Dr. Detective
Courtesy of: Swimming World
By Dr. G. John Mullen, PT, DPT, CSCS of Swimming Science, Owner of COR PT , Creator of Swimmer's Shoulder System, Swimming Science Research Review, and >, Swimming Troubleshooting System Swimming World correspondent

SANTA CLARA, California, October 30. SCREENING and prevention exercises will not resolve all injuries in any sport, thus making understanding the injury process a valuable tool for any coach. Unfortunately, this topic is rarely discussed in many coaching circles, although many deal with this on a daily basis. The Swimming Troubleshooting System injury process is typically broken down into three categories:

1) Inflammation

2) Repair
3) Remodeling

Although low-back pain is extremely common in developed worlds, proper treatment is far from ideal. For one, unnecessary MRIs are typically requested by uneducated patients resulting in many physicians aiding to unnecessary medical costs. Most notably, abnormal MRIs are not correlated with back pain. For example, as we age, much wear and tear occurs in our body. This wear and tear is notable in the late teens in many people, yet back pain does not occur with this structural abnormality.



This makes the MRI standard of care highly questionable, as MRIs may actually impair the psyche of recovery in a patient (read more at 7 Low Back Pain Confusions).

Although exercise is commonly associated with improving low-back pain, one could imagine how swimming (flip turns, undulation, etc.) increases the stress at the low back. This makes the low back the second most-injured site in swimmers, after the shoulder. Understanding the process and identifying the injury phase as a coach is possible and crucial for helping athletes keep swimming, avoid further injury and know when to back off.

The Patient
Danielle, 21, was at a top university and returning for her junior year. The team was in their first month of training, just starting to increase the intensity. Her pain initiated a few years ago without a specific injury. As she notes, it just "started after a regular practice." She had only seen the athletic trainer for the pain and reports short-term improvement with massage (myofascial releases) to the quadratus lumborum and with ice. She notes not trying anything else and reports not taking any medication, as many non-steroidal anti-inflammatory medications (NSAIDs) upset her stomach.

The Patient's Signs and Symptoms
Danielle was an IM specialist, approximately 5'9" around 140 pounds with a lean build. She noted constant pain in her low back, which worsened during flip turns and was stiff for approximately one hour upon waking. Her constant pain level was low, approximately a 1 -- 2 out of 10, but certain movements increased her pain to a 6 -- 7 out of 10.

The Tests and Assessments
Since the patient had pain constantly, performing tests and assessments was not indicated. This is a somewhat controversial view, as finding the root cause of the pain is often necessary for improvement. However, if a patient is already in pain, performing provocative tests will only make these symptoms worse. Also, doing these extra tests rarely finds the root cause of the symptoms, as pain makes every test positive (making them far too sensitive). For this reason, the baseline pain level was taken as the benchmark.

This patient had clinical signs of inflammation in her low back. This degree of inflammation was likely chronic due to the length of the symptoms. In this case, continued swimming may be preventing her from improving from the inflammation phase to a mechanical phase (repair and remodeling). For example, she may have had a chronic overuse injury which initiated her pain. This initial injury likely resulted in some level of inflammation. By attempting to continue "swimming through the pain," she may have repeatedly caused inflammation, impairing her ability to progress through the injury process.

Visual Assessment
Monica presented with typical swimmer's posture, rounded shoulders and kyphotic thoracic spine.



This position increases the pressure on the front of the spine, pressing the contents backwards.



Movement Assessment
Once again, a movement assessment was not preformed to avoid irritation and worsening of pain.

Swimming Assessment
Although she had been swimming, a swimming analysis was not performed at the initial evaluation, once again to avoid worsening the symptoms.

Treatment
When inflammation is indicated, resolving inflammation is the first course of action. In this case, where a patient does not tolerate anti-inflammatory medication, resolving inflammation is much harder. Luckily, there are foods with anti-inflammatory properties, which may help.

Boswella, garlic, tumeric, and cumin all demonstrate anti-inflammatory properties. Combine this with an improved diet (via removal of processed foods and foods rich in omega-6s) can help some. In trickier cases, like those with chronic inflammation, epidural injections may help. For this reason, the patient was referred to a sports medicine physician for their opinion.

The Outcome
After attempting an anti-inflammatory diet and eating anti-inflammatory food for four weeks, the patient noted only small improvements. Then, the patient received one epidural injection, which resolved her pain, decreasing it to a 0 out of 10.

This may sound like the end of the story, but simply improving pain does not mean the injury has completely resolved. While the epidural injection has helped, it is paramount to facilitate repair and remodeling. This likely can be aided with manual therapy and multi-planar core stability.

Summary and Recommendation
Low-back pain is extremely common in the population and in swimmers. This makes understanding the correct steps to take mandatory for coaches and the general population to hopefully mitigate unnecessary health care costs. Also, understanding what is beneficial for each phase of the injury process is important, as no single medical or rehabilitation specialist is the most effective for each case. Surround yourself with a network of experts and understand when to utilize each one for the most effective care.

Main Take-Home Points:
1) Understanding the phase of the injury is paramount for recovery.
2) Limiting the degree is pain is necessary to prevent continued irritation and inflammation.
3) No single treatment or medical specialist can improve every case.

Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University. He is the owner of COR PT, strength and conditioning consultant, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.