Course Instructor (P7)
Mechanical Back Pain- which is made worse by activity and relieved by rest is our main focus, but the clinician must rule-out other clinical syndromes. Remember non-mechanical syndromes may appear inflammatory, show constant pain, are minimally affected by activity and are usually worse at night or early morning. There are also other conditions such as sciatica and neurogenic claudication which must be ruled-out. Sciatica reveals predominately radicular pain with positive stretch signs and represents a specific dermatome level. Neurogenic claudication results in radiating leg pain or calf pain made worse with ambulation or spinal extension while showing negative stretch signs and relief with flexion.
Muscle Pull on Strain- this is a quick reference as it pertains to the lumbar spine. We will discuss muscle pulls at greater length in the upcoming text. This, of course, is the most common injury in golf resulting from repetitive twisting, straining, flexion-extension or even the lifting motion. It will result in spasm and can even occur with good body mechanics. When serious pathology has been ruled-out, reasonable rest, passive therapy modalities and manipulation on a time limited basis, is effective management. The medical approach includes NSAIDs or even muscle relaxants. A rule of thumb suggests that passive care should be followed by stretching and strengthening exercises to prevent re-injury. A modification in activities will also have to be applied.
Facet Arthropathy/Facet Syndrome- afferent pathways of pain perception originate in the dura, posterior longitudinal ligament, annulus fibrosis and paraspinal muscles, as well as, in the intra-articular joint.
Kleynhans classifies three types of facet syndrome:
- Traumatic – where there is an acute onset of inflammation of synovial linings of the joint with effusion, synovitis and decrease range of motion.
- Pathologic – where there is an apparent narrowing of the intervertebral disc space which permits an approximation of the joint surfaces. Kirkaldy-Willis identified stages of pathologic facet syndrome as dysfunction, instability and re-stabilization.
- Postural – the presence of a protruding abdomen due to weak musculature with increased lumbar lordosis is common. All classifications can develop into osteophytes and stenosis either in the lateral recess or the vertebral canal. Classic facet syndrome includes local tenderness, pain on hyperextension, hip, buttock or back pain on Straight Leg Raise and an absence of neurological signs.
Herniated Disc – this spinal insult is commonlyidentified by a history of a specific trauma, leg pain greater than back pain, neurologic deficit or pain measurable by a decrease in nerve tension/stretch signs; pain increases with sitting and leaning forward; increased intrathecal pressure; or nerve-root impingement visualized by advanced diagnostic imaging.
Sciatic Neuralgia – herniated disc, facet-joint arthropathy, spinal stenosis, as well as, annular tears can contribute to the presence of radiating pain in the lower extremity. Golf is often reported as a culprit in the cause of these syndromes. As a quick reference, straight leg raise can identify probable root compression. Valsalva’s test identifies probable intrathecal pressure. Pain on hyper-extension identifies probable facet irritation, while myositis or myogenic irritation requires a quick dynamic exam called the Stress Tests. Myositis of the lumbar paravertebral muscles can be reproduced with active or passive stress tests. Active tests are performed with the patient prone, arms lying next to the body and hands besides the hips. The examiner places his or her hand between the patient’s scapulae and provides downward resistance while the patient uses the paravertebral muscle to extend his or her spine. Reproduction of pain is positive for lumbar paravertebral myositis. The passive procedure has the supine patient grasping both knees to the chest. The examiner then flexes the neck forward. Reproduction of pain suggests lumbar paravertebral myositis.
Gluteal myositis is also evaluated with the active and passive stress tests. For active testing, the prone patient flexes one knee to 90° then attempts to lift the knee off the table against downward pressure. During the passive stress testing, the patient lies supine and the examiner maximallyflexes one leg while the other leg is left straight. The examiner then adducts the hip and brings the knee toward the contralateral axilla. Both procedures are repeated on the opposite side. Reproduction of pain in the gluteus maximus muscles is a positive test result for myositis.