For many athletes following any major endurance event they will return to their houses, to recover, celebrate, reflect and rebuild to their next career step. Some, like the athlete in this case study will need to now focus attention on delayed decisions concerning whether to go under the knife to sort out a chronic injury.�El Paso, TX’s Injury scientist, Dr. Alexander Jimenez takes a look at the study.
My client has been competing in triathlon for 10 or more years, although his career has included a range of serious injuries which have kept him from races for months on end. In the previous two to three decades, however, he’s enjoyed a sustained period of injury-free training and racing, and has climbed to the peak of the world rankings. But the emergence of hip pain has seen him once more return to the physio’s table.
The triathlete’s accident history highlights a common pattern among sportspeople: 2 tibial stress fractures, a femoral neck stress fracture and a serious ankle sprain — every one of these on his right side. The significant contributing element to the bone stress injuries is a 1.5cm leg-length gap (his right leg is shorter).
He’d first experienced comparable hip pain in 2004; it kept him from running for three months. At that time, nothing was detected on a bone scan or MRI, or so the pain went paralyzed. An intra-articular cortisone injection (CSI) elicited no improvement. The athlete remembers that he chose to train on his painful hip, never allowing the symptoms to settle. The nearest he ever came into an investigation was a hypothesis that he could have a little, undetected, labral lesion.
The present episode of hip pain began initially at night after a hard three-hour bicycle ride. Earlier this, however, he hadn’t cycled for five times. He described his initial symptom as a profound hip tightness (lateral and lateral), together with slight pain in his groin. He was able to continue to train however, was feeling that the hip tightness and pain following both cycling and running (swimming was symptom-free).
A week later his symptoms dramatically worsened when he flew from Australia to Singapore, on his way to a French high- altitude camp. As he got off the airplane, he felt deep hip pain as well as the tightness. As elite athletes tend to do, he coached anyway, running a tricky track session, which made the hip much worse: he was unable to ride or run without pain. He instantly started a course of anti- inflammatories.
I met him in Singapore and evaluated him in the airport, initially ruling out any prospect of a disease or systemic matter. He explained he had been feeling an ache during the night, lying in bed; on waking, the hip would be OK, but got worse the longer he walked.
On assessment, he had the following physical signs:
� walking with obvious limp
� pain on hopping (6/10)
�painful right hip quadrant/impingement test (full hip flexion/adduction)
� reduced right hip flexion (-10 degrees compared to left)
� reduced right hip internal rotation (-10 degrees compared to left)
� increased tone on palpation of TFL, adductors, hip flexors, gluteal, piriformis and deep rotators
� lumbar spine and SIJ were OK
� femoral shaft bone stress test was OK � leg length discrepancy (right side 1.5cm shorter)
� right innominate (pelvis) anteriorly rotated
� weakness in right hip abductors/extensors
� reduced calf endurance on right side (-5 reps)
� ankle dorsiflexion range of movement was OK
� reduced proprioception on right (single leg stance, eyes closed).
I thought the differential diagnoses were:
� femoral neck stress fracture
� labral tear, possibly with hip synovitis
� FAI (femoro-acetabular impingement), possibly with hip synovitis.
I initially treated the triathlete with soft- tissue techniques to reduce the tone around the hip joint. Trigger-point releases were performed on his TFL, adductors, gluteals, piriformis, deep rotators and iliopsoas.�This reduced his jump pain into 3/10. Manual long-leg grip further decreased the strain on hopping (2/10). He still had pain and stiffness on walking but it sensed “simpler. As he prepared to embark on his long run flight to Europe, I counseled him to not sit for too long and maintain his stylish as straight as possible to decrease any potential impingement from hip flexion.
Luckily, the hip didn’t get worse throughout the flight. On arrival at the French high-altitude training centre, we initiated a strategy of two swims and two intensive treatments a day, aiming at reducing muscle tone, restoring his range of hip movement and normal muscle control and stamina. We had been expecting that the problem was not a stress fracture, but just minor hip synovitis that could settle quickly. Following a week of conservative treatment, though, we were just able to keep his hop pain in 2/10, and that he still could not run 20 meters without any pain and limping.
In collaboration with medics, we flew to London to see a sports doctor and get MRI scans. The scans revealed no bone stress reaction, fracture or labral ripping — which was a big relief; however, it did show signs consistent with FAI (femoro-acetabular impingement). He had hip synovitis with a rectal lesion on his femur.
Hip injuries aren’t much reported among triathletes — in fact they are notably absent from reports on Olympic and Ironman triathlons, which mention knee, back, H/ Achilles, lower leg, ankle and shoulder as the most common accidents (1-3).
In this state, when the hip is in maximum flexion and internal rotation, the labrum and cartilage abut and impinge; damage to the articular cartilage and acetabular labrum results from this pathologic bony contact. The contact generally results in a structural abnormality of the femur (“camera impingement”) along with the acetabulum (“pincer impingement”) or a combination of both (“mixed impingement”). Over time, via repetitive micro-trauma, the aggravating motion hurts the hip cartilage or labrum (or both) during normal joint motion. This happens along the anterior femoral neck and the anterior–superior acetabular rim. FAI is a possible trigger of early hip joint degeneration (4).
Arthroscopic surgery is the direction of choice for FAI if symptoms do not settle; however as his next Competition was only three and a half a year off, surgery was not an option. Instead, over a five-day interval, the athlete had two cortisone (CSI) and local anesthetic injections into the hip joint (under ultrasound guidance) to settle the indicators.
Our aim was to grow the hip range of motion and extend the capsule to reduce any additional impingement, slowly returning to regular training. Following the competition, the athlete would then should see a hip arthroscopic surgeon to acquire a surgical opinion to the best option for long-term direction.
Injection Relief
After both shots my customer felt sore for five days. The initial CSI settled his pain on hopping to 1/10 and after seven days he managed to operate without symptoms. But minor hip stiffness and aching at the end of the day prevented him from progressing to optimal training, so that he then underwent a second steroid injection. This settled the hop pain into 0/10 and decreased the aching; so after five times he returned to mild cycling and after seven days he started running again, also.
The athlete admitted that, following the first shot, he had done more and gone tougher in training than directed, as he had felt “good. This mistake of “too much too soon — all too common in elite athletes — had led to excessive inflammation and aching in the hip nightly after training. After the next injection he returned to normal intensity slower and more gradually.
My client built his training up to regular levels by four months following the final injection (swimming five times per week, cycling four days and running six to seven days). He began with very easy cycling on a wind trainer for 30 minutes, building slowly to 90 minutes before cycling on the street. He cycled two days on and one day away and avoided hills to the first two weeks. He started jogging on the apartment for 15 minutes and slowly built up to 90 minutes after three weeks. He did not run hills or about the track; and as he ran only on every single day, he would diligently concentrate on technique.
From week six to week 11, my client remained on anti inflammatory medication and underwent two treatments a day.
The hands-on treatment continued to:
� increase hip range of movement
� stretch the hip capsule
� normalise pelvic symmetry and hip muscle tone
� improve muscle control and strength � improve proprioception
� ensure optimal biomechanics via video assessment (cycling and running).
Eleven weeks after he first felt his hip pain, the triathlete returned to racing; however he failed to finish the first race, partially because of minor hip stiffness but mainly due to “fitness. Fortunately there were not any prolonged symptoms after the race and a week after he successfully returned to competition, coming second in a really strong field. His very minor ongoing symptoms were handled with anti-inflammatory drugs and hands-on treatments.
If this athlete wants to pursue a long- term triathlon career up to the London Olympics, then he will now require surgery. The arthroscopic surgical technique initially assesses the cartilage and labral surfaces, debrides any abnormalities of the hip joint cartilage and hip labrum, removes the non-spherical segments of the femoral head�and any prominent sections of the anterior femoral neck and bony growths on the acetabular rim that may continue to contribute to hip joint impingement.�The alternative is early joint degeneration and onset of osteoarthritis.
References:
1. Wilk B et al: �The incidence of musculoskeletal injuries in an amateur triathlete racing club�. J Orthop Sports Phys
Ther 1995 Sep;22(3):108-12.
2. Collins K et al: �Overuse injuries in triathletes. A study of the 1986 Seafair Triathlon�. Am J Sports Med 1989 SepOct;17(5):675-80.
3. Korkia PK et al: �An epidemiological investigation of training and injury patterns in British triathletes�. Br J Sports Med 1994 Sep;28(3):191-6.
4. Ganz R. et al (2003): �Femoroacetabular impingement: a cause for osteoarthritis of the hip�. Clin Orthop Relat Res. 417:112�120. For more information see: www.hipfai.com
El Paso, TX. science based chiropractor, Dr. Alexander Jimenez looks at this uncommon problem � and how it can be treated.
The true incidence of obturator externus accidents is unknown, as frequently they may be misdiagnosed as hip joint pathology and/ or groin pathology as the website of symptoms as well as also the presenting objective signals may mimic other pathologies such as hip joint labrum pathology, anterior femoral triangle issues and perhaps even gluteal pathology.
Injury for this muscle gifts as a deep obscure groin/hip pain and functionally the muscle may still hide direct involvement as a pain generator since it is primarily a equilibrium muscle rather than a force-producing hip muscle.
This case study presents an unusual case of hip-related pain in a professional baseball player which also shown itself as an injury to the contralateral adductor longus.
The Player
As he was wrestled to the floor, his right hip was compelled at a rapid and loaded flexion/internal turning position. His first sensation was pain deep inside the anterior hip/groin area.
When he presented to the medical team with the accident, he complained of a profound catching sensation inside the hip joint location. It had been difficult to fully bend the hip and to also twist on the stationary limb (because he did whilst kicking a ball). His prior background consisted of a right-sided inguinal hernia repair five seasons before as well as a few gentle on again/off back osteitis pubis-type signs that would normally flare from the first period as his goal-kicking amounts have been increased. He was obviously a left- footed goal kicker.
On examination, he observed that the pain to become worse on passive flexion/internal rotation of the hip (hip walkway test). He was noticeably tight and irritated from the shallow TFL muscle, and also posteriorly across the greater trochanter around the insertion for the gluteals and deep hip rotators. He was also particularly high tone in the right iliopsoas muscle.
He was initially diagnosed clinically because of hip joint sprain due to the mechanism of harm being a pressured flexion/internal rotation type position that would always put pressure on the anterior hip joint capsule/labrum.
He was treated initially with deep iliopoas muscle sparks and hip joint mobilizations using a seat belt to gap the hip joint. He reacted reasonably well with the therapy and immediately felt more comfortable on a hip joint quadrant test. He was rested from coaching for 2 days and ran on the next day and played a match on the fourth day. But during the match, though his right hip did not create any pain, he’d notice pain on his left adductor source that was more pronounced during kicking.
Three days post-game he detected this ongoing left adductor origin pain and it was made worse by kicking again through training. An MRI was performed to Look at the left adductor origin and also the report noted:
Grade 1 left adductor longus strain deep in the
Grade 2 right obturator externus strain on its femoral attachment
Grade 1 right iliopsoas muscle strain in the MTJ.
The surprise finding on the MRI of a grade 2 obturator strain prompted the medical team to more formally assess the participant for ongoing hip joint disorder. The particular features to notice from this medical examination were:
Subjective
? A sensation of weakness and instability in the right hip whilst kicking with the left foot.
? No pain in the right hip with running, even with top-end speed. However, the left adductor longus was symptomatic on running and kicking.
Objective
? Pain on passive right hip internal rotation whilst in 90-degree hip flexion. This pain was deep anteriorly in the hip, almost presented as a groin problem.
? Some discomfort on resisted right hip flexion/external rotation deep inside the iliac fossa.
? Pain and weakness in the left adductor on adductor squeeze tests. These squeeze tests performed at 0/45/90 degrees of knee flexion with a pressure cuff between the knees. Usual pre-season scores measured 260/260/250. On current testing they measured 150/170/180. Pain was felt at the end of the squeeze.
? Discomfort with prone lie hip passive internal rotation. This pain was more focused around the right greater trochanter posteriorly.
Pathomechanics
It had been suspected that this player had endured a secondary injury to the left adductor longus (a muscle used a lot in goal-kicking) due to the inherent failure in bolstering the proper hip throughout the plant phase of the kick due to the inhibition of the right obturator externus, a muscle considered to be an important hip stabilizer and turning control muscle at the hip. With insufficient hip stabilization in kicking, the left hip was required to create more power to compensate for the unstable right hip to gain the length from the kick. Then the left adductor longus failed along with a strain injury led.
Management
The management of the matter initially centered on the two key features being the left-sided adductor strain and the right- sided obturator externus strain.
In the week following the accident, the player was sent to get a series of Actovegin shots to the left adductor longus. This was done according to protocol that was three injections every 48 hours — Monday/ Wednesday/Friday. In this five-day period the adductor longus was handled with deep tissue flush massage and gentle isometric adduction exercises at supine (chunk squeezes) in the three positions of examining — 0/45/90 levels of knee flexion — also as wall squat adductor squeezes in the same positions. The obturator externus was medicated with heavy tissue releases (obtained through the anterior groin region) and direct theraband strengthening of hip external rotation in sitting and in prone. Actovegin shots to the obturator externus are regarded as difficult because of problems with accessing this muscle through the superficial hip musculature.
The adductor exercises progressed into through array adduction with theraband resistance (equally with the left leg being the motion leg as well as the stability leg).
By 12 days post-injury it had been detected that the obturator externus strength had not improved and the player still had deep- seated right back pain pain. It was rationalised that perhaps the direct treatment to this muscle and also the direct open kinetic chain strengthening was possibly making the muscle texture worse. The choice was made to stop any direct hands-on therapy to the muscle and also to prevent any direct open kinetic chain strengthening. Instead the player lasted with bilateral theraband exercises of both hips into flexion and then abduction and expansion in addition to adduction. The avoidance of lead obturator externus soft tissue treatment and exercise appeared to improve the hip function immediately.
The participant started running 20 times post-injury and quickly progressed through running stages over a five-day period of conducting on alternate days. At this point the player’s adductor squeeze scores had improved to steps according to pre- season baselines. However, daily the player ran direct adductor strength operate using a Pilates reformer as a slider drill to immediately load into adduction in addition to hammering theraband adduction exercises in standing and in supine lying.
By 27 days post-injury the player managed to begin kicking, change in direction and rugby training. He played at 30 times post-injury with no ill effects.
Discussion
It arises immediately around the medial side of the obturator foramen, as well as the inferior ramus of the ischium; it also arises in the lateral two-thirds of this outer surface of the obturator membrane, and also in the tendinous arch which completes the canal to the passage of the obturator nerves and vessels.
The action of the muscle is to externally rotate the hip and also helps in hip adduction. It’s postulated to also work as a hip balance muscle in one legged stance along with the obturator internus, quadrutus femoris, piriformis and the gemelli muscles. In a practical activity such as kicking, the muscle acts to stabilize or hold the ball of the femur into the socket (acetabulum).
The incidence of harm to the obturator externus muscle is unknown because there are only a handful of case reports from the medical literature that highlight injuries for this muscle. Additionally, among the vexing issues is the difficulty in creating the correct clinical diagnosis based on the history and physical evaluation. MRI imaging is needed to correctly picture injuries to this muscle.
From the case study introduced, injury for the muscle was a direct result of forceful flexion/internal rotation mechanism to the hip joint. As the muscle primarily functions as a hip stabilizer during jogging, it is possible that a patient can mask symptoms during functioning as the muscle isn’t required to produce any hip skate for locomotion.
Nonetheless, in this event the muscle has a role in stability of the hip during kicking, and for that reason may have produced a poor pelvic/hip complicated during kicking that then led to an accident to the adductor longus on the other hand.
In addition, it seems that direct treatment to the muscle in the form of deep trigger point releases and also direct strengthening may actually delay healing in the muscle in case of injury. This may highlight the value of the muscle as a hip stabilizer instead of a legitimate torque manufacturer in hip rotation.
Most of us will experience it at some point — but how does it influence on athletic performance? Chiropractic injury specialist, Dr. Alexander Jimenez investigates.
Research postulates that 80 percent of the populace will undergo an acute onset of back pain at least once in their lifetimes. This adds a considerable financial burden not just on the medical system (physician consultations, prescribed drugs, physiotherapy) but also the financing of the workforce in lost employee hours and loss in productivity.
The types of lower back pain that an individual may experience include (but are not limited to):
1. Lumbar spine disc herniation with/ without sciatica
8. Inflammatory arthritis such as rheumatoid and anklyosing spondylitis
9. Facet joint sprains
10. Bone injuries such as stress fractures, pars defects and spondylolisthesis.
The focus for this paper will be on the previous group — that the bone injuries. This may be simply postural (slow onset repetitive trauma) or related to sports; for instance, gymnastics.
The two demographic groups that tend to endure the most extension-related low back pain are:
1. People who endure all day, for instance, retailers, army, security guards etc.. Prolonged position will obviously force the pelvis to start to migrate to an anterior tilt management. This may begin to place compressive pressure on the facet joints of the spinal column as they also change towards an expansion position since they accompany the pelvic tilt.
2. Extension sports such as gymnastics, tennis, swimming, diving, football codes, volleyball, basketball, track and field, cricket fast bowlers. This is more pronounced in sports that involve extension/rotation.
Pathomechanics
With normal extension of the lumbar spine (or backward bending), the facet joints begin to approximate each other and compress.�The articular processes of this facet above will abut the articular process of the facet below. This is a normal biomechanical movement. However, if the extension ranges are excessive, the procedures will impinge quite aggressively and damage to the cartilage surfaces within the facet joint can result. Sports such as gymnastics, functioning in tennis, and handling in American Soccer may all involve uncontrolled and excessive extension.
It would be unlikely that a bone stress response or even a stress fracture could be brought on by an isolated expansion injury. It would be more likely that a sudden forced extension injury may damage an already pre-existing bone strain reaction.
Similarly, if an individual stands daily and the pelvis migrates into lateral tilt, then the aspects will be placed under low load compression but for extensive intervals.
With ongoing uncontrolled loading, stress is then transferred from the facet joint to the bone below (pars interarticularis). This originally will manifest as a pressure reaction on the bone. This bone strain may advance to a stress fracture throughout the pars if uncorrected. This fracture is also referred to as a “pars flaw”, or spondylolysis.
It was initially considered that stress fractures of the pars was a congenital defect that introduced itself at the teenage years. However, it is now agreed that it is probably obtained through years of overuse into extension positions, especially in young sportspeople involved with expansion sports. What’s more, one-sided pars defects often occur more commonly in sport which also included a rotational component such as tennis serving or fast bowling in cricket.
The stress fracture can then advance to impact the opposite side, causing a bilateral strain fracture, with anxiety subsequently being transferred to the disk in between both levels.
Spondylolisthesis features bilateral pars defects which could possibly be a result of repetitive stress into the bilateral pars in extension athletics, but more likely it is an independent pathology that manifests in the early growing stages (9-14) as this pathology is often viewed in this age category. If they become symptomatic in later years because of involvement in expansion sports, it is exceedingly likely that the defects were there by a young age but presented asymptomatically. As a result of rapid growth spurts in teenage years and the high-volume training experienced by teenaged athletes, it is possible that these dormant spondylolisthesis then pose as ‘acute onset’ back pain in teenage years.
In summary, the progression of this bone stress reactions tends to follow the following continuum:
1. Facet joint irritation
2. Pars interarticularis stress response
3. Stress fracture to the pars
4. Pars defect (or spondylolysis)
5. Spondylolisthesis due to activity or more likely congenital and found later in teenage years due to participation in�extension sports.
The landmark publication related to spondylolysis and spondylolisthesis was presented by Wiltse et al (1976) and they classified these injuries as follows:
1. Type I: dysplastic � congenital abnormalities of L5 or the upper sacrum allow anterior displacement of L5 on the sacrum.
2. Type II: isthmic � a lesion in the pars interarticularis occurs. This is subclassified as
a. lytic, representing a fatigue fracture of the pars,
b. elongated but intact pars, and c. acute fracture.
3. Type III: degenerative � secondary to long-standing intersegmental instability with associated remodeling of the articular processes.
4. Type IV: traumatic � acute fractures in vertebral arch other than the pars.
5. Type V: pathological � due to generalized or focal bone disease affecting the vertebral arch.
The vast majority of spondylolysis and sponylolisthesis accidents are Type II — the isthmic variety.
For the purposes of this paper, we will refer to the above stages as the posterior arch bone stress injuries (PABSI).
Epidemiology
It is a lot more widespread at the L5 level (85-90 percent). It’s a high asymptomatic prevalence in the general population and is often found unintentionally on x ray imaging. Nonetheless, in athletes, particularly young athletes, it is a common reason for persistent low back pain. From the young athlete, the problem is often referred to as ‘active spondylolysis’.
Active spondylolysis is normal in virtually every gamenevertheless, sports such as gymnastics and diving and cricket pose a much greater danger due to the extension and turning character of the sport. The progression from an active spondylolysis into a non-union type spondylolisthesis has been associated with a greater prevalence of spinal disk degeneration.
Early detection through screening and imaging, therefore, will highlight those early at the bone stress phase and if caught early enough and managed, the progression to the larger and more complicated pathologies are avoided as a result of therapeutic capacity of the pars interarticularis in the early stages.
It is more common to find teens and young adults afflicted by PABSI. This will highlight the rapid growth of the spine through growth spurts that is also characterized by a delay in the motor control of the muscle system during this period. Furthermore, it’s thought that the neural arch actually gets stronger in the fourth decade hence possibly explaining the low incidence of bone stress reactions in mid ages.
The incidence of spondylolysis has been reported to be around 4-6% in the Caucasian population (Friedrikson et al 1984). The rates seem to be lower in females and also in African-American males. It has also been suggested that a link exists between pars defects and spina bifida occulta.
The incidence of spondylolysis seems to be higher in the young athletic population than in the general population. Studies in gymnasts, tennis, weightlifting, divers and wrestlers all show disproportionately high incidence of spondylolysis compared with the general population of age-matched subjects.
Tennis
The tennis serve generates excessive extension and rotation force. In addition, the forehand shot may also produce elevated levels of spinning/ extension. The more traditional forehand shot demanded a great deal of weight shift through the legs to the torso and arms. However, a more favorite forehand shot is to currently face the ball and also generate the force of this shot utilizing hip rotation and lumbar spine extension. This action does increase ball speed but also puts more extension and compressive loads on the spine potentially resulting in a greater degree of stress on the bone components.
Golf
The most likely skill component involved in golf that may cause a PABSI are the tee shot with a 1 wood when forcing for distance. The follow-through of this shot entails a significant quantity of spine rotation with maybe a level of spine expansion.
Cricket
Fast bowlers in cricket are the most susceptible to PABSI. This will occur on the opposite side to the bowling arm. As the front foot engages on plant stage, the pelvis abruptly stops moving but the spine and chest continue to proceed. With the wind-up of this bowling action (rotation), when coupled with expansion this can place large forces on the anterior arch of the thoracic. More than 50% of fast bowlers will create a pars stress fracture. Young players (up to 25) are most vulnerable. Cricket governments have implemented training and competition guidelines to avoid such injuries by restricting the number of meals in training/games.
Field Events
The more common field events to cause a PABSI would be high leap followed by javelin. Both these sports create enormous ranges of backbone extension and under significant load.
Contact Sports
Sports like NFL, rugby and AFL all require skill components that need backbone expansion under load.
Gymnastics/Dancers
It goes without saying that gymnastics and dancing involves a substantial amount of repetitive spine expansion, particularly backflips and arabesques. It has been suggested that nearly all Olympic degree gymnasts could have suffered from a pars defect. Many organizing bodies now put limits on the number of hours young gymnasts can instruct to prevent the repetitive loading on the spine.
Diving
Spine extension injuries occur mostly off the spring board and on water entrance.
Diagnosis Of PABSI In Athletes
Clinical investigation
These can pose as preventable injuries. Research shows that the incidence was emphasized from the general population that have nil indicators of back pain. But, individuals will typically complain of back ache that is deep and generally unilateral (one side). This may radiate into the buttock area. The most offending movements tend to be described as expansion moves or backward bending movements. This may be a slow progression of pain or might be initiated by one acute episode of back pain in a competitive extension motion.
On clinical examination:
1. Pain may be elicited with a one-leg extension/rotation test (standing on the leg on the affected side) � stork test.
2. Tenderness over the site of the fracture.
3. Postural faults such as excessive anterior tilt and/or pelvic asymmetry.
The one-legged hyperextension test (stork test) was suggested to be pathognomonic for busy spondylolysis. A negative evaluation was stated to effectively exclude the diagnosis of a bone stress-type injury, thus creating radiological investigations unnecessary.
But, Masci et al (2006) examined the connection between the one-legged hyperextension test and gold standard bone scintigraphy and MRI. They discovered that the one-legged hyperextension test was neither sensitive nor specific for active spondylolysis. Moreover, its negative predictive value was so poor. Thus, a negative test can’t exclude energetic spondylolysis as a possible cause.
Masci et al (2006) go on to indicate that the bad relationship between imaging and the one-legged test may be because of a number of factors. The extension test would be expected to move a significant extension force on to the lower back spine. In addition to putting substantial strain on the pars interarticularis, it might also stress different regions of the spinal column like facet joints as well as posterior lumbar disks, and this may subsequently induce pain in the existence of other pathology such as facet joint arthropathy and spinal disc disease. This will explain the poor specificity of the test. Conversely, the inadequate sensitivity of the test may be related to the subjective reporting of pain by issues performing the maneuvre, which may vary based on individual pain tolerance. Additionally, this evaluation can preferentially load the fifth cervical vertebra, and so bone stress located in the upper lumbar spine may not test positive.
Grade 1 spondylolisthesis are normally asymptomatic; nonetheless, grade 2+ lesions often present with leg pain, either with or without leg pain. On examination, a palpable slip could be evident.
Imaging
Clinical assessment of active spondylolysis and the more severe pars defects and spondylolisthesis can be notoriously non-specific; this is, not all patients suffering PABSI will present with favorable abstract features or positive signs on analyzing. Thus, radiological visualization is important for diagnosis. The imaging methods available in the diagnosis of bone stress injury are:
1. Conventional radiology. This test is not very sensitive but is highly unique. Its limits are partially because of the cognitive orientation of the pars defect. The oblique 45-degree films may show the timeless ‘Scotty Dog’ appearance. Spondylolisthesis can be looked at simply on a lateral movie x-ray.
2. Planar bone scintigraphy (PBS) and single photon emission computed tomography (SPECT). SPECT enhances sensitivity in addition to specificity of PBS than straightforward radiographic study. Comparative research between PBS and conventional radiology have shown that scintigraphy is more sensitive. Patients with positive SPECT scan must then undergo a reverse gantry CT scan to assess whether the lesion is active or old.
3. Computed tomography (CT). The CT scan is considered to be more sensitive than conventional radiology and with higher specificity than SPECT. Regardless of the type of cross-sectional image utilized, the CT scan provides information on the state of the flaw (intense fracture, unconsolidated flaw with geodes and sclerosis, pars in procedure for consolidation or repair). The “inverse gantry” perspective can evaluate this condition better. Repeat CT scan can be used to track progress and recovery of the pars defect.
4. Magnetic resonance imaging (MRI). This technique shows pronounced changes in the signal in the amount of the pars. This is recognized as “stress response” and can be classified into five different degrees of action. MRI can be helpful for evaluating elements that stabilize isthmic lesions, for example intervertebral disc, common anterior ligament, and related lesions. The MRI isn’t as specific or sensitive as SPECT and CT combination.
Therefore, the current gold standards of investigation for athletes with low back pain are:
1. bone scintigraphy with single photon emission computed tomography (SPECT); if positive then
MRI has many advantages over bone scintigraphy, for instance, noninvasive nature of the imaging along with the absence of ionizing radiation. MRI changes in active spondylolysis include bone marrow edema, visualized as increased signal in the pars interarticularis on edema-sensitive sequences, and fracture, visualized as reduced signal in the pars interarticularis on T1 and T2 weighted sequences.
However, there is greater difficulty in detecting the changes of busy spondylolysis from MRI. Detecting pathology from MRI relies on the interpretation of distinct contrasts of signals compared with normal tissue. Unlike stress fractures in different parts of the body, the little region of the pars interarticularis may make detection of those changes harder.
However, unlike MRI, computed tomography has the capability to differentiate between acute and chronic fractures, and this differentiation might be an important determinant of fracture healing. Accordingly, in areas using pars interarticularis fractures discovered by MRI, it might nonetheless be necessary to execute thin computed tomography slices to determine whether or not a fracture is severe or chronic — an important factor in fracture resolution.
Chiropractor, Dr. Alexander Jimenez summarizes some fascinating injury stories in the combat game…
I was recently on a holiday in Koh Lanta in Thailand and throughout my holiday I visited a Muay Thai training gym for two reasons. Firstly, as I’ve had a fascination with the sport for some time having formerly handled some injuries in some fighters in Australia it was to have a private Muay Thai training session with a few of the boxers. I was that I could use as material. I clarified the purpose of my visit and approached the head coach and discover a few of the interesting injury stories they’d out and he was pleased for me to talk to a few fighters. The following are just two case studies from this fact-finding mission.
The Biker’s Elbow
The initial fighter was a seeing K1 fighter out of Holland who spends six weeks a year in Thailand. He had been a fit and healthy 25-year-old man with a history of prior knee and back injuries; nonetheless, his complaint at this stage was pain on the inside of the right elbow that made grappling through fighting and also lifting weights at the gym hard.
The pain had started only a few days to his recent trip to Thailand and had been present for about five days. It had been focused around the medial epicondyle of the elbow. Any powerful gripping moves whilst flexing the elbow was shown to be debilitating. It had been affecting his coaching as some other work that was grappling was too painful and he was unable to perform any type gym movements such as chin ups and rowing motions. All pushing type movements were asymptomatic.
He whined no preceding elbow pain and refused any trauma to the elbow such as a arm lock-type situation or a hyperextension type injury during training or fighting.
He had been tender to palpate the source of the wrist flexor muscles which start on the elbow along, as well as any forceful wrist extension was uneasy. His elbow felt secure and using a stress test. Strong grip of the hands was painless until he was put to a position of wrist extension that is complete.
With no history of injury and without any changes to his coaching regimen I quizzed him. We exercised that whilst in Thailand he traveled on a scooter — a pastime for thieves to tackle when. He’d spent plenty of time around the sightseeing on the bicycle when he came.
The type of scooter he used was a automatic without equipment shifting the accelerator is on the right side of the bars. The reasoning was because of the continuous wrist extension used to accelerate the scooter at a pronated position, the wrist flexor muscles were put in a position of stretch with constant tension due to the co-contraction of this wrist flexor/extensor group required to do this particular movement. Coupled with this was that the vibration that is constant on the bicycle caused by the movement of the scooter in addition to the frequent pot holes and undulating road typical of Thai roads. The diagnosis was an inflammatory response in the wrist flexor origin.
I made the following suggestions:
1. Regularly extend by putting the hand flat on a table with the wrist turned to supination, the wrist flexors. He was to hold this for 30-second efforts.
2. Soft tissue massage to the wrist flexor muscle group, something he could do in Thailand using the massages on offer.
3. Moderate outrageous wrist flexor exercise working with a 5kg dumbbell using the forearm put on a desk (palm upward) and also to slowly lower the weight into wrist extension and use the flip side to help the concentric lifting. He was to do this
4. Change the hand place on the accelerator. It was suggested he can do three distinct things to achieve this. Primarily he can flare the elbow out broad whilst riding to decrease the amount. He up to this point kept the elbow close in to the body to perform this. Secondly he could occasionally hold the accelerator handle on the end so that he could keep his forearm supination position as this requires radial deviation to quicken the bike. Finally, on stretches of street I invited him undo the grip so he utilized wrist flexion to accelerate the bicycle and to actually supinate his forearm.
5. Rub some topical gel.
Two weeks later, I saw him and he maintained that the elbow pain had entirely subsided.
The Buzzing Thigh
A 30-year-old Thai local fighter had whined a six- month history of a ‘buzzing’ kind pain on the outside of the thigh and in the calf that was ideal region. It’d started after he obtained a hard kick to the back of his right hip. The kick was so strong that he lost function of his right leg at the time and needed a sensation down the thigh into the foot and calf. As this occurred in training, he rested on the leg and stopped and used the Thai concoction of heat and ointments to manage this harm. He returned to coaching a couple of days later and had been involved in a couple of fights after. He felt he had been still practical, but still felt a buzzing sensation every time. He claimed that he managed to perform everything and even blows to the thigh and hip were no longer painful than normal.
On examination he had movement in both hips his internal rotation when lying prone was decreased compared to another side. He was able to squat and perform a single leg pain free. All knee motions and ligament testing demonstrated unremarkable.
What was painful was a slump test on the ideal side and this reproduced the proper- sided throat sensations he experienced with kicking. The pain was made worse with dorsiflexion of the ankle whilst at a slump position.
It was concluded that when he had sustained the blow to the posterior hip, he had bruised the subsequent hematoma and the right piriformis muscle had created fibrosis around the sciatic nerve. Each time he had to stretch into full hip flexion with the knee extended and the foot dorsiflexed to complete a roundhouse kick, he had been effectively stretching the nerve against the port made by the scarring and fibrosis around the guts by the preceding injury to the soft tissues. This would be sufficient to give him a neuropathic-type pain down the leg across the course of the nerve and in the superficial peroneal nerve.
I explained that the way to remove this was to frequently ‘extend’ or move the guts from the vents to try to release the nerve out of any fibrosis. I showed him how to run his own gentle nerve mobilizations as a slide and slide method (neurological wracking) and also how to hold the place on stretch to make a sustained elongation.
He did so sitting on the conclusion of the fighting ring at a full slump position (neck flexed, spine arched into flexion) and he had been to straighten the ideal knee with the foot dorsiflexed until he felt a gentle uncomfortable tug onto the guts (felt like a buzzing down the ideal leg). This was to be achieved to this point of discomfort but not pain. I explained that if he overdid motion and this stretch he could make the issue worse, so I invited him to underdo this and not over do this. He had been to spend five minutes after a warm-up finishing a string of knee extension and release the stretch. After a pause continue this on/off movement for five minutes per day and he was to stretch again.
I didn’t figure out how this solved as this movement would take a few weeks to make a noticeable shiftI can expect that he would have discovered a relief from his signs at some stage in the future.
Chiropractor, Dr. Alexander Jimenez looks at the way this common injury shows itself.
Introduction
Iliotibial band syndrome (ITBS) between the knee is frequently diagnosed in sport injury clinics. ITBS presents having an incidence rate of around 22% in most lower extremity running-related injuries (1) also has been said to be the second most common complaint amongst distance runners (2). ITBS has been given the expression ‘runner’s knee’.
Trainers like endurance runners who perform flexion and extension combined with loading are subjected to this illness. ITBS presents during the first two or three miles in running with no mechanism of injury, which can make identifying the cause more interesting. With plenty of factors having been considered within the literature, changes are often purported to be a cause of ITBS. But some biomechanical factors have been researched and have been found to have little or no effect in the start of ITBS. Therefore this text’s point would be to examine the biomechanical changes which may induce an individual to the beginning of ITBS. The research published reviewed is largely based on a current systematic review that was published in Physical Therapy in Sport in 2014 (3).
Anatomy & Function
The iliotibial band (ITB) encapsulates the tensor fascia latae (TFL) presenting with both deep and superficial fibre attachments at the pelvis (4). In addition to attaching to the TFL, approximately three-quarters of the gluteus maximus tendon also conjoins with the ITB (4). The ITB courses along the lateral aspect of the hip and passes the greater trochanter. The ITB maintains an attachment on the posterior ridge of the femur whilst attaching itself to the fascia. The ITB has a fixed attachment at the lateral femoral condyle where it then divides into three segments with the first being the lateral patella (3). The remaining two segments cross the knee joint to insert at the head of fibula and most distally at the infrapatellar tubercle also known as Gerdy’s tubercle on the tibia (3). Figure 1 illustrates the location of the ITB.
The ITB passively functions to resist hip adduction, hip internal rotation and internal rotation of the knee in accordance with its attachments at the pelvis, femur and tibia(3). The gluteus maximus functions, through its attachment, to increase stability through the hip and knee complex by increasing the tension of the ITB(4). It is possible to see, based on its attachments at both the knee and hip, how changes could bring about the onset of ITBS.
Studies have proposed that as the knee flexes and extends the ITB ‘slides or flicks’ over the lateral femoral condyle of the knee causing an irritation beneath. This notion was debated by Falvey and colleagues (5), who stated that it was highly unlikely that the ITB would flick or slide over the bone during knee flexion due to it not being a loose structure. But the authors did agree that the impact of compression on the richly innervated fat pad was pain’s cause but by strain of the ITB where pain presents crossing the lateral femoral condyle. Strain rate and strain magnitude were measured in a prospective study involving female runners (6). The results indicated that frequency of strain of the ITB at the lateral femoral condyle was greater that the strain magnitude. This implies that a runner might have the ability to run for a short period but then incur lateral knee pain because of the strain to the ITB.
MRI scans have ascertained the knee flexion angle of 30� elicited the greatest compression of the ITB at the point of heel strike, whereas others have said that maximal compression occurs between 20-30�(2,6). A knee flexion angle at the point of heel strike has been found to be significantly different with 20.6� in ITBS patients compared to 15.3� in the control(7). Downhill running produces a greater knee flexion angle at the point of heel strike eliciting a larger strain load to the ITB and therefore this is often a main precursor to ITBS (6). Although an elevated knee flexion angle at the point of heel strike has been considered to contribute to ITBS, it is essential to examine the lower extremity from the frontal and transverse planes too and not solely from the sagittal plane (2).
Rearfoot Eversion
It’s possible to envisage how rear foot eversion could contribute to ITBS causing internal rotation of the tibia resulting at the distal attachment in greater strain of the ITB. In contrast Ferber and colleagues (2) indicated that there was no significant difference in the peak eversion angle of the female subjects, who were previously diagnosed with ITBS but were now symptom free, compared to controls. In a similar study non-significant differences were found between the currently symptomatic ITBS patients and controls for rear foot eversion (8).
Louw & Deary(3) found that ITBS patients sometimes demonstrated decreased eversion angles, accompanied by decreased internal rotation of the knee, at the point of heel strike. Ferber and colleagues (2) noted an increased inversion moment in the ITBS group which was suggested to control and limit the eversion moment. By comparison, currently symptomatic ITBS patients demonstrated a substantial difference compared to a control group with twice the rear foot motion during running (9).
Knee Internal Rotation
Peak internal rotation angle of the knee was found to be significantly greater in the ITBS patients when compared with controls at the point of heel strike (2). This research was supported by other studies who also found a significant effect for increased internal rotation of the knee following a run of moderate intensity to physical exhaustion(7). With excessive rotation comes compression due to increased strain of the ITB at the attachment.
An explanation of increased internal rotation of the knee was attributed to excessive external rotation of the femur perhaps due to shortening of the piriformis, gemellus inferior and superior and the obutrator externus (8). The authors added that excessive rotation at the hip might result from muscular activity of the rotators that were hip being the medius, minimus and the tensor fascia latae. These studies(2,7) were retrospective in design in that they tested healthy runners with a history of ITB pain, whereas(8) was a prospective study of patients with ITBS at the point of testing.
Hip Adduction Angle & Hip Abductor Strength
The hip adduction angle during the stance phase has been suggested to be greater. Ferber and colleagues(2) found that the peak hip adduction angle was significantly greater in the ITBS cohort and stated that with 95% confidence. Increased angle results in increased stress to the ITB and consequently increased compression at the lateral femoral condyle when combined with increased internal rotation of the tibia.
Figure 2 illustrates, when peak hip adduction and internal rotation combine, how this may result in increased the compression of the ITB at the lateral femoral condyle. Louw and Deary(3), however, stated that it remained inconclusive whether the peak hip adduction angle was a substantial element. Additional research is therefore required to support Ferber and colleagues'(2) initial findings as this study was a retrospective study carried out on healthy female runners with a history of ITBS.
Hip Abductor Strength
It’s been proposed that an increased peak hip adduction angle may coincide with hip abductor activity involving the gluteus medius in this group. During the stance phase of gait the gluteus medius functions to keep stability. Research has indicated that during stance the adduction forces can exceed three times an individual’s body weight(3). What’s more, it was stated that these forces were beyond the metabolic capacity of the gluteus medius to main pelvic stability during the stance phase using just this muscle alone(3).
Louw and Deary (3) were not able to identify a heightened hip abductor moment in the ITBS patients with increased peak hip adductor angles and suggested that it was more of an issue of timing as opposed to the size of the hip abductors. Louw and Deary (3) stated that the research is yet to examine trunk and pelvic movements in ITBS patients and it is plausible to suggest that biomechanical changes from higher up the kinetic chain has the potential to be a contributing element in ITBS etiology.
A research study of 24 (14 female, 10 male) patients with ITBS undertook a six-week rehabilitation programme to increase the strength of the hip abductors(10). Following six weeks of hip abductor strengthening to running 22 patients reported being pain-free and had returned. The female patients reported an average hip abductor torque increase of 34.9% and the male patients found 51.4% increase. However this study used a hand held dynamometer to measure isometric strength and therefore Fedricson (10) findings should be viewed with caution.
A more recent study assessed the hip abductor strength of currently symptomatic patients with healthy controls in a fixed position(11). The results indicated that no substantial differences occurred for static and dynamic hip abductor strength between the groups. Further research should look into the EMG and strength of the hip abductors in the role of managing ITBS. Table 1 shows of significance in the some of the variables of the studies used in this text.
Rehabilitation programs, following periods of immobilization and during, should include gluteal exercises to provide stability to the leg that is involved. If active exercises for the gluteal muscles are provided in a manner that is secure and effective then this can influence the period of transition from non weight. It’s prudent based on the research provided to date to develop function although research is lacking in terms of quality and volume as to the biomechanical influences on the etiology of ITBS. This guarantees that once load bearing commences that the leg that is involved has the stability and control that is active to keep the beginning of load of the ITB.
Summary
The recent review published by Louw and Deary(3) indicates that much of the research published within the literature depending on the etiology of ITBS is inconclusive. The level of research is relatively low and is based on retrospective trials. The research does indicate that knee biomechanics and abnormal hip is involved in the occurrence of ITBS. The authors ascertain that muscle strength is involved as is foot biomechanics that are abnormal. It is recommended that future research should measure kinematic movements of the hip and knee during downhill running as this is a complaint of ITBS onset.
References
1.Clini J of Sports Med, May 2006,16, (3), 261-268
2.J of Sports Phys Therap, Feb, 2010, 40, 2, 52-58.
3.Phys Therap in Sport, 2014, 15, 64 e75.
4.Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 – 446
5.Scand J of Med & Sci in Sports, Aug 2010, 20 (4), 580-587.
6.Clini Biomech, 2008, 23, 1018-1025.
7.Gait Posture. 2007 Sep, 26 (3), 407-13
8.Clini Biomech, Nov 2007, 22 (9), 951-956.
9.Med Sci in Sport & Ex, 1995, 27, 951-960.
10.Clini J of Sports Med, 2000, 10:169�175.
11. Int J of Sports Med, Jul, 2008, 29 (7), 579-583.
In the first part of the 2-part article on femoro-acetabular impingement (FAI), chiropractor, Dr. Alexander Jimenez discussed FAI and how it can lead to insidious onset abdominal pain and damage the hip joint labrum, leading to early arthritic changes. Given that conservative management generally fails in young athletes and needs operation, part two describes the post-operative rehabilitation period required to take an athlete back to full competition.
The post-operative rehabilitation period is highly dependent on the magnitude of pathology and the subsequent procedure; weight-bearing development is consequently variably reported in the literature.
If the labrum is surgically repaired, then protected weight bearing is encouraged to allow the repair site in order to be protected during the early healing phase. Also, avoiding extremes of flexion (beyond 60�) and also internal/external rotation for the initial 4 to 6 weeks is important to safeguard the repaired labrum. Any positions that possibly create an impingement and boost inflammation ought to be prevented. These include:
Deep squatting
Prolonged sitting
Low couch sitting
Lifting off the ground
Pivoting on a fixed foot
These positions are more safely tolerated following the six week post-operative period. But on account of the selection of hip flexion limitations imposed in the initial six months, usual activities of daily living are rather restricted, making yield to work and daily chores challenging if not impossible from the first few weeks following surgery. Therefore, the post- surgical patient does have to make substantial lifestyle changes and they need assistance in the first six weeks following surgery.
Special precautions in certain types of FAI processes. Reshaping of the femoral head- neck junction can weaken the rectal neck so particular care must be taken in this post- operative period. Fracture of the femoral neck is an unlikely but potentially serious complication after a reshaping process. The athlete may be allowed to bear full weight, but crutches are needed to avoid twisting movements during the initial four weeks after surgery. High impact pursuits and high torsion moves should be prevented in the first 3 months, as bone grafting requires around three weeks to attain full structural integrity.
Furthermore, if microfracture of this femoral head is also done for femoral head cartilage defects, then the athlete ought to be restricted to partial weight- bearing for two weeks so as to optimize the premature maturation of the fibrocartilaginous healing response.
Key points
1. Weight bearing status is dependent on the kind of reshaping procedure, whether the labrum was repaired, and also what the surgeon favors
2. Steer clear of hip flexion beyond 60� in the first 4-6 Weeks
3. Avoid extremes of rotation
Post-Surgical Rehab
Rehabilitation protocols provided in the literature have a tendency to be quite generic in their own advice and at best explain broad transitional phases during the rehab process. They usually describe the transition in weight bearing status, the development of gait through walking into jogging, and give general guidelines as to how to and when to progress activity based on a time dependant strategy.
They then progress describing transitions into twisting and affect actions — usually explained as beginning at 3 weeks following surgery — and generally the guidance is that the speed with which the athlete progresses is variable and might need yet another 1 to 3 months to get full return based on the game. Trainers are usually advised that return to sports after surgical correction of FAI can require 4 to 6 weeks. However it’s critical that progression through rehabilitation phases is driven more by subjective and objective measures during the transition phases. This allows the athlete and therapist to track load (type and quantity) and ascertain whether the joint arrangements are able to withstand changes in load securely.
Wahoff et al (2014) have provided some standards which may be utilized to guide the transition from one point to the next(1). They describe their rationale and supply a complete description of all of the cited tests in their printed clinical comment. Essentially, the exit criteria they offer in each phase are as follows;
So as to advance through the six clarified stages, the athlete may undergo extensive physiotherapy, focusing on hip range of movement exercises, manual therapy and trigger point releases, active stretching, potentially deloaded activities like hydrotherapy or Alta G walking/ running and strong hip rotator and gluteal strengthening exercises. Much of this will be ‘controlled’ and led by the wishes of the surgeon as they will provide the framework on if and what happens concerning loading.
But more direct physiotherapy Interventions have been devised to direct the physiotherapist through the rehabilitation protocol. The Takla-O�Donnell Protocol (TOP) is a validated physiotherapy intervention program which may be utilized to induce the arthroscopically handled FAI patient (Bennel et al)(2).)�This protocol is shown in box 2.
Hip Muscle Control
The focus of the rest of this article Will be to summarize some common yet powerful hip strengthening exercises which may be used to progress the hip muscle control throughout the rehabilitation phases.
Regaining hip muscle power, particularly in the heavy hip external rotator group, is imperative from the FAI recovering athlete. Good muscle endurance and strength in those muscle groups will ensure adequate hip joint compression happens with motion to reduce any shearing effect between the head of femur and acetabulum(3). The muscle groups needing focus are (see figure 5):
Posterior fibres Gluteus Medius (PGMed)
Gluteus minimus
Superior and Inferior Gemellus
Internal and External Obturator
Quadratus Femoris
Piriformis
There’s plenty of exercises that can be utilized to fortify the hip joint musculature. The chosen ones below are a sample of some effective exercises that can be used throughout the rehabilitation phases. However, the key requirements of the contained exercises include:
1. Performed in neutral stylish places to no more than 60 degrees hip flexion. This range of movement protects the hip joint from any possibly damaging impingement.
2. Minimal rotation of the hip, letting them be used in most stages of the rehabilitation process.
3. Performed isometrically or utilizing little oscillating concentric/eccentric contractions — to contract and hold to maintain the hip joint compacted and stable. This represents how these muscles work in individual function.
Summary
In many ways. hip joint labral tears, capsule sprains, cartilage and muscle accidents and bony architectural issues like FAI can all lead to debilitating hip pain. FAI is a real concern for the athlete as the existence of a bone abnormality may lead to a painful hip impingement, damage to the acetabular labrum and premature onset degeneration. FAI’s don’t respond to conservative management. If the athlete suffers debilitating pain that affects competition then the options are either to cease competition all together or have the FAI surgically corrected. Once corrected by the surgeon, regaining complete motion and muscle strength and ultimate game related functional skills will require some time. Hip rotator muscle strengthening must shape the foundation of all handling post-surgical FAI issues.
References
1. International Journal of Sports Physical Therapy. 9(6); pp 813-826
2. Arthroscopy. 2006;22(12):1304-1311
3. Int J Sports Phys Ther. 2012;7(1):20-30.
In the first part of this 2-part series, chiropractor, Dr. Alexander Jimenez looked at the likely signs and symptoms of disc Herniation, in addition to the selection standards for micro-discectomy surgery in athletes. In this report he discusses the lengthy rehab period following a micro-discectomy procedure, and provides a plethora of strength based exercises.
Surgeries to ease disc herniation, with or without nerve root compromise, comprise traditional open discectomy, micro-discectomy, percutaneous laser discectomy, percutaneous discectomy and micro- endoscopic discectomy (MED). Other surgical conditions are employed in The literature like herniotomy that’s interchangeable with fragmentectomy or sequestrectomy. The saying ‘herniotomy’ is defined as removal of the herniated disc fragment just, and the ‘standard discectomy’ as elimination of the herniated disc along with its degenerative nucleus in the intervertebral disc space.
When surgery is required, minimizing tissue disruption and strict adherence to an aggressive rehabilitation regimen may expedite an athlete’s return to perform(1), that explains why micro discectomy is a favored surgical procedure for athletes. Micro discectomy procedures entails Removing a small part of the vertebral bone over a nerve, or removing the fragmented disc stuff from under the compressed nerve root.
The surgeon can then enter the spine by removing the ligamentum flavum that insures the nerve roots. The nerve roots can be visualized with functioning eyeglasses or with an operating microscope. The surgeon will then move the nerve to your side and to subsequently remove the disc material from beneath the nerve root.
It’s also sometimes required to eliminate A small portion of the related facet joint to permit access into the nerve root, and additionally to relieve pressure on the nerve root resulting in the facet joint. This procedure is minimally invasive since the joints, muscles and ligaments are left intact, and the process doesn’t interfere with the mechanical construction of the spinal column.
Endoscopic Lumbar Discectomy
Local Doctor performs lumbar discectomy using minimally invasive techniques.�From the El Paso, TX. Spine Center.
Surgical Outcomes
In general, athletes with lumbar disc Herniation have a favorable prognosis with traditional therapy; more than 90 percent of athletes using a disc herniation improve with non-operative treatment. Many demonstrate a response to conservative treatment with increased pain and sciatica within 6 weeks of the initial onset(2). This implies that the requirement to function immediately could be considered hasty.
However, in case of failed Conservative therapy, or together with the pressure of a significant upcoming competition, surgery might be needed in some instances. Even though it involves surgical therapy, micro-discectomy has been reported to have a high success rate — over 90 percent in some studies(3,4). Patients generally have hardly any pain, are able to return to preinjury activity levels, and therefore are subjectively happy with their results.
The achievement rate of micro-discectomy is The following studies have been summarised to underline the success rate of micro-discectomy procedures:
1. In a survey on 342 professional athletes Diagnosed with lumbar disc herniation in sports like hockey, football, basketball and baseball, it was discovered that powerful return to perform occurred 82% of this time, and 81 percent of surgically treated athletes returned for an additional average of 3.3 years(5).
2. From a limb paresis which might be associated with a disc herniation following surgical treatment. If the preoperative paresis was mild then they could anticipate an 84% likelihood of full recovery. Patients with more severe paresis have less chance of recovery (55%)(6).
3. Wang et al (1999) in a study on 14 athletes demanding discectomy processes found that in single degree disc procedures, the return to game was 90%. However when the procedure involved 2 levels enjoyed considerably less favorable results(7).
4. In a study of 137 National Football League players with lumbar disc herniation, surgical treatment of lumbar disc herniation led to a significantly more career and greater return to play rate than those treated non-operatively(8).
5. Schroeder et al (2013) reported 85% RTP rates in 87 hockey players, with no substantial difference in outcomes or rates between the surgical and nonsurgical cohorts(9).
6. A study by Watkins et al (2003) coping with professional and Olympic athletes revealed the acceptable outcomes of micro-discectomy concerning return to play, since elite athletes in general were highly encouraged to return to perform(10). Also, athletes who had single-level micro- discectomy were more likely to come back to their original heights of sports activities than were people who’d two-level micro- discectomies.
7. A study by Anakwenze et al (2010) investigating open discectomy at National Basketball Association participants demonstrated that 75% of patients returned to perform again compared with 88 percent in control subjects who did not undergo the operation(11).
8. A recent review found that conservative therapy, or micro-discectomy, in athletes using lumbar disc herniation seemed to be satisfactory concerning returning the injured athletes into their initial levels of sports activities(12).
These studies conclude that though a Analysis of lumbar disc herniation has career-ending potential, most gamers have the ability to return to play and generate excellent performance-based outcomes, even if surgery is required.
What is also apparent from research Studies is the level of this disc herniation can also determine prognosis after surgery. Athletes shower a greater difference in progress between surgical and non-operative treatment for upper amount herniations (L2-L3 and L3-L4) compared to herniations at the L4-L5 and L5-S1 levels. Patients using the upper level herniations needed less progress with non-operative treatment and marginally better operative outcomes than those with lower degree herniations(13).
There are several possible explanations A range of studies have revealed that low spinal canal cross-sectional area is associated with an increased likelihood of symptomatic disc herniation, and increased intensity of herniation symptoms. The spinal cross-sectional region is the smallest (thus contains a larger possibility of nerve compromise) at the most upper posterior section and the cross-sectional region increases further down to the lower lumbar spine(14).
The location of the disc herniation�(foraminal, posterolateral or central) may also contribute to differences.�In this study, upper lumbar herniations were more likely to happen in the much lateral and foraminal positions than were people in the lower two intervertebral degrees(13).
Post-Surgical Rehab
After micro-discectomy surgery, the Small incision and restricted soft tissue injury makes it possible for the patient to be ambulatory reasonably fast, and they’re usually encouraged to start rehabilitation sooner or later during the 2-6 weeks after surgery.
In a review on the efficacy of busy Rehabilitation in patients following lumbar spine discectomy, it may be reasoned that individuals can safely take part in high or low-intensity supervised or home-based exercises initiated at 4 to 6 weeks following first-time lumbar discectomy(15).
Herbert et al (2010) discovered that with Effective post-surgical rehabilitation plans, there was a key accent on lumbar stabilisation exercises(16). Second, positive trials tended to initiate rehabilitation earlier in the postoperative interval compared to negative trials (about 4 vs 7 weeks).
Outcome Measures
The most widely used result Measure following back injury and/or disc surgery is the Oswestry Disability Questionnaire(17). This questionnaire is reported to have good levels of test-retest reliability, responsiveness, and also a minimum clinically important difference estimated as 6 percent(18) Furthermore, treatment success has been defined as a 50 percent decrease in the Modified Oswestry Disability Questionnaire score(19).
Concerning physical performance measures following back disc or pain operation, a commonly used clinical examination is that the Beiring-Sorensen Back Extension examination (see Figure 1)(20). This test is performed in a prone/horizontal body position with the spine and lower extremity joints at neutral position, arms crossed at the chest, lower extremities and pelvis supported with the top back unsupported against gravity.
Rehabilitation Program
Presented below is a five-stage rehabilitation program. The stages involved in rehabilitation are:
1. Optimize tissue healing — protection and regeneration
2. Early loading and foundation
3. Progressive loading
4. Load buildup
5. Maximum load
This program has been designed to get a field hockey player with had a L5/S1 lumbar spine discectomy. Even though the progressions from one point to the next are driven by the exit standards related to that stage, it might be anticipated that the athlete could progress in post-surgery to ‘fit to compete’ in about 12-13 weeks.
In this phase it’s anticipated that the athlete will remain relatively quiet for 2-3 weeks post surgery. This allows for full tissue recovery to happen, including scar tissue maturation. The athlete is allowed to completely mobilize in full weight-bearing; however care needs to be taken using any flexion and rotation motions and no lifting will be allowed.
The athlete can begin with the physiotherapist with the objective to manage any gluteal and lumbar muscle trigger points and start�nerve mobilization techniques that show how to engage the TrA and LM muscles (see Figures 2a and 2b).�If the physiotherapist has access to your muscle stimulator (Compex), then this can be utilized in atrophy manner on the lumbar spine multifidus and erector spinae. The key criteria to exit this early phase are curable walking as well as also an Oswestry Disability Score of 41-60%.
Early Loading & Foundation
The primary feature of this phase is that the athlete can start early and low-load strength exercises focusing on muscle activation in a neutral spine position, along with a progressive selection of motion program to improve lumbar spine flexion, extension and rotation. In this stage that the physiotherapist will guide the athlete through safe and gentle stretches to your hip quadrant muscles like the hip flexors, gluteals, hamstrings and adductors. The athlete also lasts gentle neuro-mobilization exercises to advance the freedom of the sciatic nerve — an issue in this condition as neurological tethering is a chance as a result of scar tissue formation caused by the surgical procedure.
The athlete can also be encouraged to start hydrotherapy in the form of walking in water (waist high) along with swimming fitnesscenter. In addition, he/she must start a string of low degree muscle activation drills in this stage (see Figure 3) that can be performed every day. This exercise teaches the athlete to hip flex (fashionable hinge) whilst maintaining a neutral spine. The neutral spine is maintained by using a light broomstick aligned with the back with the touch points being the occiput, the 6th thoracic vertebrae (T6) and the posterior sacrum.
Progressive Loading
In this phase the athlete continues with a variety of movement progression along with the physiotherapist progresses manual therapy to the pelvis and lumbar spine. Neuro-mobilization techniques can also be progressed. The significant change in this phase is that the progression of load on many of the strength and muscle control exercises.�Two exercises here are the �standing twisties� and the �crook lying pelvic rotation� exercise (Figures 4 and 5).�These movements are the introductory spinning based movements. The primary progression about fitness drills is the athlete can begin pool running drills.
Load Accumulation
This is the stage where the athlete begins to advance the load in strength-based exercises. Resistance is used in the form of barbell load and band resistance. Three exceptional exercises performed here are the ‘kneeling hip thruster’, ‘deadbug antirotation press’ and also the ‘quadruped walkout’ (Figures 6-8 — explained in detail in the online database of exercises).
The athlete also begins running drills at this phase and it might be expected that as well as building running Amount, the athlete should progress over four weeks to close to full sprint speeds. This is also the stage whereby they would initiate mild to moderate sports special skills drills. Another characteristic of this stage is that the athlete starts the ‘Sorensen test’ exercise (Figure 9) and it will be expected that they can maintain the position for no less than 90 seconds before advancing to the next phase.
Maximum Load
In this final stage, the athlete spreads all core and strength exercises to maximum loads, and they work with the fitness trainer on coming to squat and functional fitness center lift movements. Skill progression can also be advanced alongside sprint and agility drills. The last exit standards prior to advancing to endless strength and training work is they have to keep the ‘Sorensen test’ for 180 seconds and their self documented Oswestry scale ought to be someplace between 0-20%.
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So as to advance through the six clarified stages, the athlete may undergo extensive physiotherapy, focusing on hip range of movement exercises, manual therapy and trigger point releases, active stretching, potentially deloaded activities like hydrotherapy or Alta G walking/ running and strong hip rotator and gluteal strengthening exercises. Much of this will be ‘controlled’ and led by the wishes of the surgeon as they will provide the framework on if and what happens concerning loading.
Hip Muscle Control
Summary
In this phase it’s anticipated that the athlete will remain relatively quiet for 2-3 weeks post surgery. This allows for full tissue recovery to happen, including scar tissue maturation. The athlete is allowed to completely mobilize in full weight-bearing; however care needs to be taken using any flexion and rotation motions and no lifting will be allowed.
Early Loading & Foundation
The primary feature of this phase is that the athlete can start early and low-load strength exercises focusing on muscle activation in a neutral spine position, along with a progressive selection of motion program to improve lumbar spine flexion, extension and rotation. In this stage that the physiotherapist will guide the athlete through safe and gentle stretches to your hip quadrant muscles like the hip flexors, gluteals, hamstrings and adductors. The athlete also lasts gentle neuro-mobilization exercises to advance the freedom of the sciatic nerve — an issue in this condition as neurological tethering is a chance as a result of scar tissue formation caused by the surgical procedure.
Progressive Loading
In this phase the athlete continues with a variety of movement progression along with the physiotherapist progresses manual therapy to the pelvis and lumbar spine. Neuro-mobilization techniques can also be progressed. The significant change in this phase is that the progression of load on many of the strength and muscle control exercises.�
Load Accumulation
This is the stage where the athlete begins to advance the load in strength-based exercises. Resistance is used in the form of barbell load and band resistance. Three exceptional exercises performed here are the ‘kneeling hip thruster’, ‘deadbug antirotation press’ and also the ‘quadruped walkout’ (Figures 6-8 — explained in detail in the online database of exercises).
The athlete also begins running drills at this phase and it might be expected that as well as building running Amount, the athlete should progress over four weeks to close to full sprint speeds. This is also the stage whereby they would initiate mild to moderate sports special skills drills. Another characteristic of this stage is that the athlete starts the ‘Sorensen test’ exercise (Figure 9) and it will be expected that they can maintain the position for no less than 90 seconds before advancing to the next phase.
