RICE & MICE will periodically review injuries that are common, uncommon or just plain unique in hockey. I hope to provide some insight to the “how’s, why’s, and when’s” of the injuries that might keep players out of the lineup.
The Flyers announced last night that the NHL granted a two game extension to Michael Leighton’s conditioning stint with the Adirondack Phantoms that allows him to stay on LTIR status for another week. Leighton underwent surgery on October 11th for a herniated disk in his lower back and while the surgery was successful, he is still experiencing residual numbness and weakness in one of his legs. Thus, I have the perfect segue into discussing lower back disk injuries.
Disks sit between vertebrae of the spine and act as shock absorbers or cushions. In order to provide structure to the disks, the outside portion is strong dens fibrous tissue in circular layers called the annulus fibrosis. The annulus fibrosis surrounds a gel like center called the nucleus pulposis. There are also 2 ligaments that run the length of the spinal column. A disk will bulge when there is a weakening or tear in the outer fibrous portion of the disc. Usually the nucleus pulposis will follow the path of least resistance and can leak out and put pressure on the spinal cord or the spinal nerves. Most injuries to an athlete’s body occur when body mechanics or conditioning cause a weak spot in a structure and this is equally true with disc injuries in hockey players. The injury commonly occurs when flexion (forward bending), rotation or twisting, as well as, compression of the spine happen simultaneously.
Disk herniation can cause weakness, burning, numbness and tingling of the nerve that is being compressed by the injury. Forward flexion will exaggerate the herniation and may increase symptoms, while extension or arching of the back may force the nucleus pulposis back into its usual position to alleviate compression of the nerve and alleviate symptoms. Just like any other injury, there are grades to a herniated disc that can range from a bulge in the annulus that has not completely torn, so the nucleus pulposis is still contained within the annulus, to a tear in the annulus with the nucleus oozing out to finally having all to a nucleus that is completely expelled and no longer attached to the annulus fibrosis.
In the low back (aka lumbar spine) there are 5 vertebrae. The disk between the 4th and 5th lumbar vertebrae (L4 & L5) as well as the disk that is under the 5th lumbar vertebra (L5 & S1) are the most common locations for this injury. Symptoms may include pain that radiates down the back of the hip and all the way down the leg. A herniation to the disk between L4 and L5 may cause the following symptoms: low back pain, groin pain, and/or pain to the back of pelvis, numbness or tingling in the outside of the thigh the front of the lower leg, top of the foot and middle 3 toes. There could also be weakness in pulling the big toe up toward the shin. A herniation to the disk between L5 and S1 would may cause pain in the low back, groin, and back of pelvis, numbness or tingling in the back of the outside of the thigh and lower leg, outside of the foot and the baby toe. Weakness is often seen in the muscles that allow you to stand on your tiptoes.
So how are herniated disks diagnosed? Well, MRI is typically the best way to diagnose a herniated disk and is considered the gold standard. There is looming cloud of mystery over Leighton’s injury, including when it started and why there were multiple opinions needed to diagnose it. Paul Holmgren said that Leighton passed a physical and had an MRI in July that didn’t show a herniated disk. A good question would be: were they looking for a herniated disk? If his injury occurred in the playoffs, there should have been sufficient time for inflammation to decrease and I could speculate that had the injury been addressed in the off-season, he may have been able to avoid surgery, or if not, at least avoided significant time lost this season. It’s also completely plausible that the herniated disc didn’t actually happen until the preseason game against Toronto. It may just be a mystery that is never fully explained.
Most low back injuries can be treated conservatively without surgical intervention. Gone are the days of bed rest for weeks at a time. There is an initial period of rest and reduced activity that focuses on pain reduction and decreasing any muscle spasm. Nonsurgical treatment methods include using cold and heat therapy, pain medication, anti-inflammatory medication, muscle relaxers, electrical stimulation and massage, and most importantly decreased physical activity. Epidural steroid injections are also commonly used. Regardless of surgical or conservative intervention methods exercise programs are always implemented to strengthen the core muscles of the body. These include abdominal, back, and hip muscles. Surgical procedures for a herniated disk include spinal fusion, open decompression, and other minimally invasive procedures. Leighton had a partial discectomy, meaning the bulging part of the disk was removed.
“It’s something that… it’s not just numbness, it’s just strength,” said Leighton. “The doctor did say that the nerve has to regenerate itself. It just takes time. It’s been longer than I expected, and the doc wasn’t quite sure how long it could take. I played two games with it, and I felt pretty good. It’s just certain movements and it doesn’t feel right. So we are just going to give it an extra week, which is going to be next Saturday. I think that will be good for me.”
Sports-specific activities and drills can be started when the athlete has full strength and is pain-free mobility. Return to play normally requires full pain-free range of motion, strength, power, and the absence of neurological symptoms. Yeah, you read that correctly: full strength and the absence of neurological symptoms. Numbness and weakness are both neurological symptoms that Leighton continues to deal with. You may recall the numbness/weakness was there prior to the surgery. Yes it’s possible that this is just a bit more bad luck for Leighton, it’s also possible that he waited too long to speak up about the injury. Perhaps this could all have been avoided. Former Flyer, Ryan Parent battled back issues for years before finally having surgery to correct a herniated disk. It was reported that Leighton spoke with him before the surgery. Parent has residual numbness in one of his legs; Leighton is having problems with numbness and weakness. Will he fully recover? Only time will tell.
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