Clinical Anatomy of the Back BMJ

8/15/2019 Clinical Anatomy of the Back BMJ

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Professor Emeritus Moira O’BrienFRCPI, FFSEM, FFSEM (UK), FTCD

Trinity Coe!e

Du"in

MOB TCD

Cini#a $natomy of t%e Ba#&


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Pro!ress

TimeTime

'o% et al Cin Biome#% ***+-.*

MOB TCD


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S/ine

Consists of 0 Cer1i#a 2erte"rae

0 T%ora#i# 2erte"rae

0 3um"ar 2erte"rae

0 Sa#rum

MOB TCD


5/108

0 T%e stren!t% of t%e s&eeta#oumn is 4ue to t%e si5e an4

s%a/e of t%e 1erte"rae

0 Its fe6i"iity is 4ue to t%e many

7oints t%at are #ose to!et%er

MOB TCD

S/ine


6/108

2erte"ra Coumn

03ot of stress in 1ariety of s/orts

0 Cer1i#a /at%oo!y

0 Pain may "e referre4 to u//er

im"

0 3um"er /at%oo!y0 3o8er im"

MOB TCD


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9oun! S/ine

:orma #ur1ature of

infant’s s/ine:orma um"ar #ur1e

of to44er’s s/ine

MOB TCD


8/108

3o8 Ba#& Pain in S/orts

0 ;


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0 Ma7ority of s/orts in7uriesto um"ar s/ine

0 Soft tissue an4 many are

not re/orte4

0 Fra#tures0 Fra#ture 4iso#ation

0 $"rasions, "ruisin!

0 Contusions

Ta A De 2aut Cin S/orts Me4 **.+->

MOB TCD



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0 Must &no8 t%e s/ort0 Must un4erstan4 t%e

"iome#%ani#s an4 stressesin1o1e4 in t%e s/ort

0 Must e6amine t%e s/ine

in t%e a//ro/riate /osition

MOB TCD



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Ty/i#a 2erte"rae

0 Basi# /arts0 Bo4y an4 neura ar#%

0 %i#% #onsists of

/e4i#es, amina an4 s/ine

0 T%e trans1erse /ro#essesarise from t%e /e4i#es

0 Su/erior an4 inferior

arti#uar /ro#esses

MOB TCD


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3um"ar 2erte"rae

MOB TCD


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0 Bo4y &i4ney s%a/e40 :o arti#uar fa#ets for ri"s0 Inferior fa#ets fa#e anteroatera0 Su/erior fa#ets fa#e /osterome4ia0

Inter1erte"ra not#% in#rease insi5e0 $##essory /ro#esses "ase

of trans1erse /ro#ess0 Mammiary /ro#ess on /osterior

as/e#t of su/erior arti#uar/ro#ess

MOB TCD

3um"ar 2erte"rae


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0 Bo4y is #on1e6 anteriory0 Foramina on t%e /osterior

as/e#t are for t%e "asi#1erte"ra 1eins, 8%i#% 4raininto t%e interna 1erte"ra

/e6us0 T%e 8as of t%e 1eins,8%i#% are 1a1e ess, %a1eafferent ner1e fi"ers

0 Se#on4aries #an s/rea4

from /e1is, /rostate,a4rena !an4s un!s an4"reast

MOB TCD

3um"ar 2erte"rae


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0 T%e su/erior an4 inferiorsurfa#es of t%e "o4y are fat

an4 #o1ere4 "y a t%in ayer

of %yaine #artia!e

0 T%e "o4y of t%e 1erte"ra#onsists of tra"e#uar or

#an#eous "one

MOB TCD

3um"ar 2erte"rae


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Ty/i#a 3um"ar 2erte"rae

0 Su/erior an4 inferiorarti#uar /ro#esses

0 $rise from t%e 7un#tion oft%e /e4i#es an4 amina

0 Su/erior fa#e/osterome4iay

0 it% rou!% mammiary/ro#esses on t%e /osterior"or4er

0 Inferior fa#e anteroateray0 $##essory /ro#esses at t%e

"ase of trans1erse /ro#ess

0 Pre1ents rotation

MOB TCD


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T%e 3um"ar Fa#ets

0 2ary from t%e sa!itta4is/osition at t%e first an4se#on4, to amost #orona int%e o8er

0 Fa#et tro/ism is 8%en t%e fa#et

on one si4e is in t%e sa!itta/ane an4 t%e ot%er is in t%e#orona /ane, 8%i#% a44s torotationa stress

0 T%is #%an!e may o##ur in t%eo8er t%ora#i# 1erte"rae

MOB TCD


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Pars Interarti#uaris

0 Pars interarti#uaris0 Portion of amina "et8een

su/erior an4 inferior

arti#uar /ro#esses

0 Site of s/on4yoysis ors/on4yoist%esis

MOB TCD


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3um"ar S/ine

0 Can#eous "one0 ?


20/108

3um"ar 2erte"rae

MOB TCD


21/108

3um"ar 2erte"rae

MOB TCD


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3um"ar S/ine

0 Can#eous "one0 ?


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$nterior 3on!itu4ina 3i!ament

0 $tta#%e4 mainy to t%e "o4ies0 T%is i!ament %e/s to /re1ent us from

eanin! too far "a#& (%y/ere6tension)

MOB TCD


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Posterior 3on!itu4ina 3i!ament

0 $tta#%e4 mainy to t%einter 1erte"ra 4is#s

0 T%is i!ament %e/s torestri#t for8ar4 "en4in!(%y/erfe6ion)

MOB TCD

MOB TCD


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3i!amentum Fa1a

0 Runs "et8een t%e aminaeof t%e neura ar#%es

0 e/s to restri#t %y/erfe6ion

0 It e6ten4s to t%e #a/sueof t%e fa#et 7oint

0 It is %i!%y easti# an4 ensurest%at t%e i!ament 4oes not"u#&e in e6tension

MOB TCD

MOB TCD


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0 'i1es easti#ity to t%e /osterioras/e#t of t%e fa#et 7oints

0 e/s form t%e /osterior

"oun4ary of t%e inter1erte"ra

foramen

0 T%e i!amentum fa1a is

t%i#&er in t%e um"ar re!ion

MOB TCD

3i!amentum Fa1a

MOB TCD


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S/ina 3i!aments

0Inters/inous i!aments

0 Stron! su/ras/inous i!aments

0 T%e inter>trans1erse i!aments

7oin t%e trans1erse /ro#esses

an4 are t%in an4 mem"ranousin t%e um"ar re!ion

MOB TCD

MOB TCD


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Fift% 3um"ar 2erte"rae

0Larger, superior andinferior articular facetsin the same plane

0 Fift% um"ar 1erte"rae %as

ar!e trans1erse /ro#esses

0 $rise from t%e "o4y as 8e

as t%e /e4i#es

MOB TCD

MOB TCD


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$rt%ritis of S/ine

0 Painfu0 3imitation of mo1ement

0 E6tra /ro7e#tions

0 :arro8in! of 4is# s/a#es

MOB TCD

MOB TCD


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2erte"ra oints

0 Se#on4ary #artia!inous 7oints"et8een t%e "o4ies

0 yaine #artia!e #o1erin!"o4ies

0 Dis# of fi"ro#artia!e in

"et8een0 Syno1ia /ane 7oints "et8een

t%e fa#ets

MOB TCD

MOB TCD


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Inter1erte"ra Dis#s

0 $nnuus fi"rosis0 Con#entri# amina run

o"iGuey

0 Ty/e I #oa!en at /eri/%ery,

ty/e II near nu#eus0 ea&est /ortion is t%e

/ostero>atera an4 /osterior

0 Peri/%ery %as a ner1e

su//y

MOB TCD

MOB TCD


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:u#eus Pu/osus

0 'eatinous, %y4ro/%ii#, /roteo!y#an !e in

#oa!en matri6

0 3ies /osterior in t%e 4is#

0 T%ere are no ner1e en4in!s in a mature 4is#

0 :er1e en4in!s are foun4 in t%e /osterior on!itu4inai!ament an4 t%e 4ura

0 :utrition of t%e 4is# is "y 4iffusion 1ia t%e #entra


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0 y4ration of t%e annuus an4 nu#eus is/ro/ortiona to t%e a//ie4 #om/ressionastress

0 In 1i1o, t%ere is a oss of #m stan4in!%ei!%t o1er t%e #ourse of t%e 4ay

0 $ 4is# oa4e4 in 1itro for four %ours "y


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0 T%e /osition of t%e s/ine 4etermines8%ere t%e #om/ressiona for#es are!reatest

0 T%e /osterior on!itu4ina i!ament ist%in an4 e6/an4e4 at t%e e1e of t%e

4is#0 i!% #om/ressiona oa4in! at

3,3?,S may "e 4ue to en4 /atefra#ture an4 not to ru/ture of t%e annuus

0 En4 /ate faiure is a /ossi"e /re#ursor of 4is#4e!eneration

:u#eus Pu/osus

MOB TCD


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$6ia 3oa4 an4 En4>/ates

MOB TCD


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En4>/ate Me#%ani#s

0Fun#tionay, t%e 1erte"ra en4>/ate4is/ays #%ara#teristi#s of a tram/oine

0 it% t%e su">en4>/ate tra"e#uar

"one a#tin! as s/rin!s to sustain

an4 4issi/ate a6ia oa4

0 Des/ite t%e t%inness of t%e 1erte"ra

en4>/ate

0 T%e %y4raui# nature of marro8 an4

"oo4 1esses 8it%in t%e 1erte"ra "o4y,

a#t to 4am/en a6ia oa4s, uness t%e

o#a /oint /ressure is too %i!%

MOB TCD


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0 En4>/ate esions #an "e in4u#e4e6/erimentay "efore a 4is# 8i

/roa/se t%rou!% t%e anuus,

su!!estin! a /rote#ti1e me#%anism

o1er annuar in7ury an4 /otentiay

#or4 or root #om/ression

0 E6#essi1e oa4s may resut in

/erforation of t%e en4>/ate, usuay

in t%e re!ion of t%e nu#eus an4

often in t%e /at% of t%e4e1eo/menta not#%or4

En4>/ate Me#%ani#s

MOB TCD


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En4>/ate Sus#e/ti"iity

S#%mor A un!%anns T%e %uman s/ine in %eat% an4 4isease

:e8 9or&- 'rune A Stratton, *@?

Notochord

MOB TCD


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Fa#et oints

03,3 Fa#ets sa!itta/ane

0 3o8er 7oints in #orona

/ane

0 Syno1ia /ane 7oints0 Menis#oi4 stru#tures

0 Syno1ia mem"rane

some #ontain fat

0 Su//ie4 "y me4ia"ran#% of 4orsa ramus

MOB TCD


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0 :arro8in! of 4is# s/a#e,resuts in stress on

fa#et 7oint

0 i!%est /ressure 4urin!

0 Com"ine40 E6tension

0 Rotation

0 Com/ression

Fa#et oints

MOB TCD


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Fa#et oint Syn4rome

0E6tension an4 rotation

0 Pain risin! from fe6ion

0 Pain 8orse stan4in!

0 3atera s%ift in e6tension

0 Point ten4erness o1erfa#et

0 Referre4 e! /ain

MOB TCD


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Se!menta Rotation

Sin!er et al. Mus#uos&e Res


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Mo1ements of 3um"ar S/ine

0 Fe6ion imite4 "y

4is# /ro"ems

0 3atera fe6ion

0 E6tension imite4 "y

fa#et 7oint /ro"ems0 2ery itte rotation

0 E6tension an4 rotation

affe#t fa#et 7oints

MOB TCD


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:er1e Su//y

0 :er1e su//y0 Peri/%era annuus

0 Fa#et 7oint

0 :er1e is me4ia "ran#%

4orsa ramus

MOB TCD


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0 3um"ar arteries0 Interna 1enous /e6uses

0 E6terna 1enous /e6uses

0 Basi1erte"ra 1eins

0 2a1eess

Boo4 Su//y

MOB TCD


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3um"ar 2erte"rae

MOB TCD


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Can#eous Bone

0 Can#eous "one

0 ?


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$natomi#a $"normaities

0 S/ina Bifi4a O##uta

0 Fa#et Tro/ism

0 Ky/%osis

0 S#oiosis

MOB TCD


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Ky/%osis S#oiosis

MOB TCD


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0 emi>1erte"ra0 S/ina Bifi4a

O##uta

0 Fa#et Tro/ism

0 S#oiosis0 Ky/%osis

MOB TCD


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0 Uniatera um"arisation

0 Uniatera sa#raisation

MOB TCD


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T%e S/ine in S/orts

0 S/ine in7ury e/i4emioo!y

0 Conta#t 1s non>#onta#t s/orts

0 S/ine in7ury me#%anisms

0 O1eruse H o1eroa4 H o1eroo&e4

0 2erte"ra en4>/ate in7ury0 Dis# in7ury

0 Future issues

MOB TCD


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E/i4emioo!y

Coo&e A 3ut5 P%ys Me4 Re%a" Cini#s : $m


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Coo&e A 3ut5 P%ys Me4 Re%a" Cini#s : $m


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0 Ma7ority of s/orts in7uries

are to t%e um"ar s/ine

0 Many soft tissue in7uries

are not re/orte4

0 Fra#tures

0 Fra#ture 4iso#ation

0 $"rasions, "ruisin!

0 ContusionsTa A De 2aut Cin S/orts Me4 **.+->

MOB TCD


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C%roni# 3o8 Ba#& Pain

0 3o#a stru#tures

0 Mus#es

0 3i!aments

0 Poor iftin! te#%niGues

0 oints0 Bones

MOB TCD


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Ba#& Pain

3o#a stru#tures

0 Mus#es, i!aments

0 oints

Referre4 /ain

0 $"4omina or!ans0 Pe1i# or!ans

Must out rue

0 Infe#tion

0 Tumours

MOB TCD


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$#ute 3o8 Ba#& Pain

0 :on>s/e#ifi# o8 "a#& /ain

0 Usuay settes Gui#&y

0 istory

0 E6amination

0 Pain reief 0 Stay as a#ti1e as /ossi"e

8it%in imit of /ain

MOB TCD


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$#ute 3o8 Ba#& Pain

0 :er1e root /ain

0 3e! /ain 8orse t%an "a#&

/ain

0 :um"ness an4 /ins an4

nee4es

0 :euroo!i#a si!ns

0 Refer to s/e#iaist

0 If it 4oes not reso1e in

first 8ee&s

MOB TCD


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In1esti!ate 3o8 Ba#& Pain

0 Un4er < or o1er ?? years

0 :on>me#%ani#a /ain

0 Past %istory #an#er

0 T%ora#i# /ain

0 Steroi4s or I20 Un8e, 8ei!%t oss

0 i4es/rea4 neuroo!y

0 Stru#tura 4eformity

0 'ait 4istur"an#e or s/%in#ter

4istur"an#e

MOB TCD


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C%roni# 3o8 Ba#& Pain

Pain referre4

0 $"4omina or!ans

0 Pe1i# or!ans

Must out rue

0 Infe#tion0 Tumours

MOB TCD


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Pain Referre4

MOB TCD


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9oun! $t%ete

0 unior ru!"y team ?

years of a!e

0 M S#%euermann

0 ? S/ina "ifi4a o##uta

0 T%e s#rum %af %a44e!enerati1e fa#et 7oint

#%an!es

MOB TCD


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Sa#roiia# oint H S#iati# :er1e

MOB TCD


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S/ina Stenosis

0 Con!enita or a#Guire4

0 $"normay s%ort /e4i#es oramina

0 Formation of osteo/%ytes

0 Osteo>art%ritis of fa#et 7oints

0 Pain a!!ra1ate4 "y 8a&in!

0 Reie1e4 "y rest

MOB TCD


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S/ina Stenosis

MOB TCD


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Pre4is/osin! Fa#tors

0 Intrinsi# fa#tors

0 $natomi#a a"normaities

0 Biome#%ani#a

0 E6trinsi# fa#tors

0 S/ort0 Surfa#es

0 EGui/ment

0 Trainin!

MOB TCD


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Pre4is/osin! Fa#tors Ba#& Pain

0 Poor /osture

0 O1er8ei!%t

0 Unfit

MOB TCD


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0 Poor #ore sta"iity

0 ea& a"4omina

mus#es

0 ea& !utea mus#es

0 Mus#e im"aan#e

MOB TCD


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0 Poor #ore sta"iity

0 ea& a"4omina

mus#es

0 ea& !utea mus#es

0 Mus#e im"aan#e0 Pronate4 or #a1us feet

MOB TCD


71/108


0Ba4y 4esi!ne4 furniture0 :o "a#& su//ort

0 Poor /osture at 8or&

$ 3 B & P i

MOB TCD


72/108

$#ute 3o8 Ba#& Pain

MOB TCD


73/108

$nnuar tears

0 3oa4e4 #om/ression 8it%

rotatory #om/onent

0 $s itte as . 4e!rees of

%i!% torGue rotation

0 Fa#ets /rote#t 4is#

0 $s annuus fais, fa#ets

7oints may "e in7ure4

MOB TCD


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$nnuar Bu!e

Di 3 i

MOB TCD


75/108

Dis# 3esion

9 $t% t

MOB TCD


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9oun! $t%ete

0 unior ru!"y team ?

years of a!e

0 M S#%euermann

0 ? S/ina "ifi4a o##uta

0 T%e s#rum %af %a44e!enerati1e fa#et 7oint

#%an!es

MOB TCD


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S#%euermann’s Disease

'reene et al Pe4iatr Ort%o/ *?+?-

S/on4yoist%esis

MOB TCD


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S/on4yoist%esis

P I t ti i

MOB TCD


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Pars Interarti#uaris

0 Pars interarti#uaris, /ortion

of amina "et8een su/erior

an4 inferior arti#uar

/ro#esses

0 Site of s/on4yoysis or

s/on4yoist%esis

S 4 i t% i

MOB TCD


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S/on4yoist%esis

S 4 i 4 S 4 i t% i

MOB TCD


81/108

S/on4yoysis an4 S/on4yoist%esis

P I t ti i F t i t

MOB TCD


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Pars Interarti#uaris+ Fa#et oint

S/on4yoist%esis MOB TCD


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S/on4yoist%esis

Ra/i4 Fe6ion an4 E6tension

0 'ymnasti#s, fi/s0 2autin!

0 Baet, ara"esGue

0 3iftin! 4urin! 4an#e

0 Di1in!

0 Butterfy s8immin!

0 De#at%on

0 Poe 1autin!

$n&yosin! S/on4yitis Infe#tion

MOB TCD


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$n&yosin! S/on4yitis, Infe#tion

@? $t%etes 3o8 Ba#& Pain MOB TCD


85/108

(M.+F;)mae (.*) femae()

S/ina Bifi4a O##uta (SBO)

@@=() =(@)

3um"arisation

.?=() =()Sa#raisation

= (;) @= (*)

S/on4yoist%esis (.)

.


86/108

Me#%anism of In7uries

0 Com/ression or 8ei!%t

oa4in!

0 TorGue or rotation

0 Tensie stresses /ro4u#e4

"y e6#essi1e motion of

s/ine

0 y/ere6tension an4 fe6ionat&ins A Diin, *?

Com/ression or ei!%t 3oa4in!

MOB TCD


87/108

Com/ression or ei!%t 3oa4in!

0 S/orts reGuirin!

0 Massi1e stren!t%

0 i!% "o4y 8ei!%t

0 ei!%t ifter

0 oo&er an4 :o

0 restin!

0 3ine "a#& $meri#an foot"aat&ins A Diin, *?

ei!%t 3iftin!

MOB TCD


88/108

ei!%t 3iftin!

0 < = 8ei!%t ifters %a1e

o8 "a#& /ain

0 'reatest stress is 8%en 8ei!%t

is ifte4 a"o1e t%e %ea4

0 Dan!erous time is s%ift from

s/ina fe6ion to e6tension $!!ra8a et al Br S/orts Me4 *;*+.-?>@

$6ia Com/ressi1e 3oa4in!

MOB TCD


89/108


0 ea4 on #oisions

0 Motor s/orts

0 Boatin! a##i4ents

0 restin!

0 orse"a#& ri4in!0 Bi#y#in!

0 Bo"sei!%

MOB TCD



90/108


MOB TCD



91/108


MOB TCD



92/108


Com/ression Stress

MOB TCD


93/108

Com/ression Stress

Rotationa Stress

MOB TCD


94/108

Rotationa Stress

Rotationa Stress

MOB TCD


95/108

Rotationa Stress

S/on4yoist%esis MOB TCD


96/108

/ y

Ra/i4 Fe6ion an4 E6tension

0 'ymnasti#s, fi/s0 2autin!

0 Baet, ara"esGue

0 3iftin! 4urin! 4an#e

0 Di1in!

0 Butterfy s8immin!

0 De#at%on

0 Poe 1autin!

$ustraian Foot"a 3ea!ue

MOB TCD


97/108

$ustraian Foot"a 3ea!ue

Se8ar4 A Or#%ar4


98/108

'of

0 i!%est in#i4en#e of "a#&

in7uries in /rofessiona s/orts

0 Torsiona stress is essene4 "y

s/rea4in! t%e stress o1er t%e

entire s/ine

0 Ri!i4 a"4omina #ontro

0 Parae s%ou4ers an4 /e1isat&ins an4 Diin, *?

Sustaine4 Postures > y/ere6tension

MOB TCD


99/108

Sustaine4 Postures y/ere6tension

MOB TCD



100/108


MOB TCD



101/108


Sustaine4 Postures > Fe6ion

MOB TCD


102/108

Sustaine4 Postures Fe6ion

S#oiosis 4ue to Uniatera S/orts

MOB TCD


103/108


0 Ra#Guet s/orts

0 Fen#in!

0 S8ee/ ro8in!

0 a1ein

0 Freestye uniatera"reat%in!


MOB TCD


104/108


Runnin!

MOB TCD


105/108

Runnin!

0 Poor /osture

0 Poor a"4omina

0 Pronate4 feet

0 Mus#e im"aan#e

0 3e! en!t% 4is#re/an#y0 Osteo/orosis

Cri#&et

MOB TCD


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0 Bo8ers

0 Rotationa for#es

0 E6tension foo8e4 "y

rotation an4 fe6ion

T%an& 9ou

MOB TCD


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T%an& 9ou


108/108

BM Pu"is%in! 'rou/ 3imite4 (BM 'rou/J)

Documents

Clinical Anatomy of the Back BMJ