Dan Kelly

Back Pain – Lumbar Disc Injury

What is Lumbar Disc Injury?

Lumbar disc injuries either occur as a result of a bending/twisting/lifting event or, more commonly, due to poor habits that become compounded over time. Many patients are unable to identify a specific movement or event that triggered disc pain.

Lumbar disc pain is usually felt in the lower back and can radiate down one (or occasionally both) legs. An injured disc can commonly have an impact on its adjacent nerve root, which can cause nerve-related symptoms in the leg(s). These include pins and needles, tingling and weakness of particular muscle groups.

A disc is shaped like a jam doughnut, with a shock-absorbing fluid centre, and a strong, doughnut shaped ligament wall that contains it. This ligament wall attaches very firmly to the vertebrae above and below and because of this, the notion of a “slipped disc” is not particularly accurate; perhaps a “disc sprain” is a more accurate term.

A disc usually becomes injured when forces on the disc cause the disc wall to fail, pushing the disc fluid closer to the outside of the disc. There is a large spectrum of severity with disc injuries, from small sprains, to complete disc wall ruptures, meaning parts of the disc have broken out and are left out of place and irreparable. The majority of disc injuries, although painful, recover with conservative treatment and without the need for surgery.

Most of the time, disc injuries happen towards the back of the disc as a result of repeated or forceful bending, or prolonged poor sitting postures characterised by flexion (or forward bend) in the spine. Aggravating activities often include sitting, driving and bending, while standing, lying down and walking tend make the pain decrease. There is typically a loss of range of movement of the lumbar spine, be it obvious or subtle, in one or more directions.

Interestingly, there is poor correlation between low back pain and accompanying scans or X-rays, so referral for scanning is not usually required unless there are special reasons to do so.`

Treatment:

As physiotherapists, we offer treatment techniques and strategies to decrease symptoms by improving movement of the spine. This often includes gentle, pain-relieving exercises and manual therapy. Your physio will place a big emphasis on identifying clear cause-and-effect relationships between movement and activity, which makes the problem manageable while a clear roadmap for recovery is identified.

In addition to abolishing pain and recovering full range of movement, there should always be a focus on establishing good strength and stability of the spine so it can handle future rigours and prevent recurrence.

Tips:

1. Sit well. You should always maintain the slight backwards curve of your low back when sitting. Most office chairs offer some form of lumbar support for this reason, however a lumbar roll makes a good alternative if your chair isn’t helping.

2. Reverse your curve. If you are spending a lot of time in sitting or bending positions, spend some time arching your back backwards every hour or two.

3. Stay strong and check your technique. Exercise such as Pilates or weight training can be a great way to stay strong. Remember that when you’re lifting things, either in the gym or in real life, neutral spine is the key. If in doubt, ask your physio.

4. If you suffer an episode of low back pain, get to your physio sooner rather than later. Many people suffer with symptoms for far too long simply because they did not seek help at the beginning.

Knee Injuries – the ACL

Injuries involving the anterior cruciate ligament (ACL) of the knee are incredibly common these days. They are particularly prevalent amongst professional athletes and given the required time away from sport, they are certainly well covered in the media. Here are a few pointers surrounding injury mechanisms, assessment procedures and rehabilitation options if you have suffered a suspected ACL injury.

ACL ruptures usually occur with non-contact, pivoting injuries where the foot of the affected leg remains stuck to the ground. Typical examples include during a mistimed side step during a soccer match while wearing studded boots, or when falling during skiing at low speeds, when the ski bindings fail to release. Typically there is a cracking sound, immediate pain and swelling. The time it takes for pain to subside varies greatly between individuals. Many people who have suffered an ACL injury fail to recognise its significance initially because they are quickly able to walk, and even run is straight lines, without pain. They quickly find, however, that an unidentified ACL injury will give rise to sensations of instability or “giving way” during twisting or pivoting movements.

ACL injuries often occur in combination with damage to other structures, such as the medial meniscus or medial collateral ligament, so it is fair to say there is a big variation of presenting symptoms between one person to the next; from slight discomfort through to bellowing pain and disability.

If you have injured your knee and suspect an ACL tear, it is important to follow the RICE rules for acute injuries. They are: rest (avoid painful activities), ice (20 minutes every couple of hours is the current convention), compression (using a Tubigrip or compression bandage) and elevation (above the level of your heart if you can). Then get yourself in with your physio for a thorough assessment.

Management for an ACL injury involves a visit to your physiotherapist who can test your knee for ligament deficiencies. If an ACL tear is suspected, you will usually be referred to an orthopaedic surgeon, who specialises in ACL reconstruction procedures, for further assessment and opinion. Sometimes the surgeon may ask for you to have an MRI scan, however in some instances the diagnosis can be obtained confidently with clinical testing.

If an ACL rupture is confirmed, the surgeon will discuss your options with you. Some people are able to fulfil their desired activities without the need for surgery, however today’s conventional approach is to look toward reconstruction surgery if your lifestyle is likely to involve any twisting-type activities. These can include anything from playing backyard soccer with the kids to competing at the Rugby World Cup. Your physio will be around to ensure you regain all of the required strength and flexibility to return to the activities you love whether you decide to undergo surgery or not. The most common reconstruction procedures require up to 12 months before return to play is recommended.

Running Assessments

How can a physiotherapist help you before a running event?

Running can be a really effective and really enjoyable way to exercise. Of course we have the benefits of staying fit and feeling good, however there can be downsides to running, the most obvious being injury. We understand from surveys that consistently more than half of runners suffer an injury in any given year. This is disappointing, given how much we now know about how to prevent these injuries from occurring in the first pace.

Given the repetitive nature of running, most of these injuries present as overuse-type injuries, rather than traumatic incidents. Traumatic events include injuries like broken bones or sprained ankles, while overuse injuries build up over time and include conditions like patellofemoral pain syndrome (PFPS), tibial stress syndrome (commonly known as “stress fractures”), low back pain, Achilles and patellar tendon problems, plantar fasciitis (pain under the foot) and ITB friction syndrome.

We always need to look closely at the extrinsic factors that will impact on a runners loading tolerance. Footwear, increases in training load, environmental conditions and running surface all play a part in how much load we are subject to.  These are best discussed with your physiotherapist or running coach.

We also know that our biomechanics, the way we move, impact heavily on the prevalence of these overuse conditions. A great way to identify, then rectify, a lot of these underlying factors is to utilise video-analysis of a person’s running technique and reverse-engineer some corrective and preventative strategies to give runners the best possible chance of getting through their training loads without breaking down.

While problems show themselves in different ways during video-analysis assessments, there are certainly some common root causes that can be common amongst a number of overuse injuries. These include poor mechanics of the foot, core strength and stability problems, pelvic control issues, problems with deep hip muscle stabilisation, stride inconsistencies, unnecessary trunk movements and gender specific differences.

A typical video analysis session should occur after your physiotherapist has had an in-depth discussion with you regarding you injury history, running background, current training loads and goals. Once the extrinsic issues have been ironed out, a running video analysis can take place.

An in-clinic video analysis will usually take place while you run on a treadmill. Some markers are stuck to the surface of your skin in key positions for ease of identification and assessment. Your physio will use video capture software to record your technique from a few different angles. After the filming is complete, you sit down with your physio, and go through all of the finer details of where you may be able to improve and what the best strategies will be to do it.

Video analysis can be an extremely effective tool in run technique coaching and helps us to fast track any corrections that may be required. The best part about this kind of technology is that it gives people the opportunity to identify problems BEFORE they become injuries, which is so important for repetitive sports like long-distance running where we know we can have such a positive influence on injury prevention. What’s more, because injury prevention and performance enhancement fit so nicely together, you might even find you run faster too!

If you are keen to build your running load and speed, and particularly if you are thinking about entering an event, get yourself in for a video analysis. You might be surprised at what you find!