Thursday, March 29, 2012

Reduce Your Fracture Risk, Take Vitamin "D" Daily




Been thinking about Vitamin D?  You should.  Although there are a myriad of supplements on the market that may, or may not, do anything other than give you expensive urine, the association between musculoskeletal problems and low vitamin D levels has been pretty well worked out.  The Mayo Clinic has " found that there is strong evidence to support the use of vitamin D with calcium for bone health..."  The actual dosing level isn't totally clear but currently Mayo recommends, for patients 1 - 70 years of age, 600 IU (International Units) per day, 800 IUdaily for those over 70 and 600 IU per day for pregnant or lactating females. 
Two studies are presented from the American Academy of Orthopedic Surgeons that show this pretty clearly.  Even though the second report is from postmenopausal females, life is a continuum and can easily apply it to others.



Orthopaedic trauma patients and vitamin D
Low serum vitamin D levels “have been linked to numerous musculoskeletal andnonmusculoskeletal conditions,” noted the authors of “Incidence of Vitamin D Deficiency in Orthopaedic Trauma Patients.”
This retrospective, Institutional Review Board-approved, chart review identified patients who had 25(OH)D levels noted in their charts and were treated for a fracture. Patients younger than 18 years and those with known risk factors for vitamin D deficiency were excluded.
A total of 889 patients (487 females, 402 males; mean age, 53.8 years) treated between January 2009 and September 2010 met the inclusion criteria. The data on the patients’ vitamin D levels were available in the patients’ charts, noted the researchers, because a protocol to check vitamin D levels on acute fracture patients had been established due to concerns about vitamin D deficiency.
The overall incidence of vitamin D insufficiency was 78 percent, while the incidence of vitamin D deficiency was 39 percent. “This indicates how widespread low vitamin D is,” they said.
These findings reinforce the fact that “vitamin D insufficiency and deficiency in acute orthopaedic trauma patients are relatively common.” Researchers noted that more research is necessary to learn more about the clinical significance of this finding.
“Because vitamin D plays a vital role in bone metabolism and has been implicated in not only increasing risk of fracture, but also in ability to heal fractures, documenting the prevalence of vitamin D deficiency in a trauma patient population is of vital importance as a first step in raising awareness among orthopaedic traumatologists and further determining a screening and treatment strategy for vitamin D deficiency in the trauma patient population,” they concluded.


Vitamin D levels in postmenopausal women
A Korean study on “Hypovitaminosis D in Postmenopausal Women with a Distal Radius Fracture” investigated serum vitamin D levels in postmenopausal women.
“On average, distal radius fractures (DRFs) occur 15 years earlier than hip fractures and may be an indicator for subsequent hip or vertebral fractures,” noted the authors. “To reduce the risk of future fractures, we thought it may be appropriate to identify the risk factors for patients experiencing their first DRF.”
The study included 104 postmenopausal women who had been surgically treated for a DRF and 107 age-matched control patients without a fracture (control group).
Investigators compared serum vitamin D levels, taking into account age and seasonal variations. They measured and analyzed the following to determine if there was any association with vitamin D levels: bone mineral density (BMD), serum parathyroid hormone (PTH) levels, and several bone turnover markers, including serum osteocalcin, C-telopeptide, and urine N-telopeptide.
Results showed that the DRF group had a mean serum vitamin D level that was significantly lower than that of the control group (P < 0.001). In particular, DRF patients in their 50s and 60s had significantly lower vitamin D levels than their age-matched counterparts in the control group (P = 0.001 and 0.013, respectively), whom the authors noted “may be a good target group for prevention of future fractures.”
“When seasonal variation was considered, significant differences in serum vitamin D levels were found between the groups in autumn and winter,” they stated. “Hip BMDs were significantly lower in the DRF group than in the control group, and we found a positive correlation between serum vitamin D levels and hip BMD.” No significant differences in bone turnover markers were found, although serum PTH levels were somewhat higher among DRF patients (P = 0.08).
“Further studies are warranted to determine whether hypovitaminosis D is a risk factor for DRFand whether vitamin D supplementation helps rehabilitation and the prevention of future fractures in patients with a DRF,” they concluded.
_____________________________
In summary, a great percentage of folks have been asked to take low dose aspirin daily.  In my opinion, vitamin D should be added to that list.

Image 1, Google Images

Tuesday, March 20, 2012

For Those Who Can't Run Or Are Always Injured/Exercise and Diabetes Genetics


"Man's most valuable sense is a judicious sense of what not to believe."    Euripides 

There are more tri forums out there than you can shake a stick at.  Many opportunities for the give and take of advice, especially when the questioner has some type of physical issue that, more than likely, has been experienced by others in the forum.  But, when questions are answered by an anonymous poster, how valuable is the response rendered?  Does Captain Underpants really know whether or not I should get a PRP (Platelet Rich Plasma) injection into my Tennis Elbow or is this bogus advice?
A short while back, Jeff Yeager, a level headed participant in the Slowtwitch.com tri forum, posted the information below as one way to allow the body to adapt to the changing stress levels placed on it by triathlon.  I have posted the statistics before that  in recreational runners, upwards of 50% will have a running related injury this year and it climbs closer to 90% for marathon runners.  Here's Jeff's approach (printed with permission) which has worked for many athletes.  You might be one of them.

Hawaii 2009 057

From Jeff Yeager:

This is a public service announcement. 
I always hear non-runners, some sedentary, some cyclists or swimmers, saying that they can't run because "insert statement here about a bad piece of anatomy".

I think that in 95% of these cases these people have not attempted to adopt a running program in the proper way.
Before I go any further I want to go on record as saying that for people with a serious existing injury or degenerative disease that persistence won't pay off in your case. If you have a specific diagnosis or medical advice, don't follow my suggestions.
We have all heard that contrary to intuition, triathletes experience running injuries as often or more often than runners (here 'runners' means someone that focuses only on the sport of running).

The reason for this is simple. By running every day, runners adapt to the stresses of running far more readily than a triathlete does. Running is all about physical adaptations to the specific stresses of running.

Change your mindset about running and stop considering your running 'limiter' to be your cardiovascular or muscular endurance. First and foremost it's the ability of your bones and connective tissue to endure the impact.
What worked for you when you were 16 years old and joining the track team doesn't work for you later in life when you are probably heavier and have far less growth hormone coursing through your body. And besides this, many high school and college running programs have a 25-50% injury rate each season!

When I returned to triathlon (and running) about 5 years ago I began to experience a string of running injuries one after another. They all occurred before I even exceeded 15 miles per week and affected me nearly continuously for 4 years.
There were shin splints (repeatedly), plantar's fasciitis, aching knees, a serious run of SI joint dysfunction (2 years!), torn calf muscle, finally culminating in a torn plantar's fascia that resulted in a whole season of racing but no run training.

When I began to return to run training once again here's the approach I took:

5 minutes of running on a treadmill 3 days per week. I did this for 3+ months. I then moved to the next phase which was 10 minutes at a time. Phase 3 was adding 5 minutes on the other 2 weekdays between the 10 minute days.
Right now I am 1 year in to my VERY gradual build and I'm doing alternating 2/5 mile runs on weekdays with a Sunday run also. I'm still building and will be for 1-2 more years.

The big breakthrough is that now after a 5 mile run in the morning I feel like I could go for a second run in the afternoon. The next morning when I get out of bed I don't feel any of that leg tenderness that I've been plagued with the next morning for 5 years.

I attribute this to 2 things:

1) allowing my build to be VERY gradual knowing it was all about conditioning the body to the trauma, not for the cardio benefits.

2) running 6 days per week.

In regard to your running you need to change your mindset. You aren't training to be a killer runner next season, but 3-4 seasons from now. Your best friend is being injury free so you can run every day. Even 3 miles per day every day for 3 years will have you racing faster than going from 50 mile weeks with speed work to 3 months injured over and over again.
The body adapts when it receives a stressor that exceeds it's current adaptation level. This is why those extremely long weekend rides are important for Ironman. it's why those long weekend runs are so valuable for marathon.
If you were immune to injury then running 3 days per week with a 20 miler on the weekend would be a great way to train for triathlon, but it's a recipe for injury unless you are starting out as an avid single-sport marathoner already.

So my advice for you is simply this:

1) if you are 'fragile' then take a far longer view of your run training and start with something that seems pointless: 5 minute runs. (or whatever amount you KNOW is easy on your body)

2) Run 6 days per week. Fit this in to your current routine by adding 5 minutes of running either after your bike or after your swim on the days you don't normally run. This extra 5 minutes on off days should be easy because it's only 5 minutes. And doing it after the swim or bike? That's because you are already warmed up and I think that our bodies are a bit like car engines. In a car engine 90% of the wear the engine experiences is during the first few seconds after a cold start. I think that much of the trauma our bodies experience when running is the first mile and that is largely mitigated by never starting a run cold.

3) When it's time to add intensity (perhaps a YEAR in to a daily running regimen?--Remember this is talking to those prone to injury), then I suggest adding the intense running in the same way you added slow running...some ridiculously small amount initially....like 5 100 yard stride outs...then eventually becoming 5 minutes of speed/tempo placed in to a regular training run and over the course of many months you will ONLY THEN be ready to do a 'typical' speed workout seen in many training plans.  
_________________________________
Put this in the back of your mind as one way to approach this thing we call training.  WWED?  Or,What Would Euripidies Do?


___________________________________________

Exercise Alters Epigenetics

Exercise causes short-term changes in DNA methylation and gene expression in muscle tissue that may have implications for type 2 diabetes.
By Hannah Waters | March 6, 2012
Flickr, Joint Base Lewis McChordFlickr, Joint Base Lewis McChord
Exercise can delay the onset of diabetes by boosting the expression of genes involved in muscle oxidation and glucose regulation. A new study, published today (March 6) in Cell Metabolism, suggests that DNA methylation drives some of these changes, and that they can occur within just a few hours of exercise, providing a potential mechanism for how exercise protects the body from metabolic disease.
“It’s one of the first studies that really proves that DNA methylation can affect things in a very short timeframe,” said Marloes Dekker Nitert, who studies diabetes epigenetics at Lund University in Sweden and was not involved in the research.
People with type 2 diabetes are less responsive to insulin than healthy individuals, and thus have difficulties maintaining normal blood sugar levels. Certain metabolic genes, such as those involved in glucose transport and mitochondrial regulation, have been shown to be expressed at lower levels in diabetics, possibly explaining their decreased insulin responsiveness.

Sunday, March 18, 2012

Notes From a Pregnant Athlete



I did a 3 part series on The Female Athlete in December concluding with pregnancy 12/11/11.  As a man, my knowledge base goes only so far.  (I can hear the "Amen's" from here!)  Like me, our featured athlete Andrea is a member of the Virginia Masters Swim Team. She's been a life long athlete starting with soccer as a kid, through marathons, triathlons and even an Ironman as an adult and currently participates in a local multi sport series.  She joined Masters swimming to improve her technique and allow her to be competitive during non-triathlon months. Although this may seem a little lengthy, I'd like to give you her (nearly) exact words as it really imparts her emotional input.
____________________________




     "When I initially found out that I was pregnant, it was right at the start of the triathlon season.  I had also just splurged on a new time trial bike.  It was difficult for me but I decided that I would defer all of my triathlon race entries and opt out of swim meets and road races while I was pregnant.  However, I fully intended to keep up all training for the duration, which I luckily had been able to do.

     I would like to share what worked for me and what didn't, not specific to swimming Masters.  During the first trimester, I basically continued exactly what I'd been doing and alerted my coach to my new condition. I wanted to move out of the "animal lane" with swimmers I find difficult to challenge non-pregnant but subsequently found myself in another "animal lane."  We are all distance swimmers and love open water, so overall an internally intense lane, yet supportive of one another.  I also noted that morning practices really helped to alleviate both morning sickness and those carbohydrate cravings.
 
      As I entered the second trimester, the morning sickness went away and I had more energy.  I continued with my advanced workouts and kept my yardage at around four thousand.  However, my intervals definitely got slower. I used some of my older, stretched out suits and several team mates donated suits on their way to swim suit heaven.  I didn't find a maternity competition suit anywhere.

     Then the most difficult trimester came.  I slowed considerably with all intervals and distances.  I still did fly, my favorite stroke, but very, very slowly.  My flip turns took on a whole new format as I had to hold both arms out to balance myself as I flipped.  Breast stroke was nice, too, as it took the strain off of my lower back.  Fins and pregnancy do not agree.  Pregnancy and pull buoys don't really mix.  It seemed impossible to do a flip turn with a giant belly and a pull buoy.  Also, I drank at least two bottles of water during our 90 minute practices which seemed vital.

     Toward the end of my last trimester, my team mates joked that I might have the baby in the pool.  One of our lifeguards seemed quite alarmed when I asked him if he'd had any training in delivering a baby.  One of my team mates is a doctor, but he mentioned several times that he was not that kind of doctor!

     So, now the final surprise.  The baby was breech, but, possibly from so much swimming,he flipped into the correct position. Five weeks before my due date, after dinner and a party, I awoke at one a.m. with my water breaking.  It was New Years Day, barely.  Luckily we found a sober doctor and, a quick C-section later, Henry Anthony Latell was born 1/1/2012, the first baby of the New Year.  After a few initial days in the NICU, he was pronounced healthy and we all went home. The (helpful?) swim team offered theories as to why he came early including a distaste for being "in the front seat" on flip turns. Some said he just wanted to come out and do his own flip turns.

     I have had an amazing experience swimming pregnant with my team. Many have come to our house to deliver a home made dinner and to see Henry. Also, the team splurged and gave me a gift certificate for a much needed massage.  We have a close, special and supportive team.

     Swimming definitely kept me in reasonable shape and made me feel so much better mentally and physically. I gained the recommended amount of weight and bounced back pretty quickly getting back into the pool 9 days after Henry was born.  I have been bringing him with me and putting putting him in a nice corner spot while I take an end lane near him.  I have been able to swim for about an hour in between feedings and he seems totally content with familiar pool noises around him. I'm back to
my pre-pregnancy intervals and pre-pregnancy weight. I also think that this activity has done wonders for post-partum blues.  My OB was well aware of my fitness regimen, both supportive and knowledgeable regarding what I should and shouldn't do while training pregnant.

     The general consensus is that Henry will be a swimmer.  But since he's so quick out of the blocks, a sprinter for sure."

Andrea Latell

P.S.  When I asked Andrea  later about her attention to other sports while pregnant, this was her reply:

 " I ran and cycled the entire time. I ran much, much slower at the end and incorporated a little bit of walking. Biking on my trainer was no problem at all, however I couldn't get into my aerobars so just biked upright which worked okay. I did the exact same with my first pregnancy.  I also did some modified pilates, yoga and weight training. I gained 26 pounds and lost all of it within two weeks. I'm also nursing and plan to for a year. I did with my older son and still did all of my racing and even ran one marathon when he was about six months old. I think it's just important to eat a lot when you are training and nursing and to eat healthy and drink a ton of water.







Images, Andrea Latell

Notes From A Pregnant Athlete




I did a 3 part series on The Female Athlete in December concluding with pregnancy 12/11/11.  As a man, my knowledge base goes only so far.  (I can hear the "Amen's" from here!)  Like me, our featured athlete Andrea is a member of the Virginia Masters Swim Team. She's been a life long athlete starting with soccer as a kid, through marathons, triathlons and even an Ironman as an adult and currently participates in a local multi sport series.  She joined Masters swimming to improve her technique and allow her to be competitive during non-triathlon months. Although this may seem a little lengthy, I'd like to give you her (nearly) exact words as it really imparts her emotional input.


____________________________


 



 


 


 


     "When I initially found out that I was pregnant, it was right at the start of the triathlon season.  I had also just splurged on a new time trial bike.  It was difficult for me but I decided that I would defer all of my triathlon race entries and opt out of swim meets and road races while I was pregnant.  However, I fully intended to keep up all training for the duration, which I luckily had been able to do.


 


     I would like to share what worked for me and what didn't, not specific to swimming Masters.  During the first trimester, I basically continued exactly what I'd been doing and alerted my coach to my new condition. I wanted to move out of the "animal lane" with swimmers I find difficult to challenge non-pregnant but subsequently found myself in another "animal lane."  We are all distance swimmers and love open water, so overall an internally intense lane, yet supportive of one another.  I also noted that morning practices really helped to alleviate both morning sickness and those carbohydrate cravings.


 


      As I entered the second trimester, the morning sickness went away and I had more energy.  I continued with my advanced workouts and kept my yardage at around four thousand.  However, my intervals definitely got slower. I used some of my older, stretched out suits and several team mates donated suits on their way to swim suit heaven.  I didn't find a maternity competition suit anywhere.


 


     Then the most difficult trimester came.  I slowed considerably with all intervals and distances.  I still did fly, my favorite stroke, but very, very slowly.  My flip turns took on a whole new format as I had to hold both arms out to balance myself as I flipped.  Breast stroke was nice, too, as it took the strain off of my lower back.  Fins and pregnancy do not agree.  Pregnancy and pull buoys don't really mix.  It seemed impossible to do a flip turn with a giant belly and a pull buoy.  Also, I drank at least two bottles of water during our 90 minute practices which seemed vital.


 


     Toward the end of my last trimester, my team mates joked that I might have the baby in the pool.  One of our lifeguards seemed quite alarmed when I asked him if he'd had any training in delivering a baby.  One of my team mates is a doctor, but he mentioned several times that he was not that kind of doctor!


 


     So, now the final surprise.  The baby was breech, but, possibly from so much swimming,he flipped into the correct position. Five weeks before my due date, after dinner and a party, I awoke at one a.m. with my water breaking.  It was New Years Day, barely.  Luckily we found a sober doctor and, a quick C-section later, Henry Anthony Latell was born 1/1/2012, the first baby of the New Year.  After a few initial days in the NICU, he was pronounced healthy and we all went home. The (helpful?) swim team offered theories as to why he came early including a distaste for being "in the front seat" on flip turns. Some said he just wanted to come out and do his own flip turns.


 


     I have had an amazing experience swimming pregnant with my team. Many have come to our house to deliver a home made dinner and to see Henry. Also, the team splurged and gave me a gift certificate for a much needed massage.  We have a close, special and supportive team.


 


     Swimming definitely kept me in reasonable shape and made me feel so much better mentally and physically. I gained the recommended amount of weight and bounced back pretty quickly getting back into the pool 9 days after Henry was born.  I have been bringing him with me and putting putting him in a nice corner spot while I take an end lane near him.  I have been able to swim for about an hour in between feedings and he seems totally content with familiar pool noises around him. I'm back to


my pre-pregnancy intervals and pre-pregnancy weight. I also think that this activity has done wonders for post-partum blues.  My OB was well aware of my fitness regimen, both supportive and knowledgeable regarding what I should and shouldn't do while training pregnant.


 


     The general consensus is that Henry will be a swimmer.  But since he's so quick out of the blocks, a sprinter for sure."


 


Andrea Latell


 


P.S.  When I asked Andrea  later about her attention to other sports while pregnant, this was her reply:


 


 " I ran and cycled the entire time. I ran much, much slower at the end and incorporated a little bit of walking. Biking on my trainer was no problem at all, however I couldn't get into my aerobars so just biked upright which worked okay. I did the exact same with my first pregnancy.  I also did some modified pilates, yoga and weight training. I gained 26 pounds and lost all of it within two weeks. I'm also nursing and plan to for a year. I did with my older son and still did all of my racing and even ran one marathon when he was about six months old. I think it's just important to eat a lot when you are training and nursing and to eat healthy and drink a ton of water.


 


 


Images, Andrea Latell


 



Thursday, March 8, 2012

Top Ten Mistakes in Your First Race of the Season

"We are what we repeatedly do. Excellence then is not an act but a habit."        Old Chinese saying

Little snowmen surprise in (hopefully) the seasons final snowfall


I've written many pieces on how running success and running safety go hand in hand.  It's been frequently noted that one of the "arrows in your quiver" is your local running shoe store where, when you talk to the old hands, they've seen and helped runners with just about any running related issue imaginable.  I've also been quoted as saying that they know more than many physicians in this realm.

Our local first really big (about 2500 competitors) road race, The Ten Miler, is almost upon us and our runner's expert, Mark Lorenzoni, wrote the following.  It's so good, that I've published it in it's entirety. Even if your race isn't one of ten miles, this will benefit you for sure.
_____________________

Speed Bumps: The Top Ten Mistakes made by Ten Miler Racers


1. Storing too much hay in the barn the weekend prior to the race.
Most experts recommend a day/mile recovery before shifting your engine into high gear. If you want to race feeling fully recovered then run nothing further than seven miles the weekend prior to race day.

2. Not resting your piggie wiggies enough the day before the race. 
The smoking gun for "dead legs" on race day can often be directly traced to how much time you spent on your feet the day before. Especially beware of hanging out on concrete-based floors!

3. No race day navigational chart. 
One of the most dangerous pre-race phrases is "I'm simply going to run how I feel... I'm just trying to finish." Set your game plan prior to race day and visualize it. A good rule of thumb for those racing their first 10-miler is to cruise at about 20-40 sec/mile faster than what your normal long run base has been. Still would rather "race how you feel"? Well, that's exactly what's going to happen: you'll run fast at the beginning, when you're feeling great, and slow down to a crawl towards the end, when you're feeling dead tired!

4. Not enough high octane in the tank.
Improper hydration, especially if the temp or humidity is unseasonably high, can lead you down a dangerous road. Sip, not gulp, plenty of hydrating fluids the day before and morning of race. If it's warm and/or humid on race morning, make sure to take a few sips (3-5 oz) at every aid station, which are spaced 2 miles apart throughout the course. Don't wait till you're thirsty to have your 1st drink. Drink early and often!

5. Last minute cramming. 
Taking a little extra time to pick up your race packet the night before can afford you some quiet time to digest the important info included and avoid the stress of standing in long lines the morning of the race. Packet includes shirt, race #, shoe chip and important race day instructions, which are obviously useless to you if you don't pick them up until a few minutes before the start!

6. Wearing too much to the dance. 
Often the C10 lands on one of those much dreaded hot and humid early spring days and because it's often chilly at the start, many novices pile on too much clothing, forgetting the act of running warms you up. Exercise physiologists say expect to feel 15 degrees warmer than actual air temp. If you feel chilled prior to starting, layer lightweight clothes and peel it off along the course.

7. Unveiling the "new you" on race day. 
Race morning is NOT the time for experimenting... therefore no new shoes, socks, sports bras, gels, sports drinks, shirts or anything else you're tempted to add to your race experience. Any experimenting should be done during your practice long runs prior to race day!

8. Emulating the hare instead of the tortoise.
 No other rule is broken more than this mother of all mistakes and the results are always ugly! Start off your race experience on the right foot by lining up behind your predicted pace group and taking it easy for the first 2 miles. Resist the temptation and make the 1st mile your slowest, you will surely be rewarded with an excellent finish!

9. Not going for "the gold" on the downhills.Most folks moan about the uphills of the 10 Miler course, but few talk about the steep downhills along the way. There's no better way to compliment your own race performance and to make up for the tough uphills then to let yourself go by opening up your stride and leaning into the downhills. Caution: Don't practice this until race day because your knees will rebel!

10. Not knowing when to take a vacation. Most injuries associated with racing the 10 Miler occur in the weeks AFTER the race, when many folks, instead of throwing the engine into low gear, continue to pound the pavement because they're "motivated and feeling so good." Don't run more than 4 miles for a given run in the 2-3 wks after race day. This not only affords your some physical recovery, but also allows for a break in the mental intensity of training for a big race. Spend this special post-race time celebrating your accomplishments. After all, don't you deserve it?!
____________________________________

A corollary to number 10 involves the general category of rest. Yep, it's a four letter word as some will tell you.  Many of us who gravitate to running or triathlon are so-called type A personalities who'd rather please their log book than do what makes sense over the long haul.  "That is so true," notes Virginia based fitness guru, and mud enthusiast Dana Tornabene.  "I see client after client who, despite knee pain, an achy Achilles or no sleep when the baby kept her up all night, push through a hard work out anyway.  When asked if this is logical, they only answer weakly, 'Well, that's what the coach had planned for me.'"


Tornabene goes on to encourage athletes to always think big picture, what's their goal for next month if not 6 months from now.  "Making the best decision today seems easier when placed in that context," she says.


Tornabene gutting it out in the mud.



______________________

It might not be a bad idea to print this off, put it in your log book, and maybe remind yourself from time to time of your long term goals and how well you're doing staying on the road toward them.  Is it the same as doing your best to avoid injury?  Maybe.  As it says above, who knows, excellence can be habit forming.


Wishing you the best of successes in this racing season - John Post, MD


Sunday, March 4, 2012

Back Pain in Triathletes, Herniated Discs, Spondylolisthesis



Support comes in many packages, some sane, some.......


Low Back Pain
Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.
Anatomy
Understanding your spine and how it works can help you understand why you have low back pain.
Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.

Vertebrae


Parts of the lumbar spine.
These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.
Five lumbar vertebrae connect the upper spine to the pelvis.

Spinal Cord and Nerves

These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.

Muscles and Ligaments

These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.

Facet Joints

Between vertebrae are small joints that help your spine move.

Intervertebral Disks

Intervertebral disks sit in between the vertebrae.
When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.
Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.
Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.
Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.

Healthy intervertebral disk (cross-section view).
Description
Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.
Cause

Lumbar ligament tear.
There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!

Over-activity

One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.

Disk Injury

Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.

Herniated disk.
A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Disk degeneration.

Disk Degeneration

With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.

Spondylolisthesis.

Degenerative Spondylolisthesis

(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.

Spinal Stenosis

Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.

Spinal stenosis.
When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.

Scoliosis

This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.

Additional Causes

There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
Symptoms
Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
  • Back pain may be worse with bending and lifting.
  • Sitting may worsen pain.
  • Standing and walking may worsen pain
  • Back pain comes and goes, and often follows an up and down course with good days and bad days.
  • Pain may extend from the back into the buttock or outer hip area, but not down the leg.
  • Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
Tests and Diagnosis

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.

Nonsurgical Treatment

Medications. Several medications may be used to help relieve your pain.
  • Aspirin or acetaminophen can relieve pain with few side effects.
  • Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
  • Narcotic pain medications, such as codeine or morphine, may help.
  • Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
  • Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
  • Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
  • Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
  • Traction is often used, but without scientific evidence for effectiveness.
  • Other exercise-based programs, such as Pilates or yoga are helpful for some patients.

Surgical Treatment

Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.

Thanks to AAOS for this piece.

Top Ten Mistakes in your first race of the Season

"We are what we repeatedly do. Excellence then is not an act but a habit."        Old Chinese saying


 


I've written many pieces on how running success and running safety go hand in hand.  It's been frequently noted that one of the "arrows in your quiver" is your local running shoe store where, when you talk to the old hands, they've seen and helped runners with just about any running related issue imaginable.  I've also been quoted as saying that they know more than many physicians in this realm.


 


Our local first really big (about 2500 competitors) road race, The Ten Miler is almost upon us and our runner's guru, Mark Lorenzoni, wrote the following.  It's so good that I've published it in it's entirety. Even if your race isn't ten miles, this will benefit you for sure.


 


Speed Bumps: The Top Ten Mistakes made by Ten Miler Racers


 


 


1. Storing too much hay in the barn the weekend prior to the race.
Most experts recommend a day/mile recovery before shifting your engine into high gear. If you want to race feeling fully recovered then run nothing further than seven miles the weekend prior to race day.


 


2. Not resting your piggie wiggies enough the day before the race. 
The smoking gun for "dead legs" on race day can often be directly traced to how much time you spent on your feet the day before. Especially beware of hanging out on concrete-based floors!


 


3. No race day navigational chart. 
One of the most dangerous pre-race phrases is "I'm simply going to run how I feel... I'm just trying to finish." Set your game plan prior to race day & visualize it. A good rule of thumb for those racing their first 10-miler is to cruise at about 20-40 sec/mile faster than what your normal long run base has been. Still would rather "race how you feel"? Well, that's exactly what's going to happen: you'll run fast at the beginning, when you're feeling great, & slow down to a crawl towards the end, when you're feeling dead tired! 
Two Mile Time Trial - Ten Miler Race Potential Chart


 


4. Not enough high octane in the tank.
Improper hydration, especially if the temp or humidity are unseasonably high, can lead you down a dangerous road. Sip, not gulp, plenty of hydrating fluids the day before & morning of race. If it's warm and/or humid on race morning, make sure to take a few sips (3-5 oz) at every aid station, which are spaced 2 miles apart throughout the course. Don't wait til you're thirsty to have your 1st drink. Drink early & often!


 


5. Last minute cramming. 
Taking a little extra time to pick up your race packet the night before can afford you some quiet time to digest the important info included and avoid the stress of standing in long lines the morning of the race. Packet includes shirt, race #, shoe chip and important race day instructions, which are obviously useless to you if you don't pick them up until a few minutes before the start!


 


6. Wearing too much to the dance. 
Often the C10 lands on one of those much dreaded hot & humid early spring days & because it's often chilly at the start, many novice pile on too much clothing, forgetting the act of running warms you up. Exercise physiologists say expect to feel 15 degrees warmer than actual air temp. If you feel chilled prior to starting, layer lightweight clothes & peel it off along the course.


 


7. Unveiling the "new your" on race day. 
Race morning is NOT the time for experimenting... therefore no new shoes, socks, sports bras, gels, sports drinks, shirts or anything else you're tempted to add to your race experience. Any experimenting should be done during your practice long runs prior to race day!


 


8. Emulating the hare instead of the tortoise.


 No other rule is broken more than this mother of all mistakes and the results are always ugly! Start off your race experience on the right foot by lining up behind your predicted pace group & taking it easy for the first 2 miles. Resist the temptation & make the 1st mile your slowest, you will surely be rewarded with an excellent finish!


 


9. Not going for "the gold" on the downhills.
Most folks moan about the uphills of the 10 Miler course, but few talk about the steep downhills along the way. There's no better way to compliment your own race performance & to make up for the tough uphills then to let yourself go by opening up your stride & leaning into the downhills. Caution: Don't practice this until race day because your knees will rebel!


 


10. Not knowing when to take a vacation. 
Most injuries assocated with racing the 10 Miler occur in the weeks AFTER the race, when many folks, instead of throwing the engine into low gear, continue to pound the pavement because they're "motivated and feeling so good." Don't run more than 4 miles for a given run in the 2-3 wks after race day. This not only affords your some physical recovery, but also allows for a break in the mental instensity of training for a big race. Spend this special post-race time celebrating your accomplishments. After all, don't you deserve it?!


______________________


 


It wouldn't be a bad idea to print this off, put it in your log book, and maybe remind yourself from time to time.







 


 



Back Pain for Triathletes, Herniated Discs and Spondylolisthesis
















Support comes in many packages, some sane, some.......



 


 


 Low Back Pain




Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.




Anatomy




Understanding your spine and how it works can help you understand why you have low back pain.




Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.




Vertebrae





Parts of the lumbar spine.





These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.



Five lumbar vertebrae connect the upper spine to the pelvis.




Spinal Cord and Nerves



These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.





Muscles and Ligaments



These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.





Facet Joints



Between vertebrae are small joints that help your spine move.





Intervertebral Disks



Intervertebral disks sit in between the vertebrae.



When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.


Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.


Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.


Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.






Healthy intervertebral disk (cross-section view).






Description




Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.





Cause






Lumbar ligament tear.





There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.




As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.




These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!




Over-activity



One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.



This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.




Disk Injury



Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.



Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.


Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.





Herniated disk.




A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.


Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.


A herniated disk often occurs with lifting, pulling, bending, or twisting movements.







Disk degeneration.




Disk Degeneration



With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.



This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.







Spondylolisthesis.




Degenerative Spondylolisthesis



(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.





Spinal Stenosis



Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.






Spinal stenosis.




When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.




Scoliosis



This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.





Additional Causes



There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.






Symptoms




Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.




Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.




People with low back pain may experience some of the following:




  • Back pain may be worse with bending and lifting.

  • Sitting may worsen pain.

  • Standing and walking may worsen pain

  • Back pain comes and goes, and often follows an up and down course with good days and bad days.

  • Pain may extend from the back into the buttock or outer hip area, but not down the leg.

  • Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.



Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.





Tests and Diagnosis




Medical History and Physical Examination



After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.



Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.




Imaging Tests



Other tests which may help your doctor confirm your diagnosis include:



X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.


Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.


Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.


Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.


Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.





Treatment




In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.




Nonsurgical Treatment



Medications. Several medications may be used to help relieve your pain.




  • Aspirin or acetaminophen can relieve pain with few side effects.

  • Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.

  • Narcotic pain medications, such as codeine or morphine, may help.

  • Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.


Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.



  • Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.

  • Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.

  • Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.

  • Traction is often used, but without scientific evidence for effectiveness.

  • Other exercise-based programs, such as Pilates or yoga are helpful for some patients.




Surgical Treatment



Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.



In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.


Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.


Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.


Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.


Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.


The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.


The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.


Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.


The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.


The surgery is done through your abdomen, usually on the lower two disks of the spine.


 


Thanks to AAOS for this piece.