The following article is a follow up to Spinal Stress Fractures and Running - Part 1 and will explore a functional approach to preventing Spondylolysis and Spondylolisthesis. Preventing lower back injuries that could progress to more common running injuries should begin with proper and well orchestrated flexibility and strength training programs. The following should be emphasized:
- Trunk and muscular flexibility (specifically the paraspinal, hamstring and gluteal muscles)
- Improving range of motion
- Strengthening the erector spinae muscles
- Strengthening the abdominal muscles
- Learning and implementing proper neutral spine position for training and daily activities
Unfortunately, most back pain is still caused by trying to do too much, too quickly, too often. Simply reminding the athlete (or coach) to gradually increase the work load associated with progressive strength development can have tremendous preventive effects. Proper periodization principles with emphasis on recovery based training and prevention of overtraining should be the cornerstones of a triathlete’s training program.
As eluded to previously, along with proper progression and periodization principles, a sound flexibility and strength training program are crucial to preventing or recovering from spondylolysis or spondylolisthesis. If a more common running injury such as piriformis syndrome develops as a result of these lower back issues, the athlete may only treat the secondary injury rather than treating the source, thereby progressing the injury to a worse degree.
The foundation of a sound flexibility and strength program is to understand and implement neutral spine position and proper core strengthening.
Management and prevention of back pain begins by understanding the neutral spine position. Three natural curves are present in a healthy spine. The neck, or the cervical spine, curves slightly inward. The mid back, or the thoracic spine, is curved outward. The low back, or the lumbar spine, curves inward. The neutral alignment is important in helping to cushion the spine from too much stress and strain.
The natural curves of the spine are the result of the muscles, ligaments and tendons that attach to the vertebrae of the spine. Without these supporting structures, the spine would collapse. They support the spine much like guide wires support the mast of a ship. This guide wire system is made up mainly of the abdominal and back muscles. The abdominal muscles provide support by attaching to the ribs, pelvis and indirectly to the lumbar spine. The muscles of the back are arranged in layers, with each layer playing an important role in balancing the spine. By using these muscles together, it is possible to change the curves of the spine.
Controlling pelvic tilt is one way to begin helping athletes balance the spine. As certain muscles of the back and abdomen contract, the pelvis rotates. As the pelvis rotates forward, the lumbar curve increases. As the pelvis rotates backward, the curve of the low back straightens. Rotation of the pelvis is like a wheel centered at the hip joint. The muscles of the upper thighs also attach to the pelvis, and contraction of these muscles can be used to change the curve of the spine.
The abdominal muscles work alone or with the hamstring muscles to produce a backward rotation of the pelvis. This causes the slight inward curve of the low back to straighten. If these muscles cause the curve of the low back to straighten too much, this may produce an unhealthy slouching posture.
In the other direction, as the hip flexors contract and back extensors contract, the pelvis is rotated forward, thus increasing the curvature of the lower back. If this curve is increased too much, another unhealthy posture may result, termed lordosis.
A balance of strength and flexibility is the key to maintaining the neutral spine position. This balance is the basis for optimal muscle function. Like a car, an imbalance may lead to wear and tear, eventually damaging the various parts.
Muscle imbalances that affect the spine have many causes. One common cause of muscle imbalance is weak abdominal muscles. As the abdominal muscles sag, the hip flexors become tight, causing an increase in the curve of the low back. This leads to the swayback posture mentioned above. Another common problem results from tight hamstrings. As the hamstring muscles become tight, the pelvis is rotated backwards. This produces an abnormal slouching posture.
The aim of core stability training is to effectively recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements. The deep muscles of the trunk include the transverse abdominis (TA), multifidus (MF), internal oblique (IO), paraspinal and pelvic floor. The co-contraction of these muscles produce forces via the "theracolumbar fascia" (TLF) and the "intra-abdominal pressure" (IAP) mechanism, which stabilize the lumbar spine, and the paraspinal and MF muscles act directly to resist the forces acting on the lumbar spine.
It is not simply the recruitment of these deep-trunk muscles but how they are recruited that is important. The co-contraction of the TA and MF muscles occurs prior to any movement of the limbs, suggesting that these muscles anticipate dynamic movements, which may act on the lumbar spine and stabilize the area before any movements.
Prior to core specific training, it is important to emphasize flexibility drills first since flexibility is crucial to successful lumbar stabilization training because flexibility allows the muscles to assume the neutral position easily. The following exercises should be recommended:
Stretching should be performed three to four times daily. Each stretch should be held for approximately 30 seconds.
Training the Core Musculature
As with any type of strength and conditioning training, the training protocol for improving the function of the deep-trunk muscles must be specific to the task required. This specificity of training must take into account the type of contraction, the muscle fiber type and the anatomical position required. By definition, the deep-trunk muscles act as "stabilizers" and are not involved in producing movements but instead involve isometric contractions. These muscles do not need to be very strong, but they must be correctly coordinated and capable of working continuously. In addition, these stabilizer muscles should act by holding the lumbar spine in the neutral position, which is the correct alignment of the pelvis that allows for the natural 'S' curve of the spine.
Core training begins with learning to co-contract the TA and MF muscles effectively as this has been identified as key to the lumbar-support mechanism. To perform the TA and MF co-contraction, the "abdominal hollowing" technique with the spine in the neutral position must be performed. The following should be taught to the athlete to properly perform this exercise:
- Start by lying on the back with knees bent.
- The lumbar spine should not be arched up nor flattened against the floor but aligned normally with a small gap between the floor and the back.
- Breathe in deeply and relax the stomach muscles.
- Breathe out and draw the lower abdomen inward as if the belly button is going back towards the floor. This can be described as zipping up a tight pair of pants.
- Hold the contraction for 10 seconds, making sure to breathe in and out as the tension is held in the lower stomach area.
- Repeat 5-10 times.
Instruct the athlete to:
- Not let the whole stomach tense up or the upper abdominals bulge outward since this recruits the rectus abdominis not the TA and MF muscles.
- Not brace the TA muscle too hard since it is muscular endurance not maximal strength that is the focus.
- Not tilt the pelvis nor flatten the back.
The Next Step
After having learned to effectively recruit the TA and MF muscles correctly in various positions, the athlete can progress to simple core exercises. Some of these basic exercises that the triathlete can perform are listed below. These exercises may also involve the oblique muscles, other lumbar muscles and gluteal muscles to assist the TA and MF in maintaining the lumbar spine in a stable neutral position.
Lying on the back with the knees bent and the feet flat on the floor, tighten the stomach muscles and push the lower back into the floor. Hold for 5 seconds and relax. Repeat 10 times.
Tighten the stomach muscles and press the lower back into the floor. Lift one leg several inches off the floor and hold for 5 seconds and lower it. Lift the other leg off the floor, hold for 5 seconds and lower it. Alternate legs, doing 5 repetitions with each leg.
Prone Hip Rotation
Lie on the stomach on the floor. Bend the knees so the thighs stay on the floor and the lower legs are perpendicular to the floor. Keep the knees on the floor and shoulder width apart. Cross the legs over each other as far as possible. Keeping the knees on the floor, uncross the lower legs and move them as far apart as possible. Hold for 2 seconds. Repeat 10 to 20 times.
Remembering that the ultimate goal of core training is to ensure that the deep trunk muscles are working correctly to control the lumbar spine during dynamic movements such as running is important. Once the athlete has achieved proficiency of the simple core exercises, the athlete can progress to achieving stability during more functional movements with the following two exercises:
- Stand with feet hip width apart in front of a mirror.
- Place the lumbar spine in neutral with the back tall, shoulders back and head up.
- Lunge forward and bend the knee only halfway down.
- Ensure that the front knee is in line with the toes and the back has remained upright with the lumbar spine in neutral and your hips level.
- Push back up, initiating the movement by pushing down into the floor with the front foot.
- The force from the legs should bring the athlete back up quickly and easily to their starting position.
- The back should have remained completely still and the hips level as the athlete performed the push back.
Many athletes do not initiate the up movement correctly as they pull their heads and shoulders back first. This extends the lumbar spine, losing the neutral position. Others have problems keeping their pelvis level while performing the lunge. The athlete must learn to use their deep trunk and gluteal muscles to hold their lumbar spine in neutral and pelvis level as they perform the movement up and down. The movement should only come from the leg muscles.
- Start from the knees, even if this means it is easy for the upper body.
- Hands should be slightly wider than the shoulders, and the head must be in front of the hands.
- Lift the hips so that there is a straight line from the knees through the pelvis and lower back, through the shoulders and all the way to the head.
- Ensure that the lumbar spine is in neutral with the help of a training partner or mirror.
- To maintain a neutral spine and a straight back during the exercise, the trunk muscles must provide active support.
- Slowly lower down, bending the arms to the floor. Keep the head still with the neck straight relative to the back.
- Push up, initiating the movement by pressing down into the floor with the hands.
These two exercises enable the athlete to learn core stability while performing dynamic movements. By reducing the resistance, the focus is on the trunk stabilizers and achieving perfect technique rather than working the major muscle groups. The rationale behind core strengthening can be defined as the ability of the core muscles to work in an efficient and coordinated fashion to maintain correct alignment of the spine and pelvis while the limbs are moving. It is this kinetic chain as a whole that must be trained, strengthened and stretched to elicit positive outcomes.
By identifying the root cause of potential running injuries as they relate to the lower back, it is possible to rehabilitate triathletes in a proper, periodized fashion so that loss of training time is reduced and performance is not negatively impacted. However, a proper flexibility and strengthening program emphasizing the core musculature should be implemented year round to prevent any such injuries from developing in the first place.
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