Jan 29, 2015Full Body Approach
An athlete who presents with low back pain may also have a movement dysfunction. Both problems need to be addressed in order for the athlete to fully recover.
By Guido Van Ryssegem
Guido Van Ryssegem, MS, ATC, CSCS, NBFE, RN, is Coordinator/Clinical Athletic Trainer at Oregon State University. He serves as Director for the Oregon National Strength and Conditioning Association and is the Founder of Kinetic Integrations. He can be reached at: [email protected].
Low back pain–whether sudden or gradual in onset–is one of the most common complaints athletes have. For gymnasts, swimmers, and tennis, volleyball, and football players, it ranks as a top reason for visiting the athletic trainer or team physician. Yet athletes seem to consider it a common result of their training regimen and many do not visit the athletic training room until the pain is unbearable and they are no longer able to participate in their sport.
What these athletes don’t understand is that low back pain can cause imbalances and movement dysfunctions that strain other parts of the body, setting them up for injury. For example, let’s say an ice hockey player is experiencing some low back pain, but does not seek treatment. If the hockey player continues practicing, their body will naturally find a way to compensate for the pain.
A common example would be if the athlete started to favor one side, which can lead to a muscle imbalance in the hips. It would only be a matter of time before they suffered a strained leg muscle or tore a knee ligament.
Mounting evidence shows that athletes with low back pain often exhibit movement dysfunctions such as the one detailed above. These athletes move differently to compensate for the pain, often to the point where it affects their gait pattern. This makes them vulnerable to injury as the dysfunctional pattern perpetuates the body’s kinetic chain.
As important as it is to address an athlete’s back pain, for those of us who prevent, treat, rehabilitate, or recondition athletes, it is paramount to also identify and correct any movement dysfunctions that have surfaced as a result of the back pain. If we don’t, it is likely the athlete will suffer an injury or re-injury.
Movement dysfunctions are actually normal neuromuscular adaptations to preserve function. If that sounds conflicting, think about it this way: Say you are walking across the African savannah gathering food. Suddenly a lion starts chasing you, looking for a quick and easy lunch.
Luckily, there are some trees ahead where you can hide, but while sprinting you step in a hole and twist your back. Agonizing pain shoots through your spine. What are the options? Either you stop running and become lunchmeat, or you keep running to save your life. Of course you would continue running, albeit with a dysfunctional movement pattern.
Considering that the altered movement pattern was necessary in order for survival, what is wrong with how you ran? This is an extreme example, but the problem is that more often than not, survival patterns do not disappear–even after the back pain subsides. The dysfunctional movements become habit as the body has found the path of least resistance. And the longer an athlete is firing their muscles in a different sequence and changing the way their body’s kinetic chain is being used, the more likely they are to suffer an injury.
For example, research has shown high correlations between low back dysfunction and knee injuries. A 2007 study found that athletes with low back pain showed a more forward-leaning posture, which altered their knee mechanics and actually forced them to rely on their already-hurting low back muscles even more than usual.
The study also found weakness and imbalances in muscles around the athletes’ hips and pelvises. If the hip muscles are not properly stabilizing the femur, it will rotate away from its normal alignment and have a destructive effect on the functioning of the knee and kneecap. All in all, the athletes who had low back pain placed a higher demand on weaker, fatigued, unbalanced, and possibly inhibited muscles, resulting in further movement dysfunctions that overloaded the low back, pelvis, and lower extremity joints and eventually caused injury.
Through my 20-plus years of working with athletes at the professional and collegiate levels, I have noted that predictable patterns of dysfunction develop when the human movement system is not functioning optimally. For example, low back pain often results in postural dysfunction, poor balance control and body awareness, weak hip abduction and external rotation, and poor lumbopelvic stability.
New diagnosis and treatment models that recognize low back pain as part of the movement system and kinetic chain are emerging. I have developed a model called Kinetic Integrations that is centered upon this idea. It is an evidence-based approach to reversing dysfunctional movement that has arisen as a result of back pain through awareness, correction, and the formation of new habits.
The first step to correcting a movement dysfunction is to find it. Kinetic Integrations uses simple tests to detect dysfunctions associated with back problems. Through careful observation, these tests screen for strength weaknesses with respect to standard movement, limitations, and asymmetries. They can also help predict the potential for injury should the weakness not be addressed.
One of the tests is a modification of the eccentric step test, which is classically used to detect patellofemoral joint dysfunction. The procedure can detect movement dysfunctions in the form of internal knee rotation/adduction, poor neuromuscular control through descent, hip hiking, and/or early plantar flexion while performing a heel lift.
Simple postural assessment that involves an athlete balancing on one foot with their eyes open and then closed, as well as muscle strength testing, nicely augment the movement dysfunction tests. Not only is movement often affected by low back pain, but strength, balance, proprioception, and stability are, too. All must be addressed before the athlete returns to activity.
It’s important to note that some movement dysfunctions are more difficult to identify than others. For example, a wrestler comes into the athletic training room with low back pain and you don’t detect any imbalances or movement dysfunctions. Then he mentions that 10 years ago, he strained his back while wrestling in a youth club and had a limp for weeks afterwards. Even though the injury happened a long time ago, the body’s connective tissues and central nervous system still bear an imprint of that limping pattern. It may not be visible to the naked eye and the wrestler probably isn’t even aware of it, but he may still be favoring one side slightly just out of habit.
In addition to compensating for pain in the low back area, movement dysfunction can also be the result of repetitive motions and/or poor posture. This is easily recognizable in the legs and foot placement of a ballerina and the hunched shoulders of a swimmer or wrestler. Repetitive use and misuse of the body molds it.
As active as athletes are during practices, training sessions, and contests, they are not immune to poor posture. High school and collegiate athletes spend a lot of time sitting in classrooms, at team meetings, at the dinner table, watching TV, playing video games, studying for exams, and driving. How often are they slumped over, with their shoulders rounded and spine out of line? Pretty often, wouldn’t you say?
BACK TO FUNCTIONALITY
Once a movement dysfunction has been identified, it’s time to come up with a treatment plan to fix it. Even if the athlete is experiencing pain only in their back, it is important to remember that our bodies move as one complete system. Think of the kinetic chain: The head bone is connected to the neck bone, the neck bone is connected to the back bone, the back bone is connected to the hip bone, and so on.
Historically, the Western medical model hasn’t been very helpful in dealing with low back pain, and I believe this is because it’s based on treating only the symptoms of low back pain and not the root cause of the symptoms. I also believe this is why back pain has such a high recurrence rate. Even after an athlete is treated and returns to play, they are often haunted by the same pain again sometime down the road.
For example, an athlete who shows signs of low back muscle spasms is often diagnosed with just that: low back muscle spasms. They are then prescribed treatment for the spasms, which may include stretching and low back strengthening exercises. The stretching and strengthening may temporarily relieve the athlete’s symptoms and they may even return to full functionality, but the likelihood that they will again suffer from low back pain is very high.
In the above scenario, the focus was only on the symptoms. The athlete’s spasms might resolve through these interventions, but the associated dysfunctions need to be addressed as well so that return to full function can occur with minimal risk of re-injury or injury somewhere else in the body.
One of the main keys to resolving low back pain and any associated movement dysfunctions is to create new neuromuscular options so old (bad) habits can go by the wayside. This is achieved through the conscious practice of new movement and stability patterns.
There has also been a growing amount of research in the field of motor control. Studies have identified a number of motor control issues that can affect the overall stability of the lumbar spine, and research has identified key muscles that play an important role in spinal stability, including the multifidus, transverse abdominis, the pelvic floor muscles, and the diaphragm.
Low back pain is a common problem in the athletic population. Research has shown that it is associated with movement dysfunctions. Addressing these overlooked dysfunctions will facilitate more efficient return to activity, prevent re-injury, and optimize sports performance.
Sidebar: BACK IN ACTION
Billy is a college basketball player suffering from pain around his right kneecap. After being carefully questioned about his health history, it is revealed that in addition to his knee pain, he has a history of low back pain.
For the last six months, he has been periodically experiencing the back pain when sitting in class and after he has been standing for a while. In the morning, his back feels very stiff and it takes a while for him to “loosen up.” He has tried icing his knee and back and replacing his running program with a cycling regimen for a few weeks, but every time he resumes running his knee pain returns.
Billy has an obvious slouching posture, both when he enters the exam room and when he sits down. His knee exam reveals nothing except for some discomfort underneath the kneecap during a patellofemoral compression test, but his back exam reveals quite a bit: symptoms of spinal derangement in the lumbar and cervical spine with limited range of motion and a forward head position, poor thoracic spine mobility with poor rotation range of motion, atrophy and delayed contraction of his right low back multifidus, poor lumbopelvic stability, and poor balance with his eyes closed.
Billy’s step-down test also reveals femoral internal rotation with increased adduction and knee discomfort when he bends his knee while stepping down. His right hip abduction isometric strength is weaker on his injured side and he has right anterior hip impingement with poor and uncomfortable range of motion. Lastly, an x-ray reveals that he has mild patellar chondromalacia.
After explaining to Billy how his two injuries are connected, he understands their relationship and why manual therapy and corrective exercises are needed to get detrimental forces off his kneecap. His first treatment session includes manual therapy to the neck and thoracic and lumbar spine, followed by McKenzie extension exercises. This immediately decreases his low back discomfort and increases his spinal range of motion. Hip and patellar mobilizations are applied, eliminating the hip impingement while also improving range of motion.
Billy performs these exercises at home and continues to show improvement in symptoms and range of motion. A sitting hip stretch is added to his home exercise program.
Now that Billy has mobility, corrective strengthening exercises can start. First is the hip mini-band exercise progression. While applying sound postural cueing and exercise repetition, improved motor control quickly becomes apparent. After performing just 10 repetitions of the first exercise, his step-down test improves dramatically and does not cause discomfort.
A home balance exercise program is explained and demonstrated, and Billy is taken to the swimming pool to start running in the deep end with a floatation belt around his waist. To his surprise, neither his knee nor back bother him after deep-water running for 30 minutes. It is brought to his attention that when he started running in the pool he showed limited stride-length on his right side, exhibiting running movement dysfunction. Billy quickly learns how to correct it and expresses that he feels more normal running this way.
Consecutive treatment sessions continue for manual mobilizations as needed, and his corrective exercises are progressed as tolerated. Kinetic Integrations trunk stabilization exercises are also applied prior to his return to the field. Seven weeks after he first came in for his knee pain, Billy is back to his old self and playing better than ever.