low back pain

Monday, November 11, 2013

The shelf life of an NFL running back is much too short. The body is asked to absorb repeated hits and that is coupled with turf that is unforgiving on knees and ankles. The career life expectancy of an NFL player is about 6 years but running backs may or may not last that long. Last month, Houston Texan Arian Foster made news by offering fans the opportunity to buy shares in his future earnings, but that was forever ago and now his stock is dropping because of planned season ending back surgery for a bulging disc.

Mr. Foster joins the 40% of the American population who suffer from low back pain. Most often it is because of a pulled muscle and the pain resolves with a little time and TLC. But sometimes, the cause of the pain is damage to one of the structural elements of the back and surgery may be required. It is rare that surgery is emergent and often, an operation is planned when other options like physical therapy, chiropractic care and medication injections fail.

The spine is made up of stacked vertebrae that are supported by muscles and ligaments. In between the bones lay the discs that act as shock absorbers to cushion the force of walking, running, jumping and twisting. The vertebrae also protect the spinal cord and the nerves that enter and leave, transmitting signals to and from the brain. Over time, because of age or due to trauma, the spine can degenerate and arthritis can set in, limiting the function of the back to move and to absorb the shocks of daily life. This may cause the muscles and ligaments to become inflamed but it can also cause the discs to bulge or rupture.

spinal disc

While the damaged disc can cause pain because of the local inflammation of the injury, the potential complication is that the disc can irritate a nerve root as it leaves the spine. In the lumbar spine, the low back, these nerve roots come together to form the sciatic nerve and the pain can radiate into the buttock and down the leg causing significant distress. The disc can also bulge and press back into the spinal canal where the cord is located and press on the cord, causing the pain and numbness to be felt in both legs.

bulging disc

The initial treatment remains the same for most patients but when muscles begin to weaken or reflexes are lost, an urgency exists to consider surgery to relieve the pressure on the nerve root or spinal cord. This progresses to a true emergency if the ability to urinate is lost and the patient becomes incontinent of stool, a condition known as cauda equine surgery, and if there is hope for the spinal cord, surgery needs to be done within hours.

Arian Foster’s medical course seems to be following the urgent, non-emergent course.  His back pain has been diagnosed as a bulging disc and he is seeking opinions as to when it is best to have an operation. He may opt to have surgery sooner than later because he is reaching the halfway point of his NFL career and may not want to spend months waiting to see if therapy may work. Add to the equation is that his job is not sitting at a desk or standing in front of a classroom, it is being hit by 300 pound linemen who do not care that he has a fragile low back.

For most people, ice, heat, over the counter anti-inflammatory medications and activity as tolerated is the mantra to healing low back pain. Better yet is maintaining good back health by keeping weight under control, working on abdomen and back core strength, stretching to maximize flexibility and using proper lifting techniques. Unfortunately for Mr. Foster, he and his running back fraternity, are not like most people.


Illustration attribution: webmd.com, denverchiropractor.com

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heads, backs and bones

Monday, October 28, 2013

This week touches base this week on a couple of medical items floating through the sports world.

Josh Freeman, the concussed Minnesota Viking, didn’t get much love from NBC analyst Rodney Harrison, who questioned the diagnosis, the recovery time and the general will to play of the injured quarterback. Freeman. Harrison tweeted: “I played safety at a high level for a long time and I was bangin’ and I never missed a game because of a concussion so it just seems like an excuse to me.”

As we learn more about traumatic brain injury, its symptoms and healing, Harrison’s stance is just wrong in too many ways. The first lesson to learn is that the diagnosis of concussion is often missed because the player may not recognize that the brain has been shaken. Symptoms can be delayed by hours or days and may be very subtle. Symptoms may include difficulty with concentration, studying and processing information, sleep disturbance, headache and difficulty tolerating sound and light. School performance may suffer and it may take months for grades to recover. The second lesson is that there is no test to confirm that a concussion has occurred and there is no test that can say that the brain has healed completely.

Harrison may be trying to be old school where a player would rub some dirt on an injury and get back on the field no matter what. Instead he fails to appreciate that the decision to keep Freeman on the sideline was made by the team medical staff and it is an important message that the pros send to young players. High school players share the same drive to compete and on any given Friday night, trainers can be seen taking away a concussed player’s helmet to underscore the importance that their brain is more important than any game.

Every little leaguer dreams of playing in the World Series. How disappointing for Shane Victorino to be so close and yet have to sit on the bench because of low back pain. The muscle strain that has bothered him most of the year flared to the point that he could not perform and he joins the millions of Americans who suffer with low back pain. At least 40% of people will suffer an episode of back pain in their lifetime. Too often, the cause is never found and in fact, it is rarely sought. Most low back pain is due to mechanical abnormalities in the muscles and joints and resolves with time and supportive care. Arthritis of the spine, degeneration or rupture of disks and osteoporosis are causes that increase with age. Infections and tumors are rare. Diagnosis and treatment often depend upon history and physical exam.

While pro athletes are routinely Xrayed, CTed and MRIed, regular patients tend to be treated with high touch instead of high tech. Initial treatment with rest, ice and anti-inflammatory medications can be supplemented by exercise, physical therapy and chiropractic care. The lesson to be learned from the athlete is that once a back is injured, the next occurrence is to be feared and preventive measures are key. Core strength training, balancing the muscles of the abdominal wall with those of the back, is supplemented with stretching and flexibility. Perhaps most important is paying attention to back symptoms and learning when it is completely healed and ready to return to work or play. Mr. VIctorino has struggled with back issues all year and his decision to play through the pain put his World Series dream at risk.

Regardless of what the NFL says about Denver Bronco’s Peyton Manning high ankle sprain, this injury does not affect the ankle. Instead, it is an injury to the syndesmosis or interosseous ligaments that attach the tibia and fibula in the lower shin. (inter=between + osseous=bone). The damage occurs when there is a twisting injury to the leg on a planted foot with the damage occurring well above the ankle joint. While the swelling and tenderness tends to be higher than the ankle joint, there can be associated ankle ligament damage that may confuse the diagnosis.

Ankle sprains are very common, presenting most often with swelling and tenderness on the lateral or outer side of the ankle joint. They tend to heal with rest, ice, compression and elevation. Syndesmotic injuries may heal with that care as well, but there is the risk of instability surgery may be required to drill a screw that keeps the tibia and fibula tethered together. These injuries can take months to heal and rehabilitate and are definitely not the rolled ankle from the Y pickup basketball game.

This is the same Peyton who survived four neck surgeries and has returned to all-star form. Perhaps the NFL is right and his is just a sprain.

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