The most frequent sports injury is the classic ankle inversion sprain. The outer ligaments are overstretched causing pain and inflammation whereas the joint on the big toe side of the ankle is impacted, and this area of the body potentially might attempt to cope with the force by loading or creating movement the Subtalar joint.
To stand upright and walk requires a balance between stability and flexibility. The weight of our body presses down through the spine, into the sacrum, through the sacroiliac joints, and down the legs. To maintain our upright posture while walking requires that the pain-sensitive sacroiliac joints allow a small amount of movement. As the sacrum nods forward it locks, becoming more stable and as the sacrum nods backward it allows more play. This locking and unlocking occur as we walk, move and bend. Restriction or excessive play in these important joints can give a deep local ache on the belt line on either side of the spine, or opposite the joint over the hip.
Intervertebral Disc Pain:
A very good reason to not round your back while lifting heavy weight is that spinal flexion switches on the 6 pack, (8 pack or in truth 2 * 4 pack), and inhibits the muscles that support the spine, potentially allowing the load to be transferred into the disc. Our spines are protected by muscles and ligaments that if working properly should limit disc damage. Where the muscles are deconditioned and fatigued then classically an early Spring gardening session with sustained bending, digging and twisting could fatigue the spinal muscles and end with a damaged disc wall. Where no inner gel is extruded we term this an Annular tear or strain.
John Gibbons Osteopath and author describes these discs, “as amazing structures. They have cells, called proteoglycan aggregans, located within them that are like tiny sponges and can carry approximately 500 times their own weight of water. Over time these unique cells eventually die so the water content within will naturally reduce. This process will eventually lead to a condition called degenerative disc disease (DDD). The disc is kept living by the vertebral endplates. These structures have been likened to parts of a tire – the inner nucleus is the ‘air’ within the tire, the annulus is the tire’s strong walls and the tread of the tire is the end plates. The discs are mainly avascular structures; however, discs are hydrated through diffusion by the vertebral bodies and subsequent end plates. The nerve supply is mainly from the Sinuvertebral nerves and it is only innervated to the periphery of the disc.”
John likes to “think of a disc as a ‘tube of toothpaste’, with the cap still on, and if you simply squeeze one end then the fluid will migrate to the other end and vice versa, however, the contents are still maintained within the tube, so there is no seepage. Now, if you take the cap completely off the tube of toothpaste and now squeeze the tube then the contents will obviously come out of the end and in this case you can apply the paste to your toothbrush. Let us think about this concept a little bit more and relate it to this book and the nerves…..think of the paste as the ‘nucleus’ and the outer shell of the tube being the ‘annulus’ then hopefully you are on the same wave length as myself………but this time the cap is on but almost coming off, (if it is 10 turns to lock it and 10 turns to lift the cap off then say for arguments sake its on 8 turns), so now if you squeeze the tube you might notice the end ‘bulging’ (as in a bulging disc) and if you squeeze hard enough the fluid might actually be seen to ooze out and this might be what you call a ‘protrusion’. If the cap actually comes off then this is what you can call a herniated or prolapsed disc and if some of the fluid detaches itself, so it is now separate from the rest, then this is what they call a ‘sequested’ disc. Hopefully, all that I said in this paragraph makes rather a lot of sense!”
Quote from his new book due to be published in 2020.
A reasonable question would be how might we confirm that a disk has been damaged? Typically osteopath’s use mainstream medical tests like the Straight Leg Raise (SLR) and the Slump test to aggravate the Sciatic Nerve confirming disc involvement. The classic disk injury gives a noticeable, “pop”, as the disc contents discharge, with considerable pain upon getting up the following day. Your posture may be affected where you stoop or bend away from the pain called antalgic posture. We would ask you about Pins n Needles, numbness, altered sensation and weakness to indicate the involvement of nerves. Discs are interesting because the pain we feel on the bulge is felt as the inner gel is viewed by our bodies immune system as foreign and as such is attacked by the immune system causing localized inflammation and pain. Undamaged discs have no sensory fibers to feel pain or position and as such only grow sensory pain fibers after damaged where new arteries are grown to deliver the blood. With every artery comes a nerve and a vein.
Bend backward or twist around while standing upright and feel a local pain in your back which stops your movement. Excess movement in your back is limited by little synovial joints called Facets. These joints are highly endowed with nerves that report pain when the nerve endings are stimulated when the joint is compressed or the surrounding joint capsule is stretched. Held within these joints is a tiny fibrocartilage ball that can leave the joint when you bend forward and then, as you straighten up, the fibrocartilage ball becomes trapped between the upper and lower facet surfaces causing severe pain.
Ligaments connect bones to other bones and have a role in limiting the mobility of joints. Research states that two ligaments in your back produce pain: the Interspinous and Iliolumbar ligaments. Each ligament then has certain movements which provoke pain.
The Interspinous ligament stops the spinous processes from over-separating and can report pain when you bend forward, this pain will initiate as you progressively bend forward and then cease as you continue. Pain can be local to the spine and also perceived as referred pain down into the lower limbs.
The Iliolumbar ligament connects the lowest Lumbar vertebra to the pelvis and resists spinal rotation, forward and side bending: this when pressed on directly, will report tenderness. Some research suggests that other structures may be responsible for tenderness over the area. These include the LIA Lumbar Intermuscular Aponeurosis, the lumbosacral joint or the muscles of the low back.
Nerve Root Pain:
Nerve root pain arises from where the nerve in the spine emerges from the foramina between the upper and lower vertebrae. Nerves carry signals containing messages about sensations and the control of muscles and organs, and so disorders of nerves can cause pain, pins, and needles, numbness, increased sensitivity or weakness of muscles. The pain is often felt in the area of the
body supplied by that nerve. It is common for the nerves in the legs and arms to be affected. Nerve roots can be compressed or pinched, perhaps due to trauma, normally this pain occurs from a combination of irritation and compression. Anything that can fill up the hole where the nerve root emerges can cause physical or chemical irritation.
Nerve injuries can occur anywhere in the body. Within the brain, they show a myriad of confusing signs and symptoms that can mimic musculoskeletal pain.
- Muscle Weakness – Pyramid Weakness where bending being stronger than straightening in the arms and the reverse in the legs.
- The slowness of movements with a loss of control.
- An increase in the tone of muscles, known as spasticity.
- Clasp-knife response where resistance applied to an arm will elicit initially a strong then weak response like a knife which resists being opened.
- Babinski’s Sign is normal for infants up to 12 months in age, but a sign of injury in adults where we stimulate the sole of the foot causing the big toe to bend up rather than down.
- Increased deep tendon reflexes. Many people have been tested at the GP with a Patellar hammer at the knee, ankle, elbow and middle finger. This tests the responsiveness of the nerves supplying the area. No one would use a Patellar Hammer on the middle finger, rather the hand is held in a relaxed position and the fingernail is clicked downwards, a positive Hoffman’s has the other fingers curling in response to the nail click.
- Pronator Drift is a test where we ask you to hold your hands out with the palms straight up while closing your eyes. If one hand is observed to drift down into pronation then the test is positive.