Rotational and torsional sports have certain characteristics in common. Baseball, golf, and the javelin all require rotation and have distinctly different demands on the spine. The javelin requires a tremendous amount of force to be generated in going from a hyperextended to a full flexion follow-through position. You do not throw a javelin 200 feet with your arm. While shoulder and arm injuries are common in javelin throwers, the key is rigid abdominal strength that produces the torque necessary to throw the javelin. Attempting to throw with the arm only will produce arm injury and in no way can generate any type of distance. Every arm injury in a javelin thrower has to be treated with trunk exercises and trunk strengthening. A rotatory lumbar spine injury in a javelin thrower is a completely debilitating injury that requires tremendous care and correction prior to returning to the sport.
Golfers notoriously have the highest incidence of back injury of any professional athlete. Paul Callaway and Frank Jobe reviewed injuries of 300 professional golfers on the Professional Golf Association tour from 1985 to 1986. Of theses 300 golfers, 230 were injured, for an incidence of 77%: 43.8% of the total injuries were spine related and 42.4% were lumbosacral. Lumbar spine pain in golfers results from torsional stress on the lumbar spine, and the key to prevention of lumbar spine pain in golfers in to minimize the torsion stress by absorbing the rotation in the hips, knees, and shoulders and spreading the rotational stresses on the spine out over the entire spine. Maintaining rigid, tight control through the power portion of the swing is critical. Proper technique in golf begins when addressing the ball. The knee flexion of the address position tenses the abdominal musculature. This abdominal tension is initiation of the trunk control necessary for a properly placed swing. The majority of the emphasis is on maintenance of parallel shoulders and pelvis through the swing. This requires rigid abdominal control and rotation between the shoulders and hips, and loss of this rigid parallel of the shoulders and pelvis can generate rotational strain on the lumbar spine. Rotation occurs between the hips and shoulders in the back swing, and the amount of back swing is not as important to the power of the swing as the ability of the golfer to regain tight muscle control as he or she proceeds from maximum back swing down through the power portion of the swing. It is the ability to obtain tight control, parallelism, and maintain it that produces the power and protection for the lumbar spine. The first advice for any recreational golfer with back pain is to cut down the back swing and the follow-through. Concentrate on the power portion of the swing. Concentrate on tight abdominal control during the power portion and minimize the excesses of rotation with back swing and follow-through. It is important also that the golf swing be symmetrical. The same amount of extension on the back swing and follow-through is important. Lateral bending should be avoided, especially in the follow-through. There is a tendency to bend to the left side and load the spine asymmetrically, producing injury. Golf is usually restricted according to the patient's symptoms.
There is no condition of the lumbar spine for which we specifically restrict golf. Many people with spondylolisthesis, through superb conditioning and care, can play relatively pain free. Premature, symptomatic degenerative disk disease is common among golfers who play a great deal, especially among professionals who not only play, but also practice long hours. People can return to golf after decompressive lumbar surgery or spinal fusion. There are significant questions about the effect of a spinal fusion on an adult professional golfer. The effect on adjacent segments and on overall spinal function may not allow any better function. Under these circumstances, fusion should be a last resort.
Because golf is not an aerobic sport, aerobic conditioning should be included in any effective lower back rehabilitation program. Fairbank et al1 showed that higher aerobic fitness shows a strong negative correlation with the incidence of both lower back pain and disk herniation. Exercise results in increased aerobic metabolism in the outer annulus and the central portion of the nucleus pulposus, bringing about reduction of lactate concentration.26
Also, aerobic conditioning plays a significant role in muscle coordination during periods of fatigue. Fatigue can produce abnormal muscle function and overcompensation and thus resultant injury. Fatigue obviously can affect performance through a lack of proper balance and coordination as a result of selectively weak muscles.
Unfortunately, some patients cannot tolerate certain types of aerobic conditioning that have high levels of loading to the spine, such as jogging. However, several types of aerobic conditioning exercises are highly effective without loading the spine (e.g., water exercises12 and the stair climber).
As structure governs function, similarly, abnormal structure governs dysfunction.26,28 Thus, a thorough evaluation must be undertaken before strengthening and stretching exercises are begun. The examination is completed by use of radiographs, magnetic resonance imaging, computed tomography, muscle testing, range of motion, segmental testing of vertebrae for hypomobility and hypermobility, postural evaluation, palpation, and various other methods and/or tests.
Once the dysfunction is identified, appropriate treatment techniques must be used to correct the structural abnormality. This will allow for enhanced function and therefore improve the rehabilitation process in which trunk strength, muscle coordination, and balance are stressed. Trunk strength involves the muscles of the thighs, hips, and trunk. The trunk muscles include the rectus abdominus, oblique abdominus, paraspinal musculature, latissimus dorsi, and, further up the spine, the scapular stabilizers. The muscles that insert into the lumbodor-sal fascia play a key role in providing adequate balance and strength for the lumbar spine and the trunk during the golf swing. Trunk strength provides a synchrony of motion between the upper and lower extremities in that there is a controlled unwinding of the upper body relative to the trunk. The power of the golf swing is transferred from the strong leg and hip musculature through the trunk and out to the end of the club head.
Trunk fatigue produces a loss of this synchrony between the upper and lower extremities. This reduction in muscle strength prevents a proper transfer of force and leads to compensations by the body. Thus, the improvement of muscle strength, coordination, the firing sequence of muscles, and body balance underlies the entire rehabilitation process and facilitates the golfer's achieving a consistent, reproducible, effective swing.
An injury to the spine can cause pain, which produces weakness and a loss of muscle control. This loss of muscle control, which can lead to further injury because the joint is now unsupported, is similar to quadriceps weakness and its cause-and-effect relationship to a knee injury. As soon as referred pain begins, muscles in the area of referred pain become weak. Any attempt to reproduce a proper golf swing under these circumstances can be difficult and can lead to continued pain, poor swing mechanics, and subsequently poor performance. Obviously, just as in a knee injury, the solution to this problem is to first correct the structural or damaged area and then strengthen that area by use of golf-specific exercises.
Hitters, who make up another interesting group of players, include any athlete who has to swing a bat. Hitters who take a lot of batting practice, swing with great velocity, and swing with a heavy bat are subject to lumbar spine injury. An infrequent hitter, such as a pitcher, who does not have good hitting mechanics, is also vulnerable to injury. Lumbar spine problems in hitters begin with their eyes, that is, the ability to see the ball is a critical factor in swing mechanics. Abnormal swing mechanics involve a loss of control between the hips and shoulders, essentially a loss of body synchrony. Irregular and uncoordinated motion of the upper extremity and upper torso puts undue rotational strain on the lumbar spine. Injury of the lumbar spine in someone engaging in this type of torsional activity further compounds the problem by producing stiffness, weakness, and asymmetry that add to the pain and prevent satisfactory healing. The biomechanics of hitting can be considered an ocular-muscular reflex, a reference to the fact that the triggering of the bat mechanics (the triggering of the muscles) is a split-second response to what the hitter is able to see. A hitter who is not picking up the ball well tends to open the hips too early. With the bat and upper torso lagging behind, there is a sudden tor-sional stress to catch the shoulders and the bat up with the rest of the body. Poor visualization of the ball produces delays in hand and arm responses.
To diagnose and treat lumbar spine problems in the hitter, the physician should understand that hitting mechanics require power in the legs and trunk, a rigid, solid cylinder of torque transfer, and fine muscle control of the arms and wrists.
For a more practical understanding of hitting, we turned to a hitting coach and a skilled batter.16,29 The swing starts with the stance, which relies on balance. Every player will be a little different: open or closed, feet further apart, feet closer together. The ideal is probably placement of the feet at shoulder width, but the key is balance. The batter can fashion a hole for the back foot to use in pushing off, changing the stance slightly from closed to opposite-field open for an inside pitch. Control is based on balance in the stance and proceeds to the forward stride. As a pitcher begins the windup and approach to the plate, the hitter coils up. This coiling maneuver brings the bat to the position necessary to initiate the swing. Again, regardless of the amount of motion activity, most bats come to a relatively standard position in relation to the strike zone just before the forward stride is initiated.
The hitter assumes the correct body position: the coiled hips and head are approximately parallel to the ground and the knees are slightly bent. There is some flexion of the lumbar spine, the shoulders are level, and the head is turned as the hitter looks directly at the pitch, chin against shoulder. Hand position varies slightly according to each player. A reasonable position is 4 to 8 inches from the body, letters high to shoulder high. In the coiled position, the hitter holds the bat at approximately 45 degrees, with the elbow parallel to the ground and out from the body. Hands held too far from the body may reduce power, whereas if they are too close to the body or too low, the bat speed will be reduced. In most missed pitches, especially the fast ball, the hitter swings below the ball. Holding the hands too low reduces the bat speed and, except in exceptional cases, may reduce the contact zone. In the coiled position, the hitter begins moving with the forward arm motion of the pitcher, picking up the ball from the pitcher's hand and beginning to time his stride forward and swing.
The number one key to hitting, obviously, is vision. The hitter who does not see the ball can only guess and will not be able to make contact. Not only is visual acuity a critical factor, but eye control and eye functions are of equal importance. The hitter must have clear binocular focus to be able to visualize the ball and to predict its location. The speed of the ball makes it virtually impossible to completely follow the ball to the bat. The ideal is to follow the ball as far as possible and then make a prediction as to its line of projection. Without visualization, concentration, and focus, the hitter will fail to project the arrival point of the ball, and inadequate ball contact is the consequence. In addition, balance and control are determined by eye focus, as in any coordinated muscle activity. If the eyes and head are locked and focused on a point, the body has a much greater chance of reproducing a coordinated, balanced motion than if the eyes are closed or poorly focused.
Thus, the key in the stance and coil position is balance, eye focus, and body readiness to start the stride. What happens before this coiling mechanism is not of great importance, but body and head position in the coiled portion of the swing should at least place the bat in a position that will facilitate the stride.
Batting coaches indicate that there are five basic aspects of the swing starting with the stride, as follows:
1. Back foot rotation, in which the heel is rotated out and the body pivots on the ball of the back foot.
2. Forward stride with the left foot.
3. Rapid hip and trunk rotation that takes the navel from a position parallel with the pitch to being perpendicular to the pitch.
4. Triangulation of the arms and extension of the arms.
5. Lateral flexion of the wrist.
Efficiency of motion is essential to the hitter.29 The hitter must avoid needless motion. Motion must be balanced and coordinated in the forward stride. The backward motion in the coiling position precedes the forward motion. The front leg internally rotates, and the coil position will externally rotate in the stride. The stride should be directly toward the pitcher. The weight shift in a hitter is very important. With the forward stride, the weight stays back on the back foot as the forward foot strides forward lightly on the ball of the foot. The front leg now rotates externally, and the knee goes into extension. The ability to lock the knee of the front leg, providing firm rigid resistance to body motion, is important in keeping the axis of rotation of the body centered. If the knee flexes, the body weight shifts forward, and the proper axis of rotation is lost. As the foot lands evenly, it may be slightly open. The knee, of course, is initially slightly flexed as the foot lands and then locks in extension as the hips come through. This rotation around a center axis is important.
The midsection is the core of the swing action from which the hitter generates power.29 Maintaining a center axis of motion and balance plays a critical role in maintaining head position. Too much head motion equals loss of both coordination and visualization of the ball. Locking the head to the center of axis of rotation is a key to the stride and swing positions. The bat in the coiled position is approximately at a 45-degree angle. As it comes through, there is a relative leveling of the bat, usually with less than 10 degrees of angulation. The pitch starts high because the pitcher is on the mound and throwing downward, whereas the bat comes through level. There will be a difference of a certain number of degrees of angulation between the ball and the bat. The bat comes down as the ball comes down.
The forward stride of the legs and the rotation of the hips are reasonably standard in speed and approach. Large muscles of this type cannot be controlled quickly enough to allow the hitter to adjust to the speed at which a pitch is thrown. Therefore, the stride, at a fairly standard distance, with standard open or closed length, allows compensation. One of the important parts of batting-training technique is a rapid, sudden hip twist in which the navel goes from 90 degrees to the pitch to directly parallel to the pitch. A rapid, swift twist of the hips is what, in many ways, determines the bat speed and allows the hitter to be in a prime position to adjust to the speed and type of pitch. Therefore, stride length and hip rotation, with the navel toward the pitcher, is the same in virtually every pitch and must be a standardized, balanced, well-coordinated motion.
After this sudden hip rotation occurs, adjustments to pitches of various speed and pitch locations become crucial. As in golf, there is a ratio of derotation of the body as it leaves the coil position to the point of contact. In hitting, there is an adjustable ratio of derotation. With the power generated through hip and belly rotation, the fine control comes with the speed of (1) the upper body uncoiling, (2) elbow extension, and (3) wrist lateral flexion. Location of the pitch, of course, will vary tremendously, and the fine adjustment takes place in these latter three aspects. Therefore, the upper body trails behind the derotation of the hips. Trailing behind does not imply a helter-skelter, uncoordinated motion. Because the ratio of derotation of upper body to lower body must vary with the pitch, it requires even more muscular trunk control to allow the proper rotation to take place, depending on the pitch. Therefore, the hitter must visualize the ball and, in less than a second, determine the ratio of derotation of the upper body, as well as the position of the head, elbows, and hands for the point of contact with the ball. This requires excellent muscle control, balance, and coordination. Proper hitting depends on retraining muscles to fire and respond to changes in balance and coordination and retraining trunk muscles to maintain a tight, rigid, but mobile control between the upper and lower body. Lumbar pain that prevents proper rotation or that causes muscles to stop, to work improperly, or to work in an uncoordinated fashion can have a devastating effect on the player's ability to deliver the bat to the ball.
After hip rotation, with the upper body trailing behind slightly under maximum muscle control at a specific ratio of derotation determined by the pitch, the upper body rotates through to the point of ball contact. The head is level, going down with the pitch while the eyes focus on the ball. The chin of the right-handed batter, which is against the left shoulder in the coiling position, will end up against the right shoulder after ball contact. (The opposite, of course, is true for the left-handed hitter.) Again, head motion equals poor efficiency. At this point, with the bat coming through the strike zone, the shift is to the shoulder and upper arms, with triangulation of the arms: the chest as the base and the two arms parallel as they extend out. Locking the lead shoulder is of critical importance. Stabilization of the lead shoulder allows extension of the lead elbow and proper generation of bat speed. The bottom hand pulls and anchors the bat: the top hand pushes and guides the bat. As the arms and elbows extend, the bat is still trailing behind, with the wrists still in the cocked position.
Obviously, proper technique, including the weight shift from the back foot to the forward foot and the position of the elbows, hands, wrists, and bat, allows the hitter to delay the final commitment of bat position as long as possible. It provides longer visualization of the ball and a better prediction of the point of contact, all taking place at the same time that the body is generating tremendous torsional force. Therefore, the reproducible bat swing must generate the power and force necessary for the swing while delaying final commitment of bat position, allowing the wrists and hands to provide fine bat control and bat position at the point of contact. It is certainly possible to make contact with the ball with neither trunk rotation nor power but without sufficient results on the field. The follow-through after ball contact is not of major consequence. Weight will be shifted to the front foot, and the left knee will be locked. Adequate control of quadriceps function of the front leg is imperative. The arms will be extended; the top hand will roll over at an appropriate time and should not be rushed.
In summary, stance, balance, control, head in proper position, stride, standardized lower body stride and position, and uncoiling of the upper body require maximum trunk control and balance to produce the correct ratio of derotation that will allow the bat to arrive at the appropriate place. The locked lead shoulder provides a rigid upper arm for proper elbow extension. Tight wrist control is obtained with proper lateral flexion of the wrist. The head rotates from the lead shoulder in the coiled position to the trailing shoulder in the follow-through.
Some of the most difficult cases of lumbar spine problems are seen in baseball pitchers. It is extremely common in spring training to see throwers, especially baseball pitchers, having pain in the opposite side SI joint. This is due to unaccustomed torsional strain, probably in the lower facet joints, after the winter break. There is a high incidence of back stiffness in throwers as they start to regain peak mechanical functioning and begin throwing again. A common occurrence is referred diskogenic or facet joint pain in the typical pattern (through the facet joint, across the posterior superior iliac spine, SI joint, posterior ilium, and into the area of the greater trochanter). A concomitant problem is the development of secondary contractures, weakness, bursitis, tendonitis, and inflammations in the referred pain area. Often a pitcher will have greater trochanteric bursitis or SI joint pain that produces its own secondary effects.
A key aspect of a pitcher's rehabilitation is not only the resolution of the back problem; the secondary inflammatory effects of referred pain can produce the same biomechanical abnormalities in the pitching motion, thus leading to further injury. Indeed, the pain itself may prevent proper pitching and performance and thus cause additional injury. True sciatica and muscle weakness in a leg result in a critically important dysfunction in a pitcher: severe abnormalities of pitching motion that place the arm, shoulder, and elbow in jeopardy. Sciatica, especially with associated pain of increasing intradiskal and intra-abdominal pressure, can result in severe dysfunction during the throwing motion. Trunk stability is critical to a pitcher's throw, and any pain that produces weakness and stiffness can lead to a potentially catastrophic injury.
Chard and Lachmann,30 reporting on racquet sport injuries, separated the incidence into squash (59%), tennis (21%), and badminton (20%). Thirty-eight percent of professional tennis players have missed tournaments due to back pain. Trunk strengthening should be a major part of the tennis player's
Tennis as a sport involves speed, rotation, and extremes of flexion, lateral bending, and extension. It involves the power aspects of the overhead serve, the effect of trunk strength on shoulder function, and many of the aspects brought out in the other sports. The one most consistent, important factor in protecting the spine in tennis is to bend the knees. Leg strength, quadriceps strength, the ability to play with a bent knee, and hips in a flexed positioned while protecting the back are the keys to prevention of back pain. In the serve, trunk strength in pro ceeding from the back extended to the follow-through position requires strong abdominal control. Gluteal, latissimus dorsi, abdominal obliques, and rectus abdominus strength controls the lumbodorsal fascia and delivers the power necessary through the legs up into the arm.
In summary, the keys to proper management of lumbar spine problems in athletes include comprehensive diagnosis, aggressive and effective nonoperative care, and pinpoint operations that do as little damage as possible to normal tissue but correct the pathologic lesion.
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