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SPORTS MEDICINE DISABILITY SPORT
TABLE 5: GUIDE TO MOTOR AND SENSORY LOSS AT EACH SPINAL LEVEL (5)
Simplified myotomal distribution C5: elbow flexors (biceps, brachialis)
C6: wrist extensors (extensor carpi radialis longus and brevis) C7: elbow extensors (triceps)
C8: finger flexors (flexor digitorum profundus) to the middle finger
Illness or managing the
consequence of disability may inevitably result in some requirement to understand specific problems in relation to disability, which we discuss in greater depth in this article.
DIFFICULTIES WITH SPINAL INJURIES
Athletes with spinal injury have had an insult that affects the functioning of the nerves of the spinal column, either through congenital problems, such as spina bifida, or through an acquired injury, such as spinal injury (fracture/ dislocation), transverse myelitis, tumour, infection or polio. These conditions can give a myriad of symptoms and signs, depending on the area affected and the degree of damage, eg. complete or incomplete cord transaction. In spinal injuries, athletes are
classified by the limbs affected and how completely the effects are seen: n 25% complete tetraplegia n 28% incomplete tetraplegia n 28% complete paraplegia n 19% incomplete paraplegia
When considering this diagnosis, it does not mean that a completely tetraplegic person cannot move any limb but that the effect of the spinal lesion at the spinal level quoted is complete rather than partial. A T1 complete lesion affects the upper
and lower limbs; however, only those muscles supplied by T1 are affected. Most athletes come with a very clear story of their level of spinal injury and whether they are complete or incomplete. Table 5 indicates the likely outcome of a spinal injury.
Effect on autonomic nervous system Autonomic function can be severely affected, with considerable implications. A spinal lesion around T1–4 will sympathectomise the heart, limiting the maximal heart rate to 110–130 beats per minute. A spinal lesion at T6 or above is likely to result in the risk of autonomic dysreflexia (see figs. 1 & 2). There will generally be ineffective sweating below the spinal lesion and hence difficulty with thermoregulation (lack of shivering will also impair the ability to raise body temperature when cold). Impairment of bladder and bowel sensation and control will inevitably lead to dysfunction in this area. Apart from the obvious locomotor issues, other difficulties arising from lack of muscle control may include the following: n Pooling of blood in lower legs and hypotension n Increased risk of deep vein thrombosis (DVT) n Inability to move off pressure areas (which are, in any case, insensitive)
T1: small finger abductors (abductor digiti minimi) L2: hip flexors (iliopsoas) L3: knee extensors (quadriceps) L4: ankle dorsiflexors (tibialis anterior) L5: long toe extensors (extensors hallucis longus) S1: ankle plantar flexors (gastrocnemius, soleus) Dermatomes by spinal level C2: occipital protuberance C3: supraclavicular fossa C4: top of the acromioclavicular joint C5: lateral side of antecubital fossa C6: thumb C7: middle finger C8: little finger
T1: medial side of antecubital fossa T2: apex of axilla
T3: third intercostal space (IS) T4: fourth IS at nipple line T5: fifth IS (midway between T4 and T6) T6: sixth IS at the level of the xiphisternum T7: seventh IS (midway between T6 and T8) T8: eighth IS (midway between T6 and T10) T9: ninth IS (midway between T8 and T10) T10: tenth IS umbilicus T11: eleventh IS (midway between T10 and T12) T12: midpoint of inguinal ligament L1: half the distance between T12 and L2 L2: mid-anterior thigh L3: medial femoral condyle L4: medial malleolus L5: Dorsum of the foot at third metatarsophalangeal joint S1: lateral heel
S2: popliteal fossa in the midline S3: ischial tuberosity S4–5: perianal area (taken as 1 level)
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