Spinal Injuries: Part 2
For information purposes only. Exercise at your own
risk. Always consult a doctor if you sustain an injury
Mid Back (Thoracic Spine) and Rib Injuries
by Jon Hobbs MSc MCSP SRP
In this series of 3 articles we will be taking a look at the most common spinal injuries that can arise from both MMA training and competition. Due to the structure of the spine and the nature of spinal injuries we shall divide the spine into its three natural anatomical areas; the neck (cervical spine), the mid back (thoracic spine) and the lower back (lumbar spine).
The Mid Back
Function
The function of the mid back or thoracic spine is to support the trunk, form the rear of the rib cage, create attachments for the trunk muscles for movement and respiration (breathing) and protect the spinal cord. Due to the fact that the ribs attach to the thoracic spine movement in this region is limited to some degree.
Anatomy
Vertebrae, Ribcage and Discs
The thoracic spine is made up of twelve mid-sized vertebrae stacked on top of each other to form the midsection of the vertebral column (between the cervical and lumbar spines). Attached to each of the twelve thoracic vertebrae on each side is a rib making twelve matching pairs (Contrary to popular belief you don’t have a spare one!). The ribs curve from the spine towards the front of the body and join at the breast bone (sternum) at the front of the rib cage. The ribs form a joint with the thoracic vertebrae and have cartilage at the sternal end to allow movement during breathing. The purpose of the ribs is to form a protective framework for the lungs, heart and other vital organs. Attaching to the top of the sternum on the left and right and running to each shoulder are the collar bones (clavicles). The clavicles form a joint with the shoulder blades (scapulae) on each side forming the only bony connection between the trunk and the upper limbs (arms).
In between each one of the vertebra is a wedge shaped gel-like disc (intervertebral disc) which allow movement, help to absorb shock, distribute stress, and help keep the thoracic spine in correct alignment. The discs have a gel like interior with a fibrous outer coating which allows them to deform under stress and absorb huge amounts of force through daily life. The thoracic spine, like the cervical spine also has facet joints that link the vertebrae together with the one above and below. In the thoracic spine the facet joints are more suited to rotation than bending forward or backwards.
Muscles, Tendons and Ligaments
Surrounding the bones and discs are a complex system of ligaments, tendons, and muscles which help to support and stabilize the thoracic spine. Ligaments are inelastic bands of fibres that prevent excessive spinal movement that could result in serious injury. Tendons attach the muscles to the bones and the muscles control movement as well as providing stability and balance.
Central and peripheral nervous system
The movement of the muscles is controlled by nerve impulses that originate in the brain and are sent via the spinal cord to the nerves of the body. The spinal cord is situated in the centre of the spine or spinal column is a vertical channel called the spinal canal. The bones that create the spinal canal serve as protection to prevent injury to the cord itself. Through spaces between each vertebra small nerve roots branch off from the spinal cord and extend out into the entire body. The nervous system itself is split into two major regions: the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS consists of the brain and spinal cord whilst the PNS consists of the nerve roots and all nerves beyond the central spinal cord. The CNS and PNS are responsible for all movement in the body. As the spinal cord is a major part of the CNS and the vertebral column houses and protects the spinal cord the spine is an area you want to avoid injuring at all costs!
Injuries
The majority of problems occurring in the thoracic region in MMA practitioners will be from impact. There are a number of congenital (born with) disorders of this area that can show up later in life but they are beyond the scope of this article. Thoracic spine pain as with all areas of the spine may be Acute (recent) or Chronic (longstanding). Acute injuries of the mid back will tend to be soft tissue injuries (STI) which covers basically everything that isn’t bone. Due to the size and density of vertebrae fractures of the Thoracic spine are usually wedge or compression fractures that occur with falls from a great height.
Acute Injuries
The most common ways to incur an acute STI of the thoracic region in MMA will be from excessive rotation under stress or from direct impact. Direct impact to the thorax usually occurs in MMA whilst on the ground though it can occur also in the clinch in standing or from stand up strike range and also as a result of a throw. Generally the further away (kicking range) you are when you strike your opponent in the ribs the greater the potential force you can generate is but the closer in you are (guard position) the less force you can generate but the frequency with which you can land a clean strike is much higher. Injuring the ribs or intercostals muscles (“between ribs” muscles) will affect your opponent’s ability to breathe deeply by causing pain on movement of the rib cage. The harder you breathe the greater the movement of the rib cage, the more trauma of the ribs and intercostals there is the less your opponent will want to deep breath. Without sufficient air going into the lungs he (or she) will fatigue….and as you know “Fatigue makes a coward out of anyone!” If you yourself receive an injury in this area don’t hold your side whilst fighting as your opponent will be relentless in their pursuit of your pain! As the old boxing adage goes ”Kill the body and the head will die!” If an injury occurs in training, stop immediately and get it checked out by your GP and/or Chartered Physiotherapist. If it occurs in competition and you’re struggling it’s better to throw in the towel and return to competition within a month or so than have your ribs broken even further and risk puncturing a lung and ending your fight career altogether. On impact, ribs will give and spring back but a direct blow with enough force or repeated blows to that area may break (fracture) a rib but it will usually remain intact. Repeated blows to a fractured rib however may cause a flail segment (loose piece of broken rib) to occur and puncture a lung causing a pneumothorax collapsing that lung. Damage to the ribs may also occur when landing bbadly from a throw.
STIs to this area will usually occur whilst rotating during a throw or in the clinch and is usually uncomplicated and limited to one specific area. With the adrenalin of competition or intense training these injuries may not be felt until later on or even the next day. As with the Lumbar spine this sort of injury is more likely to occur as you fatigue as a fight progresses or at the end of a gruelling training session. That’s why when performing any strenuous movements that rely on the back, technique is always of paramount importance.
Another common area for STIs in the thoracic region is the mid back between the spine and inner side of the shoulder blades (medial border of the scapula). Here the deep stabilising muscles of the scapula are often injured or become over stressed as a result of poor biomechanics of the shoulder or poor neck postures. As a huge majority of neck pain is posture related problems in this area are extremely common. As always any back pain is not there to be trained through, pain is your body trying to tell you something and it’s usually something you should listen to! If in the days following a mid or upper back injury you have referred pain, pins and needles, numbness or burning to another site on your body then you need to seek advice and assessment from a Chartered Physiotherapist ASAP. If you suffer any of the above symptoms immediately following a mid or upper back injury during training or competition you need to stop and seek appropriate advice. Due of the location these problems they are very rarely serious but are very often persistent and usually require some encouragement (physiotherapy) to get rid of.
Chronic
As with the neck and low back any mid or upper back pain that has been around for more than a few weeks or has occurred without any injury (insidious onset) will often be biomechanical in origin. This means postural i.e. the way you sit, stand and move about. As stated previously, in MMA most practitioners are amateur and not pros so they have to work for a living at something else during the day. I’ve said this before but I’ll say it again because it’s that important, 40 hours at a desk, sitting in a van or working over a bench will give you a back problem in no time at all. Underlying mid or upper back pain like this may soon start to impact on your training if not remedied, although some may actually go away when training only to return again at rest. If that is the case then the problem will most usually be postural. Again, any mid or upper back pain that persists, whatever the cause should be assessed and treated.
Treatment
Assessment
If you have suffered a mid or upper back pain then see a Chartered Physiotherapist and get the problem assessed. I’ve said this before as well but I’ll keep on repeating it until everyone is clear on the matter, when dealing with any back pain avoid the advice of mates down the pub or even in the dojo (even if they do mean well!). It’s important you look after it correctly and get it treated properly 1st time around. Assessing the problem correctly is paramount to successful treatment. Remember that the same as elsewhere in the body pain is a symptom and not actually a diagnosis!
Treatment
As with all uncomplicated STIs, PRICE(MM) is the favoured approach. The Protection, Rest, Ice, Compression are fine although Elevation is not really practical. Medications and Modalities (physical treatments) should be sought from your GP or Chartered Physiotherapist if the pain persists more than a few days.
If pain from the injury persists beyond 24 hours it’s a good idea to start to increase the movement in that area gently. This can be done with a few, gentle range of movement exercises.
1) Lie on your back with your knees bent and your feet flat on the floor.
Gently rock your knees from side to side.
Increase your range of movement until the side of your right leg reaches the floor.
Repeat this movement to the left.
Continue to repeat this movement for ten repetitions each side.
Try to keep your head and shoulders flat on the floor and remember to breathe gently throughout the exercise.
2) Lie on your back with your knees bent and your feet flat on the floor.
Take hold of your knees in your hands and slowly pull them up towards your chest.
Hold them to your chest for a count of five seconds then slowly return them to their starting position.
Continue to repeat this movement for ten repetitions.
Try to keep your head and shoulders flat on the floor and remember to breathe gently throughout the exercise.
3) Lie flat on your front with your hands palm down on the floor underneath your shoulders.
Slowly straighten your arms so your head and shoulders rise up from the floor.
Keep your low back relaxed so it begins to arch backwards as you straighten your arms and rise up.
Keep the back relaxed (it’s not a press up) and remember to breathe gently throughout the exercise.
Slowly lower yourself down and return to lying face down on the floor.
Continue to repeat this movement for ten repetitions.
For fractured ribs take the immediate advice of your GP or Chartered Physiotherapist regarding returning to training but other than rest and strapping there is very little that can actually be done.
Most treatment plans for the back will include manual therapy (manipulation and mobilisation), exercises (gentle bending and rotation of the neck and back) and modalities such as electrotherapy (ultrasound) or acupuncture (for pain and inflammation). All these treatments however are injury specific, so again assessment is very important.
Rehabilitation
With the exception of rib or intercostal injuries the injuries in the thoracic region don’t tend to impact too much on training. The problem is though they do impact on deep breathing and so they can limit cardiovascular (CV) training. As a result your level of CV training may need to be reduced as will your level of physical contact although some light training may be beneficial. As always each case is individual so take the advice of your GP and Chartered Physiotherapist. With any injury, you, your coach/trainer and your physio should work together at devising alternative training programmes as soon as possible particularly if you are a competitive fighter. If your CV training is effected you may use the injury period as an opportunity to strengthen weaker areas whether they be physical, mental, technical or tactical. Your physical rehab plan should include exercises to restore normal strength and full range of movement using progressive resistance exercises and stretching then continue to further develop strength in that area to protect it from possible future injury. In addition in the later stages rehab you should include some combat-specific drills (with an emphasis on proper technique). It must also be appreciated that the power, speed and angles which occur during competition may far exceed the criteria for successful completion of rehabilitation exercise. To be ready for competition you must perform over and above what you are required to do in competition.
Return to Training/Competition
If you have incurred a rib fracture or injury, it may take several months of physical therapy for you return to full training or competition. Muscular injuries may be days to weeks whilst rib or joint injuries often take months to rehabilitate before you make a return to full MMA training/competition. As always two key factors exists for return to full training/competition; firstly the risk of re-injury and secondly the ability to fight/perform at a satisfactory level. These factors are often intertwined. When there is a risk of re-injury, the potential for further or permanent damage must also be considered. The criteria for return to competition after a thoracic or rib injury include restoration of normal strength, flexibility and mobility of the ribs when deep breathing. With postural or biomechanical problems it is important to identify the specific activity or posture that caused the initial injury so that activity or posture can be avoided or modified. Avoidance steps may include changing technique, training habits, and equipment, and modifying posture and ergonomic practices at home and at work as well as during training.
This is just a brief outline of the mid, upper back and rib injuries you may incur during MMA training and competition and a rough guide to treatment and rehabilitation principles. If you have any specific problems in this area you will need to seek first hand advice, assessment and treatment from an experienced sports injuries Chartered Physiotherapist.
Check out parts 1 & 3 in this series: Neck (Cervical Spine) Injuries & Lower Back (Lumbar Spine) Injuries
This article is for the purpose of information only and it is not intended to diagnose or treat medical conditions and is not considered to be a substitute for individual medical assessment and advice.
