REHABILITATION FOCUS

REHABILITATION OF THE SPORTING BACK - THE ‘MULTI-MODAL’ APPROACH

By Dr Simon Petrides MB BS, DO, Dip.Sp.Med

Low back pain affects the elite athlete as much as the inac- tive slouch potato, but there are differences in the nature of the pain, the diagnosis and expectations regarding rate of recovery. The recovery is often faster when dealing with ath- letes due to the underlying level of fitness.

Treatment is more effective when using a multi-modal approach aimed at: 1. Reduction of inflammation 2. Mobilisation 3. Stabilisation 4. Sport specific functional restoration 5. Correction of biomechanical abnormality eg. muscle imbalance, overpronated feet

6. Correction of sports technique eg. fast bowling, tennis serve 7. Correction of training errors.

Lower back pain in sport can come from a number of sources and could be either acute or chronic in nature.

Acute low back pain Sources of low back pain include: 1. Annular disc tear 2. Nuclear disc-herniation 3. Facet joint strain/dysfunction 4. Pars interarticularis stress reaction/fracture 5. Spondylolysis/listhesis 6. Sacroiliac joint strain/dysfunction.

The slump test is invaluable in differentiating between discogenic and non-discogenic pain (although not always!)

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Contrary to popular belief among the sporting population, muscle strains are rare in the lumbar spine unless partaking in extreme torsional events such as javelin, shotput or hammer when the quadratus lumborum can be at risk.

Chronic low back pain Recurrent low back pain frequently arises from instability due to a combination of disc degeneration (and loss of disc height), off- set articular processes and subsequent inflammation of the apophyseal joints resulting in inadequate capsulo-ligamentous support (1). Instability of the lumbar spine can be more signifi- cant if there is underlying ‘hypermobility’ as is the case in Ehlers Danlos Syndrome.

‘Lumbar instability’ can be a clinical diagnosis inferred from the history and/or clinical findings alone

Recent research has concluded that an associated finding in chronic low back pain is an imbalance of tonic/postural muscle groups namely transversus abdominis and multifidus (2). Co-acti- vation of these muscles and others is inadequate and consequent instability results in greater strain on inert structures (ligaments and discs) producing further ligamentous insufficiency (3). Poor posture and postural control is either a result of, or a predispos- ing factor in, muscle imbalance.

Arthrosis of the facet joints can also be a consequence and this can give rise to further pain and discomfort. It is also possible that a sacroiliac pain may be due to one of the sero-negative spondylitides and this may present as a sports injury.

It is prudent to remember the more sinister causes of low back pain such as malignancy or chronic infection which may present as persistent pain unrelated to exercise but are deemed to be a result of a sporting activity.

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