This month, thousands of rowers will descend upon the Schuylkill River in Philadelphia for the Aberdeen Dad Vail Regatta, the largest collegiate rowing event in the United States. Amid all the fanfare and competition, though, is the nagging prevalence of lower back dysfunctions. The combination of year-round training plus the actual rowing motion itself makes these athletes prone to injuries of the lower back. With its high strength and aerobic demands, it is one of the most strenuous sports. Among college rowers, the lower back is the second most commonly injured site.¹

Che majority of injuries sustained by rowers tend to be overuse rather than acute injuries, according to the experts ADVANCE spoke with. The sport is dependent on repetitive motions. "Can you get in there and get your body to do something many times in a row?" asked Paul Giannotti, MEd, ATC, LAT, senior athletic trainer, Rollins College, Winter Park, FL.

A study showed 89.5 percent of male rowers and 76.9 percent of female rowers had an MRI positive for some type of disc disease.² Crew athletes have worse lumbar disc pathology than other athletes, according to Marc Nowak, MSPT, therapist at Sports Physical Therapy Institute, Princeton, and official physical therapist for the U.S. National Rowing Team. Rowing consists of lifting, forward bending and rotating that increase the compressive forces on the spine, a combination of activities that physical therapists generally advise patients to avoid.³

Some injuries that PTs and ATCs who deal with this population encounter are herniated discs, lumbar strains, sacroiliac joint dysfunctions, dysfunctions of the lower thoracic spine, scoliosis, sciatica, spondylosis and spondylitis. Often, pain caused by lower disc injuries will radiate into the buttocks. College-aged rowers will complain of pain while sitting in class. They also frequently exhibit back spasms and a lack of flexibility, such as the inability to bend forward and touch toes, where it was previously indicated.¹

Mark Nowak, MSPT, treats rower Anna Mickelson at the Sports Physical Therapy Institute in Princeton, NJ.

"Most of the injuries I see with our rowers are muscular," said Giannotti. Besides the lower back, the hip flexors and the oblique abdominals are often very tight from sitting position of the sport. The gluteals and the IT bands also get tight.

Repeat, Repeat

Repetition of the rowing motion along with poor technique leads to injuries. As rowers grow fatigued, they lose control of their core muscles and spinal stabilization, leading to increased trunk flexion.³ Unlike other sports, competition is not the main time that rowers injure themselves. Injuries can just as easily happen during practice. At least half the injuries in rowers Giannotti treats are not necessarily related to the sport itself but instead come from too much volume in the weight room or overuse from running or other cross training activities.

A lack of core strength can also make these athletes prone to injury, according to Donald Nguyen, PT, ATC, LAT, assistant athletic trainer, University of Texas, Austin. The back is a particular cause of concern because in other sports the back is used as a transitional force and the upper and lower extremities do most of the work. Rowers engage their back muscles to generate force and extension to maneuver the oars.

Sweepers row with one oar and scullers row with two oars. Sweepers can develop asymmetry in their bodies, with a short, tight, strong side, and a long, stretched-out weak side. Clinicians should look at the side of the boat where the rower's oar is located, and find out whether it hurts while they're sweeping the oar, indicating the pain is one-sided.

They should also examine technique. A proper rowing stroke begins as the oar enters the water, also known as the "catch." The rower's legs extend, the back opens into a less flexed position and the arms flex. The rower removes the oar from the water and turns the blade parallel in the oarlock, called "feathering." The body then returns to the start position.⁴ The shoulder closest to the oar should be lower and go through less of an arc of movement. Scullers' primary motion is forward and back, causing hypo-mobility, limited trunk mobility, side bend and rotation. Because they're sitting, rowers increase the sheer forces of the lumbar spine. Spinal discs are designed for compression loads, not sheer loads. Most problems occur with the L 3-4 and L 4-5 vertebrae.

"Timing, teamwork and efficiency are very important," said Giannotti. Rowing is very team-oriented and rowers depend on the other athletes in the boat. "If someone else's technique is off, it makes you work harder and you can hurt your back," Nguyen said. That team-first attitude can be a problem when it comes to treating injuries. Rowers are reluctant to take time off. Unlike basketball for instance, where another player can substitute for an injured one during practice, rowers prefer to have the same roster all the time for team psyche. "The hardest part is slowing them down," acknowledged Nowak. Yet experts agree that overuse injuries will not improve unless athletes rest.

Manual Focus

Other than rest, there are a series of manual treatments plus modalities that physical therapists employ when rehabbing rowers with low-back dysfunctions. "Core stability is the main thing you focus on," said Nguyen. A strong and stable core has a long-term effect in overcoming back problems. Initially, PTs also concentrate on the lumbar-pelvic region, decreasing stress and restoring extension. "We work the spine and hips from a neutral to a hip extension pattern," getting away from flexion, noted Nowak. Restoring hip extension and sideways rotation is another goal of therapy. Hip mobility needs to be normal to reduce stress on the back. Lower-body stretching and flexibility works to free up movement in the hips. Hip flexor, gluteal and IT band stretching are all part of the routine as well. Therapists also focus on the hamstrings and the quadriceps.

Sciatic nerve restrictions can mimic hamstring tightness and nerve tension restricts mobility. "Soft-tissue mobilization is essential in restoring hip, joint and soft tissue function," said Nowak. Nerve gliding, deep-tissue massage and joint mobilization work to restore range of motion. Therapists also focus on patients' positioning, educating them about appropriate seated posture both in and out of the boat.

In terms of exercises, bridges, planks and side planks, along with any other prone cross-extension activities can alleviate symptoms. Nowak recommended combining the three planes of motion into most of the exercises. Cross-training activities such as swimming, jogging and elliptical training can dissipate symptoms, although caution is warranted because such exercises can also lead to over-use injuries.

Side bending and rotation exercises on an exercise ball can help with mobility. Equipment like bands, medicine balls and cable pulleys can also be helpful. Some rowers display functional scoliosis, so a scoliosis type training regimen could be appropriate. Modalities such as moist heat, electrical stimulation and ultrasound can work depending on the patient. Some physical therapists and athletic trainers use kinesiology tape if indicated to facilitate relaxation and muscle fire of the lumbar spine and hips.

Keeping Warm

Nguyen highlighted the importance of warm-ups, such as maintaining a daily core exercise program and stretching to prevent injury. Elite rowers should focus on core stability to prevent future injuries; flexibility for the full-range of motion of the thoracic-lumbar spine; and endurance to maintain proper form in long races. The majority of rowers are long and lean and those who are less fit have trouble keeping up with the rest of the boat. That synchronization is important. Some dysfunctions can be caused or aggravated by timing miscues, like not putting the oars in the water at the same time.

After an injury, modifications should be made to rowers' techniques, training regimens and equipment to reduce the possibility of a recurrence. With land-based training, rowers should be careful of ergometers, two-handled rowing machines commonly found in weight rooms. Among collegiate rowers, sessions of longer than 30 minutes on ergometers led to instances of low-back pain.

Following injury, rowers should also address their mechanics and equipment. Is the boat rigged appropriately for each individual? Oar size can have an impact, with a longer oar putting more stress on the spine. Having the proper timing lessens the stress on the lower back. The seat in the boat slides all the way up to the "catch." If the timing is right, rowers lock their pelvis and get force from their legs. This needs to happen at the same moment they fire up their back muscles, according to Giannotti.

Nowak and his fellow therapists are highly motivated when treating rowers. Since these athletes are an overachieving group who put pain and dysfunction aside, when one comes into the clinic with complaints, he deals with it immediately. A small problem today can become a large problem later. However, if conservative treatments don't alleviate symptoms in about two weeks, Nowak recommends they see an orthopedic specialist. 

References

1. Hosea, T., & Hannafin, J. (2011). Rowing Injury Prevention. www.stopsportsinjuries.org/rowing-injury-prevention.aspx#prevention

2. Hosea, T., et. al. Aetiology of low-back pain in young athletes: Role of sport type. British Journal of Sports Medicine, 45, 352.

3. Campbell, R., & Pinciotti, D. (2011). Boathouse Doc: Spinal Stabilization Program. www.usrowing.org/Safety/BoathouseDoc/BHDSpinalStabilization.aspx

4. St. Vincent's Health Services. (2011). Rowing Injuries. www.saintvincenthealth.com/Services/Sports-Medicine/Sports-Injuries/Rowing-Injuries/default.aspx

Danielle Bullen is an assistant editor at ADVANCE and can be reached at dbullen@advanceweb.com