Firebird WRler

Injury Clinic
1

Judging by many of your posts I am under the assumption that you may be able to share some insights regarding connective rehabiltation.

In your experience, what type of active/passive recovery methods are available/effective for the rehabilitation of a sprained interspinous ligament in the L5 region with pain referring downward over the sacrum.

I orginally irritated the area over year ago when performing reactive squats. I went to a sports med ortho, had CT scan which showed no structral damage to discs etc. I basically avoided performing lifts which caused pain and within a few months I was lifting without pain in lifts which heavily load the low back (GMs, DL’s, etc).

The better part of a year later I reinjured the area, only this time during the concentric portion of a conventional DL, just as I neared lockout. This time I had access to an ART guy, and after a few visits we determined that there was not much being accomplished as the ligament was not very responsive to the manipulations.

I was fortunate enough to have Allen Degenaro take brief look at me and he determined that my piriformis and or hamstring origins were tight, as my pelvis posteriorly rotates when descending past the half squat position, thereby creating excessive stretching of the connective tissues in the L5 region on down.

Aside from performing various flexibilty protocols for piriformis and hamstring origin points are you aware of any direct rehab methods that I may utilize for the interspinous?

Thoughts are appreciated.

2

This will basicly come down to a strengthening issue. The piriformis and biceps femoris muscles are most likely tight due to the original injury and “favoring” that injury. Did you do any therapy for the original injury, or did your ortho suggest letting it heal on it’s own?

The problem with the back is that it is so complicated and there are so many crucial structures (such as spinal nerves) that you must take into account with rehab. The muscles along the spine have three functions, with one function being more important than the previous. First, they move the torso (twisting, extension, etc.). Second, they provide support to the body during dynamic actions. And third (and most important), they provide the majority of stabalization for the spinal column during motion. If the spinal column is in any danger, the spinal muscles tighten up and make the spine as rigid as possible to prevent serious injury.

The whole point to my long ramble is that strengthening the paraspinal muscles is paramount for any low back injury. The GM’s and straight leg DL’s the back remains straight and the paraspinals are used isometricly. During a traditional DL, however, the vertebrae are flexed in conjunction with the weight distribution. If the paraspinals where not able to handle the load dynamicly, this is most likely the cause of the second injury.

Unless the ligament shows tightness from scar tissue, I strongly suggest against manipulations. Stretching a normal range ligament to a loose range will predispose that ligament and joint to further injury. If the ligament is loose due to the injury and the healing process/ rehab, then musculature becomes the key factor (as it seems to be in your case). Using back extension exercises will work wonders for these types of cases. Remember not to push the load too quickly. Triggering a muscle spasm can easily set you back.

If you have anymore questions or would like me to go into a little more detail, I would be happy to oblige. Sorry about the long post.

3

I appreciate the response, I should have noted that I do have good understanding of the functions of the low back musculature, however, I do appreciate the time you took to illustrate this.

The inhibition that you refer to, as the GTO/muscle spindle complex fires at the onset of possibility of imminent injury, is something that I have been consciously battleing.

I recently tested where I was at on my pin 3 DL. My previous PR is 625. I went up to 500 without a belt and felt the slightest twinge. I then proceeded to 550 with a belt and as soon as I began to pull I felt as if something was going to go, so I backed off as I felt the musculature shut down. The strength is there, as I have been performing many special exercises which do not cause pain (reverse hypers, back extensions, band GMs, light GMs, pull throughts, etc) however, there is obviously still a particular pathology which is triggering the protection response.

I am comforted that you have outlined what I have already been intuitively performing (eg numerous relatively low load back extension lifts)

I do know, however, (and in hindsight) feel that the tightness in the biceps femoris and piriformis has actually been there for many years. Which certainly predates the original injury.

I do appreciate the detail. Please continue to go deeper if you are willing to do so.

Again, I do have a solid working knowledge of anatomy/physiology/kinesiology/biomechanics, etc. What I seek and am in great appreciation of is your practical experience with such rehabilitative matters.

Much appreciation

4

One thing still bothers me about your original post. What kind of manipulations was the ART practitioner using? Did the ligament show adhesions and limit your ROM? How is your hip girdle strength? Are you experiencing numbness, tingling, or pains shooting down your leg?

After rereading your post, I see that the muscle tightness possibly caused the original injury. Are you experiencing bilateral tightness? What other injuries have you had to the hip, knee, or lower leg? There may be an underlying cause to the musclular tightness, which in turn caused your injury. Until you determine the cause of the original problem, you may continue to go around in circles. do you have any leg-length discrepancies, anatomical abnormalities, functional abnormalities, etc.? Do you experience pain with the valsalva maneuvre?

Have you tried any PNF strategies for flexibility? Is this a dynamic or static flexibility issue (or both)? Have you tried therapeutic ultrasound using a very low frequency and a non-thermal setting?

Sorry about all the questions, but it’s hard to give good advice without obtaining a good history of the problem first.

5

James, I know you directed the post to Firebird, but if I may I’d like to ask you, how do you know you have a sprain to the interspinous ligament in the L5 region? Was this evident on the CAT scan. Why a CAT scan not an MRI?

Thomas

6

The practitioner isolated the accute area from which the pain originated and then by applying manual pressure he ran me through various spinal articulations from a seated position to include:

deep flexion
lateral flexion
rotation
transverse rotation

again, all from a seated position.

The only instance in which I felt pain was when descending past a certain degree of extreme flexion in the sagittal plane, as this is obviously an articulation of extreme stretch to the low back.

My hip girdle strength is strong and I do not experience and pain referring in any direction. The pain is very accute/localised to the area of injury.

I do experience tightness bilaterally in the piriformis and biceps femoris, although the tightness in the piriformis on my left side is slightly more pronounced. Also, I tend to feel the pain in the L5 area slightly to the right of the spinal colum.

I have not experienced any remarkable prior injury to hip, knee, or ankle.

No anatomical or functional abnormalities which affect gate or articulation of any joint complex.

I do not feel pain when performing valsalva although when seated or standing I do feel some pain when I draw in and posteriorly rotate at the pelvis.

I have personally initiated some PNF patterns and passive maneuvers. The reduced flexibility tends to express itself both under static and dynamic conditions.

I have not utilized any ultrasound or EMS measures.

My limited flexibilty in the known muscles has never presented a problem in the weight room until I sustained the first injury last year. I have been weight training since 1988. My muscular development is favorably proportioned as well as my strength levels in extensor and flexor chain movements, as this is a dyamic which has been important for me for many years.

An idea of my agonist/antagonist strength capabilities:

parallel box squat (belt only) 500 3x1
full squat (belt only) 405 although it is important to note that I never perform this lift and this was over a year ago
parallel squat (no belt) 405x3, again a lift which I rarely perform
SS bar parallel box squat (belt only) 450x1
Conv DL off of 4 inch platform 500x2
Pin 2 sumo DL 605
Pin 3 sumo DL 625
GHR with 100lb plate held against chest for 6-10 reps
bent over GM (no belt) 275 for reps
bent over GM (belt) (340-360?)x4
pin GM from just above waist high 400x1
reverse hyper (Louie’s) 10 plates for reps
45 degree back raise with 135 on back for reps
Bulgarian split squats with 100lb dumbbells for sets of 5

As you can see I have completely mediocre strength levels, yet no glaring deficiency in any particular area

All of this is at a bodyweight of 235-240 at 6’1’’
I am 31 and lift ‘clean’

I fully appreciate your need for as much information as possible and I greatly appreciate your time.

7

Thomas, thanks for your interest.

The chiro/ART guy determined that my interspinous was the site of injury.

The scan was peformed after the first injury and this was the decision of the head orthopedic surgeon for the San Diego Chargers. The scan showed no damage what so ever, so the ortho simply advised me to perform various core strength endurance protocols. He said this after having me perform a single leg hip pop up and noticed a small dip at the hip flexor when I attempted to hold myself statically.

Thomas, I sent you an email.

8

I’ll start by saying that I don’t believe that those strength indicators are mediocre at all. I’m actually quite impressed.

Did you experience any problems once back to full strength from the first injury? How severe was the original tear? Did you perform any high intensity workouts before reinjury (was the back fatigued)? What type of progress has the flexibility training yielded?

Was the second twinge in the same place as the first (may sound like a stupid question, but got to ask just in case)? Was the pain the same as the first? How close are you to being back to 100% since the second injury?

9

Appreciated, yet if you view my levels from the standpoint of an elite powerlifter or master of sport weightlifter, of the same weight division 110kg, then you would correspondingly view my strength indicators as mediocre.

  1. no
  2. actually not sure if there was a tear at all, as the CT scan showed nothing and I did not have an MRI
  3. Yes, and yes I believe the reinjury was absolutely a result of fatigue. I have yet to have sustained a training related injury that, in my view, was anything other than a result yielded from my stupidity in the weight room
  4. I have not been consistent enough with the flexibility training to warrant an informed consensus
  1. very close (L5 area) yet not exactly the same. the second twinge felt a little right of the spinal column while the first (if memory serves) felt completely centered
  2. again, similar, yet not entirely the same. The first injury resulted in the half squat position, during the fast descent into the half squat. The second injury occured very near lockout of a conv deadlift
  3. not even close as I am unable to confidently, or pain free, GM or DL any where near my previous maxes. Again, the strength is there but I am not willing to push it in fear of reinjury.

Due to certain circumstances I have been without medical insurance for the last nine months. I will, however, be back in line come the first of May. I will then have an MRI performed in order to get a more accurate assessment of my particular pathology.

After speaking with Thomas on the phone, I am now unsure as to whether the interspinous is the root of the problem. Again, the chiro/ART guy was the one who diagnosed the interspinous, not a radiograph. Accordingly, I wish to have the MRI provide an understandably more accurate and possibly all together different diagnosis.

Again, much appreciation for your time.

10

From all the info that you have given, it sounds like the original injury was the ligament, but the second sounds like one of the paraspinals. You need to go back to rehab mode as far as the back goes. Back extensions, superman twists, flexibility training, ems, ultrasound, etc. would be the way to go. Take care of the flexibility so that problems do not persist. Why did the ortho not do the MRI the first time? I understand the CT scan, but I just figured that they had done the MRI first.

Good luck, and I hope I was able to help a little.

11

Hi!
I have no idea where you are with your posts, but when I saw the original one, I sent it to a friend of mine -trying to get to the forum still, so I’ll just cope/paste the response. I hope it adds something!

"Problem area:
Supraspinous / Interspinous Ligament (4, 5, LS) connects the tips of the vertebral spinous processes together, and also connects the lowest vertebra (L5) to the sacrum. These ligaments are important in limiting the degree of forward flexion in the spine. Can be sprained during lifting injuries.

Initial Treatment:
A diagnostic ligament injection is first performed with local anaesthetic / steroid. If the ligaments are the cause of the backache, then there is usually a dramatic reduction in pain afterwards for usually 2-3 weeks, the backache returning to its normal state afterwards".

From 2nd email:
"To be fair nobody could give a rehab. regime without having tested specific things so as to establish the following:

  • The mechanism of injury with an exact description of the event leading to the pain
  • The exact localization and duration of the pain
  • Any pain radiation
  • Movements that aggravate or minimize the pain

After the latter have been accomplished, tests would be carried out and these would be:

  • With the patient in a standing position, evaluate for obvious deformities, changes in alignment, or difficulties in achieving changes in position or full ROM. Evaluation of these signs may provide clues to muscle spasm and activities that worsen the pain.

-Palpation of painful area: Palpation, performed with the patient in a prone position, helps reveal the area and the size of muscle spasm(s) and the location of any point tenderness if present. A point-specific midline back pain between the spinous processes indicates a ligamentous injury or lumbar interspinous bursitis (kissing spines).

-Neurologic examination: Evaluation of lower extremities should include a motor examination, a sensory evaluation, and reflex testing at the knees and ankles. The straight-leg raising test helps evaluate disk involvement, sciatica, or a neurological deficit(but in this case you ve cleared that there is no disc involvement with the MRI). A positive Patrick test points to a sacroiliac joint inflammation and should be negative in lumbosacral sprains and strains.

  • Your type of injury is fairly common in most in athletes while lifting weights during their training sessions or while performing unexpected coupled motions (eg, lateral bending and flexion, lateral bending and axial rotation). During the aforementioned activities, tremendous loads are placed on the lumbar spine, which may cause a temporary instability with a subsequent injury to the soft tissue surrounding the spine.

Risk factors for low back injury include the following:

  • Muscular imbalances or weaknesses of abdominal and posterior spinal muscles may constitute a risk factor to sustain an injury.
  • Deficits in the afferent or efferent pathways or proprioceptors are known risk factors for spinal soft tissue injuries.
  • Preexisting structural deformities, such as scoliosis, spondylolysis, or spinal fusions, may predispose to an injury. Preexisting injuries make athletes more vulnerable to sustain reinjury of the same area, which is the sort of case in this occasion really…

I would also ask whether you have been prescribed with any medication and what sort of…e.g.:painkillers, anti-inflammatory?? Do you take them?

And I would certainly not look at it solely as an infraspinous lig prob… I would engage you to a more holistic approach, e.g., not only increase the flexibility of hamstrings but what about quadriceps which act as antagonists when you, for instance, flex your knees…

I would also definetely cut down weights, if possible… You dont want to risk it… Spine is a difficult area to deal with… I would do flexibility exercises for all muscles to create a good balance maybe strengthen your abs and trunk muscles so that you can maintain a good posture, which will be able to tranfer the load efficiently and effectively when in need to… But I couldnt prescribe sth more specific than that to be honest, as I would need to test you myself…"

Also, keep in mind that your posts haven’t been seen by this person…
Let me know…

12

I am unsure as to why the ortho did not suggest an MRI the first time. I will, however, have one performed within the next couple of weeks. Better late than never in this unfortunate case.

Thanks very much for your insight.

13

Nikoluski, thanks very much for forwarding my information and to your friend for providing such a detailed response.

Much appreciated.

14

Nikoluski, your post is full of great information.

The injection with corticosteroids are usually one of the last resorts for athletes. Though they may be a quick fix for pain, athletes should wait about 2 weeks after thye injection to return to full participation. This is because the steroid breaks down connective tissue so that it can build back up stronger.

This is right on the money. That is why I asked as many questions as I did. There is no way that I could fully prognose his injury without a hands on evaluation.
Thanks for the input and advice!

15

Firebird, I fully appreciate the requirement for hands on assessment, and certainly view this to be the most optimal evaluation under the majority of conditions. I, however, belive (and I am confident you would agree) that many individuals who comprise a vast majority of all these related professions, and certainly in the states (AT,PT, S&C, etc) are mediocre at best. For this reason, I have no hesitation in corresponding, via this medium, with individuals who I view to be of the upper echelon in their respective fields in order to further my understanding and perception of the related topics.

I have simply encountered far too much incompetence at the professional level all the way up to the MD/PHd level. Accordingly, given my proficient understanding of various physiological regimes, I am able to effectivley benefit from, and assimilate, the insights of individuals such as yourself and Thomas and the information provided by Nikoluski, without the advantage of a hands on evaluation.

I have no hesitation in stating that I have usefully assimilated more from the discussions I have had with you on this post, Thomas on the phone, and Nikoluski’s contribution, (concerning this particular pathology of mine) than I have after having personally received consultation from various medical professionals over the past year.

Mediocrity is far too commonplace.

Thanks again to all who have contributed to this thread.

16

I couldn’t have said it better myself. If you check out the “chiropractors” thread we hit on this topic pretty hard. Unfortunately I have met quite a few dumb doctors, but they still have the God complex and think they have all the answers.

Again, good luck with the rehab and keep us posted.

17

Just to re-state that the comments provided in my post were not mine.

I’ll FWD all comments/posts and if something is worth adding, I’ll let you know!

Good luck!