Spondylolisthesis

Introduction

• Spondylolisthesis refers to slipping of part or all of one vertebra forward on another.
• Usually associates with bilateral pars defects
• Most common in children (9-14yr of age)
• Familial predisposition. Athletes overuse injury (stress fracture) rarely progress to Spondylolisthesis
• Usually L5 slips forward on S1

Staging

1. Grade 1 (<25% slip)
2. Grade 2 (25 - 50% slip)
3. Grade 3 (50 - 75% slip) 
4. Grade 4 (>75% slip)

Diagnosis

• Present with low back pain +/_ lower leg pain
• A gap may be palpable on examination
• Lateral Xray show the slip

Management for Grade 1 and 2 slip

• Symptomatic approach
• Rest from aggravating factors
• Strengthening of abdominal and extensor + stretching Hamstring
• Manipulation and mobilisation of stiff joints above and below (should not manipulate at the level of slip)
• Can return to sports when pain free on lumber extension and 

Management for grade 3 and 4 slip

• Symptomatic management
• Should avoid contact sports and high speed sports
• If slip progress, can consider Spinal Fusion 

Spondylolysis (Fracture of Pars interarticularis)

Introduction

• Usually childhood fracture
• Usually in Lumber spine
• In sports that require episodes of Hyperextension, especially if combined with rotation. Eg; of common sports - Gymnastics, fast bowling (cricket), Tennis, rowing, dance, weightlifting, wrestling, pole vaulting and high jump and throwing activites
• Usually at opposite side of activity (that is; In right handed person, fracture is common seen in Left).

Clinical Features

• Unilateral low back pain, occasionally associated with somatic buttock pain
• Aggravated by movements involving hyperextension of lumber spine
• Occasionally asymptomatic

O/E

• Pain maybe reproduced by hyperextension with rotation of Lumber spine
• And on extension while standing on the affected leg.
• Associated hamstrings spasm may present
• Tender over fracture site

Diagnosis

• Xray - maybe normal (or) may showScotty dog appearance of a pars defect in Long stranding fracture
• If Xray Normal, SPECT scan to detect active stress fracture or stress reaction (Increase bone uptake)
• If SPECT positive - CT (reverse gantry) - to detect fracture line
• Alternatively - MRI can be used (not as sensitive as combined use of SPECT and CT)

Stages (by Radiology images)

• Early - Focal bone absorption or Hairline defect
• Progressive - Wide defect and small fragments
• Terminal - Sclerotic changes

Prognosis of healing

• Early and half of progressive type achieved radiological healing
• Terminal cases - will not heal
• L4 fracture is better change of healing than in L5

Management

• Initially - rest and avoid aggravating movment (ie; lumber extension and rotatoin)
• There is no definitely time set period for rest, use PAIN as a guide
• Rehab program - painfree progressive exercises
• When no tender locally and aggravating activity is not tender, Gradual resumptoin of the aggravating activity over 4 - 6 weeks.
• Specific exercise program training on Transverse abdominus and Multifundus (O'Sullivan et.al.)
• Core stability exercise
• Assessment and modification of biomechanics and technique

Reference: Brukner and Khan's clinical Sport and Exercise medicine

Plantar Heel pain

-          It is a poorly understood condition, characterised by pain at medical calcaneum.

-          The heel pad has been recognised as an important structure in dissipating the impusive transients associated with heel strike.

-          The effect of plantar heel pain on the morphology and mechanical properties of the heel pad, thickness of heel pad, and elasticity of the heel pad are unclear.

-          Barefoot running may change biomechanics of running pattern from heel strike to forefoot strike.

-          However, again, barefoot running is found to be associated with deformation of Heel pad.

Planter fascia – Specific stretching exercise

Proximal plantar fascitis is the most common cause of heel pain

Resolution of symptoms occurs in majority of patients within 10months.

10% of individuals could go on to have chronic pain.

Hamstring Injury

Anatomy – Hamstrings are a group of three muscles

Medially Semimembranosus and semitendinosus and

Laterally Biceps femoris, which as a short and long head  

They are known as bi-articular muscles because they cross two joints – the hip and knee, and this gives you a phenomenon known as Lombard’s paradox.

Lombard’s paradox: High knee position during sprinting, Hip extends under pull of hamstrings and Knee extends by pull of Quadriceps.  This is paradoxical since hamstrings shorten in proximal and lengthen distally. This produces tremendous straining forces within hamstrings that have to be resisted or the muscles will tear.

Hamstrings lengthen considerably during sprinting (110% of their resting length in Biceps femoris) and have to cope with considerable forces (again Force the greatest in Biceps Femoris) towards the end of swing phase. Most of the force is generated by Muscle itself but 1/3 from elastic recoil of tendon. Biceps femoris is more prone to injury and worse prognosis.

Risk factors for injury

1. -      Muscle Fatigue (eg: injuries tend to happen at second half of football season)
2. -       Lack of Race-fitness (Early season, when athletes are not fit enough yet)
3. -       Previous Hamstrings injury (usually re-injury at same spot, if no rehab is done properly)
4. -       Poor flexibility of Hamstrings or quadriceps

Muscles work in 3 ways of contraction; Concentric (shorten during loading), Isometric (same length) and Eccentric (lengthen during loading) loading.  During movement, muscle cycles between concentric and eccentric phases (so-called Stretch-Shortening cycle) If they are weak when lengthening or poor eccentric strength, they are prone to have tear during stretching phase.  For example;

1. -      Weak at end-range (lack of strength when the muscle is in a lengthened position) – prone to injury
2. -       Strength imbalance between left and right (prone to injury on weaker side)
3. -       Dominance of quadriceps strength over hamstrings
4. -       Subtle back injures – slipped disc, weak core

Prognostic factor in acute injury

1. -      Time to return to walking without pain (If <24hr, usually good px)
2. -       Medical hamstrings injury (good prognosis)
3. -       Distal injury (the more proximal, the worse prognosis)
4. -       Flexibility and strength immediate after injury SLR/Knee bending (Usually not accurate)
5. -       Size of injury on an MRI or USS scan (very accurate)

90% of injury improves in first 6 weeks, but it takes about 6 months to heal 100%. Significant risk of re-injury if poorly rehab or return to sport early.

Rehabilitation for Hamstring injury

1. -      RICE in acute phase for 24 – 48hrs
2. -       Early stretching and mobilization
3. -       Early return to brisk walking and jogging
4. -       Accelerated rehab progressions
5. -       Eccentric loading – Nordic exercise or hamstring curls
6. -       Rapid concentric loading (late stage when running 80% or faster)

Accelerated rehab programs for Hamstrings (progress to next level when pain free at previous stage

Start gentle stretching after initial rest of 24-48hf

Stage1 – Slow walking

Stage2 – Brisk walking

Stage3 – Jogging (40%)

Stage4 – Striding over 100m up to 50% of maximum running speed (10 reps)

Stage5 – Striding over 80m up to 60% (8reps)

Stage6 – Striding over 70m up to 70% (6reps)

Stage7 – Accelerate over 60m up to 80% (6reps)

Stage8 – Accelerate over 50m up to 90% (6reps)

Stage9 – Full training up to 100%

Stage10 - Race fitness

Benefits of eccentric loading

1. -      Prevents further injury
2. -       Treats injuries
3. -       Optimum length of muscle is increased – meaning athlete has more strength at end-range (when muscle is at its most vulnerable)
4. -       Studies showed that sprinting times are improved with eccentric loading

Eccenteric loading of Hamstring

Hamstring Curl

Reference The good, the bad and the painful by Dr. Leon Creaney

Fluid replacement during Endurance exercise

Marathon, 26.2-mile race, could be daunting experience for athletes.

One common medical conditions that come across during recent marathon is Dilutional hyponatremia.

Elite athletes are less likely to develop significant dehydration or over-hydration, and tend to drink less during marathons. They tend to finish slightly dehydrated (ie; 1 -2% ), which showed to be beneficial. Their fluid recommendations are geared toward providing sufficient energy for fast-paced running.

The longer a runner takes to finish, the greater risk of coming to harm from over-hydration.

Aim – To finish the race having neither gained weight through over hydration nor lost more than 2-3% of starting weight.

Sports drinks contain fluid, Carbohydrate and electrolytes. Athlete can add more glucose, sugar and salt to become their favored drink that suited their personal needs.

Fluid intake should begin from the start of the marathon and continue at a rate of 400 - 600ml of fluid per hour during competitive running.  Preferably drink according to thirst, but not to drink according to weight loss.

Carbohydrate should be provided in the form of glucose mixed with other sugars, including sucrose and glucose polymers to aid absorption, intake should be at a rate of 30-60 grams per hour. High carbohydrate concentration of CHO can impair absorption form the stomach and may cause stomach upset.

Electrolytes such as sodium, potassium and lost in the sweat, need to be replaced as well. Drinks should have 10-70mmol/L (average 30mmol/L) of Sodium and 2-5mmol/L of Potassium to match sweat losses.

Caffeine (roughly 2 cups of coffee) at least one hour before the start of the race, can help mobilizing alternative fuels, has a CHO sparing effect, and may facilitate absorption of glucose in the intestine.

To calculate own estimate sweat rate – Weight naked, run 1 hr and when return, dry all the sweat with a towel and weigh again.  Difference between the two is hourly sweating rate.

Usually replace 50-80% of this amount per hour during marathon, since the body makes water as by produce of burning fuel.

Recipe for Average sports drink

Juice crused from one orage (provides flavor and potassium)

Make up to 1 L water

30mmol of Sodium (1.74gm salt)(1/2 to one teaspoon)

30gm of glucose powder/sugar mixture

mix well

Reference: Marathon medicine by Dr. L Creaney and Dr. P Dijkstra