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Tiger Woods Is Not Getting It-One Way or Another

Tiger Woods is either getting bad advice from his medical team or ignoring the advice he is given. 

He needs to understand 3 things to give himself the best chance for recovery.

  • An “out of place” sacrum or weak muscles are not the problem.  It is his lumbar disc.
  • The lumbar disc takes a long time to heal and does so incompletely.
  • Rehabilitation should focus as much on re-engineering his golf game as it does strengthening his spine.

Despite my prior posts, he has  yet to contact me for guidance.  So, I intend for this to be the last time I write about his lingering low back problems.

That is, unless he, his advisors, or self-promoting medical professionals make additional statements that are out of touch with clinical reality.  

A Weakened, Sensitized, Lumbar Disc is Tiger's Problem: Here's Why

Lumbar Disc Herniation

Lumbar Disc Herniation

To reach the point of a disc herniation causing sciatica, at least 2 things need to happen.

  • The outer (annular) fibers need to be injured and/or torn.
  • The inner (nuclear) disc material, that is highly pressurized and usually contained by healthy outer fibers, needs to push through the weakened regions, extend outside of normal disc boundaries, and then compress the nerve.

A simplified illustration of this is seen on the left.

Briefly reviewing what I had previously written HERE and HERE; the lumbar micro-discectomy he had is designed ONLY to remove disc material compressing a nerve and relieve sciatic pain.  

  • It does NOT treat low back pain.
  • It does NOT heal or repair the damaged disc fibers.
  • It does not improve a lumbar disc’s ability to handle heavy, forceful, loads.

Tiger’s current problems are now the result of a de-pressurized, mechanically weakened, and chemically sensitized disc that is no longer able to manage the forceful loads placed upon it.

As I had mentioned earlier, the structural weakness in his lumbar disc probably pre-dated his surgery and resulted from vigorous, repetitive, and asymmetrical forces placed on his spine. 

Contrary to popular belief, it is extremely difficult to herniate a lumbar disc with any single mechanical force or injury. (1)  More commonly, a disc herniation is the end result of a degenerative process (often asymptomatic or with episodic back pain) allowing the inner (well-hydrated) disc material to extend through tears in it’s outer supporting network. (2)

As a part of this early degenerative process, water content in the lumbar disc is lost leading to reduced internal disc pressure. (3)  Although it is not yet entirely clear why some discs degenerate and others don’t, it is felt that age, genetic influences, and excessive mechanical loading each play a role. (4)  The only effect his lumbar micro-discectomy would have on those earlier degenerative changes would be to increase the risk of them worsening over time. (5) An average disc height loss of 25% has been reported after discectomy and this has been associated with increased pain and disability. (6)

A depressurized and dehydrated lumbar disc loses its ability properly distribute the loads and forces placed upon it. (7)   Maintaining pain-free spinal stability then becomes even more difficult due to:

  • Disc bulging and more rapid loss of water with loading. (8)
  • Increased stress concentrations on pain-sensitive structures. (9)
  • A release of enzymes and inflammatory chemicals causing further degradation and increased sensitization of the disc.  (10)

Also directly related to Tiger Woods’ situation is that asymmetric compression (such as what occurs repeatedly during a golf swing) will cause even  more tissue injury and release of disc degrading enzymes and inflammatory chemical substances. (11)

Considering the above makes it easier to understand Tiger’s recurrent low back pain.

Quite simply, his lumbar disc remains weak.  He continues to place stress upon the disc that it cannot bear and thus cause further injury.  And, he hasn’t allowed enough time for adequate healing to occur.  

How Well Does a Disc Heal-How Long Does it Take?

Lumbar discs have a limited capacity for healing. The healing that does occur takes time and results in a tissue that is of inferior quality to normal healthy disc structure.  (12)

As discs degenerate, there is a decrease in the number of disc cells leading to reduced production of the essential “building-blocks” necessary for normal disc integrity. (13).  This, combined with impaired nutrient delivery, (14) serves to compromise healing from the start.  The intrinsic healing capacity of the disc is also felt to be disrupted by the persistent release of substances that inflame and degrade disc tissue. (15)  You will recall from reading earlier, that asymmetric forces placed upon the spine (such as when Tiger continued to golf) cause increased release of such substances.

In controlled experiments, the first phase of healing is felt to take up to 22 weeks, resulting in a thin layer of tissue bridging the original site of injury.  

Repair occurs first on the outer parts of the disc with the inner fibers taking up to 1 year to heal. Even when complete, the “healed” tissue is not normal, but rather consists of biomechanically inferior fibrous tissue (12) that remains susceptible to further injury with continued loading. (16)

Ongoing disc injury, either through acute events or cumulative strain, leads to a disc that becomes even more sensitized due to an ingrowth of nerves and blood vessels as a result of the reparative process. (17)

As a part of Tiger’s microdiscectomy, it is likely that his surgeon may have used materials designed to “seal” the defect created by removing disc material.  Several are commercially available. However to date, none of these have been shown to compensate for the lost disc material, restore disc hydration, or prevent further damage to disc fibers. (18,19)

Swinging With The Tiger-What He Needs To Do

Tiger Woods first needs to recognize that his lumbar disc has been irreparably altered and will forever be unable to withstand the tremendous forces he had placed upon it.

His degenerated lumbar disc, with reduced hydration, pressurization, and injury to its external support ring (annulus fibrosus) will now deform easier, at lower loads, and be more susceptible to re-injury. (20,21,22).

Because of this he needs to:

  • Allow adequate time for maximum healing to occur.
  • Avoid engaging in activities that exceed what his spine can currently handle.  Such activities lead to continued tissue injury and ongoing release of damaging and sensitizing chemical substances.  Since annular disruption (internal disc failure) results from a combination of compression, bending, and torsion (23) it is obvious that all golf-related activities should be suspended for a reasonable period of time.
  •  His early rehabilitation program should focus on extension based exercises, both passive and active as this type of program avoids the damaging torsional stress to the spine and has been found to be effective in a large percentage of lumbar disc patients. (24).

Once enough time has elapsed for acceptable tissue healing to occur (this is not clearly defined but I would allow at least 3 months) Tiger will need to address the residual instability in his lumbar spine. 

Clinical instability has been defined as the spine’s loss of ability to maintain normal patterns of  pain-free movement when under load. (23)  Studies have shown that ligamentous injuries to the spine (and the lumbar disc can be considered a ligament) results in an increased “neutral zone” leading to impaired spinal control, especially with complex and forceful patterns of movement. (25)

Because of this, Tiger’s second phase of rehabilitation will have to emphasize smaller arcs of  movement, performed slowly, and without pain.  He could then progress through wider arcs and towards more dynamic movements as his body allows.

The final phase of Tiger Woods’ rehabilitation will need to be equal parts mental, tactical, and physical.  

The mental part has already been discussed.  That being, the recognition and acceptance that his old ways will no longer work, especially over the long-haul.

The physical and tactical side of his rehab go hand-in-hand and can occur simultaneously.  

There are currently no reliable scientific studies that provide guidance about what type of swing modifications would prevent recurrent pain in golfers.  (26)  However, it is felt that the “modern golf swing” with exaggerated lateral bending or “crunch factor” and excessive hyperextension or the “reverse C’ position place tremendous stress on the low back. (27)

This “crunch factor” was studied over several tournaments and in several golfers finding that 55% reported a history of low back pain with over half of these complaining of pain on the trailing side of their swing. (The same side of Tiger Woods’ injury).  They also found an increased incidence of spinal arthritic changes on this side as compared to age-matched controls. (28)

The specifics of how to make the necessary modifications in Tiger’s swing are best left to his professional instructors.  However, it is clear to me that modifications will need to be made in order to reduce his risk of recurrent injury and pain.  

In closing, Tiger faces many challenges in his recovery.  The largest of these, I believe, will be with his ability and willingness to do things differently than he has in the past.  

Judging by his recent comments, a bigger challenge may be in either getting, or listening to, better advice.  

REFERENCES:

 

  1. Adams MA, Hutton WC. Prolapsed intervertebral disc. A hyper-flexion injury. 1981 Volvo Award in Basic Science. Spine 1982: 7
  2. Moore RJ et al. The origin and fate of herniated lumbar intervertebral disc tissue. Spine 1996: 21
  3. Urban et al. Swelling pressure of the lumbar intervertebral discs: influence of age, spinal level, and degeneration. Spine 1998;13
  4. Adams MA et al. Why do some intervertebral discs degenerate, when others (in the same spine) do not? Clin Anat, 2014, April 14th.
  5. Schroeder JE et al. Disc degeneration after disc herniation: are we accelerating the process? Evid Based Spine Care J. 2012 Nov;3(4)
  6. Barth M et al. Two-year outcome after lumbar disctomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome. Spine 2008;33
  7. Urban PG and Roberts S. Degeneration of the intertebral disc. Arthritis Research & Therapy. 2003 Vol 5. No. 3
  8. Frobin W. et. Al. Height of lumbar discs measured from radiographs comopared with degeneration and height classified from MR images. Eur Radiol. 2001;11
  9. McNally DS et al. In vivo stress measurement can predict pain on discography. Spine 1996;21
  10. Ciurea AV et al. Imipact of changes in extracellular matrix in the lumbar degenerative disc. Journal of Medicine and Life. 2011 Vol.4. Issue 3
  11. Walter BA et al. Complex Loading Affects Intervertebral Disc Mechanics and Biology. Osteoarthritis Cartilage. Aug 2011;19(8)
  12. Bron JL et al. Repair, regenerative and supportive therapies of the annulus fibrosus: achievements and challenges. Eur Spine J. 2009;18
  13. Guteri CC et al. Challenges and Strategies in the Repair of Ruptured Annulus Fibrosus. Eur Cell Mater, Jan.2, 2013;25
  14. Junger S. Effect of limited nutrition on in situ intervertebral disc cells under simulated physiologic loading. Spine. 2009;34
  15. Wuertz K et al. Inflammatory and catabolic signaling in intervertebral discs: the roles of KF-kappaB and MAP kinases. Eur Cell Mater. 2012;23
  16. Natarajan RN et al. Recent advances in analytical modeling of lumbar disc degeneration. Spine;29(23)
  17. Stefanakis M et al. Annulus fissures are mechanically and chemically conducive to the ingrowth of nerves and blood vessels. Spine. 2012;37(22)
  18. Bourgeault C. et al. Biomechanical assessment of annulus fibrosus repair with suture tethered anchors. Spine Arthroplasty Society, Berlin.
  19. Gorensek M. et al. Clinical investigation of intrinsic therapeutics. Barricaid, a novel device for closing defects in the annulus. NASS 2006
  20. Adams MA et al. Sustained loading generates stress concentration in lumbar intervertebral discs. Spine. 1996;21
  21. Kazarian LE. Creep characteristics of the human spinal column. Orthop Clin North Am 1975;6:3
  22. Virgin W. Experimental investigations into the physical properties of the intervertebral disc. J Bone Joint Surg 1951;338
  23. White AA, Punjabi MM. Clinical Biomechanics of the Spine. Philadelphia, Lippencott-Raven 1990.
  24. Donelson R. The McKenzie approach to evaluating and treating low back pain. Orthop Rev 1990;67
  25. Panjabi MM. Clinical Instability and low back pain. Journal of Electromyography and Kinesiology. 2003;13
  26. Gluck GS et al. The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention. The Spine Journal, 2008;8
  27. Hosea TM, Gatt CJ. Back pain in golf. Clin Sports Med 1996;15
  28. Sugaya H et al. Low back injury in elite and professional golfers: an epidemiologic and radiographic study. Science and golf III: proceedings of the World Scientific Congress of Golf. Human Kinetics, 1999
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