostate,
adrenal glands lungs and
breast
15. MOB TCD
Lumbar Vertebrae
• The superior and inferior
surfaces of the body are flat
and covered by a thin layer
of hyaline cartilage
• The body of the vertebra
consists of trabecular or
cancellous bone
16. MOB TCD
Typical Lumbar Vertebrae
• Superior and inferior
articular processes
• Arise from the junction of
the pedicles and lamina
• Superior face
posteromedially
• With rough mammillary
processes on the posterior
border
• Inferior face anterolaterally
• Accessory processes at the
base of transverse process
• Prevents rotation
17. MOB TCD
The Lumbar Facets
• Vary from the sagittal
disposition at the first and
second, to almost coronal in
the lower
• Facet tropism is when the facet
on one side is in the sagittal
plane and the other is in the
coronal plane, which adds to
rotational stress
• This change may occur in the
lower thoracic vertebrae
18. MOB TCD
Pars Interarticularis
• Pars interarticularis
• Portion of lamina between
superior and inferior
articular processes
• Site of spondylolysis or
spondylolisthesis
19. MOB TCD
Lumbar Spine
• Cancellous bone
• 50% compressive
strength
• Facet joints 20% in
standing upright position
22. MOB TCD
Lumbar Spine
• Cancellous bone
• 50% of the compressive
strength
• Facet joints, 20% of the
strength in the standing
upright position
23. MOB TCD
Anterior Longitudinal Ligament
• Attached mainly to the bodies
• This ligament helps to prevent us from
leaning too far back (hyperextension)
24. MOB TCD
Posterior Longitudinal Ligament
• Attached mainly to the
inter vertebral discs
• This ligament helps to
restrict forward bending
(hyperflexion)
25. MOB TCD
Ligamentum Flava
• Runs between the laminae
of the neural arches
• Helps to restrict hyperflexion
• It extends to the capsule
of the facet joint
• It is highly elastic and ensures
that the ligament does not
buckle in extension
26. MOB TCD
Ligamentum Flava
• Gives elasticity to the posterior
aspect of the facet joints
• Helps form the posterior
boundary of the intervertebral
foramen
• The ligamentum flava is
thicker in the lumbar region
27. MOB TCD
Spinal Ligaments
• Interspinous ligaments
• Strong supraspinous ligaments
• The inter-transverse ligaments
join the transverse processes
and are thin and membranous
in the lumbar region
28. MOB TCD
Fifth Lumbar Vertebrae
• Larger, superior and inferior
articular facets in the same
plane
• Fifth lumbar vertebrae has
large transverse processes
• Arise from the body as well
as the pedicles
29. MOB TCD
Arthritis of Spine
•
•
•
•
Painful
Limitation of movement
Extra projections
Narrowing of disc spaces
30. MOB TCD
Vertebral Joints
• Secondary cartilaginous joints
between the bodies
• Hyaline cartilage covering
bodies
• Disc of fibrocartilage in
between
• Synovial plane joints between
the facets
31. MOB TCD
Intervertebral Discs
• Annulus fibrosis
• Concentric lamina run
obliquely
• Type I collagen at periphery,
type II near nucleus
• Weakest portion is the
postero-lateral and posterior
• Periphery has a nerve
supply
32. MOB TCD
Nucleus Pulposus
• Gelatinous, hydrophilic, proteoglycan gel in
collagen matrix
• Lies posterior in the disc
• There are no nerve endings in a mature disc
• Nerve endings are found in the posterior longitudinal
ligament and the dura
• Nutrition of the disc is by diffusion via the central 40%
of the cartilaginous end plate
• The discs are thicker in the cervical and lumbar
sections of the vertebral column
• Where there is more movement. The largest disc is
between L5 S1
33. MOB TCD
Nucleus Pulposus
• Hydration of the annulus and nucleus is
proportional to the applied compressional
stress
• In vivo, there is a loss of 1 cm standing
height over the course of the day
• A disc loaded in vitro for four hours by
100% body weight will lose 6% of the
fluid from the nucleus and 13% from the
annulus
• May be due to end plate fracture
• There is more rotational stress in the posterior part of
the disc
34. MOB TCD
Nucleus Pulposus
• The position of the spine determines
where the compressional forces are
greatest
• The posterior longitudinal ligament is
thin and expanded at the level of the
disc
• High compressional loading at
L4,L5,S1 may be due to end plate
fracture and not to rupture of the annulus
• End plate failure is a possible precursor of disc
degeneration
36. MOB TCD
End-plate Mechanics
• Functionally, the vertebral end-plate
displays characteristics of a trampoline
• With the sub-end-plate trabecular
bone acting as springs to sustain
and dissipate axial load
• Despite the thinness of the vertebral
end-plate
• The hydraulic nature of marrow and
blood vessels within the vertebral body,
act to dampen axial loads, unless the
local point pressure is too high
37. MOB TCD
End-plate Mechanics
• End-plate lesions can be induced
experimentally before a disc will
prolapse through the anulus,
suggesting a protective mechanism
over annular injury and potentially
cord or root compression
• Excessive loads may result in
perforation of the end-plate, usually
in the region of the nucleus and
often in the path of the
developmental notchord
39. MOB TCD
Facet Joints
• L1,L2 Facets sagittal
plane
• Lower joints in coronal
plane
• Synovial plane joints
• Meniscoid structures
• Synovial membrane
some contain fat
• Supplied by medial
branch of dorsal ramus
40. MOB TCD
Facet Joints
• Narrowing of disc space,
results in stress on
facet joint
• Highest pressure during
• Combined
• Extension
• Rotation
• Compression
41. MOB TCD
Facet Joint Syndrome
•
•
•
•
•
Extension and rotation
Pain rising from flexion
Pain worse standing
Lateral shift in extension
Point tenderness over
facet
• Referred leg pain
54. MOB TCD
Epidemiology
• Back pain in the community
is 60% - 80%
• Recurrence of back pain is
70% - 90%
• Progression to chronic back
pain is 5% - 10%
Cooke & Lutz. Phys Med Rehab Clinics N Am 2000;11:837-65
55. MOB TCD
Low Back Pain in Sports
• Majority of sports injuries
are to the lumbar spine
• Many soft tissue injuries
are not reported
• Fractures
• Fracture dislocation
• Abrasions, bruising
• Contusions
Tall & De Vault. Clin Sports Med 1993;12:441-8
57. MOB TCD
Back Pain
Local structures
• Muscles, ligaments
• Joints
Referred pain
• Abdominal organs
• Pelvic organs
Must out rule
• Infection
• Tumours
58. MOB TCD
Acute Low Back Pain
•
•
•
•
•
•
Non-specific low back pain
Usually settles quickly
History
Examination
Pain relief
Stay as active as possible
within limit of pain
59. MOB TCD
Acute Low Back Pain
• Nerve root pain
• Leg pain worse than back
pain
• Numbness and pins and
needles
• Neurological signs
• Refer to specialist
• If it does not resolve in
first 4 weeks
60. MOB TCD
Investigate Low Back Pain
•
•
•
•
•
•
•
•
•
Under 20 or over 55 years
Non-mechanical pain
Past history cancer
Thoracic pain
Steroids or HIV
Unwell, weight loss
Widespread neurology
Structural deformity
Gait disturbance or sphincter
disturbance
61. MOB TCD
Chronic Low Back Pain
Pain referred
• Abdominal organs
• Pelvic organs
Must out rule
• Infection
• Tumours
63. MOB TCD
Young Athlete
• Junior rugby team 15
years of age
• M. Scheuermann
• 5 Spina bifida occulta
• The scrum half had
degenerative facet joint
changes
65. MOB TCD
Spinal Stenosis
• Congenital or acquired
• Abnormally short pedicles or
lamina
• Formation of osteophytes
• Osteo-arthritis of facet joints
• Pain aggravated by walking
• Relieved by rest
73. MOB TCD
Annular tears
• Loaded compression with
rotatory component
• As little as 3 degrees of
high torque rotation
• Facets protect disc
• As annulus fails, facets
joints may be injured
76. MOB TCD
Young Athlete
• Junior rugby team 15
years of age
• M. Scheuermann
• 5 Spina bifida occulta
• The scrum half had
degenerative facet joint
changes
79. MOB TCD
Pars Interarticularis
• Pars interarticularis, portion
of lamina between superior
and inferior articular
processes
• Site of spondylolysis or
spondylolisthesis
85. 465 Athletes Low Back Pain
(M318;F147)
male (39)
female(14)
Spina Bifida Occulta (SBO)
6.6%(21)
4.1%(6)
Lumbarisation
3.5%(11)
1.4%(2)
Sacralisation
2.2% (7)
6.1% (9)
Spondylolisthesis (13)
30% had SBO; 21 of 56 had other pathology
MOB TCD
86. MOB TCD
Mechanism of Injuries
• Compression or weight
loading
• Torque or rotation
• Tensile stresses produced
by excessive motion of
spine
• Hyperextension and flexion
Watkins & Dillin, 1985
87. MOB TCD
Compression or Weight Loading
•
•
•
•
•
•
•
Sports requiring
Massive strength
High body weight
Weight lifter
Hooker and No 8
Wrestling
Line back American football
Watkins & Dillin, 1985
88. MOB TCD
Weight Lifting
• 40 % weight lifters have
low back pain
• Greatest stress is when weight
is lifted above the head
• Dangerous time is shift from
spinal flexion to extension
Aggrawal et al. Br J Sports Med 1979;13:58-61
89. MOB TCD
Axial Compressive Loading
•
•
•
•
•
•
•
Head on collisions
Motor sports
Boating accidents
Wrestling
Horseback riding
Bicycling
Bobsleigh
98. MOB TCD
Golf
• Highest incidence of back
injuries in professional sports
• Torsional stress is lessened by
spreading the stress over the
entire spine
• Rigid abdominal control
• Parallel shoulders and pelvis
Watkins and Dillin, 1985
The late natural history the thoracic kyphosis is for progressive deformation:
This deformation occurs within the vertebral bodies in women with a greater contribution from disc degeneration in males.[Goh et al 1999]
Those sports that predispose the individual to hyper-kyphosis during the adolescent years and beyond, should be studied to determine the association between the structural deformation and back pain.
[[Those of us destined to keyboard activity will identify with the evolutionary trend depicted above]]
As can be seen on the left, the vertebral end-plate is a tenuous cartilaginous membrane which from direct measurement is approximately 0.5mm thick, connected to trabecular bone within the cortical shell.
Lesions of the end-plate arising from sporting activities are reported to be frequent. Typical aetiology involves dynamic compressive axial loads, common in landing sports: eg: gymnastics
Discal material is extruded through the end-plate into the vertebral body. At the time of injury, the lesion may be painful due to the inflammatory response to the lesion. It has been postulated that such injury predisposes the disc to early degenerative change [Roberts et al, 1997 European Spine Journal 6: 387]
The late stage of healing involves sclerosis of bone around the site of injury, demonstrated on the right [arrow] form a CT at T11-12
The notochordal streak, as depicted by Schmorl & Junghanns from their classic text, showing a foetal specimen [left] and the progressive apoptosis of these cells during maturation and differentiation of the disc and vertebral body.
Typically, Schmorl’s nodes occur close to this site, suggesting both a functional and genetic predisposition to compressive load failure of the end-plates in some individuals.
In a recent CT study, 42 patients suspected of disc and facet joint pain were rotated within the CT scanner prior to scanning. They were fixed into this position for both right and left side scans which were compared with their neutral [conventional] scan images.
Very slight separation of the facet joints occurred at most levels and particularly where the anatomical alignment was mostly coronal [usually the lowest segments].
Joints with a more sagittal alignment, typically the upper lumbar spine, appeared to offer greater resistance to torsion.
Spine injuries can occur through overuse, overload, trauma or a combination of these events.
Injuries may occur to any component of the mobile segment: disc, vertebral bodies or facet joints, however disc and end-plate lesions are the most commonly affected.
The reported statistics for back pain according to Cooke & Lutz [2000] are:
Lifetime prevalence of back pain in the community = 60-80%
Back pain recurrence = 70-90%
Progression to chronic back pain = 5-10%
Back pain a common feature in most sports, particularly competitive contact sports.
Back pain is higher in young athletes compared with age matched controls and,
Back pain may occur in response to various conditions of load, fatigue and trauma
The reported statistics for back pain according to Cooke & Lutz [2000] are:
Lifetime prevalence of back pain in the community = 60-80%
Back pain recurrence = 70-90%
Progression to chronic back pain = 5-10%
Back pain a common feature in most sports, particularly competitive contact sports.
Back pain is higher in young athletes compared with age matched controls and,
Back pain may occur in response to various conditions of load, fatigue and trauma
The incidence of end-plate lesions in sport participants varies, however, these may result from pre-existing anatomical abnormalities.
In the case of Scheuermann’s disease, there can be multiple end-plate lesions over many segments.
According to Sorenson, the characteristics of this disease involve four or more segments with lesions of the end-plates, and corresponding vertebral wedging.
Accentuated kyphosis and a painful thoraolumbar spine are the main clinical features.
AFL is a dynamic game that involves various types of play and physical encounters. Injuries are common, predominantly to the knee [ACL], hamstring and groin regions.
In a major survey of AFL injuries undertaken by Drs Seward & Orchard, identified a recurrence rate of 32% for injuries to the neck, back, and ribs.