Lower back pain in 24 year old rugby player

[cafra23]

Hello,

I am sure that there is a very simple answer to this one, but being new to all this, and not yet having secured a propper job I am a little baffled and would really appreciate some help.

24 year old male with gradual onset of LBP and 'stiffness' for 4/52. Plays amateur rugby once a week in the 'lock' position and trains twice a week and has done so for the last 10 seasons. Also attends the gym twice weekly and completes a weights programme aimed at improving upper body strength. Reports having experienced "general lumbar stiffness" following games previously, but never anything that has affected his normal activities. He cannot recall any impact or injury that may have caused the problems and his symptoms have gradually worsened over the last 4/52 to the point where he has trouble putting his socks on and getting up from the sofa. He works as a labourer and has done so for 5 years, but is finding his job incresingly difficult as it involves lots of bending and heavy lifting.

O/E - reduced lumbar flexion (can only slide hands down legs as far as the knees) and extension (finger tips will reach just below the buttocks). Hamsting length is normal.
Active trigger points in the traps and rhomboids and only what I can describe as "gristle" in the muscles of the paravertebral and sacral area.
He experienced no discomfort with PA accesories but the was a marked stiffness from L1-L5. His symptoms (an intense, sharp, stabbing pain) were only reproduced with unilateral PA's to the transverse processes of L1 (possibly L2).

I have tried unilateral mobs to the affected area and massage as well as heat therapy which does help to reduce symptoms but not fully and only temporarily.

Sorry this is so long-winded and the language a bit basic, but I have not yet mastered to skills of being clear and concise! Any advice will be greatly appreciated (by both myself and my very patient, patient!).

Cat.

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[alophysio]

Hi Cat,

Interesting case to look at. Some questions I have:

1. You mention that he has lower back pain but then go on to point out traps and rhomboid issues - does he get pain higher up?

2. What are his spinal curves like - I am going to hazard a guess and say he has increased lordosis and decreased kyphosis (just guessing!)

3. Is he able to get any flexion in his spine at all? e.g. can he go onto all fours and put his buttocks on his heels (like a muslim prayer position)?

4 What are his PPIVMs into flexion and extension like?

5. When he tries to FF, is there any L/S motion?

6. Were his PA glides stiff because it was "joint-locked" stiff or because of "spasm" stiff?

7. You haven't mentioned if you think there is a disc or any neural involvement. Any sciatica or nerve root signs?

The reason for the questions are because i think this guy is compressing his L/S through overactive spinal extensors. He probably has overactive external obliques as well. Why this has happened i don't know.

The lower thoracic / upper lumbar region is known for its change in convexity and therefore placing these bones under high loads of stress. He is probably loading unevenly now therefore sore on unilateral PA.

I think the solution lies in regaining segmental ROM. I wouldn't bother with massage or anything except to release them enough for you to restore whatever motion is lost (i am guessing flexion - that's why PA in prone wasn't too bad but stiff because you were probably at EOR extension).

Once movement has been regained, teach control of the L/S with co-contractions of TrAb and Multifidus (beware how people activate this muscle - most people use their obliques and not their TrAbs). Then resotre controlled F and E with neutral spine and work into segmental motion.

Good luck and let us know how it goes...

No doubt others will post about MacKenzie method or other generic assessments but i think this guy has a control issue. The information above is based on Peter B. O'Sullivan's work on the classification of chronic low back pain. You can find his articles on medline.

Thanks

[physiobob]

Right on alophysio! I couldn't have summed it up any better. Seems like a pretty easy one but the guys willl need major re-education and correction of his tehcniques both in the gym, at work and on the field. Look forward to the answer to your questions. Afterall a neuro should be the first step so please comment on whether all is OK on that side of things

[cafra23]

Hi, Thank you so much for your response. I have since seen this patient again and have had a chance to look at some of the things you suggested. The answers to your questions are as follows:

1. The LBP is the main problem and he doesn't complain of pain higer up, just stiffness post game.

2. You were right about his standing posture! Although it is not that marked, he does have increased lordosis and decreased kyphosis.

3. He can get in to the muslim prayer position, although his buttocks do not quite reach his heels. He says the stiffness is the limiting factor rather than any pain.

5. When he forward flexes, there seems to be very little L/Sp movement and he pushes back up in to standing using his hands on his thighs.

6. His PA glides are stiff due what appears to be joint locking rather than muscle spasm

7. There are no neural or disc signs. One thing that came up during the sujective Ax was that he had periodically been experiencing numbness of his forearm (? C7) although I am not sure if this is related.

After his last session he reports that his symptoms eased a little, but then returned after his next game (he is reluctant to stop playing). I have taught his some core stability exercises as on Ax he had poor control, but could you please explain what you mean by "Then restore controlled F and E with neutral spine and work into segmental motion" and how I would go about it!

Thank you so much for your help, it really is appreciated.

Cat.

[alophysio]

Hi Cat,

Thanks for getting the information - I am going to go through some of what i think is going on in your patient.

1. He reports pain in the L/S but not up higher. I think it is only a matter of time before he feels pain in his T/S. This is because he seems to have overactive back extensors that are "crushing" his vertebrae. With the increased lordosis and flattened T/S, the L/S is placed into extension already. In neutral spine, the facet joints of the L/S should only be bearing 0-15% of the total load, the discs bearing most of it. But into extension, obviously the load increases due to increased joint contact and so the joints can get sore. The same thing goes for the T/S. Because the kyphosis and lordosis curves of the spine act as shock absorbers to vertical compression forces, a flattened T/S will transmit more forces (GRF) further up the spine. Give his posture, he probably also has trouble keeping his inferior angle of the scapula down. Again, this is because of the altered relationship the scapula has with the thorax. The back extensors can produce ?200kg of compressive force (don't remeber reference so don't quote me on that!!!). If he is overactive in them, then he will be sore.

2. With the Muslim prayer position, it makes sense that he feels restriction rather than pain. The position requires L/S flexion to get there (but you didn't mention his L/S segmental ROM). But any joint or muscle along the lower limb kinetic chain can restrict (e.g.decreased knee F etc). But i suspect that the L/S is not flexing like it should - in fact, he probably flexes a lot from the mid-thoracic spine upwards with an extended or flat L/S.

3. with the decreased L/S F in standing, again it fits with the theory of overactive extensors preventing segmental flexion of the L/S. The difficulty with standing up again...i am not sure why. Perhaps his extensors are tired or weak or he is unconsciously trying to avoid L/S extension (unlikely i think). Perhaps because he doesn't have L/S flexion, then the moment arm / torque of having the body further away from the axis of rotation creates more difficulty...

4. Same goes with PA glides - don't bother doing these - it will not help him - he is in extension already. I would suggest PPIVMs into flexion or prone over a pillow (to try increase L/S flexion) then trying to mobilise as if you are trying to increase flexion. i.e. angle your pressure toward his neck, not towards the floor.

5. No neural or disc signs are good - for now. He is young. If he continues, i will guarantee you will see disc degeneration, maybe end-plate fractures / Schmorl's Nodes and early OA changes to the Z-joints. The cervical general numbness can be due to the excessive contraction around his thoracic outlet or nerve roots. See if his scalenes or SCM or traps / lev scap are overactive...

6. Teaching core stability is a good idea. Unfortunately that means so many things to so many different people.
* How are you doing this?
* What exercises?
* What are your instructions to the patient?
* How often does he have to do it?
* What are your specific goals for the exercises?

Like I said in the post below, teach a co-contraction of TrAb and Lumbar Multifidus (LM). I think there is an article in 1995 Manual Therapy by Richardson et al that deals with this. The secret is not to overload him.

7. My treatment plan would be as follows:

a. Talk to him about what is going on. He needs to know that his lack of flexion and excessive extension is causing his non-specific pain. Once he corrects this, he will improve but it will take some time. He may want to see someone about relaxation strategies (I have found NLP (neuro linguistic programming) practitioners very helpful with this...). I can't emphasis how important this step is. If he doesn't understand why he is doing this seemly "wierd" treatment approach, then he will find someone else to go to who won't necessarily understand what is going on.

b. Restore L/S segmental flexion ROM. Use whatever methods you have been taught. You can use Maitland mobes, Muscle Energy Technique, Mackenzie (i think - never done much of Mackenzie), Mulligan techniques (these are nice), etc. I don't think electrotherapy will help much except maybe to relax him. So things like heat, sports rub, etc may be helpful - so long as he understands that it is to help him relax, not fix something pathological (otherwise he will fixate on getting this done and not changing his behaviour). Maintain all movement gains with exercises at home such as pelvic tilts etc.

c. Teach co-contraction of TrAb and LM with the pelvic floor (but without the diagphragm - normal breathing). Once he can master this in neutral supine / standing / prone / 4 point kneeling, then add arm movements slowly. once arm movements can occur without overactive use of obliques or rectus abdominis etc, then add trunk movements (move out of neutral). Please remember that he needs to have L/S flexion restored before doing this! I have found that Pilates is useful for exercise ideas. Beware, however, because not all Pilates is good from a physio point of view. I have found Polstar and Stott methods fairly good (because physios developed it!). I am working currently with another group to teach them all these ideas to incorporate into a "pilates method" to be taught...

_______________
A few more comments...

There are many ways to achieve the things i have suggested above. I am by no means correct, of course, on what is wrong with this man or how to treat him. You are the physio. You have the training. You have done the assessment. Use your skills to see if what i am saying is right or not. Does it make sense? Is it consistent? Does what other people say make more sense? What seems to be helping the most.

This is a process you should apply to any advice that you receive. I have always told my patients they are free to go elsewhere (because i charge more!) but i always remind them that they need to be getting better. I haven't had many people leave because they know they get the results quickly. That is not to say that other physios aren't good, just that I believe what i provide is very good and if it is not, then i need to learn more to make it very good. The patients appreciate if you admit you don't know and they appreciate even more if you go out of your way to find out how to help (like you are doing). The point of this paragraph (sorry!) is that you now have knowledge that I am guessing most physios in your area do not have (these ideas don't seem widespread...yet). Your patient needs to understand why you are doing this so that he will stick with the programme. Have confidence in your ability to sell this idea to him (if you think it is right!).

Lastly, there are courses i think you should do and authors you should read and keep a track of (because you are a new grad...):

1. Barbara Hungerford's MET courses for the C/S, T/S and L/S. She is in Australia, Singapore and UK - www.amta.com.au. Good physio. There are probably other people in your country who do Muscle Energy Technique. It is nice to have these skills. Barb has changed MET slightly to make it more in line with current researach etc.

2. Anything by Diane Lee or LJ Lee - www.dianelee.ca or www.ljptconsulting.ca (?). I am an unashamed admirer of Barb, Diane and LJ. If you want to see gurus in action, do their courses - they are awesomely organised, great notes and fantastic skills. It is worth travelling to do their courses.

3. Peter O'Sullivan. another fantastic physio. His work suits my personality and thinking (big picture, holistic, etc). His research is good to keep a track of.

4. Carolyn Richardson, Julie Hides, Paul Hodges, Gwen Jull, Ruth Sapsford, Bill Vincenzino etc. I have only done Bill's course on lateral epicondylalgia. These people are from University of Queensland in Australia (where LJ Lee is completing her PhD) and provide a lot of research into what we take for granted these days. Get their books, read their research, do their courses. They seem to be more "specific" in a pedantic way but i think in practice they are quite fluid in their approach.

5. Any course by Manual Concepts. www.manual concepts.com.au (?). Kim and Toby are great presenters. I have done the Mulligan courses and the 8 day certificate of spinal manual therapy with them and it changed my career. They are from Curtin University (same as Peter O'Sullivan).

I am sure there are many other great physios out there doing courses. These are the ones i know about in my tiny little corner of the world (!). But they have provided me with skills that have paid for themselves within a month, easily.

If you want to do a Masters in Australia, then University of Western Australia (UWA) does distance education combined with an on-campus 3 month semester. Curtin Uni and Uni of Qld are on-campus only for 1 year. I wouldn't go anywhere else (I am at UWA doing my masters).

Thanks for listening / reading. Please let me know how things go. I am constantly having to review this material (theory) to make sure that I add the things that I wasn't ready to learn earlier so this case study has been good for me - I hope it helps you.

Let us know - and if anyone else has any suggestions, please post them...

[wutti]

These are all really good posts, i am impressed!! and i can only aggree with most of the written stuff. however, concerning to the stiffness of pa glides, if he has a hyperlordisis in lumbar spine, the facett joints are locked anyway, because of increased shear/pressure on joints. the ab´s might be overstretched, so strengthing of all abdominals would be important.
Most important: check his Gym programm, make sure he is strengthing all muscle groups the right way, not only six pack etc., deep muscle groups and main stabilizers!!! also make sure that the hip joints have the appropiate ROM in all directions, because if not he compensates with lumbar spine.
the same for thoracic spine ROM. If stiff, his numbness of forearm may result of compensation of cervical spine.
good luck!!

[alophysio]

Hi Wutti,

I agree wholeheartedly - there are so many aspects of his treatment that i would include. However, Cat indicated that she was a fairly new physio so i didn't want to confuse matters by adding an SIJ examination that she probably has never done before.

Also, there are so many possibilities as to why someone may have increased L/S extension from the foot through to her head. I had a patient once who didn't tell me about her chronic ankle injury "because it didn't hurt". But she had decreased DF in her ankle so it changed her posture into a sway back posture...etc

For Cat: I would still try the above first. If it is not working, then start moving away from the area. This works as a general rule.

For example, I had a patient yesterday come in to see me for her intermittent medial knee pain. The area of pain was just medial to the medial border of the patella. No mechanism of injury. All ligament tests were negative. All meniscal tests were negative. ROM was normal and pain free. Walking up one step gave her the pain as did sit-to-stand. Palpation of the knee was negative as were mobes of the tib-fem, tib-fib and patellofem joints.

To me, the knee wasn't the perpetrator of the pain, it was merely the victim. There was no good reason why the knee was causing the pain. So i went to examine her hip - problems with control and imbalance of muscles. I checked her SIJ = problems with load bearing on the ipsilateral side.

Simple solution was to treat the hip and SIJ and within 10 mins of walking in, she was significantly better with a home programme of stretches for the hip and we will start core-stability work next treatment.

The moral of the story is - if it looks like a duck and it walks like a duck - it probably is a duck. If it doesn't, look for something else!

Thanks again Wutti for the encouragement and comments!

[wutti]

hi alophysio!!

your are right with not bothering with to much stuff at the beginning. my experience is thet espacially amateur athletes are often doing the *same* things wrong. no appropriate cool down and stretching after exercise. so often muscular imbalance is the main cause of skeleteal problems. but its right that any joint instability might cause problems in *far away* areas. however, i think cat will manage the problem with all these good comments.
good luck for that!!

[cafra23]

UPDATE!

Sorry it has taken me so long to get back to you, but I thought you would like to hear how things have been going with this guy.

Thank you so much for all your helpful ideas and suggestions - they have been invaluable. Having a wide variety of treatment options available helped build my confidence in my own abilities and as a result, my patients confidence and belief in helping himself.

I used Mulligans techniques to increase lumbar flexion ROM, taught pilates type exercises (partly based on those you suggested and partly on those I have learnt myself at classes) with incorporated upper and lower limb movements. I also went with him to see him in the gym, where it became apparent (despite my lack of experience in this area), that his techniques were poor and he was putting a lot of stress though his LS. With the assistance of one of the experienced Personal Trainers we were able to work on this and develop a more suitable gym programme.

As well as this, I found that he had been spending a lot of time during the day sitting slumped in a fork lift which had been aggravating his symptoms - simply using a rolled up towel helped with this.

Overall, he has reported a 90% improvement with his symptoms, and importantly has incorporated the "pilates" exercises into to his x3 weekly gym sessions.

Sorry for waffling on, but I am so pleased with the results I just wanted to let you know! Thanks again for all your advice and time, you are incredibly kind.

Many Thanks,

Catherine.

[alophysio]

Hi Cat,

Excellent work. Thanks for the feedback.

Hope everything else is going well. This patient should be one of your "success stories" that you should bring up whenever you want to feel better (believe me, sometimes you need to remember that you help a lot of people - the old one bad comment to 10 compliments rule!).

THanks again for the feedback

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