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The lumbar spine is a highly vulnerable area for injury in a number of different sports. The reported incidence varies from 7% to 27%.4,6,19 It appears that while the incidence is significant and time lost may be significant, probably the most important problems lie in fear of spinal injuries and the necessity of a therapeutic plan. Lumbar pain is a big part of many sports, but an organized diagnostic and therapeutic plan can prevent permanent injury and allow full function and maximum performance.

Gymnastics

With reference to lumbar spine injuries, gymnastics is probably the most commonly mentioned sport.20 The motions and activities of gymnastics produce tremendous strains on the lumbar spine. The hyperlordotic position used with certain maneuvers (such as the back walkovers) exerts tremendous forces on the posterior elements and requires a great deal of flexibility. The amount of lumbar flexion/extension used during flips and vaulting dismounts requires a great deal of strength to support the spine during these extremes of flexibility. Jackson2 pointed out that female gymnasts have an 11% incidence of spondylolysis. Spondylolysis is a fatigue fracture of the neural arch, and it is thought that the vigorous lumbar motion in hyperextension in gymnastics produces the fatigue fracture. It is also interesting to note that Jackson found spina bifida occulta in 9 of 11 gymnasts with pars interarticularis defects. It is known that there is a hereditary predisposition to spondylolysis, and the findings of occult spina bifida may point out a weakness of the dorsal arch in some of these gymnasts. But certainly the role of the sport itself plays a tremendous role in a much higher incidence of spondylolysis and a much higher incidence of back pain in general. Garrick and Requa21 reported a very high incidence of low back pain in female gymnasts and recommended the vigorous trunk strengthening exercises that are used today to properly prepare gymnasts for their sport.

Ballet

Many of the motions used in ballet are similar to those in gymnastics. The classic maneuver that produces back problems is the arabesque position. This position requires extension and rotation of the lumbar spine. Performing a proper arabesque maneuver is the key to preventing lumbar strain. Several points have been emphasized: keep the pelvis stable, keep the extension of the spine symmetrical over all levels, and obtain good extension through the hip joints.22

Ballet involves the lifting of dancers, often in awkward positions. The outstretched hand produces tremendous level arm stresses across the spine of the lifting partner. Off-balance bending and lifting is a hallmark of back problems in industrial workers and yet, ballet, while balanced, is designed often to produce some of the most difficult lifts. The male dancers follow the body weight of their female partners very closely.

Spondylolysis and spondylolisthesis are common in dancers and may often produce severe mechanical back dysfunction.

Water Sports

In addition to injuries to the wrist and cervical spine, the lumbar spine in diving is subjected to added strain not only due to rapid flexion/extension changes, but also the severe back arching after entering the water. While swimming and water exercises are a major part of any back rehabilitation program, certain kicks, such as the butterfly, produce a lot of vigorous flexion/extension of the lumbar spine, especially in young swimmers. The swimmer must develop good abdominal tone and strength in order to protect his or her back during a vigorous kicking motion. Thoracic pain and round back deformities in young female breast stroke swimmers can be a problem because of the repeated round shoulder-type stroke motion.

Pole Vaulting

Pole vaulting is another sport that involves maximum flexion/extension and muscle contraction during the sport. The range of motion of the lumbar spine has been documented with high-speed photography to change from 40 degrees of extension to 130 degrees of flexion in 0.65 seconds. One can imagine the tremendous forces generated across the spine with this functional demand.23

Weight Lifting

As we move from the motion sports, those sports that require tremendous amounts of flexibility (in addition to strength) and involve large degrees of changes in range of motion, we go to the heavier sports. These sports require strength, lifting, and high body weight. Of course, the most common would be weight lifting. The incidence of lower back pain and problems in weight lifters is estimated to be 40%.24 The tremendous forces exerted on the lumbar spine by lifting weights over the head produce a tremendous lever arm effect and compressive injury to the spine. The three most important things in performing weight lifting are "technique, technique, technique." Squats and dead lifts can be done, but the technique must be perfect in order to decrease the risk of a disk injury. For example, a dead lift requires erect posture, lumbar lordosis, and balance of the weight on the heels. Most lifts are begun with the spine in tight, rigid muscle control. Tremendous extension forces occur at the hips and knees with the spine in a rigidly stable position. Success in this portion of the lift requires the body to generate tremendous rigid immobilization of the spine in the power position of slight flexion. To do a forward bent motion with the spine out of this position can be quite dangerous, resulting in tremendous shear forces across the spine. Lifting weights with the spine flexed at 90 degrees, whether they are lighter arm weights or weights across the upper back, generates tremendous lever arm effect forces. The weight times the distance to the spine result in tremendous shear forces across the lumbar spine, especially if weight is to be moved in this position. One cannot imagine muscles that must be strengthened in this dangerous and mechanically disadvantaged position. A dangerous time for weight lifters is the shift from spinal flexion to extension that occurs with lifting the weight over the head as in the clean jerk maneuver or the "snatch." Making the transition from the flexion to extension position must be done with rigid, tight muscle control. Inexperienced lifters, especially, will have no muscle control as the spine shifts from flexion to extension. A trained lifter controls that shift with rigid muscle control of the lumbodorsal fascia. The position of holding weight over the head invariably brings increased lumbar lordosis. These tremendous extension forces of the lumbar spine naturally lead to discussion of spondylolysis and spondylolisthesis. The incidence of spondylolysis in weight lifters has been estimated at 30% and the incidence of spondylolisthesis at 37%.25 Many newer training techniques in weight lifting emphasize the role of general body conditioning, flexibility, aerobic conditioning, speed, and cross-training in addition to the ability to lift weight.

Football

Football players lift weights. It is part of the sport. The upper body forces and leg strength necessary to play football for most of the athletes involved in the sport require tremendous strength. Some football players, of course, rely on great agility jumping, and throwing ability and eye-hand contact, but strength is the backbone of football. Every year, every professional team needs heavier, stronger athletes, especially on the offensive line. These athletes invariably go through their period of mechanical back pain as training camp begins. It is difficult to prepare an athlete in the off-season for the tremendous, rapid back extension against weight necessary for blocking in the offensive line. Extension jamming of the spine produces facet joint pain, spondylolysis, and spondylolisthesis. It is similar to the weight-lifting position of weight over the head, except it must be generated with forward leg motion and off-balance resistance to the weight while trying to carry out specific maneuvers such as blocking a man in a specific direction. These athletes require specific training in back strengthening exercises in order to prevent lumbar spine injuries.26,27

Safety in weight lifting is an important part of football. To have a promising football player injured in the weight room is not an uncommon occurrence. It has been estimated that more injuries may actually occur in training rather than competition.28 This can be avoided through proper weight-lifting techniques. In addition to these extension/lifting-type forces, football involves sudden off-balance rotation. This rotation may produce transverse process fractures, torsional disk injuries, and tears in the lumbodorsal fascia. Sudden off-balance twisting is part of the game and may be caused by tremendous loads in a loose, unloaded position. Football has the added dimension of receiving unexpected, severe blows to the lumbar spine that may produce contusion or fracture. A helmet in the ribs produces rib fractures; a helmet in the flank can produce renal contusion, retroperitoneal hemorrhage, transverse process, and spinous process fractures. Many receivers and runners suffer spondylotic defects for the same reasons as gymnasts and ballet dancers, but the most common incidence of problems is in the weight lifting. The role of the strength coach in teaching proper weight-lifting techniques and designing training schedules that prepare the lumbar spine for what is expected with football is important in preventing lumbar spine injuries in football players.

Running

Another sport that produces stiffness is running. Distance runners must cross-train with flexibility in order to prevent injury. Running involves maintenance of a specific posture with tremendous muscle exertion over a long period of time. Low back pain as well as periscapular, shoulder, and neck pain is very commonly reported in the runner. We cure the vast majority of runners who have mechanical low back pain with stretching exercises. There is also the natural tendency in runners to develop isolated abdominal weakness. Running does not naturally involve contraction of abdominal and spinal stabilizing musculature. There frequently is a significant imbalance between flexors and extensors, not only in the legs but also in the trunk. Periscapular and back pain also results from abnormal posture during running. The key to posture is good isometric trunk strength that holds the body in an upright chest-out position. Runners with low back pain should be treated with the following:

1. Vigorous stretching program that stretches the trunk as well as lower extremities.

2. Cross-training and muscle strengthening techniques that strengthen the antagonist muscles.

3. Abdominal strengthening and isometric trunk stability exercises to enhance abdominal control.

4. Chest-out strengthening exercises. Begins with abdominal strengthening and adds upper body shoulder shrugs, arms behind the back, etc., types of exercises to emphasize chest-out posturing and tight abdominal control. The basis of treating back pain in runners is stretching exercises.

5. Proper footwear for cushioning and enhancement of foot function.

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Dealing With Back Pain

Dealing With Back Pain

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