Herniated Herniated DiscsDiscs

By Michael LaBellaBy Michael LaBella

ObjectivesObjectives• You will be able to identify the You will be able to identify the

anatomy of the lower backanatomy of the lower back• You will understand the types of You will understand the types of

trauma that can cause a herniated disctrauma that can cause a herniated disc• You will be able to identify the signs of You will be able to identify the signs of

a herniated disca herniated disc• You will be able to evaluate athletes You will be able to evaluate athletes

with potential herniated discswith potential herniated discs• You will be able to follow a typical You will be able to follow a typical

treatment program for herniated discstreatment program for herniated discs

AnatomyAnatomy

• Vertebral column Vertebral column (spin) consists of 33 (spin) consists of 33 vertebrae vertebrae

• Spine is divided into Spine is divided into thoracic, lumber, thoracic, lumber, cervicalcervical

• Each section of spine Each section of spine containing 5-12 containing 5-12 vertebraevertebrae

• We will be focusing on We will be focusing on the lower back or the lower back or lumbar regionlumbar region

Lumbar AnatomyLumbar Anatomy

• The lumbar section The lumbar section of the spine is of the spine is made up of the made up of the lower 5 vertebraelower 5 vertebrae

• Commonly Commonly referred to as L1 referred to as L1 to L5to L5

• L5 connects to the L5 connects to the top of the sacrumtop of the sacrum

Anatomy of Lumbar Anatomy of Lumbar VerebraVerebra

• The vertebral body The vertebral body is a thin ring of is a thin ring of dense bonedense bone

• Consisting of the Consisting of the body, pedicles and body, pedicles and liminaeliminae

• Vertebral foramen is Vertebral foramen is a whole in vertebral a whole in vertebral body that spinal body that spinal cord runs throughcord runs through

Intervertebral DiscsIntervertebral Discs

• Gel like Tissue between Gel like Tissue between each vertebraeach vertebra

• fibro cartilaginous fibro cartilaginous cushionscushions

• serve as the spine's serve as the spine's shock absorbing systemshock absorbing system

• protect the vertebrae, protect the vertebrae, brain, and other brain, and other structuresstructures

• The discs allow some The discs allow some vertebral motion vertebral motion extension and flexion. extension and flexion.

Intervertebral DiscsIntervertebral Discs

• The disc is made up The disc is made up of 3 structures the of 3 structures the

• (1) Nucleus pulposus, (1) Nucleus pulposus, gelatinous centergelatinous center

• (2) Annulus Fibrosus. (2) Annulus Fibrosus. Its job is to contain Its job is to contain the nucleusthe nucleus

• (3) Vertebral end (3) Vertebral end plates that attach the plates that attach the disc to the vertebrae disc to the vertebrae

Herniated diskHerniated disk

• Can Occur when Can Occur when there is enough there is enough pressure from the pressure from the vertebrae above and vertebrae above and belowbelow

• This can force some This can force some or all of the nucleus or all of the nucleus pulposus through a pulposus through a weakened or torn weakened or torn part of the annulus part of the annulus fibrosus. fibrosus.

• The ruptured nucleus The ruptured nucleus will often come will often come incontact with and incontact with and press on nerves near press on nerves near the disc.the disc.

• This can result in severe This can result in severe painpain

• About 90% of herniated About 90% of herniated discs occur in the discs occur in the lumbar region. The lumbar region. The discs in the cervical discs in the cervical region are affected region are affected about 8%, those of the about 8%, those of the thoracic region only thoracic region only about 1-2%about 1-2%

• Herniated disks are one Herniated disks are one of the most common of the most common causes of back paincauses of back pain

Mechanism of injuryMechanism of injury

• There are 3 main ways discs can become There are 3 main ways discs can become herniated of rupturedherniated of ruptured

• Many older people get herniated disks because the Many older people get herniated disks because the disks have worn down over time disks have worn down over time

• The extremely overweight are very susceptible The extremely overweight are very susceptible because they are carrying around excess weight because they are carrying around excess weight which puts extra pressure on the intervertebral diskswhich puts extra pressure on the intervertebral disks

• Improper lifting form, usually associated with Improper lifting form, usually associated with bending with back and not with knees. Which can bending with back and not with knees. Which can cause a sudden strain. This can be everyday lifting of cause a sudden strain. This can be everyday lifting of objects or actual weight training objects or actual weight training

• Twisting violently can also cause a sudden strain that Twisting violently can also cause a sudden strain that could possible herniate a diskcould possible herniate a disk

RecognitionRecognition

• How can we as coaches recognize a How can we as coaches recognize a herniated disk?herniated disk?

• Sharp and shooting pain the runs down Sharp and shooting pain the runs down athletes low back, buttocks and down the thighathletes low back, buttocks and down the thigh

• If the athlete complains of numbness or If the athlete complains of numbness or tingling anywhere in lower back, buttocks or tingling anywhere in lower back, buttocks or legleg

• If athlete complains pain gets worse after any If athlete complains pain gets worse after any kind of strain to the bodykind of strain to the body

• Sometimes, the disk can pinch the nerve Sometimes, the disk can pinch the nerve controlling bladder functioningcontrolling bladder functioning

EvaluationEvaluation

• The first thing a coach should ask his The first thing a coach should ask his athlete, would be the history of the athlete, would be the history of the injury; if the athlete felt the pain injury; if the athlete felt the pain immediately after performing a heavy immediately after performing a heavy deadlift at the gym that would be a deadlift at the gym that would be a good indicator of a herniated diskgood indicator of a herniated disk

• The coach should also ask athlete The coach should also ask athlete where the pain is, sciatica is very where the pain is, sciatica is very typical with herniated diskstypical with herniated disks

Doctors EvaluationDoctors Evaluation

• A coach can never be 100% sure, so A coach can never be 100% sure, so the athlete must be sent to a doctor the athlete must be sent to a doctor to perform an MRI (magnetic to perform an MRI (magnetic resonance imaging) or a CT resonance imaging) or a CT (computerized tomography)(computerized tomography)

• An MRI is the best choice because it An MRI is the best choice because it can clearly show the bones nerves can clearly show the bones nerves and disks that might be damagedand disks that might be damaged

TreatmentTreatment

• The first thing that The first thing that should be done is to should be done is to rest and stay away rest and stay away from activity the from activity the agitate the symptomsagitate the symptoms

• Then the application Then the application of ice and heatof ice and heat

• This acts to relax the This acts to relax the muscles in the back muscles in the back which can calm pain which can calm pain and any muscle spasmsand any muscle spasms

TreatmentTreatment

• Physical TherapyPhysical Therapy– Although performing Although performing

physical Therapy physical Therapy does not directly does not directly help the disks, it help the disks, it does strengthen the does strengthen the muscles around it, muscles around it, so as to increase so as to increase stability, which can stability, which can help prevent help prevent herniated disks in herniated disks in the futurethe future

TreatmentTreatment

• Pain relievers are Pain relievers are often given to often given to patient to alleviate patient to alleviate painpain

• Anti-inflammatory Anti-inflammatory drugs are given to drugs are given to reduce swellingreduce swelling

• Although not all Although not all patients report patients report having back painhaving back pain

Physical Therapy Physical Therapy ExercisesExercises

• Exercise #1Exercise #1 while while lying on your back lying on your back bend your left knee up. bend your left knee up. Clench abs and butt, Clench abs and butt, keeping back in keeping back in neutral position. neutral position.

• Raise your other leg Raise your other leg about 12in off floor, about 12in off floor, while knee is straightwhile knee is straight

• Hold the position for 3 Hold the position for 3 secondsseconds

• Then lower leg, do for Then lower leg, do for 10 reps 10 reps

• Repeat the same with Repeat the same with your other leg your other leg

Physical Therapy Physical Therapy ExercisesExercises

• Exercise #2Exercise #2 Start with both Start with both knees on floor, clench abs knees on floor, clench abs and butt, back is straightand butt, back is straight

• Put your hands on your hips. Put your hands on your hips. • Pickup your right foot and Pickup your right foot and

place on floor in front of you, place on floor in front of you, while your left knee is still on while your left knee is still on floorfloor

• Lunge forward,. Lunge forward,. • Hold your position for 3-5 Hold your position for 3-5

seconds seconds • Return your right knee to Return your right knee to

floor floor • Do for 10 repsDo for 10 reps• Then repeat with the other Then repeat with the other

leg leg

SurgerySurgery

• Surgery is very rarely required for Surgery is very rarely required for herniated disksherniated disks

• The treatment previously described is The treatment previously described is almost always done prior to surgeryalmost always done prior to surgery

• Generally if symptoms, such as pain Generally if symptoms, such as pain and numbness grow worse over time and numbness grow worse over time surgery is requiredsurgery is required

• If herniated disk interferes with If herniated disk interferes with bladder and bowl movements, surgery bladder and bowl movements, surgery is also required is also required

RehabilitationRehabilitation

• Herniated disks can vary in severity and Herniated disks can vary in severity and the rehabilitation plan can vary the rehabilitation plan can vary depending on the severity of the depending on the severity of the symptoms;symptoms;

• Phase #1 Rest- This can last from 2 Phase #1 Rest- This can last from 2 days up to 2 months depending on the days up to 2 months depending on the nature of the injury, typically the older nature of the injury, typically the older the patient the longer the rest period. the patient the longer the rest period. As stated before, rest should include As stated before, rest should include immobilization of spinal column as well immobilization of spinal column as well as icing and heating of the lower backas icing and heating of the lower back

RehabilitationRehabilitation

• Phase #2 After symptoms have Phase #2 After symptoms have subsided, anywhere from 10days to a subsided, anywhere from 10days to a few months exercises should be done to few months exercises should be done to strengthen muscles around spinal strengthen muscles around spinal column to help prevent another hernia. column to help prevent another hernia. Doctors clearance is preferred so as not Doctors clearance is preferred so as not to begin exercises to early, which could to begin exercises to early, which could cause a re injury. These exercises may cause a re injury. These exercises may be done with some slight lower back be done with some slight lower back painpain

RehabilitationRehabilitation

• Hamstring stretchHamstring stretch• Lay down face up Lay down face up

with one leg in with one leg in door way other leg door way other leg on wall on wall

• This stretches out This stretches out ligaments and ligaments and tendons that tendons that connect from leg connect from leg to lower backto lower back

RehabilitationRehabilitation

• Cat and CamelCat and Camel• On your hand and On your hand and

knees, allow your knees, allow your back to sag for 5 back to sag for 5 seconds, then arch seconds, then arch your back for 5 your back for 5 secondsseconds

• Repeat for 10 repsRepeat for 10 reps

RehabilitationRehabilitation

• Arm/Leg RaiseArm/Leg Raise• On your hands and On your hands and

kneesknees• Tighten abs so Tighten abs so

spinal column is stiffspinal column is stiff• Raise right arm and Raise right arm and

left leg as shown to left leg as shown to the rightthe right

• Do 10 reps and Do 10 reps and switch arm/legswitch arm/leg

RehabilitationRehabilitation• After all pain has gone After all pain has gone

the following exercise the following exercise may be performedmay be performed

• Partial curl-lying on Partial curl-lying on your back with knees your back with knees bent and feet on floorbent and feet on floor

• Tuck the chin into the Tuck the chin into the chestchest

• Curl upper body Curl upper body forward intill your forward intill your shoulder blades are off shoulder blades are off the floorthe floor

• Hold the position for 3 Hold the position for 3 seconds and repeat for seconds and repeat for 10 reps10 reps

Return to playReturn to play

• In order for an In order for an athlete that has athlete that has sustained a sustained a herniated disk to herniated disk to return to play he/she return to play he/she must have clearance must have clearance from their doctorfrom their doctor

• This will not usually This will not usually happen until all pain, happen until all pain, and numbness has and numbness has gone completelygone completely

PreventionPrevention

• The stretches and The stretches and exercises listed exercises listed previously can previously can strengthen the strengthen the muscles around the muscles around the discs, which can discs, which can increase the stability increase the stability of the discsof the discs

• Teaching and Teaching and practicing proper practicing proper lifting form is lifting form is essential in preventing essential in preventing these injuriesthese injuries

ReferencesReferences• Cassisi, J. E. Ph.D.; Sypert, G. W. M.D.; Laganá, L. Ph.D.; Friedman, E. M. Cassisi, J. E. Ph.D.; Sypert, G. W. M.D.; Laganá, L. Ph.D.; Friedman, E. M.

B.A.; Robinson, M. E. Ph.D. Pain, Disability, and Psychological Functioning in B.A.; Robinson, M. E. Ph.D. Pain, Disability, and Psychological Functioning in Chronic Low Back Pain Subgroups: Myofascial versus Herniated Disc Chronic Low Back Pain Subgroups: Myofascial versus Herniated Disc Syndrome. American J. of Phy. Med. And Rehab. Volume 33(3), September Syndrome. American J. of Phy. Med. And Rehab. Volume 33(3), September 1993, p 379–386 1993, p 379–386

• Ito, T. MD; Takano, Y. MD and; Yuasa, N. MD. Types of Lumbar Herniated Ito, T. MD; Takano, Y. MD and; Yuasa, N. MD. Types of Lumbar Herniated Disc and Clinical Course. Clinical J. of Pain. Volume 26(6), 15 March 2001, pp Disc and Clinical Course. Clinical J. of Pain. Volume 26(6), 15 March 2001, pp 648-651 648-651

• Vucetic, N. MD, PhD; Astrand, P. MD, PhD; Guntner, P. MD; Svensson, Vucetic, N. MD, PhD; Astrand, P. MD, PhD; Guntner, P. MD; Svensson, O. MD, PhD Diagnosis and Prognosis in Lumbar Disc Herniation. O. MD, PhD Diagnosis and Prognosis in Lumbar Disc Herniation. Clinical Orthopaedics & Related Research. 361:116-122, April 1999. Clinical Orthopaedics & Related Research. 361:116-122, April 1999.

• http://www.mayoclinic.com/health/herniated-disk/HD99999

• http://www.neurosurgerytoday.org/what/patient_e/herniated.asp