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

You are a University Athlete, Away from Home and You are Injured. What do you do?

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Find the right TEAM of experts to work together to fix you!

Your School provides the very best they know but sometimes we need more!

Here I hope to provide you with the insight that there are professionals out there who have studied the latest in therapies, body mechanics and evaluation procedures that your school might not know about. My hope is to educate you on some of these options and how to find them.

So many times I have a patient who comes home from college on a break and they want to be evaluated for their injury that isn’t quite getting better fast enough. They’ve received the best of care by the team medical staff but still feel less than 100%.  Some have returned to play but feel as though they can’t perform as well or maybe have a fear of reinjury so they hold back. Some are fearless and play hard but get hurt soon after their return and now they are frustrated. Once in a while you get that really bad one that needed surgery but just can’t seem to get back in the game.

No matter the situation they all have a similar issue; they need help. In some cases they have to wait until they get home, talk with their parents and hope to see a Specialist that can fix them. Oh, and get that all figured out in the three weeks that they are off from school! Or better yet, in the fours days they are off because they have to get back for practice.

As a parent you want what’s best for your child. You helped them find their sport, watched them excel and finally support and admire them while they play at a University level.

If they are injured you trust that the physicians and trainers and therapists at the University are taking the best care of them. After all, it IS a Top school in a major city surrounded by teaching hospitals and the world’s best research programs. Clearly they are in good hands and wouldn’t possibly need anything more!

As an athlete you would do anything to stay in the game, work through the pain, seek a second opinion, do all of the exercises, ice, heat whatever it takes just tell me what to do!! Right?

Why is it that even our professional level athletes who have access to the best of the best sometimes go out on their own to find the latest in therapies and travel out of the country for it?

Do we need to travel far and wide to find the right expert? Or is it that we just don’t know what or who we are looking for? My point is there are great people everywhere. Maybe the problem isn’t where to go to find them but WHO exactly do we need? We need a team!

“The Whole is Greater than the Sum of all its Parts”Aristotle

Remember that when you are trying to solve a dilemma  you might need more than one expert for the solution. I like to start with these three priorities when searching for WHO might be able to help:

  1. Identify the problem (What is injured? What type of specialist do we need?)
  2. How do you Fix it? (What are our options??? Corrective Exercise, Muscle Release, rehab, Therapy? Aren’t they all the same??)
  3. How do we prevent it from happening again? (Get to the source, the cause. Who can do that?)

There are so many professions out there, so many experts in many different fields. It can be difficult to sort out if you are not familiar. It is best to go to someone that specializes in the type of problem you have.  If all we know is Orthopedics and Physical Therapy then we are living in a very narrow minded small world. Remember that there is no one person who can know all and do all for every type of injury. A good physician, trainer or therapist will know when they need help. In many cases you’ll need to work with several different types of providers in order to get back in the game. My hope here is to simply educate you on just some of the other type of professionals or credentials/certifications you can search for should you need some expert opinion. If you are a parent and your child is away and is not responding well enough to their treatment you should have this information handy to guide you in the right direction for help.

KNOW YOUR OPTIONS!

I would like to provide you with a short list of Specialists out there and websites with search engines that can help you find someone in the area you need. These recommendations are based on my nearly 20 years of experience and education and what I personally have found helpful in my practice. There are many others that are just as good so please understand that this list is not all inclusive.

I advise parents and athletes too to start NOW and assemble a team of professionals in your area that you might need to find at a moment’s notice. Sometimes you can find one Professional that has multiple credentials so you may be able to combine therapies. Many Chiropractors and Physical Therapists and British Osteopaths will study the same areas so be sure to check out the full list of what they’ve certified in.

Types of Health Professionals to have on your call list:

  • Orthopedic Surgeon – for broken bones or torn parts (Specialist in area injured)
  • Physical Therapist – rehabilitation with at  LEAST these certifications (SFMA, FAFS)
  • Chiropractor – biomechanical correction with at  LEAST 1-2 of these certifications  (DACRB, SFMA, FAFS, ART)
  • British Osteopath – biomechanical correction with at  LEAST 1-2 of these certifications  (MOst, SFMA, FAFS, ART)
  • Massage Therapist – scar and adhesions in muscle (ART, Scarworks)
  • Acupuncturist – pain control
  • Nutritionist – metabolic efficiency testing
  • Sport Psychologist – Better Mind. Better Performance

Here are some sites to reference when searching for these types of professionals.

  1. SFMA: Selective Functional Movement Assessment – helpful in finding the right diagnosis whether soft tissue tension or neurological weakness.

www.functionalmovement.com Click on Find a Certified Member and select SFMA in your search

  1. ART: Active Release Technique – useful for tight muscles, strains, pinched nerves, inflexibility

www.activerelease.com Click on Find a Provider and search by Location/Zip code. Try to find the provider with the most certifications under their name

  1. FAFS: Fellow of Applied Functional Science – these experts are the TOP in their field who understand body function in 3 dimensions. You can find many types of movement specialists here including Strength Coaches, Athletic Trainers, Physical Therapists, Chiropractors and Osteopaths.

www.grayinstitute.com Scroll to bottom of page and Click on Fellow Locator and search by location. Be sure to switch your miles radius to the lowest area. GIFT is the program with the highest level of education.

  1. ScarWorks

http://www.wheelerfascialwork.com This search is for Scar tissue release. Go to Contact Us and send a message to find a certified provider in your area

5. DACRB: (Diplomate of the American Board of Chiropractic) – These are Chiropractors who continued their post doctoral education in the physical therapy arena.

http://www.acrb.org

There are so many other techniques that are out there that can be very effective in the treatment of injuries both old and new. Some of my colleagues are certified in Graston technique, Class IV Laser therapy, Gait Analysis using Optogait system or RunScribe technology. If you take away any message from this post I hope it is at least to search for more than what is traditional or commonly recommended. Find your team of experts in a variety of fields who work together for you!

Coming soon……..Video of Soccer Specific Flexibility Training!

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.