Spinal Stress Fractures in Athletes. Who’s to blame?

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There is a growing concern happening now to our young athletes. Lumbar Spine stress fractures are on the rise. Who is to blame?

Stress fractures occur because of overuse and repeated tensions, usually a torque, on the bone. It can happen as a change of activity or too much of the same activity. In the case of spinal stress fractures, in the lower back, it is commonly found in athletes who use a high amount of rotation (baseball pitchers and hitters) or in those that have to quickly change direction of movement (soccer, tennis).

“In the confrontation between the stream and the rock, the stream always wins–not through strength but by perseverance.” – H. Jackson Brown

Repeated stress on a bone no matter how strong it is will eventually wear down and break. In the cases I have been seeing lately there seems to be an alarming number involving the lower Lumbar vertebrae. The parts of these bones that are breaking are a result of repeated torque or rotation of the spine caused by overuse. Normal body mechanics of the spine show that on rotation and extension (bending backwards) the vertebrae get closer together and in some cases can even touch together. In a controlled and slow manner this wouldn’t be any big deal. In the case of a gymnast who does obvious extreme back bends and tumbling repeatedly compressing these joints you might easily understand how their bones could break under the pressure. But what about the less obvious sports such as soccer and baseball/softball/cricket? What are these athletes doing to cause such compression? They are not bending backward? What can be causing their spine to over-rotate or extend? What part of their body is not working and causing the back to take up the slack?

It’s really very simple. Our bodies move in the path of least resistance. As we are growing and developing as young athletes we tend to overuse the muscles of our hips. We run and play hard and sometimes there is no “off season”. This accumulation of tension around the hips might go unnoticed in younger ages because of how quickly they grow but as we develop into our teenage years our growth slows and hormones shift and we begin to feel the tightness develop. If you are over the age of 35 now are you as flexible as you were when you were 10? Can YOU touch your toes??

As we age our tissues naturally tighten. This means we need to work a bit harder to keep or gain that flexibility. It’s NOT easy especially if you never had to do it when you were younger. If we had learned how to MAINTAIN our childhood flexibility by creating a ‘muscle memory’ for the movement stretch then it would be alot easier to feel loose today.

SO who is to blame???

I blame the HIP! Not a slacker by nature but quite the opposite, a truly hard worker. Tight hips means less motion. Less motion at the hip means less rotation. If we can’t rotate through the powerful muscles of the hip then the next closest area to help out is the lower back. Take the case of an athlete swinging a bat. It takes ALOT of rotation through the spine especially if they miss the ball! Proper body mechanics would allow the HIP to decelerate the power behind that swing and not let you fall off balance if you miss the ball. Ever hit yourself in the back with the bat as you finish the swing?? Not Good! It means your hips are not doing their job.

Look at the full body movement of Soccer players as they accelerate down the field and have to suddenly decelerate and change directions. If you watch them you’ll see upper body and lower body going in opposite directions leaving the pivot point to be the lower back! If there is any loss of rotation through the hips you get excessive load and torque across the spine. Over time the path of least resistance becomes an overstressed bone in the spine that can eventually break under pressure.

WHAT CAN YOU DO??

This tension is NOT just muscle tightness. It is IMPORTANT to know that the real problem here is JOINT tightness. That is very different. If we can get the back side of the hip moving better it will allow a deeper motion for the muscles like the hamstring and adductors (inner thigh) to get a better stretch. If you don’t loosen up the back hip joint then the muscles can’t lengthen and your motion is altered. This is a reason that you can go through all the right stretches but never really feel loose.

HOW TO LOOSEN THE BACK HIP!?

I’ve put together a short video of one exercise we do with every one of our tight hip athletes. The more you do it, the more you’ll remember it and the easier your regular muscle stretches will be.

Please reference our earlier blog titled: 3D Warm up and Flexibility: Lower body for more ideas to further loosen the hips.

If you are experiencing spine pain please get a full evaluation by your movement specialist for a proper diagnosis. Please reference our previous post titled: University Athlete Away from home and Injured…

QUESTIONS to ponder…….

Are we overtraining our youth?

Should there be an OFF season for athletes under the age of 18?

Are the coaches and trainers spending the time for proper warm up and flexibility training?

Dr. Donna Copertino,DC, DACRB, FAFS

http://www.drbackinaction.com

Beginner Runners….Don’t forget to Breathe!

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New runners who are committed to learning the task and eager to enjoy the reward of that infamous ‘runners high’ sometimes struggle with finding their breath. There is so much advice out there, good and bad, that it can leave someone feeling so confused or frustrated that they just give up on the task before they really get started.

Breathe in through the nose, out through the mouth, or should we breathe with mouth the whole time? Or maybe you’ve read to breathe in on every second step and out on every third? Or perhaps we could try to make grunting sounds as we exhale to warn the person ahead that we are coming and about to leave them in our dust!?  No matter the tip what I believe is that BREATHING IS A NATURAL PROCESS and shouldn’t have to be learned! We also shouldn’t have to THINK while we are running. Don’t we usually run in order to escape life’s over thinking nature?

My question is not HOW to breathe but rather WHY are we not able to breathe? Sometimes there is a physiological breathing problem you may have been born with such as asthma or allergies or cystic fibrosis or maybe you’ve suffered repeated infections and your lungs are a bit scarred down. Repeated coughing can be enough of a stressor to your muscles and leave you feeling tight all over. More often than not though the runners I see who are struggling to find their breath  simply have too much muscle tension in their necks, shoulders and torso that their bodies just aren’t able to give them what they are asking.

We are too STRESSED OUT!

We are like turtles hiding in their shells with our shoulders shrugged up to our ears! Daily life with work, school, kids, families all builds up tensions in our bodies both mentally and physically. Most beginner runners, and even some seasoned ones, have difficulty breathing because of stress and tension in the muscles responsible for proper breathing. Life can be difficult at times and sometimes our tension goes right to our shoulders. Don’t we carry the weight of the world on them?? Do you find it difficult if not impossible to RELAX!? Eliminating the tightness of these muscles can be tricky.

Trying to fit in exercise into our already packed schedules is near impossible so running is the best, fastest way to do it. Seems like a great idea until you get out there and realize that what looks so simple when you watch other people do it is actually quite the daunting task. Suddenly you feel like you’ve reached a new altitude, that somehow you are at the top of Mount Everest where oxygen levels are low and you are dizzy and sweating and gasping for air when it hits you……I’ve only gone to the end of the driveway!

Don’t quit yet! If we can alleviate some of that muscle tension and retrain your body how to breathe properly you’ll be able to find your breath naturally as you pick up your pace. Our bodies know what to do. We were born to run! Sometimes it just needs a little reminder. Below you will find some simple ways to help your breathing issues as it relates to muscular tension.

There are 2 major points I’d like to make about breathing based on my experiences in the movement industry. There are about a million other facts/theories you can learn about online. What I’d like to share with you are MY successes with runners and how we came up with ways to increase the movement of their rib cage expansion and trick the shoulders into letting go. You can either read through the boring (not to me!) Anatomy lesson here or SKIP to the end and watch the video! Ah, if I only I knew what you chose!! Ha. Enjoy either way.

  1. Breathing occurs primarily from the large muscle in the abdomen called the diaphragm and secondarily from the small muscles connecting the neck to the upper rib cage called the scalenes. Shallow breathers can get away with using the scalene muscles if they do not have much exertion during their day. These little guys get overworked and tighten up very quickly. You’ll see this in a typical office worker who sits at a desk most of the day. If you don’t train your diaphragm muscle to breathe deeply it will weaken and your breathing will become inefficient should you need more air.

“If you don’t use it you lose it”

       2. The other important  area required for breathing is the rib cage and thoracic spine (trunk). There are small muscles between the ribs that allow for the ribs to expand and separate on inhalation. There are also layers of longer muscles that connect the spine to the ribs. Tightness in any of these muscles can lead to difficulty in breathing on exertion. If your body is tight in these areas is doesn’t matter how well your diaphragm contracts you won’t be able to expand your lungs if the cage they are in is locked tight!

A 54 year old woman presented to me just the other day stating that she joined a beginners running group so that she could learn to run properly. Her hope was that someone there could help her to run without losing her breath and needing to stop. At first she did well with the 30 seconds of running and 2 minutes of walking but when the group jumped to 90 seconds of running followed with 2 minutes of walking she wasn’t able to recover quick enough. The exertion during the run made it hard for her to breathe so when she stopped she couldn’t regulate her heart rate or breath rate within the two minutes.

What we found was that during a deep breath she would greatly elevate her shoulders which told us she wasn’t pulling the air in by proper use of the diaphragm. She was using the smaller secondary muscles, the scalenes, to get the air in. Also, she had very limited range of motion in her mid spine and rib cage. It’s like trying to inflate a balloon that’s inside a glass jar. It can only expand to the size of the glass. Our lungs can only expand to the size of our rib cage expansion.

As shown in the video we gave her two simple exercises to do daily. First we gave her one to help shut down the scalene muscles so that the diaphragm was forced to work. We did that by having her carry an 8kg kettlebell in each hand while walking and breathing. This heavy weight was enough to depress her shoulders and allow the diaphragm to do the work. At first she had to walk in a very slow pace and take shallow breaths as her body fought the resistance in her depressed shoulders. The small scalene muscles weren’t strong enough to shrug and lift the weights she carried.Within just a few minutes she was able to pick up the pace and breathe a little deeper. Her homework for this was to do it often every day in order to create that muscle memory so that when she needed it she wouldn’t have to think about it.

Next we gave her a movement stretch to help open up all of the other muscles that attach to the rib cage in order to allow for greater expansion. This was performed in a doorway but can easily be performed against a wall too. The instructions are simple:

  1. Stand in a doorway and turn to one side holding onto the side molding
  2. Let one hand go and reach overhead in a side bend while allowing your hips to lean out way from your reaching hand
  3. Repeat with the other hand reaching overhead while bending to the side
  4. Turn to the opposite side of the doorway and repeat the overhead reaches on each side.
  5. After warming up the ribcage and spine with these movements repeat the pattern but stop within the stretch and take a deep breath and hold 5 seconds to allow the muscles in between the ribs to stretch.

As with all of the exercises you’ll see from me it is recommended to perform frequently throughout the day in order to create muscle memory and efficiency of movement. Your body will remember something if it is performed for just a few seconds multiple times per day rather than once per day for a longer time. More often is better than more time!

Here is a video clip to demonstrate these simple exercises. As with all activity please be sure you are cleared by your movement specialist to perform such task without injury.

Breathe on and don’t forget to inhale!

Dr. Donna Copertino

http://www.drbackinaction.com

How stubbing a Big Toe led to a Soccer Player’s Collapse six months later!

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This is a case history of a new patient I recently had the pleasure of meeting. It bears worth for sharing only because it should have never happened to her nor gone this far. It leaves me with questions of whether or not university athletic trainers are holding on to injuries too long without physician referrals. I mean no disrespect to my fellow trainers. Some of my most admired colleagues are athletic trainers. I believe they are well educated and trained but responsible for so many athletes with too many conditions it seems impossible to be all and do all for every one of them.  Do universities need a Movement Specialist on staff in addition to the trainers so pre injury screenings can take place? Are our college athletes safe? So many questions I would love to start open discussions on.

For now, here is the story line of a girl, age 20, playing her third year of college soccer. Her 16th year overall and a tremendous athlete who knows no quit.

The following information shows the body’s genius way of compensating and how a chain reaction of body movements to correct a simple issue can lead to bigger ones.

Lets start where I did which was the end of the line. She collapsed on the field while running and complained of a burning sensation across her buttocks. The school trainer evaluated and diagnosed her with sciatica and sent her for X-rays. She was referred to me by a teammate for second opinion.

Sir Isaac Newton said: “To every action there is always opposed an equal reaction”

Here is the timeline of events:

August 2015: the player catches her RIGHT big toe on the turf causing it to jam and hyperflex (bends really far in the downward direction). She experienced intense pain and went to the trainer daily for more than two weeks. She claims it was the worst pain she has ever felt. No xrays were ordered and no referral to a physician. Eventually she could tolerate walking and running so with her desire to return to the game she started to play again.

September 2015: The player reports to the trainer with LEFT groin pain that hurts with running. He treats her for a hip flexor strain and tells her to foam roll and static stretch. She continues to play.

November 2015: She complains to the trainer that both hips feel really tight and her hamstrings are sore. He tells her to stretch and foam roll more.

December 2015 – March 2016: After a well needed break over the winter her body rested and she returned to pre-season training in February. Weight training and power lifting was the main focus without much emphasis on stretching or flexibility training. No review of her previous injuries were discussed.

April 2016: The player is running down field in a game and goes to make a cut and collapses on the field with severe burning in her buttocks. Confused and frightened she realizes she can hardly walk and in no way could she run. Same trainer diagnoses her with sciatica and recommends a course of treatment with possibility of referral for xray of her spine. At a teammate’s persistence she schedules an evaluation for movement assessment and cause of injury.

First let me break down how we approach an athlete with such an issue. First, we must understand fully what her position is and what body movements are required for good performance. Next we must know what other repetitive movements her body goes through on a daily or regular basis (school, work, hobbies,etc.). Finally we need to know what other injuries she has had in her LIFETIME not just recently.

This information, which is just through interview process, is vital to understand where her body may have started to fail and compensate. You see, it’s easy to evaluate her for her pain. Most any educated therapists could palpate her, do ranges of motion and orthopedic and neurologic testing and come up with tight hamstrings, hip flexors, piriformis, IT band, etc. and diagnose her with sciatica or maybe even a pinched nerve in her spine.Most then would come up with a program to “loosen” the tight muscles and rehab her to squat properly, strengthen isolated muscles with resistant bands or weight machines and perform static stretching daily, holding for a count of 10-30 seconds depending on what article they’ve read.

Our evaluation only starts with the interview in order to point us in a possible direction of WHY this injury occurred! We want to know WHAT hurts but more importantly we want to know WHY it hurts! What good does it do to loosen these areas and perform strength training if you never really determined what caused the body to create all of that tension?

Our movement analysis revealed a lack of motion in her right foot that caused her to fall off balance when rotating her body left and right. Her right hip was locked up and restricted with side to side motion. She had no ability to extend her spine or her hips on ether side while in the standing position. This may not mean alot to you yet but for me it was a confirmation of where her cause might be coming from.

After completion of all of our testing methods it was determined that the reason she collapsed while running down field was that her main power generators, the glutes, were turned off! If you shut off the glutes, the butt muscles, your lower back will spasm and you will fall in pain. What makes the glutes turn off? Tightness, extreme tension that causes inflammation of the hip can lead to joint locking. As previously discussed in Balancing the Hips our joints are the Commanders of the muscles. This girl had been building up tension in her hips for so long that when she was running along they inflamed and finally gave the signal to surrender. The ole ‘straw that broke the camel’s back’. Interesting to note here that the Sciatic nerve passes underneath these powerful hip muscles and can be pinched as a result of this tension.

Overtrained and overused muscles therefore overworked joints lead to inflammation. When you are not taught how to do proper flexibility training that emphasizes movement you are left with the compounding effect of tension on the joint and muscles involved. The better the athlete the harder they train. No quit No surrender. They work and work and work without worry until…..something happens. What’s the old saying, ‘you can lead a horse to water…..?’

Here’s what I think happened to our soccer player and why I think her body didn’t FAIL her but rather PROTECTED her. We are divine by design therefore will not injure ourselves but rather find ways to compensate, find the equal and opposing reaction. If you follow her history she first injured her right toe. My evaluation of this showed restricted ankle and arch movement. Her body protected the injured toe and locked up a safety zone around it to avoid movement. No one looked at this movement malfunction. Her body then tried to shift weight to the opposite side. If you are running and you can’t toe off properly you are likely going to lift your legs higher therefore using or overusing your hip flexor (September injury). When this compensation was no longer effective the body started to try to find balance through the most mobile joints we have, the hips (November complaint). A rest was helpful for some of the overuse tension but without the correction of locked joints and retraining proper movement patterns required for soccer her body soon remember all that was wrong.

It didn’t take long with the weight training and return to play for the body to tighten up. I believe that as she ran and the hips tightened and inflamed more her muscles shut down and her back spasmed to protect and down she went.

Our first treatment session attacked the source which if you have been following along it was the right big toe! Using various manual soft tissue techniques we unlocked the toe, the inside arch of the foot and gave her 3D flexibility exercises to do. The only other thing we did was release the long occurring tension in her hip capsule (joint) following up with 3D flexibility. As expected the muscles around the hip (hamstrings, hip flexors, glutes, etc) let go and allowed the stretch through our 3D system. In one session she felt light on her feet and loose for the first time in months. And the best part of all she scored a goal in the next game just 2 days later!

The body loves to move! Restoring our natural body mechanics as soon as possible is the key to preventing injury. Had the trainer known how to evaluate and treat the jammed toe back in August I believe everything else could have been prevented. If every athlete knew how to warm up and train in 3 dimensions and understood the importance of proper joint mechanics in their sport I believe that not only would you see less injuries but you’ll see an overall improvement in performance.

Move Better. Perform Better.