We describe our experience in rehabilitating back injuries by following the course of a 25 year old competitive ski racer on the Women's Pro Ski Tour. Her experience may serve as a useful guide to those skiers who fly off bumps a little too early, who land a little too late, who twist where they meant to turn, and who end the day more than a little sore.

Unfortunately, one of the most common injuries sustained in sports is an injury to the spine. It is second only to the common cold as the most frequent problem seen by physicians. Back injuries in ski racers are often career ending and are typically due to a variety of reasons in addition to a ski fall. The reasons include poor postural positioning, muscle imbalances, decreased flexibility, improper lifting and training mechanics, and even the stresses of excessive travel with long plane and car rides and hauling luggage.

Rehabilitation following a back injury requires a careful assessment of the injury and predisposing factors followed by aggressive muscle and postural training if racing is to resume early and at top level.

HISTORY

C.S. was competitively ski racing for a number of years. She had a history of minor injuries until sustaining a complete tear of her anterior cruciate ligament in a twisting fall. She had ACL reconstruction at The Stone Clinic in San Francisco in the late spring and returned to competitive skiing by the fall. Three months later, she developed sharp low back pain after ski training one afternoon. The symptoms included pain with forward bending, sneezing, and any impact like running or jumping. She also reported intermittent pain in the right leg to the calf level. Her lumbar muscles were stiff with limitation into forward and lateral bending. A magnetic resonance image scan (MRI) demonstrated a minimal disc bulge on the right side of the lumber spine. Her diagnosis was a tear of the annulus that contains the nucleus pulposus of the disc, causing the disc to bulge against the nerve root. The pressure on the nerve led to muscle spasm and back pain. Her period of "rest" led to spinal muscle weakness, decreased disc nutrition and mobility, and poor spinal mechanics.

EXAMINATION

Upon initial evaluation, C.S. was unable to ski race without pain and after 2 or 3 runs was unable to ski at all due to pain. On examination she had an unstable, extended posture during standing and gait. Her pain free functional range of motion at the lumbar spine was limited in both flexion and extension. She had excellent strength of her back extensor muscles but only fair strength of her abdominal muscles. In her pelvic region, her proprioception, which is the ability to recognize what the body is doing, was poor. She demonstrated good hamstring flexibility but had tight upper quads, hip flexors, and hip rotators (piriformis muscles).

REHABILITATION PROGRAM

When constructing the rehabilitation program, a few things in particular needed to be taken into consideration. First, she should be able to return to professional ski racing with minimal pain. Second, she had to be able to find, stabilize and maintain good neutral positioning or posture of her spine during all exercises, so that it would carry over into her skiing. Third, she had to learn an optimal stabilization program to prevent recurrence.

Inflammation and muscle spasm reduction, pain reduction, and range of motion exercises were initiated immediately. Inflammation and pain control were treated with a low dose of anti-inflammatories, soft tissue massage and mobilization, icing, and passive stretching into specific ranges concentrating on contract-relax modes. Correction of soft tissue and bony abnormalities by manual mobilization and manipulation is a crucial part of inflammation and pain relief. Instruction on finding functional neutral position of the spine was also a critical component to reduce exacerbation of the symptoms.

The rehabilitation goals were fourfold. First was to determine her pain-free functional range of motion. This is the range of motion that does not reproduce pain into forward bending, extending and other various postures. As the rehabilitation program progressed, this available range should increase accordingly. Second was to use therapeutic modalities such as ultrasound and electrical stimulation, as well as manual therapy techniques to control the inflammation and improve her overall mobility. Third, pelvis and trunk proprioception should be trained through stabilization exercises to gain more control over her movement patterns. Finally, the endurance, strength, and power of the legs and trunk should be increased to give her the ability to maintain a functional position during skiing.

The treatment plan began with posture and proprioceptive training of the pelvic girdle. Endurance, strength and power training of the trunk musculature was also initiated, as well as a general flexibility program. Proper standing, sitting, and movement positioning were taught immediately. She started by standing in an unstable extended spine position (Fig. 1). She was shown the proper functional position that would be reinforced during her training sessions (Fig 2a, 2b). Use of a stick for proprioceptive response enabled the patient to understand and maintain proper pelvic position while moving (Fig. 3a, 3b, 3c). Once she was able to maintain her pelvic position with activity, resistance training gradually progressed. The program concentrated on the endurance of the trunk musculature by using low intensity, high repetition exercises.

EXERCISES

First, endurance and strength of the spinal rotators, spinal extensors and abdominals increased through the use of rhythmic stabilization and repeated contraction techniques. That is, contracting into the areas of weakness (Fig. 4, 4b, 4c). She maintained neutral position during the exercise when changes in position were made by the practitioner. In a face down position, further strengthening was achieved by performing diagonal extension exercises (Fig. 5). Increasing endurance and strength would also increase her ability to maintain a stable lumber position over an extended period of time.

Second, isometrics were performed by contracting muscles into certain positions but without moving (Fig. 6a, 6b, 6c). In particular, standing, reaching overhead, and squatting were focused. Symmetrical squatting for leg strength and postural control was then conducted (Fig. 7a, 7b). Heel wedges were used to more correctly simulate the skiing motion and range that would be needed. She was started without resistance and increased by adding weight as able.

A push and pull exercise was next added to simulate day-to-day activities and further strengthen her while moving forward and backward (Fig. 8). Again, the focus was to be able to hold the optimal position of neutral throughout the exercise.

As she was going through this initial program, cardiovascular endurance training was performed using a stationary bicycle. At this point, an interval, sprint bicycling program was introduced and a VersaClimber program started (Fig. 11). Road cycling on varying levels of terrain was also initiated while constantly maintaining a good functional position.

The next progression of the program involved using symmetrical squats with resistance (Fig. 12). Adding resistance forced the patient to adapt to outside forces that were somewhat regular but changing due to the resistance provided by the practitioner. This was further advanced and increased by using a balance board (Fig. 13a, 13b). The unstable surface forced her to maintain a position of stability through movement much like that needed in skiing.

Using an exercise ball to apply changing forces helped aid in strength and endurance training (Fig. 14). This was performed in three standing positions while maintaining good position. The force, direction, and speed was changed periodically.

The next level of difficulty involved balance board squats with resistance from an elastic tubing (Lifeline, Madison, WI) (Fig. 15). She was to maintain her functional position while performing periodic sets of high repetition with varying pull from different positions. This was particularly beneficial when the resistance was from the sides (Fig. 16). She was then able to simulate the arm and shoulder position necessary for ski racing while maintaining her balance and position throughout the squat.

Finally, she added to her cardiovascular and trunk endurance, strength and power by using a slide board. She performed eight foot side to side glides while maintaining her functional position (Fig. 17).

This step progression overlapped as she was able to tolerate new and more difficult exercises. Less challenging exercises were dropped as more intense exercises were added. This allowed the program to maintain a high level of intensity, frequency, and duration each day to give her rapid increases in certain specific components. She was treated 3-5 times per week for three weeks before she was allowed to resume skiing. After two additional weeks, she returned to ski racing without incident.

The importance of working with a rehabilitation team to help guide and progress a well structured program is of paramount importance if one wants to return to a high level of activity.

For more information, e-mail Devin Wu at: devin@stoneclinic.com