Watch this video of Dr Neil Welch, Head of SSC Lab Services discussing the causes of low back pain and how it can affect Tennis.
This video was recorded as part of SSC’s Online Evening for Tennis.
Dr Neil Welch is Head of Lab Services and Senior Strength & Conditioning Coach at UPMC Sports Surgery Clinic in Santry, Dublin.
Hi everyone, my name is Neil Welch. I’m head of SSC’s Lab services at UPMC Sports Surgery Clinic in Santry.
I’d like to take a minute just to say thanks to everyone who’s watching today, for taking time out of your day to listen. Hopefully, you’ll find the talk interesting, and you’ll find it helpful to help you get back into tennis.
|Today, I’m going to focus a little bit on back pain, because it is the most common musculoskeletal condition that we deal with.|
Very often it can be very debilitating and stop you from doing many of the activities that you want to do – in this instance, obviously tennis. So we’re going to talk about how we can stop your back from stopping your tennis.
Low Back Pain
If you do experience low back pain, I suspect there’s a good few of you who are tuning in who are dealing with it – I’ve no doubt you have tried lots of things to try and help yourself get better. That’s really common – if we have a problem that we try and solve, we’re feeling uncomfortable or feeling sore – we reach out for some simple methods to try and assist.
We might take action by using something like a back support to try and reduce the load on the back, and that’s a common approach.
It also would be very common to make other lifestyle adjustments. So I’ve had people email me lists of mattresses and for advice on what mattress to pick up and I wouldn’t be the world’s foremost expert on mattresses and neither do I think that’s going to be the way to solve low back pain either.
Similarly, I’ve had lists of chairs sent to me, and anybody who’s managed to swing one of these for the office at home, fair play. But again, I’d be of the mind that some of these external solutions the supports, the mattresses, the chairs might not be the best approach for improving your back.
Similarly, we looked at remedies as well, so when we tried dry needling, acupuncture, or something a little bit more extreme, and the use of cupping seems to be a little bit more common these days.
I guess with all these approaches, they kind of make sense in one way because we’re looking for ways to improve our situation and very often we look for ways that are external to us. We’re looking for the magic pill or the silver bullet to make us better.
Sometimes we go the way exercise. Frequently, when we look at the exercise solutions that are offered up. These images are actually from a research study looking at the impact of exercise and low back pain.
I guess two things kind of stand out. One is the research evidence around this exercise is mixed. When we look at the type of exercises that are being used, I guess you might see a reason why.
I’m a strength and conditioning coach by trade. So when I look at these images, and I look at the exercises and maybe what they’re trying to achieve – the only thing I could sort of see from this intervention is this person, if they do this for a period of time, is going to get better at balancing on a red ball.
So what I want to do today is talk you through maybe some of the factors that might be a little bit more effective for helping you manage your back, and keeping you on the court.
Managing low Back Pain
So when we talk about low back pain, broadly speaking, we’re not talking about the spine itself. I’m sure lots of you have had scans of your back and they’ve shown disc bulges or changes in facet joints, but these are very common elements or findings on an MRI scan that people without low back pain have.
More often than not, what we’re talking about are muscular issues.
So when we finally are a little bit sore on either side of the back, we might be thinking that there’s an issue with our lumbar extensors. These guys are active in lumbar extension, so when you arch your back, those muscles are working.
They also play a role in stabilizing the back, but you can see where the very bottom of the orange and yellow images, your lumbar extensors, they attach to the pelvis. They can be active in trying to control the movements of the pelvis and extend the hip.
Once we start to understand the role of the muscles, we can maybe start to figure out why they might be doing a little bit too much work for us.
Some of us might be finding that when we get a sore back, it’s a little bit more out towards the side – so what we would call our lateral quadrants.
One of the muscles out there that contributes is called a Quadratus Lumborum. This is a lumbar extensor, so again it helps you to arch your back. If you utilize those strategies quite frequently – that might be a reason why those muscles are taking on more work. They’re also responsible for assisting in lumbar lateral flexion, so that’s bending over to the side. What they also do is help control the pelvis – they help provide stability when we’re on one leg.
Broadly speaking, when we’re thinking about low back pain, we’re trying to understand why some of these muscles might be doing a bit more work than we would want them to.
What we also need to do in context as well, is try and understand the role you might be playing, while you’re playing tennis – ultimately that’s what we are discussing today is how to keep you guys on the court without your back from stopping you from doing that.
Now when we consider the musculature in the back, there are a few areas that we’re looking to try and consider. I’m sure people have heard and been told in the past their hip flexors might be a little bit weak or a little bit tight.
This is one of your hip flexors, your psoas muscle – it’s attaching to the front of your spine. I’ve crossed the hip. In this instance, the reason I’m showing this is to give you some idea of what a well-conditioned psoas muscle looks like. The dark grey image there is muscle. Any of the white bits you can see towards the bottom of the green box, a whisper of white marble, and that’s fat.
These are your lumbar extensors. So again, the same sort of thing, give you some idea of what a well-conditioned set of lumbar extensors looks like – a little bit marbling in there indicating some fat infiltration within the muscle but only a small amount. Looking at this on the scan you’re looking at a very well-conditioned set of lumbar extensors and hip flexors.
Just to give you some context what happens when we’re a little bit deconditioned or a lot deconditioned in this instance. So again we think about that psoas muscle, we think about the size and strength of that, so we are likely going to be weak here in our hip flexors, but then we can see the degree of fatty infiltration within the longer extensors.
So a lot more towards the rump steak end of the spectrum, rather than the filet steak. We can start to understand then maybe why some of the muscles in the back might not be coping with some of the work we’re asking it to do, particularly in the condition they are in.
Strengthening Exercise for the back
If we were looking to try and increase the strength of our back there are certain exercises we can do. I’m going to talk you through a deadlift now which would be one of the ones that we would use in order to be able to increase the strength of the muscles of the back of the body as a whole, but we’ve some research published that shows the increase in size and the reduction of fat within the muscles in the back from doing this.
This would be a deadlift movement – we are going to show you it in a rack, so once we’re back in gyms, hopefully, you’ll be able to do this. If you have dumbbells at home, you’ll be able to pick these up off the floor. The most important points here are the top of the lift, where Jack is really working on squeezing his bum. On the way down, most of the movements is from the hips, so he’s working very hard and pushing his bum backwards.
If you’re doing this right, you’ll feel the muscles down the back of the back the legs feeling like there’s a big stretch on them, so Jack will be feeling a stretch down his hamstrings and in his bum here.
Most important really with this is you shouldn’t feel like the back is doing most of the work – we are targeting the hips with this exercise that the back is playing in an assistance role.
If we think about our lumbar extensors, I said before about them being active in lumbar extension. If you arch the back a lot they’re working quite hard, and the key bit as well for me is the last point, hip extension.
If your primary hip extensors aren’t doing the work as well as they might, then you might be recruiting the lumbar extensors a little bit more, so essentially the hips don’t do the work, your back has to do a bit more.
Our primary hip extensors are Glute Max. It’s the biggest & strongest muscle in the body. Again as I said, if we’re underactive here and not very strong, then we’ve got to start considering what other structures are going to take that work on.
|We are looking to try and increase the strength of our glute max and this is probably one of the most important exercises that we use regularly here at the UPMC Sports Surgery Clinic for hamstring issues, hip issues, back issues, and it’s very common to have some weakness in our glute max.|
Single-Leg Hip Thrust
Single leg hip thrust is a really good option for you. You will see here the setup is to have the back on the bench, and you’ll see Jack here is keeping his eyes pointing straight down the gym – he is not throwing his head back and his ribs up.
The idea there is that all of the portion of movement comes from his bum. So you’ll see again when we go through that he is working very hard with his left glute to push up and squeeze, and to lock the hips out using the bottom, and that’s what you should feel when you are doing this, you should feel like your bum is working really hard.
Progression with that is to start adding weight by putting a dumbbell on top of the thigh, but if you could manage that with your body weight then you’re doing all right as a starting point.
We start thinking about those of us who are dealing with more lateral low back pain – it’s very common when you can kind of tell when somebody starts rubbing their back, they have the chicken wing, the elbow out to the side and then they are rubbing towards the side of their back. This is more the area that we might be thinking about. So, it’s an active lumbar extensor as well, so we can’t discount the two exercises that we’ve just done that should help. They’re also important for helping provide stability around the pelvis.
So we look at what else provides stability around the pelvis again it’s one of our glute muscles – our glute medius.
This is going to be an important one for us to exercise as well. How we might get after this is through relatively basic clam exercises there is a couple of important points here. Keeping the heels together, slowly dragging the knees apart, and just making sure we’re not rolling backwards away from the floor.
If Niall is rolling back and starting to point his hips up towards the ceiling, then his bum isn’t going to do as much work as we’d like it to. He wants to keep his right hip rolling forward and his hand provides stability there, slowly pull the band apart, and if you are doing this right, you will feel a really strong burning sensation going on the side of the bum cheek. That would be our glute medius taking on some work for us.
With all of these exercises, you should feel like you’ve had some improvements immediately after doing them, so the back should feel a little bit lighter and a little bit looser.
Obviously, in tennis, there’s a lot of rotation involved and sometimes we can use our muscles and our back a little bit more when our abdominals aren’t doing enough work.
This is where some of our rotational exercises in order to be able to target some of the muscles around the front of the body and get them doing a little bit more work for us.
Half-kneeling Pallof Press
A Half-Kneeling Pallof Press is a good option. All you need is a band at home. So some tension on the band, we are on one knee and we are slowly pushing the hands out in front of us and we hold.
We are just resisting rotation so that the hands ideally stay in the midline of the chest all the way through. The band doesn’t get an opportunity to pull us closer to the rack. By doing that, what you should feel is the muscles around your stomach, resisting that movement.
Jack here should feel the sides of his stomach working quite hard.
Again, just going to a point where you feel fatigued in the muscles in the stomach and then switching sides should help reduce some of the loading on the back, as well as obviously help our performance when we are playing.
One of the important factors again, when we start more considering overhead work, obviously serving is a large component of what we do when we play tennis, trying to understand the range of motion that we have in the shoulder becomes important.
One of the tests that we do for this is shoulder flexion. Just lying on your back and seeing whether you can get your thumbs over your head to the ground. On the second part here, I’ve just tried to flatten my back. It’s a little bit harder but I’ve got decent shoulder range of motion, get my thumbs to the floor.
If I arch my back it’s a lot easier. What that is telling me is that I am borrowing a lot more range of movement from my back. It’s not my shoulders necessarily doing the work.
So if I’m a second example in the middle here I’ve got my back flat against the floor. I can’t get my thumbs to the ground, I am lacking a bit of shoulder flexion, which means I’m going to struggle with anything overhead, or I’m going to borrow from my back in order to be able to get my arms overhead. So one of the reasons we get back pain on our overhead movements is because we lack shoulder range motion.
If you try that yourself at home, there are some exercises we can do to help them.
Lying Banded Y
So the first part is a relatively basic exercise here. We will be taking a bit of Theraband, keeping some resistance & trying to keep the back flat and just trying to work through a greater range of motion.
One of the reasons we sometimes lack range of motion around the shoulder is just because we don’t train ourselves to get into those positions. So simply by adding some of these exercises to your routine, you will your shoulder range of motion improves.
Pushing out against the band and keeping the thumbs pointing backwards will activate the muscles in your rotator cuff. It will be a good rotator cuff workout as well as improving your shoulder flexion range of motion.
Now, shoulder rotation is a very important component within tennis as well – testing your range of motion here is something you can do to find out whether it’s an area you need to develop. So just resting your elbow on a cushion, keeping the legs flat, and just seeing whether we can get the hand back towards the ground.
The temptation here is to reach for the fingers rather than trying to give the back of the hand/wrist to the floor. A lot of us will struggle in order to get the hands all the way down to the ground. In which case, again, we’re lacking some rotation range of motion, which very often comes from the muscles controlling the movement, rather than the joint itself, which means that it’s trainable.
So an exercise we can do is something we should be doing if we aren’t playing tennis anyway, providing stability and control around the shoulder is really important and our rotator cuff muscles are really important before this, is some external rotation work.
So again a very simple exercise, small dumbbell at home. Just have the elbow resting on the knee, and it’s the rotation we’re looking for. So the elbow should stay at 90 degrees all the way through, exactly where I’m grabbing my shoulder – that is where you want to be feeling it.
Sometimes it’ll take a bit of work and bit of playing around with the technique to make sure you feeling it at the shoulder blade, rather than say at the front or the top of the shoulder or play around with the exercise as soon as you have it, then a little bit of work taking that muscle to fatigue will start to condition your rotator cuff.
There will be some of us here who will have had to deal with rotator cuff tendinopathy in the past and this type of exercise would be a really important part of your rehab.
So, again by starting to implement some of these exercises into your routine – first of all, should stop you getting injured. If you do have some soreness, it will likely take care of a lot of it.
Okay so hopefully that gives you a little bit of an insight into some methods that you can take on yourselves to help with your back, to help train some of the muscles around your back so that you feel a little bit less discomfort, a little bit less pain, and help you to get back on the court.
The shoulder obviously is a really important component of playing tennis. Test your range of motion out at home. Try those little tests that we put up on the presentation there, and then what you should find gradually if you are consistent with those exercises, is when you go back to retest your shoulders you should notice some improvements.
If you need any more help at all feel free to contact us here in the UPMC Sports Surgery Clinic and we’ll see if we can help. Thanks very much for taking the time out to watch the presentation. We’ll be back shortly with some questions and answers.