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CHAPTER 7:
The Back and Ribs

Nearly all injuries to the back are muscular in nature. About 95 percent of low-back pain is the result of muscular problems caused by lack of exercise, weak muscles, or overweight. Back problems can also be due to tense muscles or strain from suddenly overloading these muscles during activity. Muscle fibers may pull or tear, sending the back muscles into spasm and causing pain.

      Even though the back muscles are the strongest in the body--you can lift four times more weight with the back than with the arms and shoulders--back injuries have become the leading occupational hazard in the United States: 25 million Americans claim that they lose at least a day's work each year due to back pain. Back pain is the second most common cause of lost time at work among people under age 45 (after the common cold), and 60 percent of people over age 30 have a propensity for back pain.

      Fortunately, most simple backaches go away within a few weeks, with or without treatment, and 90 percent of them disappear within two months. A workout that strengthens the lowerback and abdominal muscles can prevent back pain, bring relief to those suffering from pain, and help prevent pain from recurring.

BACK SPASM

When back muscles go into spasm, the force is so great that you may be disabled by excruciating pain. When these muscles go into spasm and shorten, it can cause your back to tilt severely to one side.

      The treatment for back spasm is rest for a few days, medication such as aspirin or other anti-inflammatory agents, and possibly muscle relaxants. Use ice for as long as you feel pain. You may also need support from a girdle and physical therapy, which includes ice, then heat, electrical stimulation of muscles, stretching, and deep massage to relax the muscle. This should be followed by an exercise program to strengthen the back, described later in the chapter.

SHORT LEG SYNDROME

Another common cause of lower-back pain is a difference in the lengths of the legs. A quarterinch difference can be significant in an athlete, whereas a nonathlete may get away with a difference of up to a half-inch. The back pain is usually felt on the side of the longer leg. This leg pounds into the ground when you run, throwing that whole side of the body out of alignment. The stress works its way all the way up to your back.

      If you stretch your back regularly and still feel back pain, have a sports doctor or trainer measure the lengths of your legs. You can correct the problem by putting a lift in your shoe. At first, correct for only 50 percent of the difference. For example, if you have a quarter-inch difference, put in an eighth-inch lift. If need be, you can use a thicker lift later on. Your back pain should disappear almost immediately. If it doesn't, have a doctor check for other possible back problems.

BULGING DISC

Discs are fibrous pillows filled with a gel-like material found between the vertebrae. They act as shock absorbers for the spine, cushioning the vertebrae as they move against each other.

      One of the most common back problems is a bulging disc. The wall of the disc bulges out into the spinal column. The disc, however, is not ruptured completely.

      The disc bulge looks like a weak spot on the inner tube of a tire. The pressure of this bulge on the spinal cord or on the nerve roots coming out of the spine causes the pain. See your doctor for treatment.

RUPTURED DISC

A ruptured, or slipped, disc usually occurs in the lower (lumbar) spine, the area that takes the brunt of twisting and turning. Blown lumbar discs afflict 5 million Americans each year. A lifetime of poor posture, lifting heavy objects, or repetitive twisting motions in sports can weaken the discs and eventually cause a rupture.

      A ruptured disc, also called a herniated disc, occurs when the disc capsule breaks open and protrudes into the spinal canal, pressing on nerve roots. Gel oozes out of the disc and causes more pressure on the spinal cord or the nerve roots. Over time, the gel usually disintegrates, and the symptoms may be relieved.

      When a disc ruptures, however, the pad between the two vertebrae is gone, and the gradual wearing of bone on bone leads to arthritis. This can cause serious pain if the arthritic spurs of the vertebrae press on the nerve root. The pain will worsen as years go by without treatment.

      The pain of a ruptured disc is usually sharp and sudden. Commonly, the pain will be passed along the course of the nerve impinged by the ruptured disc. A disc pressing on the sciatic nerve root causes sciatica, sending pain from the buttock down the leg and into the foot.

      A bulging disc cannot be seen on a normal x-ray but can be picked up easily on a computed tomography or MRI scan. Only when the disc has completely disintegrated can the narrowed space between two vertebrae be seen on x-ray. So you may need more than a simple x-ray for your doctor to make the correct diagnosis.

      Many ruptured discs will respond to bed rest. When you stand, each disc carries the weight of the body above it. Therefore, you need to take the weight off of the disc. Often, the disc will heal if you lie down until the pain recedes.

      A back brace may help relieve the stress on the disc, and physical therapy can help relieve any muscle spasms associated with a ruptured disc. After you have passed the stage of acute pain, you will need to engage in a back-strengthening program.

      If your symptoms do not subside, you may need surgery to remove some or all of the disc. What used to be a crude, major operation requiring long disability has become a much more sophisticated, simpler procedure with little difficulty afterward.

      The majority of patients get better without surgery, even those with acutely ruptured discs. Surgery is prescribed for the 10 to 15 percent of patients who don't respond to conservative treatment or who feel weakness or numbness in their limbs, which is a sign of neurological problems.

      The classic back operation, called a diskectomy, involves an incision in the lower back and removal of a small piece of the vertebra to expose the injured disc. Then the damaged part of the disc is cut out. Surgery now usually involves insertion of an arthroscope into the ruptured disc to suck out the gel and relieve pressure on the nerve.

      A nonsurgical procedure popular in Europe is the injection of a papaya derivative called chymopapain into the center of the ruptured disc. This natural enzyme dissolves the gel to relieve the pain. However, this treatment has hazards and is not widely used in the United States.

CRACKED BACK

A fracture of the part of the vertebra connecting the front and rear portions of the bone is called spondylolysis. Originally, this was thought to be a congenital failure of the two halves of the vertebra to fuse. Now we believe that this is due to acute fractures caused by back trauma.

      I see spondylolysis most commonly among young people who have chronic back pain for no apparent reason. Often, they have taken a fall before feeling any pain. If an x-ray reveals a fractured bone, I have to decide whether the fracture is fresh or old. A bone scan, a simple nuclear medicine procedure, helps identify fresh activity in the bone.

      If the fracture is old or congenital, the treatment of choice is a strengthening program with reduced physical activity until the symptoms cease. If the fracture is fresh, the patient must stop all sports or physical activity for six months so that it can be determined whether or not the fracture will heal. Usually, rest alone is not enough to relieve all the symptoms, and a program to strengthen the back muscles is required afterward.

      A back brace may be helpful during this time. However, a brace should be used only in the presence of acute pain. Back braces are not useful in the long run because they further weaken the back.

      If the fracture doesn't heal, it may lead to another condition called spondylolisthesis, in which the front portion of the vertebra slips forward out of line with the other vertebrae. Most of the stabilizing ligaments of the spinal column are located behind the column. If the connecting bone does not heal, then almost any activity can cause the front part of the vertebra to slip forward.

      After an initial period of rest to get the bone to heal, you can resume normal activity. If the vertebra slips, however, you will have to give up certain activities, such as diving and gymnastics, where you have to arch your back violently, and contact sports such as football and basketball, where you might take a heavy blow to the back. If a slipped vertebra progresses despite conservative treatments, you will need to have the vertebra fused surgically.

CRACKED WING

A wing is the protuberance at the lower side of each vertebra, and this wing can also crack from a blow to the back. The back muscles and ligaments attach to the spine at the wing, which is also called the transverse process. A wing fracture commonly occurs in football to running backs who are hit with a helmet from behind. Giants' quarterback Jeff Hostetler was put out of action for the last few games of the 1991 season when he broke three wings in his back.

      Although very painful, this is not as serious a back fracture. You will need to rest and take anti-inflammatory agents to ease your pain, which typically lasts a few weeks. Once the pain disappears, you can return to activity as long as you put extra padding around the wing to protect it.

SCIATICA

Sciatica is not a true back problem but refers to pain along the course of the sciatic nerve. This nerve runs from the buttock down the back of the leg to the foot. Pressure on the sciatic nerve root at the spine causes the pain. It's necessary to find out what is causing the pressure and then treat it. Possible causes include impingement of a disc, an arthritic spur of a vertebra, a muscle spasm, or neurological problems in the spinal cord. Treatment for sciatica itself is not the answer since sciatica is only a symptom of the underlying problem.

      Sciatica may be very easy or very difficult to diagnose. If you feel pain only in your thigh, it can be easily confused with a hamstring pull. If the pain goes all the way down the leg to the foot, it is obviously sciatica. Muscles and bones do not extend beyond a joint; only blood vessels and nerves traverse the whole leg, and blood vessels do not cause you pain.

      If you feel increased pain upon bending over or while doing a straight leg raise, you may be stretching a nerve. Other indications of sciatica are a weak big toe, trouble in raising the front of the foot, and a diminished ankle reflex.


Preventing Back Problems

The basic prevention for back problems is to develop a strong back. Since most injuries are due to muscle weakness, increased strength is the answer to almost every back problem.

      In the past, back doctors and sports medicine experts always recommended exercises that strengthen the flexor muscles of the back. This may be why back treatments have not been very successful. The flexor muscles are the ones that pull the back forward and down. But the body is naturally pulled in that direction by gravity. To lift your trunk into an erect position, you must use the extensor muscles. These are the muscles that you need to strengthen. Once you get through early flexion exercises, you must concentrate on extension exercises.

      Recognizing the need to concentrate on extensor muscles has led to a change in the philosophy on how to recondition an injured back. Also, with machines such as the Cybex®, we can work muscles beyond the point of pain. The machine will indicate when you have reached the danger point and should stop exercising.

      Also, through the use of electromyograph (EMG) machines, which measure muscular activity, researchers have found that the traditional sit-up used to strengthen the abdominal muscles actually does more harm than good. EMG results show that a sit-up with the fullest range of motion offers more potential for damage than a simple abdominal curl.

A Back-Strengthening Program

Back pain is slightly different in each person, and there are many different types of self-treatments. I prefer ice treatments for 20 to 30 minutes at a time, two or three times a day, for as long as the back is sore. I prescribe heat on the back only to loosen it up before activity once it has healed.

      Bed rest for more than a couple of days only weakens your muscles and can be disabling. You need to get out of bed as soon as possible. Surgery should be considered only as a last resort.

      If you suffer a back problem, chances are you will wind up on a regimen of daily stretching and strengthening exercises to recondition your back. These exercises are designed to strengthen the muscles that support the back, especially the abdominal muscles; to stretch overly tight muscles and ligaments in the back so that they are less likely to be injured; and to reduce the defects in posture that strain the back. Strong, flexible muscles around the lower back and abdomen stabilize the spine and protect it from injury.

Back-Stretching and Flexion Exercises

You can do back exercises at home to strengthen both your extensor and flexor muscles. To strengthen an acutely injured back, start with stretching and flexion exercises.

Extension Exercises

As you become more comfortable and your back muscles begin to lengthen, you can start extension exercises.

Pain-Free Sports

Orthopedists often advise back pain sufferers to avoid sports that put severe stress on the back. However, a back problem should not doom you to a life of inactivity. You can participate in almost any sport if you take some precautions.

      Pain-free activities include swimming, walking, cross-country skiing, and stationary cycling. These can all be done without sharp, sudden movements; severe arching of the back; twisting or rotating of the trunk; heavy impact; or unexpected, awkward falls.

      Bicycling is almost pain-free because it is a non-weight-bearing exercise; there is no weight on your legs and thighs and no pounding of joints. People who have back problems probably are better off using the upright handlebars on traditional bicycles. Sitting upright places less stress on the back.

      Running can lead to back problems from the impact of the foot strike, abnormal foot mechanics, the forcing of imbalanced muscles to work harder, and the attempt to run too fast, not to mention the problems that result if one leg is slightly longer than the other. If you are an avid runner, you may have to curtail your running to every other day, and you should try to run on soft surfaces with good, shock-absorbent shoes.

      Tennis can be challenging for anyone with back pain, with all of its twisting, flexing, and extending motions. If you are plagued by a bad back, try to flatten out your serve to eliminate excessive arching and twisting. You may also consider wearing a back brace. Try to pick up balls by holding them between a foot and the racquet rather than bending at the waist.

      Aerobic dancing is terrible for all kinds of lowback pain. Try low-impact, not high-impact, aerobics; or, better yet, opt for water aerobics.

      Golfers should beware of the torsion placed on the back during the swing. Tone up your abdominal muscles to help prevent back injuries. Remember to bend at the knees, not the waist, when placing a tee in the ground and when lining up a putt.

      You are at risk of throwing out your back from basketball, volleyball, downhill skiing, dancing, bowling, football, baseball, or any other sport requiring lots of arching, twisting, and sudden starts and stops. Take it easy at the start of the season, and always ease muscles in and out of activity with warmup, warmdown, and stretching. If you are out of shape, don't push yourself beyond your range of motion.

PREVENTING EVERYDAY BACK STRAIN

Equally important is learning how to perform ordinary movements so that you don't strain your back.

      Consistent, good posture is the first step toward maintaining a pain-free back. Keep your shoulders back and your lower back supported by a pillow when sitting.

      Carrying heavy loads can be a problem for someone with a bad back. When you lift objects from the floor, squat as close as possible to the object and lift with your legs, not your back. Lift smoothly; the faster the lift, the more stress on your spine.

      Know the weight of an object so that you can prepare yourself mentally before lifting it. Don't bend at the waist. The muscles in front of your thighs are among the strongest in the body; let them do the work.

      Do not carry heavy briefcases or luggage. Instead, use a luggage roller whenever possible.

      When gardening, cleaning the floor, or doing other prolonged, back-straining activities near the ground, kneel on one knee rather than bending at the waist. Back problems can be exacerbated by spending time hunched over a desk that's too low for you. Try to keep your work surface at elbow height. Adjust the height of your chair so that you can sit with your feet flat on the floor and your knees level with your hips. If you have a desk job, take frequent breaks. Get up at least once an hour and walk around for a few minutes.

      Avoid wearing high heels, which place greater pressure on the back than flats do.


THE RIBS

The ribs are bones in the chest that attach to the vertebrae. There are 12 ribs on each side of the body. They serve two functions: They act like bars of a cage to protect the lungs and heart from blows, and they help the chest wall expand and collapse so that air can move through the lungs.

      The ribs do not attach directly to the breast bone in the front. If they did, the rib cage would be so rigid that you would not be able to breathe. Flexible cartilage connects the end of each rib to the breastbone.

BRUISED RIBS

A blow to an unprotected rib cage can bruise the ribs. The treatment for bruised ribs is to rest them and apply ice until the pain is gone. You can continue activities if you use a pad to protect the ribs. This pad, made of strong plastic with an absorbent material underneath, looks like a flak jacket; it hangs on the shoulders and wraps around the rib cage. Several varieties are available in sporting goods stores.

SEPARATED RIB

A severe blow can cause a rib separation, in which the rib tears loose from the cartilage in the front.

      You will feel severe pain, usually toward the front of the rib cage, and it will hurt to breathe. When you bend over or rotate your body, you may feel a "pop." It will be particularly painful to go from a lying to a sitting position, so you may have trouble getting out of bed in the morning. If someone puts one hand on your back and the other on your breastbone and squeezes, you will feel tremendous pain.

      The treatment is to use a rib belt. This is a strap of elastic, about eight inches wide, that goes around the rib cage. It stretches tight and closes in front with Velcro®. This compresses the rib cage so that it can't expand too far. The belt holds the rib end in place until it heals and lessens the pain of everyday movements.

      No matter how much you may want to, you can't participate in sports when you have separated ribs. The resulting pain will be too much to allow you to continue.

BROKEN RIB

The ultimate injury from a blow to the rib cage is a broken rib. The pain may occur anywhere in the rib cage depending on where the rib is broken. It may be that more than one rib is broken.

      You will feel the same pain as with bruised or separated ribs, only more severe. You should be concerned about sharp ends of broken ribs and should have an x-ray. Any excessive strain or movement, or another blow, can cause a sharp end to puncture a lung, sending you to the hospital for emergency treatment.

      Again, the treatment is to rest (for about six weeks) and to wear a rib belt until the pain is gone. An x-ray must show that the ribs have healed before you can return to activity.

PULLED RIB MUSCLE

The muscle between each pair of ribs, the intercostal muscle, which is the muscle used in respiration, may pull or tear due to overstress. This can happen to a tennis or football player who makes a sudden, violent lateral motion or suddenly rotates the rib cage.

      As a result, you will feel tenderness between the ribs, not on them. Again, rest the ribs and ice them until the pain disappears, and use a rib belt until you can move about freely.




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