Spinal Injuries: Part 3
For information purposes only. Exercise at your own
risk. Always consult a doctor if you sustain an injury
Lower Back (Lumbar Spine) 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 Lower Back
Function
The function of the lower back or lumbar spine is to stabilise and support the trunk and spine, house and protect the spinal cord and allow a wide range of trunk movement (e.g., forward and backward movement and bending side to side with some rotation.)
Anatomy
Vertebrae and Discs
The lumbar spine is made up of five large individual vertebrae stacked on top of each other to form the base of the mobile vertebral column (the Sacrum is below the Lumbar spine but is fused so relatively immobile). In between each one of the vertebra is a large gel-like disc (intervertebral disc) which allow movement, help to absorb shock, distribute stress, and keep the lumbar 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. As you age the discs slowly degenerate and cause the vertebrae to get closer together causing “wear and tear” in the low back. The Lumbar spine, like the rest of the spine has two pairs of facet joints that link the vertebrae together with the one above and below. The facet joints are located at the rear (posterior) of the spinal column. It is the facet joints that help to make the spine flexible.
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 lumbar 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
There are a number of ways to develop low back pain (LBP) but in the case of most MMA practitioners we can rule out degeneration with age as by the time this occurs your training should not be in the combative arena! If you are a more senior practitioner however and you have been suffering with long standing LBP, degeneration of the lumbar spine joints may be the culprit and advice from your GP or Chartered Physiotherapist is essential if you wish to continue to train.
LBP as with all areas of the spine may be Acute (recent) or Chronic (longstanding). Acute injuries of the lower back will tend to be soft tissue injuries (STI) which covers basically everything that isn’t bone. Due to the size and density of Lumbar vertebrae fractures of the Lumbar spine are usually reserved only for falls from a great height and car crashes. Although Lumbar fractures have been reported in pro wrestling this may be theorised as being a side effect of long term steroid usage, which is know to cause osteoporosis (thinning of the bones) rather than purely a result of over zealous grappling!
Acute Injuries
The most common ways to incur acute LBP in MMA will be from spinal flexion (bending forward), lateral flexion (side bending) and/or rotation. The main cause of these movements will be grappling in standing, throws and takedowns. In the case of the Lumbar spine it may even be more likely the person executing the throw or takedown is the one more likely to become injured! Other than the impact and possible superficial bruising from being thrown the likelihood of receiving a serious low back injury from being thrown is fairly low. This all comes about because of the biomechanics of a throw. Essentially when taking an opponent down to the mat you have to control his mass (weight) and move his centre of gravity outside his base of support. If this happens he will fall down…simple. However if he decides he is going to do this back to you, then you have a problem on your hands. One of the key ways to control someone’s bodyweight is via rotation as in a hip throw or “whizzer”. If however your opponent can resist your force then the physiological stress you place on the structures of your lower back may exceed their natural strength and injury will occur. 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 rotation of the back, technique is of paramount importance.
The most common form of acute LBP injury occurring in the general population tends to be actually from poor posture and not trauma. It has been estimated that 85% of LBP is from postural dysfunction and only 15% of LBP is from actual trauma. Of the 15% suffering acute LBP from trauma most of those will have occurred from the physiological stress of excessive force on the soft tissues during flexion, lateral flexion and/or rotation.
As with all injuries LBP 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! LBP usually takes one of two general forms; the uncomplicated type with pain localised to one area and LBP that also has a component of referred symptoms into the buttocks or down into one or both of the legs. These referred symptoms may take the form of pain, pins and needles, numbness, weakness or altered sensations in various distributions in the legs.
If in the days following a back injury you have weakness, pins and needles, numbness or burning in one or both arms you need to seek advice and assessment from a Chartered Physiotherapist ASAP. If you suffer any of the above symptoms immediately following a lower back injury during training or competition or your leg(s) becomes paralysed, or there is an alteration in your bowel or bladder function, or if there is any pins and needles on your upper inner thighs then get yourself to A&E ASAP and get checked out for disc or nerve damage. Any alteration in sensation or function following a lower back injury suggests nerve involvement and although the Lumbar spine is very strong, its internal structures are very delicate and extremely important for normal function. Don’t be alarmed at A&E if they’re not concerned about X-raying your back following an injury as true disc protrusions (slipped discs) are actually much rarer than people believe. The Drs in A&E will be more concerned with what is termed your “clinical presentation” (signs and symptoms) than giving you an X-ray or MRI (Magnetic Resonance Imaging) scan. If they are concerned about your clinical presentation then they will scan you just to confirm the severity of the problem.
LBP with referred or radiating pain is known clinically as Lumbar Radiculopathy and is commonly known as “Sciatica” as it is often the Sciatic nerve that is involved. Radiculopathy occurs in specific patterns or distributions known as dermatomes. Each dermatome covers a specific area of the lower limbs (legs) and is innervated by a specific lumbar nerve and the leg pain is caused by compression of that nerve root. The diagnosis of leg and back pain starts with a detailed history of the injury and clinical examination. This compression on the nerve will usually be from a protrusion of an intervertabral disc. It is a popular misconception that you can have a “slipped disc” and that it can “pop” in and out! Due to the structure of the disc itself it can become damage by force and may bulge causing a protrusion of the disc or even extrusion of disc material into the spinal canal or press onto the nerve roots. This will usually be termed a herniated disc, ruptured disc or prolapsed disc. This protrusion may be reduced and the pressure relieved from the surrounding nerves with physiotherapy but it is not “popped” back into place. In most cases Lumbar Radiculopathy will respond to physiotherapy but in some extreme cases surgical intervention may be the only option. Remember however that due to the delicate structures of the spine and the severity of possible side effects, spinal surgery should only ever be an option when all other treatment avenues have been exhausted!
In general, with the exception of bruising all low back injuries that persist beyond 24 hours should be checked out by a Chartered Physiotherapist to evaluate the severity of the injury and advise on subsequent treatment, rehabilitation and strengthening.
Chronic
As with the neck any LBP 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. 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 LBP 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 LBP that persists, whatever the cause should be assessed and treated.
Treatment
Assessment
If you have suffered a low back injury or have LBP or stiffness then see a Chartered Physiotherapist and get the problem assessed. As always when dealing with LBP avoid the advice of mates down the pub or even in the dojo (even if they do mean well!). They can replace hips and knees but they won’t be replacing your back so 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.
Most treatment plans for the back will include manual therapy (manipulation and mobilisation), exercises (gentle bending and rotation of the neck) 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
As always one of the major goals of rehabilitation is to maintain your cadiovascular fitness levels, so for instance when you suffer a lower back injury try avoiding the continued impact of roadwork, initially try swimming instead and then progress onto aqua jogging with a flotation belt (running upright in a swimming pool without your feet touching the bottom of the pool). 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. In addition to cardiovascular fitness, 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 using progressive resistance exercises and 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). There are plenty of rehab exercises and drills that can be worked with Swiss (Physio) balls and Therabands (variable resistance elastic bands) to aid strength in both flexion and rotation without overstressing the spine. However, as with any strengthening exercise in this area professional supervision is required to ensure the correct areas are being developed in a safe and progressive way.
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
Depending on the severity of the injury, it may take several months of physical therapy for you return to full training or competition. The differing types of lower back injury makes for a wide range of recovery and rehab times. Muscular injuries may be days to weeks whilst ligament injuries often take months to rehabilitate and a disc or nerve injury may prevent a return to full MMA competition permanently even after many months of rehabilitation. 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 and in the lumbar spine permanent damage can have a huge impact on the rest of your life. The criteria for return to competition after a lower back injury include restoration of normal strength, flexibility and stability. With biomechanical problems it is important to identify the specific activity that caused the initial injury so that activity can be avoided or training or postures 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 lumbar spine injuries you may incur during MMA training and competition and a rough guide to treatment and rehabilitation principles. If you have any specific low back or spinal problems you will need to seek first hand advice, assessment and treatment from an experienced sports injuries Chartered Physiotherapist.
Check out parts 1 & 2 in this series: Neck (Cervical Spine) Injuries & Mid Back (Thoracic Spine) and Rib 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.
