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Back pain: how bad posture can hinder sports performance
Slouching will cause back injuries, damaging your sport and your health
The thoracic (mid) spine and ribcage have extremely complex anatomy, and are commonly neglected in the management of sports injuries. Yet thoracic mobility and ideal posture are vital to injury prevention and recovery.
The thoracic spine has 12 vertebrae and is the most stable region of the spine, thanks to the limitations imposed by the structural elements of the ribcage and the vast array of ligamentous and muscular connections(1). The function of this relative immobility – and hence stability – is to protect our vital organs, such as the heart and lungs, but this has implications for the contribution of thoracic spine stiffness to sporting injuries.
The ligamentous connections between the ribs and the spine and sternum (breast bone) are extremely stable and provide for only limited motion. Because of this, movement in the thoracic spine, while possible in all directions, occurs only in small magnitudes.
Flexion/extension (forward and backward bending) is more limited in the upper thoracic region; rotation/lateral flexion (twisting and side bends) are more limited in the lower thoracic spine. Movement becomes increasingly restricted with age.
There is a dearth of literature on links between the thoracic spine and sporting injuries but Harrison et al(2) showed that thoracic spine kyphosis (convex curve of the mid back) may be linked with low back pain. Pain and grinding underneath the shoulder blade has also been linked with an increased thoracic spine kyphosis(3). Although there is no specific empirical evidence, anecdotally thoracic spine stiffness and kyphosis can be a common predisposing factor to shoulder injuries in throwing athletes, as well as thoracic and low back pain.
Skeletal changes with age
A normal newborn has to have an extremely flexible chest wall, so that it can deform in order to exit the birth canal. It is mainly cartilage: bone-hardening does not occur for several months after birth, and skeletal development continues until the 25th year.
With ageing, the cartilage ends of the ribs rigidify and allow less movement, and as the ligamentous and joint capsules stiffen, the thoracic spine loses mobility. The front of the thoracic vertebrae commonly become wedge-shaped, as the result of postural issues and / or osteoporotic vertebral collapse. This contributes to an increasingly hunched-over spine. Once we are into our thirties, bone mass starts to deteriorate and, although certain kinds of weight-bearing activity have been shown to reduce the rate of bone loss, roughly 70% of over-75s have osteoporosis of the ribs and spine.
Implications of structural changes
The healthy thoracic spine has a natural kyphosis (slight forward bend). This normal anatomical position is under threat as poor, prolonged slumped postures – the curse of modern day society – force the thoracic spine into further kyphosis, or ‘structural hyper-kyphosis’ (see figure 1). Sportspeople are by no means immune. The vast majority are recreationally active and therefore as likely as their sedentary counterparts to be slumped and desk-bound for large parts of the working day. Even full-time elite athletes spend significant periods relaxing in the normal fashion: hunched over a computer game or the internet, or slouching in front of the TV. Pro cyclists and triathletes are particularly at risk as a direct result of their sporting posture.
A hyper-kyphotic thoracic spine rarely develops in isolation. As the curvature increases, there are accompanying anatomical consequences. In sitting, the upper part of the spine and head move forward. This can lead to neck pain and headaches(4). If treatment is only directed to the neck and not at the thoracic stiffness causing the problem, symptoms may temporarily reduce but the pain will never go away.
Prolonged slumped sitting and thoracic hyper-kyphosis cause backward pelvic tilting, which contributes to a rounding or loss of the natural hollow in the low back. Over a long period, the hyper-kyphotic posture becomes chronic and the accompanying neural and connective tissue adaptations become difficult to remedy. Permanent lengthening and stretching of ligaments and muscles takes place. Pain often ensues because of micro-trauma inflicted on the soft tissue structures of the low back from this prolonged stretching.
The spinal discs, especially in the mid and lower back, may also be structurally affected: compressed at the front and stretched at the back, causing some disc degeneration and potentially bulges / prolapses, which can be devastating for the sportsperson.
If the thoracic spine is held in hyper-kyphosis, the shoulder blades must also move in a relatively hunched posture – a position linked with shoulder impingement injury(5). Among swimmers, tennis players and golfers, any thoracic mobility restrictions they have will predispose them to shoulder injury. If there is a loss of natural hollowing in the low back because of the hyper-kyphotic thoracic spine and backwards pelvic tilt, the legs will be prevented from moving in an ideal pattern, which may predispose the individual to a variety of lower limb conditions. As the ends of the ribs harden and the kyphotic spine alters structurally and stiffens, reduced rib and spinal mobility will affect the normal breathing movement.
In older people the result may be to cause or lead to worsening of respiratory conditions. In athletes it may lead to reduced tidal volume and VO2 max, impacting on sporting performance.
If your mid spine has lost extension, a sports therapist should take active measures to reverse structural changes. Where there is no underlying disease responsible for the kyphosis, the therapist should aim not just to restore mobility but also to ensure the client maintains ideal posture in the future. The most important aspect of re-education will be when the patient is sitting.
Strategies for this are:
- Visual cues: posting a red dot above the computer screen acts as a reminder that whenever the dot catches your eye you should sit up straight;
- Verbal cues: set your watch or programme your computer to produce an alarm / hourly reminder to sit up straight;
- Physical cues: have a physiotherapist tape your mid back into extension to help increase your awareness of good sitting posture .
Simple home exercises to maintain and increase thoracic extension
Gentle extension exercises can be initially performed once a day, lying on your back, using:
- rolled up towel;
- foam roller;
- easy-to-use and portable products such as bakballs (see www.bakballs.com).
The support should be placed underneath each vertebra in the mid back in turn for 20 to 30 secs. As your toleration improves, the exercises should be performed 2 to 3 times a day. An alternative would be to arch back over a chair or Swiss ball.
1. Harrison D et al ‘How do anterior/posterior translations of the thoracic cage affect the sagittal lumbar spine, pelvic tilt, and thoracic kyphosis?’ Eur Spine J 2002 Jun; 11(3):287-93
2. Hiskins B (2004) Thoracic Workshop. Australian Institute of Sport
3. Kuhn J et al ‘Symptomatic scapulothoracic crepitus and bursitis’ J Am. Acad Orthop Surg 1998 1998 Sep-Oct; 6(5):267-273
4. Lewis J et al ‘Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement’ J Orthop Sports Phys Ther 2005 Feb; 35(2):72-87