dr. jack dolbin session 5 1 role of the lumbar spine: the most important region as it relates to...

Dr. Jack Dolbin Session 5 1

Role of the Lumbar Spine: The most important region as it relates

to performance, treatment and prevention of soft tissue injuries.

The relation of the spine to somatoautonomic and

somatosomatic components have recently been “discovered” by the

medical profession


Key to performance:

As it relates to the shoulderVillanova swimmers 75%As it relates to Lower Extremity injuriesAs it relates to injuries of the upper

extremityAs it relates to performance2nd most common injury in sports

Running Kinesiology



Low Back Injuries:

Sprain! StrainPars FracturesSoft Tissue injuriesDisc injuries


Golf Swing Sequence

Lumbar Sprain

Flexion: Tearing capsular ligaments, Supraspinous Ligament, possible disc injury.

Extension: Compression facet Joint. Possible Pars fracture.


Examination

Observation Inspection: APalpation: TRange of Motion: RProvocative TestsNeurology Imaging


Diagnostic Tests

KempsAdamsSitting BechterewSLRBraggardsSotoHallGolthwaits


Diagnostic Tests

Stork TestGaenslensObersThomasYeomansNachlasElys


Neurology

Lower extremity neurologyDTR’sManual Muscle testsPin WheelVascular: Dorsal pedis/TibialPathological Reflexes


Treatment

If within 24-48 hours deal with the acute tissue response

A. Ice, lazer,HVG, Kinesiotaping. CyriaxAfter 48 hours: Cyriax Cross Fiber,

Muscle energy, Impulse Adjusting. Modalities to promote circulation,

midrange exercise..Adjustments to fixated joints.


Pars Injuries

Active Spondylo: Inactive Spondylo:Pending Spondylo:

Chapter 5: Dr Terry Yochum Illustration: Steven Soffer MD. FICS


Epidemiology

Gymnasts: Female AdolescentLong Jumpers, Triple Jumpers.Weight LiftersFemale volleyball, basketball

Athletes that do repetitive hyperextension activities.


History of repetitive hyperextension activities or extreme vertical stress.

Positive Stork

Positive Kemps.


Holding our Breath


Cruising


Pars Fracture MRI


Radiological Evidence of pars Defect

Perform spec bone scan or stir MRI

If positive: Boston overlap brace: min 2 mo.

No: make alternate diagnosis

Treat conservatively as per below

Play no play decision??

Does the athlete perform rep hyperextension activities

Perform spec or stir MRI

If no the make alternative diag:

60% have SI Sub. SP/ST Iliolumbar ligament

30% have facet syndrome


Spondylolysis

There has never been a baby born with a pars defect.

Stress fracture:


Pars defect Axial View


Bilateral Pars Defect


Scotty Dog


Active Spondylo


Active or Pending


Treatment

HF 27 US .02 w/cm2 15 min.Laser/light 360 secondsBoston overlap: Minimum 2 months redo

spec bone scan or MRIOnce FX is healed: CMT, RMT,

progressive resistance exercises as per Wolfes Law.


Rehab


The Sacroiliac Joint

Normal function as it relates to performance

Dysfunction as it relates to injuryA. IT BandB. Patellofemoral syndromeC. Medial Shear at kneeD. Hamstring Injuries F. Pronation


Normal SI Structure/Function

Sits at a 55 degree angle to the sagital plane and 30 degree to the frontal plane

Nutates in both the saggital and frontal plane

Shearing forces ie: long jumping, rebounding can subluxate the sacrum on the ilium spraining the iliolumbar and sacroiliac ligaments.


Findings

History of shearing force or lifting and twisting

Palpatory exam: Iliolumbar, lumbosacral and sacroiliac ligament

Gaenslens TestYeomansNachlas


AP SI Joints


Anterior Inferior Sacrum


SI ( continued )

Injury involves the quad femoris muscleMagines Syndrome. Marc Heller DCVery prominent in the female athleteUsually involves 5th lumbar facet Iliopsoas Muscle


Pyriformis


Lumbar Plexus


Sciatic/Pyriformis relationship


Iliopsoas


Iliopsoas-Adductors


SI Joint Treatment

Modalities as per presentationAdjustment: Long axisA. Does the Innominate rotate or does the

sacrum shear?B. Cyriax on Iliolumbar LigamentC. Check the kinetic chain including the

Head of the fibula, talus, navicularF. M.E on the pyriformis. IT band.



Cervical Spine Injuries:

Diagnosis, treatment, rehabilitation, prevention.

On the Field management. A. Range of motion, Spurlings, Jacksons,

Cervical CompressionB. Upper extremity Eval: Strength,

Neurology.

Cervical Spine Treatment

Modalities as per presentationProne Long Axis Adjustment or Impulse

adjustmentMuscle Energy TechniqueRehabilitation exercisesProtection: Collar


Head and Neck Injuries

Brain and Spinal CordHeal slowlyCannot regenerateCannot be replaced

Evaluation must be quick and precise


Assume any unconscious athlete has a neck fracture

Immobilize head and neck Check airway

Check vitals: Blood pressure, pulse, respiration Assess state of consciousness Check pupils for reactivity, reflexes including

Babinski, reactivity Movement of extremities


Brain InjuriesCompressiveTensileShearing

Coup or contra coupCoup: Head is not accelerated. Injury at the

site of impactContra coup: Head is accelerated. Injury

opposite the site of impact



Skull FracturesLinear: Usually not brain injury.Depressed: Most likely to cause brain injury.


Neck Injuries Axial Loading: Most serious. Is caused by flexing the

neck at the point of impact. Can cause a burst injury to the vertebrae. A 20% neck flexion causes the bone to absorb the force.

Flexion Sprain: Injury to the posterior soft tissue, ligaments, capsule, muscles. Most serious.

Extension Sprain: Injury to the anterior soft tissue with compression of the articular facets.

Cervicle Exam InspectionObservationARTCervicle CompressionJacksons Comp.SpurlingsSotoHall


Upper Extremity Neurology

Inspection: Look for Atrophy/AsymetryARTDTRManual Muscle TestingAdsons, Allens , Wrights


Treatment

Imflammation/PainRestore normal ROM: Adjustment,

Impulse, ME,Strengthen/Stabilize



Concussions:Evaluation Impact StudyReturn to participationRepeat Concussions

Concussions

Def: A complex pathophysiological complex involving the brain induced by traumatic biomechanical forces


Concussions and Depression


Common features include

1.Maybe caused by a direct blow to the head, neck or elsewhere in the body which transmits impulsive forces to the head.

2.Typically results in in a rapid onset of short lived impairment of of neurological impairment that resolves spontaneously

3.May result in neuropathological changes but largely functional disturbance rather than structural


Common features ( cont.)

Result in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of clinical and cognitive typically follow a sequential course. In a small percentage post concussive symptoms may be prolonged

No abnormality on standard structural neuroimaging studies is seen in concussions


Symptoms

Somatic( headache) cognitive( feeling in a fog, emotional( lability)

Physical signs: loss of consciousness, amnesia

Behavioral: irritabilityCognitive: Slowed reaction timeSleep disturbance: drowsy


Evaluation

Exclude Cervical Spine injury firstAddress First Aid IssuesPhysical ExamCognitiveNote: The player should not be left alone.

Monitor for deteriorationNo RTP on the day of the injury


Concussions:Concussions: 20%/year in High school SportsGrade 1: No loss of consciousness.

Momentary period of post traumatic amnesia.Grade 2: Momentary loss of consciousness

lasting less that 5 minutes. Amnesia longer than 30 minutes but less than 24 hours.

Grade 3: Loss of consciousness greater than 5 minutes. Amnesia longer than 24 hours.


Concussions: Chronic Brain Injury:

Traumatic encephalitis Repeated head injuries.


Concussions: Post Concussion Syndrome:

Headache Dizziness Fatigue Irritability Impaired memory and concentration

Head InjuriesIntracranial Hemorrhage: Leading cause of

death from a head injury Epidural

Fracture of the Temporal bone Dramatic deterioration in consciousness in 30-

60 minutes Subdural hematoma

Most common fatal athletic head injury. Unconsciousness at the instant of impact Rapid deterioration

Head Injuries Intracerebral hematoma

Congenital malformation Aneurism Arteriovenous malformation

Subarachnoid Hemorrhage Brain bruise Aneurism a/v malformation

Head InjuriesMalignant Brain Edema syndrome

Rapid deterioration to ComaDeath in a few hours

Second Impact SyndromeHyperemiaSecond acceleration head injuryRapid progression to coma.

Concussion Eval


Return to Play Protocols

1. No Activity: Complete physical and cognitive rest. Until abate of symptoms

2. Light aerobic exercise: Increase HR3. Sport Specific Exer: add movement4. Non contact drills: exercise,

coordination, cognitive load5. Full contact: restore confidience,

assessment of functional skills5. RTP Dr. Jack Dolbin Session 5 86


Neck and Spinal Cord Injuries

Cervical SprainDamage to musculo/tendinous/

ligamentous unitRemove from competition


Spinal Cord ConcussionViolent impact to the vertebral columnTransient loss of motor or sensory

functionSymptoms last less than 24 hoursIf greater than 24 hours may produce

permanent injury



Central Cord Syndrome Greater loss in upper extremity Hyperextension Cervical

Sprain Can an adjustment cause a

disc to herniate?


Burning Hand Syndrome:

Lateral Pinch( Stinger) Radiate down arm to thumb Several minutes duration Generally if radial in distribution it is the

neck. If ulnar distribution it is the thoracic outlet.

Direct Trauma


Thoracic Outlet


Traction


Compression


Evaluation

Range of motion cervical spineRange of motion shoulder, elbow, handDeep Tendon ReflexesMuscle testingPathological reflexesMake transport decision


Evaluation

Adsons

Allens

Wrights


Treatment

Ice to effected areaLaser Impulse Adjustments to Scalene Muscles Impulse Adjustments to TOSExercises to retract scapulaReturn to competition as symptoms allow.


Return to competition decision-making

Concussions:Grade 1: 1st concussion: May return if

symptoms clear rapidly at rest and with exertion.

Grade 1: 2nd occurrence: Remove from competition for two weeks. Must then be asymptomatic for 7 days before return.

Grade 1: 3rd occurrence: Season over. No contact for three months.


MRI or EEG Neuro Psychiatric exam Grade 2: 1st occurrence: Stabilize the neck.

Asymptomatic for 7 days. Grade 2: 2nd occurrence: Asymptomatic for 1

month before return Grade 2: 3rd occurrence: Terminate season Grade 3: Transport, Remove from competition

for 1 month, asymptomatic for 1 week.


Factors to look at to prevent head and neck injuries

Head gearTechniqueNeck muscle conditioning

Return to competition after a neck injury:

Neurological Exam: Reflexes Hoffman’s sign Motor strength Sensory exam

Return to competition after a neck injury:

Orthopedic Exam: Full ROM in Cervical Spine Negative Spurlings Maneuver. Strength in all planes of motion in

Cervical Spine Normal Neuro exam

dr. jack dolbin session 5 1 role of the lumbar spine: the most important region as it relates to...

Documents

jack dolbin session

sports slide

lower extremity injuries

pars injuries active

medical profession slide

golf swing sequence

inactive spondylo

pending spondylo