Tennis Players and Low Back Pain: How to deal with musculature imbalance.

Jaqueline Barreto Lenhard

December 4th, 2014

CTTC March-June 2014

Costa Mesa, CA

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Abstract:

The research to follow examines in depth the major causes of low-back pain. The subject

is approached taking in consideration the lifestyle of a teenage tennis player, and the specific

conditions and demands this particular sport requires. While breaking down each aggravating

source of low-back pain, I have also connected it to the case study’s specific conditions, and

approached it on how the player can benefit from Pilates. The area of the body addressed in this

research is the trunk area, with specific muscles addressed such as internal and external obliques,

quadratus lumborum, erector spinae, and rectus abdominals. By creating a program that aids in

balancing one side of the body and the other, the player is able to develop equal strength on both

sides of the body, while striving for the ability to relax the muscles that are constantly being

used. Ultimately, the goal is to develop equal range of motion on the right side and the left side

of the body, while expanding flexibility and stability.

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Table Of Contents:

Abstract……………………………………………………….Page 2

Table of Contents……………………………………………..Page 3

Back Muscles Anatomy………………………………………Page 4

Abdominal Muscles Anatomy………………………………..Page 5

Case Study: Rafael Lenhard………………………………….Page 6-9

BASI Block System Program………………………………...Page 10

Conclusion……………………………………………………Page 11

Bibliography………………………………………………….Page 12-13

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The following images depict the muscles of the body targeted in this research.

Image A: Posterior View of QL and Erector Spinae (group of muscles – spinalis, longissimus,

iliocostalis)

Images B and C: Posterior view of Erector Spinae (B), and QL (C)

(B) (C)

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Image D: Lateral view of Oblique muscles and Transverse abdominals

Image E: Frontal view of Rectus Abdominals (with segments showing muscles previously

depicted in Image D)

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Tennis players are part of the group of athletes that develop a stronger or dominant side,

therefore increasing the possibilities of pain and injuries caused by muscle imbalances. The

human body is naturally prone to muscle imbalances and tightness due to daily-life activities,

and when factoring in excessive movement patterns that are most often repeated unilaterally, one

is destined to escalate the development of muscle imbalances and tightness-associated

restrictions, feasibly leading the body to an injury or impingement. One of the most common

problems athletes and non-athletes experience is low back pain, and a Tennis player who is

constantly using the same group of muscles favoring only one side of the body, is very prone to

experience low back pain. According to the International Tennis Federation website, low back

pain can be a result of multiple factors such as postural deviations like scoliosis, hyperlordosis,

kyphosis, and also fatigue posture; muscle dysfunctions that are often caused by imbalances,

shortening or weakening of a muscle or a side of the body; excessive use of a particular muscle

or group of muscles in determined area of the body; instable movement patterns; and articular

dysfunction in the lower spine that could be addressed as joints that aren’t properly working.

The athlete studied in this research is an 18 year-old male named Rafael Lenhard, who

has been playing tennis since he was a 7 year-old boy. During his sophomore year of high school

he joined a pre-professional tennis academy in Irvine-CA with a very demanding training

schedule, as the academy prepares them into the best players they can be prior to their college

education. When interviewing Rafael, he mentioned he would often times have low back pain at

the end of long training days and championships. He has also suffered from growing pains

during the first semester of 2013, which put him out of practice for about 4 months. When

analyzing Rafael’s lifestyle and previous history it is possible to say that he suffers with at least 4

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out of the 5 major reasons of low back pain, and even though some may not have resulted from

his tennis practice, without proper alignment and postural re-education it will definitely

aggravate his current situation, possibly reducing the number of years he will play in the future.

The first aspect to look into is the presence of a curvature on his spine; while performing

the roll-down it is clear to the naked eye that his vertebrae shift out of the center line towards the

right side of the body, causing somewhat of a curve that would be recognized as scoliosis.

Nowadays, scoliosis has become something somewhat “normal” since 1 out of 100 will develop

some kind of scoliosis, but fortunately these will mostly be mild cases. In Rafael’s case I cannot

diagnose how severe his scoliosis is, but assessing that most scoliosis cases start developing

during childhood, and that Rafael started playing a one-side dominant sport during that period, I

can predict that his case is moderate to somewhat severe, and the program needs to focus on

getting as much length on the right side of his body by stretching the muscles around the spine

and right hip area. One other aspect that I have noticed while working with Rafael is that his

head and neck tend to tip to the left side while he is lying supine. My assumption is that since the

right side of his muscles have been working so much harder than the left side of his muscles, the

scoliosis condition caused the spine to shift more towards the right around the thoracic and

beginning of lumbar spine causing the cervical spine to tilt away from the curve, therefore

making the S-shape curve characteristic of this condition. Lastly, extreme rotation of the spine

can also aggravate this condition, and as a tennis player Rafael is in constant use of spinal

rotation.

Muscular imbalance is also a factor that aggravates lower back pain, and when analyzed

aside all the other causes, it is one of the issues that Pilates has most access and ability on aiding

the healing process. By working bilaterally in an even and balanced body, the muscles are able to

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train and re-learn how to achieve equal strength, flexibility, control and mobility on both sides of

the body. Imbalances on tennis players can simply be analyzed by taking one of the most crucial,

constant and fundamental movement performed: the serve. The serve needs to be very powerful

and will recruit major muscles to be performed. For a right-handed tennis player like Rafael, the

serve will begin with mild torso rotation as the left arm tosses the ball up in the air, followed by

extreme right lateral flexion and deep knee flexion as the right arm slightly bends and prepares

for the strike. Then the player must use the rotator cuff muscles of the right shoulder to get the

racquet even further back, while extending the thoracic spine and creating momentum to jump

reaching as far up as possible, and finishing the movement in a half-circle motion forward with

intense counter lateral rotation of the right upper-body and left lower-body. The movement itself

is completely imbalanced, and according to Rafael’s interview, a tennis player will never switch

hands when serving.

While still analyzing the serve, the constant extreme right lateral flexion prior to striking

the ball is a clear example of another low-back pain aggravator, which is the misuse and abuse of

muscles during constant repetition. Overusing any muscle in the body can be related to many

different aspects, and sometimes we will have no power over it. During a tennis match there are

many factors that can lead the player to overusing their muscles, therefore being subject to

injury. But the unfortunate side of this is that no matter how prepared a player is there will be

intrinsic and extrinsic factors influencing the way they will play that cannot be predicted nor

changed. Intrinsic factors that can lead to misuse or extreme practice are simply identified as

feelings and emotions. No matter how focused and prepared a player gets, sometimes there may

also be extrinsic factors affecting their performance, and therefore leading to injury, such as

weather conditions, the opponent, environment conditions and so on. Despite these risks to

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misuse muscle recruitment, there is also the fact that players tend to have a rigorous training

schedule, especially at Rafael’s age since they are preparing for a career, so there will most

definitely be overuse of particular areas of the body, especially back and shoulders, so the only

solution for this sort of problem is to ensure the player is as properly aligned as he can be,

diminishing the difference of one side of the body to the other, and strengthening both sides of

the body evenly.

Tennis can be somewhat be considered a sport that has unstable movement patterns, and

the matches are unpredictable. The player must be extremely focused so that running and striking

the ball can be performed in the best biomechanics possible, allowing the body to have full

mobility with the required stability. With consistent Pilates practice and in a deeper

understanding level, a tennis player is able to train the body focusing on different group of

muscles or specific muscle at a time, allowing them to understand and recognize how each body

part complements another in the sense of stabilizing versus actually moving.

The last component that aggravates low back pain is related to pathologies and injuries,

and fortunately there is no occurrence of that on the case study. Low back pain associated with

spinal dysfunction can be a result of either a disc condition or a vertebral condition, and should

be accompanied by a doctor.

Taking in consideration all the factors that are causing low back pain on the case study,

and also analyzing the naturally round-thoracic spine, gait cycle, and various postural habits, I

have designed two programs that will help Rafael develop more balance between the right and

left side of the following muscles: internal and external obliques, Quadratus lumborum, rectus

abdominals and erector spinae. Also we will strive for maximum looseness of the hips,

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emphasizing stretching the hamstrings and increasing the range of mobility. And finally,

approach the thoracic and shoulder area so it opens-up and settles into place.

Program A (Fundamental) Fundamental Warm-up Footwork: Reformer Complete Footwork Series Abdominal: Reformer Hundred prep Hundred Hip Work: Reformer Frog Down/Up Circles Leg Openings Spinal Articulation: No exercise yet. This program is considering his visit number 0-5. Stretch: Reformer Standing Lunge Full-Body Integration: No exercise yet. This program is considering his visit number 0-5. Arm work: Avalon Chair Arms Sitting Series Stretch: Ladder Barrel: Shoulder Stretch 1 Lateral Flexion/Rotation: Ladder Barrel Side Over Prep Back Extension: Ladder Barrel Swan Prep

Program B (Intermediate) Fundamental Warm-up Footwork: Cadillac Complete Footwork Series – done lying the reverse direction because hamstrings are too tight. Abdominal: Cadillac Roll-Up Bottom loaded Spinal Articulation: Cadillac Tower Prep -Switch Springs from bottom loaded- Abdominal: Cadillac Mini Roll-Up Mini Roll-Up Oblique Hip Work: Cadillac Supine Single Leg Series Stretch: Manual Stretch with Thera-Band Full Body Integration: Cadillac Sitting Forward Side Reach Arm work: Cadillac Arms Standing Series Lateral Flexion/Rotation: Cadillac Butterfly Additional Leg work: Cadillac Squats Back Extension: Cadillac Prone 1

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Conclusion:

In conclusion, it is possible to say there’s nothing to be done to fully eliminate low-back

problems but what can be changed is the intensity and frequency this problem happens.

Ultimately, with consistency, precision and dedication to the Pilates practice, a tennis player can

achieve better health, eliminating the nagging pain of low-back-related problems. Muscular

imbalance is one of the most crucial points I have discovered in this research because if every

other aspect is “corrected” yet one side is still stronger and tighter than the other, there will be no

full range of motion, and the previous weaknesses that had already been addressed and corrected

will most likely occur again. Postural deviations may not be fully corrected or reversed, but the

muscular structure around the spine can learn how to correctly support each movement required

in this sport, therefore allowing for maximum flexion and rotation of the spine. As far as

overdoing movements, demanding sports such as tennis will most likely involve overuse, but by

having a strong and mobile spine and equal strength and flexibility on both sides of the body, a

player is able to continue with his career and daily-life with less pain and better outcomes.

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Bibliography: Book Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, California: Body and Arts Science International, 2013. Video Clip “Tennis Serve: The top 5 Secrets of the Power Tennis Serve.” Youtube. Paul Gold Channel. 19 Nov. 2014. < https://www.youtube.com/watch?v=mbLjGVd0xRs>. Websites “Scoliosis.” University of Maryland Medical Center. University of Maryland Medical Systems. 19 Nov. 2014. <http://umm.edu/health/medical/reports/articles/scoliosis>. “How Common is Scoliosis.” WebMD. WebMD, LLC. 22 Nov. 2014. <http://www.webmd.com/a-to-z-guides/how-common-is-scoliosis>. “Faulty Movement Patters as a Cause of Articular Dysfunction.” Dynamic Chiropractic. Dynamic Chiropractic, an MPA Media Publication. 22 Nov. 2014. <http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=38083>. “Low Back Pain.” ITFtennis.com. International Tennis Federation. 19 Nov. 2014. <http://www.itftennis.com/scienceandmedicine/injury-clinic/tennis-injuries/lower-back.aspx> PDF Article from the Web Davis, and, Perkings. “Musculoskeletal Injuries in Tennis.” Physical Medicine and Rehabilitation Clinics of North America. NYU Langone Medical Center. 22 Nov. 2014. <http://www.med.nyu.edu/pmr/residency/resources/PMR%20clinics%20NA/PMR%20clinics%20NA_sports%20med/MSK%20injuries%20tennis.pdf>. Pictures from Web Allen, Jared. “The Core-Pt. 1: Awareness over Strenght.” Dynamic Balance. 2 Dec. 2014. <http://www.dynamicbalancefoco.com/#!blogger-feed/c1l0u>. Brookbush, Brent. “Internal Obliques.” Brookbush Institute of Human Movement Science. 2 Dec. 2014. <http://brentbrookbush.com/internal-obliques/>. Desjardins, Lyndsey. “Functional Anatomy Part 7 – Intrinsic Back Muscles.” Lyndsey Desjardin Fitness Coaching INC. 3 Dec. 2014. <http://lyndseydesjardins.com/functional-anatomy-part-7-intrinsic-back-muscles/>.

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“Erector Spinae.” ExRx.net. Exercise Prescription. 3 Dec. 2014. <http://www.exrx.net/Muscles/ErectorSpinae.html>. Student Papers from BASI online library Schifano, Christiana. “Imbalances of a Dancer Corrected Through Pilates.” Comprehensive Course. Davis, California: BASI Pilates, 2013. Drury, Billie. “Pilates for the Tennis Player Shoulder.” Comprehensive Course: Chandler, Arizona: Ocotillo Pilates, 2012. Navarro, Antonio. “Pilates for Tennis.” Comprehensive Course: Costa Mesa, California: BASI Pilates, 2013. Toker, Elif. “Pilates for Increasing Tennis Performance and Avoiding Injuries resulting from Imbalance.” Comprehensive Course: Mersin, Turkey: BASI Pilates, 2012.