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SportsMedicineSecrets:AberrantSpinalMovementsintheRotationalAthlete
• AndrewMorcos PT,DPT,SCS,OCS,DNSP,ATC,CSCS,FAAOMPT
• MarshallLeMoine,PT,DPT,OCS,SCS,CSCS,FAAOMPT
• MichaelWong,PT,DPT,OCS,FAAOMPT
• Stephania Bell,PT,OCS,CSCS
DISCLOSURE
MichaelWong,PT,DPT,OCS,FAAOMPT
MarshallLeMoine,PT,DPT,OCS,SCS,CSCS,FAAOMPT
MedicalAppDeveloperforiPads/iPhones
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CourseObjectives
• Evidencereviewofaberrantmovementsandspinalpathology
• Evidenceforbackpainintennis• Movementanalysisintennis• Evidenceforbackpainingolf• Movementanalysisingolf• Keyimpairmentscontributingtolowbackpain• Managementstrategiesforkeyimpairments
Roleofaberrantmovementsinspinalpain…
Whathappensduringspinalrotation?
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Marras 1995
Muscleactivation!
Highlevelsofmuscleco-activation
Significantlygreaterthan
lifting!
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Velocitydependentincreasesinforce
• Increasedtwistvelocitysignificantlyincreasedspinalforcesin3planes
• Spinalcompressiondoubledthemomenttwistingvelocityoccurredinthetrunk– Freivalds 1984– Goel 1991– Granata 1993– McGill1985
Musclesprains
• Damageisassociatedwitheccentricmusclecontractions
• Varieswithdurationandintensity
• Conditioningreducestheamountofinjury
Armstrong1991
Marshall2010
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Porcinecervicalspines- mimicfailuremechanismofhumanlumbarspine
1hz
1500N
1hz
Flexionalone- posterior/lateralherniation
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Rotationandflexion- radialdelamination
• Regardlessoforderofwhenrotationoccurred
• 114Lumbarmotionsegmentsfrom47freshcadaverspines
• SeverityofdegenerationdeterminedviaMRimagingandcryomicrotome sections
• Pureunconstrainedmotionsappliedinsixloadsteps
• Flexion,extension,rightandleftaxialrotation,rightandleftlateralbending
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• Greatermotiongenerallyfoundwithdiscdegeneration,especiallyingradesIIIandIV
• GradeVdegeneration- discspacecollapseandosteophyteformationresultedinstabilization
UpperlumbarT12-L1toL3-4• Axialrotation
andflexionincreasedinGradeIVdiscdegeneration
• DecreasedwithgradeV
• LateralbendingwasincreasedingradeIII
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Lowerlumbar(L4-5andL5-S1)• AxialrotationandlateralbendingincreasedingradeIII
• Normalrotationoflumbarspine1-2degrees
• Degenerateddisksrotate2degreesormore
• Discographyissometimesusedtohelpsurgeonsselectsegmentsforfusion
• Patientisaskedifinjectionproducesconcordantornon-concordantpain
• Concordantpainseemstopredictsuccesswithfusion
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L3-4levelconcordantpainsignificantlymorerotationthannormal
Noticethatconcordantandnon-concordantpainatL5-s1hadmorethandoubletherotationthan
normal
ClinicalPearl:
• Rotationalmovementscanleadtospinalpathology
• Paininthespine,isnotalwaysbecauseitis“stiff”
• Excessiverotationofthespineassociatedwithconcordantpain
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Tennisinjury
• 2to20injuriesper1000hoursoftennisplayed(Highlevelplayers<18yearsofage)
• Acuteinjuries- lowerextremitymostcommon
• Chronicinjuries- Upperextremityandtrunk…
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Backinjury
• Lowbackinjuriesarecommonamongcompetitivetennisplayers
• 38%of143playersmissedatleast1tournamentduetobackpain(Marks1988)
• 29%sufferedfromchronicbackpain(Marks1988)
• 50%ofeliteplayerssufferedfromatleast1weekofbackpain
• 20%characterizedpainas“Severe”
• 98asymptomaticjuniortennisplayers• Meanage18years• Facetjointarthropathy 89.7%(85.4%mild)• 41synovialcyst(22.4%)
Rajeswaran, G., Turner, M., Gissane, C. et al. Skeletal Radiol (2014) 43: 925.
• Discdegeneration62.2%(76.2%mild)• Discherniation30.6%(86.1%broadbased,13.9%focal)
• Nerverootcompression2%• 41parsinterarticularis abnormalities(29.6%)• Grade1spondylolisthesisin5.1%
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L5stressreactionsanddisc/facetdegenerationatL4/5mostcommonradiologicalabnormalityinlumbarspineofadolescenttennisplayers(Aylas 2007)
Isthmiclesionsandmovements?
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Tennisserve
• Duringaplayer’sservicegame….Serveisthemostcommonlyperformedstroke
• Highforcesinthebackduringthekickserve
Phasesofserve
Ascendingwindup
Descendingwindup
AccelerationDeceleration
Loadingofspineduringserve
• Racquetbehindbody• Spinelaterallyflexedandhyperextended
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Acceleration
• Rapidreversalofextensiontoflexion• Righttwisttolefttwist
Elliott BC: Biomechanics of the serve in tennis. A biomedical perspective. Sports Med. 1988, 6: 285-294. 10.2165/00007256-198806050-00004.
Highestactivity- Descendingwinduporaccelerationphase
Ascendingwindup
Descendingwindup
AccelerationDeceleration
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Campbell2013
During”Drive”phase:
• Lumbarspinewas:
• Extended• Rotatedtowards
• Laterallyflexedtowardsracquetarm
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LBPgroup
• Increasedpeaklateralflexionforce• 4timesbodyweight• 50%greaterthannopaingroup• Peakverticalforcesoccurringatthesametime(10xBW)
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Highestactivity- Descendingwinduporaccelerationphase
AdvancedplayersincreasedROMexceptextension
HighRAactivity+Lumbarhyperextension=Highloading
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Highco-contractionofA/Pmusclesduringfollowthrough=Highcompression
Spinserve- Largestmedialdistancefromracquettoshoulder
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Maximumbackextensionanglesignificantlyhigherforkickservevs.slice(40.5vs37.3;p=0.01)Totalbackforcewasgreater(2974N- kickvs.2138N- flatvs.2568- slice)
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Serviceforces>GroundstrokesGround strokes Service
Compression 6.8N-Kg-1 9.6N-Kg-1
Extensionmoments 2.0N-Kg-1 6.3N-Kg-1
Leftlateralflexionmoments
3.6N-Kg-1 7.6N-Kg-1
Forehands- Rangeofmotion
• Forehands:Lowerlumbarrightrotationbeyondendrangeofmotion
• Backhands:Upperlumbarleftrotationbeyondendrangeofmotion
• “Rehabilitationstrategiesthatmaximizespinemobilitywhileenhancingoptimalloadandmovementdistributionthroughtheentirekineticchain(ie,hips,thoraxandshouldergirdle)tominimizeendrangestrain(especiallywhencombiningmovements)ofthelumbarspinemayprovebeneficial.“
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Whatdoyousee?
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Singlevs.Double:Differences
• Singlehandedbackhandhadmuchsmallerextensionmomentsthandoublehanded
• Leftaxialrotationmomentsandfinalshoulderandpelvisrotationanglessmallerinsinglehandbackhand
• Peakoflateralbendingmomentsignificantlysmallerinsinglehandbackhand
Nowwhatdoyousee?
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• Releasingthehandfromtheracket,allowsshoulderandelbowtosharenecessarymotion
• Thisreducesmaximalmomentsimposedonspinaljoints
Muscularimbalances
• Leftsidebending force>Right(Sward1990)• Flexionforce>Extensionforce(Roetert 1996)
• LBP: Reducederectorspinaeactivation(Correia 2016)
• Asymptomaticplayers:hadgreaterrightsidebridgeendurancetime(Correia 2016)
• Greaterflexorendurancetime(Correia 2016)
• Multipletrunkmuscleactivation(Correia 2016)– Improvingspinalstability
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LBPpatientshadLtoRerectorspinaeimbalance>30%asymmetry(L2andL4)
Thatcanbeimprovedaftertraining!
EMGimbalancelinkedtohandedness
Lefthandedplayer,Decreasedrighterectorspinae
activity
Righthandedplayer,
Decreasedlefterectorspinae
activity
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7weekexerciseprogram:
Mobilitydeficitsinassociatedregions…• SignificantcorrelationbetweenleadhipinternalrotationdeficitsandLBP
• DecreasedlumbarextensioninLBPgroupduetoincreasedloadonspineandprotectivemechanisms
WhydecreasedhipIR?
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Clinicalpearl:
• Avoidingexcessivelumbarextension• Avoidingkickservesintheyoungerspines• Muscleasymmetry– Lowbackpainmoreasymmetries– Trainingcanreducethepainandasymmetries– Flexors>Extensors
Clinicalpearl:
• Singlebackhand- limitsexcessivetrunkrotation
• Decreasedhipinternalrotationofleadlegcorrelateswithbackpain
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GOLF
GolfMechanics
• 55milliongolfersin2020– 33%over50y/o– LBP(26-52%)
GolfSwing• Compressionloads8xbodywt(6100to7500N)– Discprolapse:5,448N
• Facetsshearload596N– Parsfracture:570N– only2-3degreesofintersegmentalrotationarerequiredtoproducemicrotrauma inlumbarfacetjoints
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• 4phases:– Backswingortakeaway– Forward/downswing– Accelerationwithballstrike– Follow- through
• ModernSwing– Xfactor:Maxhip-shoulderseparationangle• Storespotentialenergy• Exceededactivetrunkrotation
XFactor
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• ModernSwing– CrunchFactor:increasedlateralbendingtowardtrailsideduringdown/forwardswing• Increasedforceatimpact• SignificantfacetOAontrailside
CrunchFactor
• ModernSwing– ReverseC:hyperextensiononfollow-through• Increasedpower• Increasedcompressiveforcesonspine
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ReverseC
• ClassicSwing– Frontheelliftsduringbackswing
• allowsincreasedhipswingandshortensbackswing• LessXfactor
– Uprighttrunkduringacceleration• LessCrunchfactor
– Erect“I”finishwithbalancedshouldersatfollowthrough• LessReverseC
• Moreuprightstance,closertoball• reducedlumbarstress,– decreasedAPshear,decreaseddiscpressure
ClassicSwing
• https://youtu.be/XyBnIfVNRG0
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Techniquevs Overuse• Amateurs:moreinconsistencies– 80%greaterpeakshear– 50%greaterswingtorque
• Pros:overuse– Upto600rangeballand18holes5daysaweek
• Rx:coachingmore‘‘classic’’swing– Specifycomponentbasedonexam(rotation,sidebend,orextension)
– Trunkmuscleconditioning– Trunkandhipflexibility
• 6xcompressionondownswing
• 1.6xmedialantshearonfollow-through
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EMGhighestwithaccelerationandfollowthrough
MostLBPoccursduringacceleration/impactandfollow-
throughphases• Muscleactivation– Leftduringtakeawayfromaddress,– Rightattheverytopofbackswingintoacceleration
• Facetirritation– Sidebend(Crunch)atimpact– Extension(ReverseC)curveatfollowthrough
Commonmovementfaults/impairmentsforrotational
sports1. Limitedhipmobility2. Impairedlumbopelvic control3. Hipmuscleweakness4. Trunk/Coremuscleweakness
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1.Limitedhipmobility
Hipmobilitydeficitsinfluenceduringgolfswing
• Asymptomaticgolfers:2matchedgroups– LimitedhipIRmobility(<20deg)– NormalhipIRmobility(>30deg)
LimitedHipIRgroup
• SignificantlyhigherLumbaraxialrotationinthetopofthebackswingandfollow-throughphase
Xfactor
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LimitedHipIRgroup
• SignificantlyhigherLumbarrightsidebend intheimpactphaseandfinishphase
Crunchfactor
LimitedHipIRgroup
• SignificantlyhigherLumbarflexionanglesintheaddress,topofthebackswing,acceleration,andimpactphases
Hipmobilityinrotationsports
• CLBPathletes- lesspassivehiprotation
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• BiggestdifferencecamefromLefthip(righthandedathletes)
LeadhipIR
Leadhipmobility• historyofLBP=decreaseleadhipIRmobility– Aswellasdecreasedlumbarextension
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Samefortennisplayers
• SignificantcorrelationbetweenleadhipIRdeficitsandlumbarextensiondeficitswithLBPathletes
SameforJudo• HipmobilityinjudoathleteswithandwithoutLBP• Decreased– ActiveIR(27vs 38)– Passiverot(96to105)ofnondom limb
LimitedHipIR,Stanceleg
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- Manualtherapytoincreasehipmobility- Lumbarstabilizationexercises• Outcome:– Improvedhiprange– ImprovedOswestry outcomescore– Improvehandicapby3strokes
HipRotationMobilizations
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HipRotationMobilizations
HipRotationMobilizations
HipRotationExercises
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HipRotationExercises
HipRotationExercises
Commonmovementfaults/impairmentsforrotational
sports1. Limitedhipmobility2. Impairedlumbopelvic control3. Hipmuscleweakness4. Trunk/Coremuscleweakness
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2.ImpairedLumbopelvic Control
• Measuredlumbopelvicmotionactive:– Pronekneeflexion– Pronehiprotation
• CLBP– Greatermaximallumbopelvic rotation– KneeFlexion:kneeflexionangle, lumbarrotationangleandearlier
– HipLateralRotation:lumbopelvic rotationangleandearlier
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LBPwithrotationsports• 3groups:– LBPgroup– Controlswhoplayarotation-relatedsport– Controlswhodonotplayarotation-relatedsport
• SignificantmorerotationimpairmentswithextremitymovementinLBPgroup
– kneeextensioninsitting(32%difference)
– hiplateralrotationinprone(33%difference)
– singlearmliftinquadruped(41%difference)
• LBPintensityrelatedtolumbarmovementcontroltests–ThevariabilityoflumbarmovementpatternsincreasedwithgreaterLBPintensity
– repetitivePickuptheboxtest– Seatedkneeextension–Waitersbow
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Lumbopelvic rotationduringpronehiprotation
• Specificvs nonspecifictreatmentforCLBPpatients
lumbopelvicrotation
hiplateralrotationpriortolumbarmotion
Specificvs nonspecifictreatment
Reliabilityofmotorcontroltestsmovementtests
• Systematicreview– 8studies,19testsused
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Goodreliabilitywithlowriskofbias
- Singlelimbstance- Pronekneebend
• SignificantlydecreasedkineticstabilityduringSLSeyesclosed
MotorControlTesting
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MotorControlTesting
MotorControlTesting
MotorControlTesting
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MotorControlTesting
Commonmovementfaults/impairmentsforrotational
sports1. Limitedhipmobility2. Impairedlumbopelvic control3. Hipmuscleweakness4. Trunk/Coremuscleweakness
3.Hipmuscleweakness
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Glutealstrengthandactivation
• GlutmedonsetandactivationSLS
• CLBPgroup- significantweaknessglutbilateral
Weakertheglutmed,greaterthe
painanddisability
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Hipweaknessaspredictorofinjury
• WeakerlefthipabductorshadasignificantprobabilityofrequiringtreatmentforLBP
• Significantdifferenceinside-to-sidesymmetryofmaximumhipextensionstrengthwasobservedinfemalesubjectswhoreportedLEinjuryorLBP
Nadleretal.
HipMMT
Commonmovementfaults/impairmentsforrotational
sports1. Limitedhipmobility2. Impairedlumbopelvic control3. Hipmuscleweakness4. Trunk/Coremuscleweakness
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4.Trunk/coremuscleweakness
• Performed13measurements– Trunkflexorandextensorendurancetests,sidebridgeendurancetest
–Maxhipextensorandtrunkextensorstrengthtests– hamstringflexibility,hipflexorsflexibilityandtrunkAROM
• PredictorsforLBPandperformance:– rightsidebridgedeficitof>12.5s Right– hipflexortightnessof>5deg– BMIof<25.7kg/m2
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ErectorSpinae andExternalObliqueMuscletiming
• LBPgolfersswitchedontheirerectorspinaemusclesignificantlypriorofstartofbackswing
BiomechanicalSwingAnalysis• Measuredbiomechanicalswinganalysis,trunkandhipstrengthandflexibility,spinalproprioception,andpostural
• GolferswithLBPmatchedtocontrols
• HistoryLBP– LessstandingneutralAROMtrunkrotationtowardnon-leadside• Butnodifferenceinrotationalangleduringswing(Xfactor)
– Decreasedtrunkextensionstrengthat60°/s
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Intra-abdominalpressure(IAP)andStability
• Spinalstabilityincreased1.8xwithdoublingofintra- abdominalpressure(5to10kPa)at60NM– Slightincreaseinstabilitywith10%maxactivationofobliques ortransversesslightly
– Nofurtherincreaseinstabilitywith20%force– Forcedactivationofrectusabdominis didnotincreasestability
• IAPbiggestfactor
IAP90/90
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Bestpracticeforrehabilitationandpreventionoflowbackinjuryingolf
TrunkTherapeuticExercise
• CoreActivation– Intraabdominalpressure• Diaphragm,pelvicfloor,andabdominals• Properbreathingandposturalcontrolneededfortrunkcontrolduringathleticactivities
– Supinequadruped standingNeurodevelopmentalrollingtechniques
• CoreStrengthening– UnstableSurfaces(bosu,dyno,swiss ball)
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Developingcorestiffness
Lee2015
Passivetrunkstiffness- measured
“Naïve” “Savvy”
“Feelcompletelyrelaxed,likeyouaregoingtosleep”
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Isometricexercises
Quadrupedarmandleglift
Forwardplank
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Sideplank
Singlelimbbridge
Dynamicexercises
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Stiffness- isometricsSignificantincreasein
stiffnessinbothnaïveandsavvygroups
Majorityoftrialsshowedstiffnessincreaseatend
ranges
Stiffness- dynamicexercisesFarfewerstiffnesschangesinbothsubjectgroups
Whyisometrics?
• Timeundertension• 10secondplankvs.10repsofcurlups• And/or• Neuralchangesandresidualstiffness
“Naïve” “Savvy”
BothSavvyandNaïvegainsignificantbenefit!
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Keythought
“Athletesmaydevelopcorestiffnessattributeswhileminimizingimposedloadstothespine.”
Aberrantmovementsreview
• Aberrantspinalmovementscanhavesignificanttissueconsequences– Rotationalmovementsgeneratehighlevelsofmuscleactivityandcompression
– Rotationalathletesoftenhavesignificantmuscleimbalances
Impairmenttestingreview• HipMobility
– IR– Hipflexorlength
• ThoracicMobility– Rotation
• TrunkMotorControl– Pronehiprotations– Pronekneeflexion– Seatedkneeextension– Quadrupedarmlift– SLSeyesclosed
• MuscleStrength– Hipabductors– HipExtensors– Assymtreric abdominals– Assymetric paraspinals– Intra-abdominalpressure
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Interventionsreview
• Mobilizeandstretchhip• Improvetrunkcontrol- failedtests• Improvehipstrenght• Improvetrunkstrengthandstability– Forwardandsideplanks– SingleLimbbridgeholds– 90/90turning
EquipmentConsiderations
• Properclubfittobodyspecifications• Pushingacartinsteadofpulling• Utilizingalongputter• Thedual“backpackstrap”distributestheclubsmoreevenlyacrossbothshoulders
Videosavailable@
• https://www.youtube.com/playlist?list=PLRwUa2CZ-5fUY5l6hbn5s_pA54mnqK-O0
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