Question
Dr. Leatherman,

Thank you for your initial response.

I always felt that what eventually caused this pain to begin, was my
assessment at the gym where the trainer had me doing reverse flies. My
muscles were shaking while doing them because they were weak in that area.
But that is just me taking a guess. My chirop has said that the damage from
sitting at the computer all day had caused several issues that were finally
brought to the forefront on that day.

I also believe that my chirop is fixing many issues with my back that may not
be relevant to my current injury, but potential issues in the long run.

I am a very active person, playing hockey several times a week, with on and
off visits to the gym. Until this most recent weeks pain (which has since
subsided - about 4 days long), I would get a stiffness feeling in my upper
back in the mornings if I looked down, but by afternoon I was just about pain
free and no stiffness.

I have begun playing hockey again since late Oct. and don't experience any
pain while playing the game.

I have also been working hard to recognize my sitting and standing posture
as well as my sleeping habits (currently I sleep in my stomach, but I am trying
to move to the side and back). Do you have any tips for this?

Lastly, I feel like my back has become very week and I would like to begin
going to the gym now to rehabilitate the weak muscles and hopefully this
combined with treatments and better posture will get back to the way I was
last year.

Do you have any recommendations that I can show my chirop so that we can
work together to build a program for me?

Thanks Again

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The text above is a follow-up to ...

-----Question-----
Hello,

I am in my early 20's and I have been very active in sports such as hockey
over the past 10 years, but I also spend most of my day in front of a
computer due to the nature of my business. About 6 months ago, I went to
the gym for a personal assessment. We went through each exercise once,
lifting about the max I could for that weight. Later that night I went to play
hockey and while covering a man in my zone I pulled something in my upper
back, right next to my spine. It was very difficult to stand up straight, but
eventually I was able to move freely, although I had a very stiff pain in my
back (like I pulled something). After a few days the pain subsided and I was
feeling 100% ok, and went back to sports and working out.

However, every few weeks, I would hurt my back again, but this pain was
slightly different. It felt more like the Ribs were sore or injured close to my
spine and the pain would not subside as fast. I finally began seeing a family
friend who is a chiropractor who began work on me. After 6 weeks of
treatments 2-3 times a week, I have begun playing hockey again and have
not had a pulled muscle since. The pain has been slowly subsiding, but
mornings still feel stiff if for example and put my neck down (pulls on the
upper back area).

In the last week, I have gotten this pain in my back shoulder blade, that is
worrying me again.

My chiropractor has mentioned that my ribs are misaligned and that the rib
tips are very sore.

It would make sense that this trauma to my back was caused by improper
sleeping and computer postures, which we are working on to correct.
However, my question/concerns are over time with these proper corrections
and treatments from the chirop, will he be able to properly heal my
symptoms so I can be pain free again or should I consider going in for an
Xray/MRI?


(note: I have a hunch that my injury is more rib related than a spinal injury,
but I am just looking for a 2nd opinion)

Thank You for your time.
Mike
-----Answer-----
Dear Mike,

Your problem is a common one and I agree that it is not a "spinal injury" per
se, but also one that requires a bit more explanation.  

When you have dysfunction concerning the joint of the rib and vertebra
adjusting that area may not help the problem.  This is because the rib also
articulates with the sternum on the front of the body, and dysfunction can be
there as well.  I have found that when rib problems do not respond to
adjustments, that often I need to address the articulation on the front instead
of the one on the back.  Anterior rib adjustments can be painful, but it only
lasts for a sceond.  Often this will take care of the problem in one to two
visits.

Additionally, the postural problems you have spoke of concerning the
ergonomics of your work station do play a role in your problem.  If you have
poor postures all day in front of the computer, this will place more stress on
the skeletal and muscular system.  Therefore, your rib problem will be harder
to correct.  Realize that the rib articulations have joint capsules and these are
made of ligamnetous tissues...they are subject to stress over time that can
cause weakening or a loss of elasticity.

Now ribs are more difficult to deal with, and they will take a bit longer to
heal, but they should heal.  Concerning x-rays, I like to have standard films
on all of my patients so that I don't miss anything, but often you will not see
anything when the rib articulation is problematic. If the chiropractor is certain
that the rib articulation is the true source of the problem I would not worry
about an x-ray at this time. Doing an MRI is a waste of money in my opinion.  
None of your symptoms would justify it, and it is an expensive form of
imaging.  If you had radiating symptoms into the arms, legs, around the
trunk, or other neurological symptoms, then an MRI would be appropriate.

I would work on making your workspace more friendly, correct problematic
ergonomic issues, discuss ways to alleviate postural stress on the
musculoskeletal system with your chiropractor, and get a few more
adjustments making sure that the doctor addresses the front and the back of
the rib articulations.  Physical therapy exercises to strengthen the rhomboids
in your upper back will most likely be beneficial as well...again discuss this
with your doctor, he should be able to train you on form and technique.

If your symptoms do not improve in the next few weeks, or get worse, then
imaging would be appropriate as well as another physical examination of the
affected area.

Respectfully,
Dr. J. Shawn Leatherman  

Answer
Dear Mike,

Well you do need to start working on the stability issue concerning your back.  What you don't want to do is start heavy weight lifting.  The important thing is to train the muscles with physiobands, light weights, and postural exercises to promote overall stability first, then you can work on increasing strength of bigger muscles.  The main muscles you need to work on are the rhomboids, serratus anterior and posterior, the erector spinae, the multifidus, and the transverse abdominus.  These will provide good stability to the spine as well as the torso.

The rhomboids and the serratus muscles help to maintain the normal position of the scapula and give support to the upper back and rib cage.  The erector spinae traverse the entire length of the spine and are thick in the low back providing support, but they are also the main muscle used in extension...they are frequently over-contracted due to constant load when posture is poor.  The multifidus is the most important stabilizer of the spine...it directly connects to the disk and the facet joints of the spine.  The transverse abdominus is very important for correct movement patterns...it is the first muscle to fire in all movement patterns, and therefore must be toned for stability in all movements.  Below is a list of websites to teach you proper form and info on the relevant anatomy.

http://www.med.umich.edu/1libr/sma/sma_rhomboid_rex.htm
http://www.myfit.ca/exercisedatabase/search.asp?muscle=serratus
http://www.exrx.net/WeightExercises/ErectorSpinae/WtBallHyperextension.html
http://www.exrx.net/WeightExercises/ErectorSpinae/BBBackExtension.html
http://www.nismat.org/ptcor/lbp/
http://www.orthop.washington.edu/uw/backpain/tabID__3376/ItemID__265/Articles/De
http://www.howtodothings.com/health-and-fitness/a3209-how-to-do-lower-ab-exercis

Lastly I want you to consider the ergonomics of your daily environment as well as frequent breaks form work to abate cumulative stress.  I have written an article on stability and tension relief that I will include below.

Training for Stability of the Neck and Back匩ot What You Think!

A brief look around any boardroom, construction site, grocery store etc?will provide any observer an insight into poor posture and de-conditioning syndrome. A deconditioned individual has only one option for lasting pain relief which is increasing their functional capacity. The average teenager and adult have pronounced spinal displacements due to chronic poor ergonomics of basic living, poor posture, and constrained working environments.  Back or neck pain is the number one reason for a visit to the chiropractic physician and medical doctor!  Shouldn抰 you work to prevent injury and strain?  The obvious answer is yes!

The most common reasons for back and neck pains are poor lifting techniques, abnormal posture, and repetitive micro-strain coupled with the lack of stability within the muscular system, and trauma.  It is sometimes difficult to avoid trauma, but if you eliminate poor technique, improve the ergonomics of your work station, and train your spine for stability, you significantly reduce your risk of injury.  Remember that we live in a gravity controlled environment and all muscular actions are in direct opposition to gravity.  We stabilize bridges and buildings so they won抰 buckle or break, you need to do the same for your spine.  

That being said, conventional strength training with free weights and isolation machines will give general overall gains in muscular strength if utilized properly, but won抰 necessarily target stability of the core or the spine.  Muscles to target are the multifidus, rotatores, intertransversales, transverse abdominis, and the pelvic floor.  Moreover, it is important to train for balance and symmetry thereby reducing abnormal weight bearing on all joints of the body.  

Lifting technique is important for optimal health and the reduction of injury.  To execute a lift properly, the back should be fairly straight while maintaining the normal lordosis (forward arch of the low back).  This position will activate the musculature properly for stability while not recruiting the ligaments for support.  Squatting is optimal, due to its neutral spinal position and the ability to use the muscles of the legs to accomplish the lift.   Stooping should be avoided, especially with repetitive movements.  Stooping creates an unstable configuration for the disk with increased tensile pressure on the posterior portion of the disk due to increased compression on the anterior portion of the disk.  This can easily result in a rupture of the disk.  In addition, objects should not be lifted if they are placed awkwardly which may require twisting and or bending, weights should be held close to the body, and jerky movements are only appropriate for highly trained individuals such as advanced athletes under the supervision of a trainer.  The last key is to create contraction of the abdominal musculature before the lift. This provides greater stabilization the spine, and your entire core.  You can easily accomplish this by sucking the belly button in toward the spine.  This activates the transverse abdominus muscle which is key for all movements.

One of the most deleterious activities people engage in is sitting. Sitting increases disk pressure more than standing and encourages abnormal flexion (forward bending) of the neck and upper back in addition to slumping in the chair.  These postures chronically load the disks, ligaments and musculature of the spine creating micro-injury and dysfunctional movement patterns.  

Many of us spend the majority of our days at a desk, computer or workstation.  We need to consider and modify our workspace carefully.  Adding a support for the lumbar spine reduces disk pressures.  A seatback angle of 5-15 degrees from vertical will reduce low back muscle activity and disk pressure.  Proper desk height is approximately 30 centimeters from the seat of the chair.  Arm rests are important in limiting strain on the upper muscular complex of the back and neck to include the trapezius, rhomboids, and levator scapulae.  The shoulders should be able to relax with the elbows bent at 90 degrees while the hands rest on the desk surface.  

Forward movement of the head on the neck is extremely problematic. For every inch forward the head moves in relation to the neck and shoulders, the compressive forces on the lower neck increase by the entire weight of the head, 10-16 lbs. Think about the difference in holding a bowling ball close to the body, or away from the body. This illustrates the differences in muscular work needed to support the weight and the ligamentous strain.  Computer monitors should be elevated so that the center of the screen is at eye level while looking straight ahead.  This will reduce eye strain; further reduce muscular tension of the neck while limiting the forward flexion of the head, therefore reducing the abnormal loading of the ligamentous complex.  This will also help reduce those 搘ork headaches?  Placing the monitor higher to induce a slight extension of the head is permissible.

Now that you have proper technique, and your workstation is optimal, structural and functional training of the musculature on the back of your body and your core is the key.  You must have a balanced and relaxed spinal cord for optimal function.  That being said, specific training is the way to achieve spinal balance and stability, and you don抰 have to go to the gym to achieve it.  If you can appreciate that we spend most of our days in a flexed position, the way to relieve that cumulative stress is to train the small stability muscles in an extended position.  

Most people are flexed forward at the hips/pelvis, have rounded shoulders, and a forward head and neck, this is called Global Flexion.  Extending the head backwards, opening up the chest by turning the palms of your hands outward and stretching your arms backwards relieves this global flexion.  The last step is to stand up and bend backwards at the waist approximately 20 degrees. You have just accomplished the task of Global Extension.  If you flex or tighten up all you muscles while in this position it further accentuates the value of the exercise and also promotes increased blood flow and oxygen delivery to the body.  This is a relief position that everyone should use frequently throughout the day to abate cumulative postural stresses.

Moving on, posture is the next consideration.  Your posture should not be a conscious task, but with the level of deconditioning in the population, conscious postural improvements are necessary.  This is mostly common sense, and your mother has telling you to do this since you were a child.  Exercise your postural muscles while walking.  Stand up straight, hold your head up high and walk with confidence looking ahead of yourself, not at the ground.  Pull your shoulders back, breathe deeply, and take confident long strides.  This alone will bring more oxygen to your body by fully opening up the lungs, increasing blood flow, and reducing abnormal stress on spinal structures.  You can also practice this position on a physio-ball or thera-ball to improve your seated posture and balance.  Complex postural issues and stability issues need to be addressed by a professional.

Remember that weight training, aerobic activity, and general fitness types of activities are only good for you if done with proper form, balance, control and stability.  If you don抰 have good posture and spinal symmetry, a traditional workout program will only make those problems worse.  It is essential to incorporate stability into your spine and your life before starting any exercise program.  You should see a medical or chiropractic physician before starting a fitness regime to make sure you are in good health and able to handle the rigors of increased physical activity.  If you have any cardiovascular issues, a stress test should be performed.  Many subsequent doctor visits are caused by improper fitness activities; it is better to see you doctor before rather than after.

All chiropractic physicians will be able to teach you about postural imbalances and how to improve your own posture, but many chiropractors have additional post-doctoral training in advanced postural biomechanics and structural correction to help you attain improved spinal dynamics.  Ask your chiropractic physician to tell you about their training, and provide written documentation about their qualifications.  To learn more about postural correction check out www.idealspine.com. In addition, a Certified Pilates instructor, www.nypilates.info, www.pilates-trainning.com or Certified Personal Trainer www.nsca-lift.org, www.ncsf.org  can have great benefit.  Remember to check their qualifications as well.

Good Luck Mike!
J. Shawn Leatherman, BA, BS, DC, CCST, CCSP?br> Director of Clinical Rehabilitation
Suncoast Healthcare Professionals