Back to Sport…A Discussion on Low Back Pain in the Athlete
SARAH L. KENNEDY, DO CAQSMSIDELINE ORTHO & SPORTS
902 W. RANDOL MILL RD SUITE 120
ARLINGTON, TX
Learning Objectives
Know the basic anatomy and physiology of the low back.
Learn the predisposing factors including specific sports that place an athlete at risk.
Determine how to properly diagnose and treat different conditions including non-operative and surgical management.
Learn how to work with your team including the athlete/parents, certified athletic trainer, physical therapist, and physician to safely allow return to play.
Who gets it?
THE YOUNG THE NOT SO YOUNG
High Risk Sports
Gymnastics (artistic > rhythmic) Diving Figure Skating Dancers Football (lineman) Wrestling Rugby
Judo Rowing Throwing (baseball pitchers) Volleyball Speed skaters Track & Field (pole-vault,
hurdlers, javelin)
Acute Traumatic vs Repetitive Extension
Risk Factors
Smaller, skeletally immature (esp. with contact sports)
Longer periods of play (ie. tournaments and sports camps)
Poor technique Abdominal weakness Tightness (hip flexors, hamstrings,
thoracolumbar fascia) Femoral anteversion Genu recurvatum Increased thoracic kyphosis
Anatomy
Anterior ColumnVertebral bodies• Epiphyseal growth plates
• Cartilaginous end plates
• Ring apophyses
Intervertebral discs
Posterior ColumnNeural arch• Facet joints• Spinous process• Pars interarticularis
***Ossification of the posterior column progresses from anterior to posterior***
Down to the bones….
Ligamentous Attachments
The nerve…
History
*PPQRST including sport *Changes in training*Acute onset or gradual *Diet*Trauma *Prior h/o injury*Repetitive hyperextension *Menstrual history*Worse with extension *Family h/o HLA-B27, *Pain with running or jumping psoriatic arthritis, ankylosing *Radiation to buttock or thigh spondylitis, Inflammatory BD
Don’t forget red flag questions:*Night time wakening *Morning stiffness*Fever *Malaise*Night sweats *Neurologic abnormalities*Unexplained weight loss *Bowel or bladder dysfxn
Physical Exam
Observation of gait & posture Ataxia, antalgic, limp, Trendelenburg Symmetry of shoulders and pelvis Scoliosis, kyphosis, excess lordosisSkin abnormalities Hemangiomas, café-au-lait spots, hairy
patches, skin dimplesRange of motion (mobility and pain) Flexion, extension, side-bending, rotation Hamstring, hip flexors
Palpation
Tenderness, TART changes
Special Tests
Stork (Single-legged hyperextension), FABER, Gaenslen, Straight leg, Adams
Neurologic exam
Motor strength, sensation, deep tendon reflexes.
Hip and Abdominal exam
Posture
Trendelenburg Testing
Assess pelvic stability
Skin findings
Neurologic Exam
Diagnostics
X-ray 3V (AP, lateral, oblique)
CT scan (fractures, bone lesions)
MRI (disc, nerve, etc.)
Bone Scan with SPECT images
The Young… Spondylolysis Spondylolisthesis Posterior Element Overuse
Syndrome Sacroiliac Joint Dysfunction Atypical (Lumbar)
Scheurmann Vertebral Body Apophyseal
Avulsion Fracture Disc Herniation Other
Kids are not little adults…
Under 8:• Increased laxity• Incomplete ossification• Horizontal facet orientation
Pars interarticularis represents a weaker area of bone due to growth
Affects at least 10-15% young athletes.
Growth spurts cause muscle imbalance and areas of weakness leading to an increase risk of injury.
Growth characteristics during the adolescent growth spurt for girls and boys
Growth Characteristics
Girls Boys
Age at start 9-10 years 11-12 years
Age at maximum growth 12 years 14 years
Age at which growth slows
>12 years >14 years
Age until growth continues
16-18 years 18-20 years
Age at maximum height growth
11-13 years 13-15 years
Purcell and Mitchell, 2009
Ring Apophysis
Repetitive flexion can lead to avulsion fractures!
Atypical (Lumbar) Scheuermann
Sports involving rapid flex & ext(diving, rowing, and gymnastics)
Flat back (↓thoracic kyphosis and lumbar lordosis)
Tight thoracolumbar fasciaXray: End-plate fractures of the lumbar vertebrae
Schmorl nodes
Vertebral apophyseal avulsions
Treatment
Activity ModificationNSAIDsPhysical therapy Core stabilization Stretching
Bracing 15 degrees of lordosis
Avulsion Fracture of Ring Apophysis
Repetitive flexion/extension
Gymnastics, wrestling, volleyball, weightlifting
Pain with flexion
Xray, CT scan
Treat with rest, heat, NSAIDS, and massage
If neurologic s/s consider surgical excision
Spondylolysis
Pars Interarticularis Injury Cause of up to 47% LBP in young
If ossification incomplete of superior portion, may predispose to stress fractures
Spina bifida occulta may be a predisposing factor
Most often at L5 and on left side
Spondylolysis
**Dance, figure skating, gymnastics are at highest risk**History:
Insidious onset
Worse in extension or with ↑ impact
+/- weakness, radiating pain, numbness
PE:
Poor flexibility
Focal ttp
Ipsilateral paraspinal mm spasm
+Stork (single-legged hyperextension)
Spondylolysis Types
1. Hyperlordotic and hyperflexible female (gymnast)
2. Muscular male with poor flexibility in hamstrings and erector spinae and recent growth spurt (football)
3. New athlete to sport with poor trunk control and abdominal weakness
Diagnostics>3 weeks, x-ray (AP, lat, oblique) Transitional vertebrae
Spina bifida occulta
Slippage
Lytic lesions
Stress reaction (“scotty dog”)
MRI vs SPECT bone scan(single-photon emission computed tomography)
Treatment
Activity Modification
Therapy Abdominal strengthening Hip flexor and hamstring stretching Anti-lordotic exercises
Bracing TLSO Lumbar corset
Return to Play: Once pain-free, gradual ↑ in activity Continue brace until full activity w/o pain; then, gradually wean
Spondylolisthesis
Bilateral spondylolysis
Lateral x-ray every 4-6 months until skeletally mature
>50% or neurologic s/s refer 25% associated with disc
herniation
Posterior Element Overuse Syndrome
Signs and symptoms similar to spondylolysis with normal imaging
Same treatment and return to play
The Not So Young Osteoarthritis
Discogenic
Spinal stenosis
Strain
Other
Mature Athlete
48% Discogenic
27% Lumbosacral strain
4% Osteoarthritis
Prior history of low back pain is most predictive of future LBP
Micheli,W. Arch Pediatr Adolesc Med 1995; 149:15-18.
Disc Pathology48% of adults11% of children
L4-5 and L5-S1 most common
Disc Herniation
Symptoms: Pain with flexion Associated back spasm Hamstring tightness +/- Buttock pain +/- Radicular symptomsPE: ↓flexion +straight-leg raise, slump ↓reflexes
Imaging
X-ray to r/o bony lesion MRI if persistent >3 months or progressive
90% of patients improve with conservative treatment
Treatment
Temporary lordotic brace Physical therapy
**extension-based stabilization program NSAIDS, acetaminophen Epidural steroid injections
RTP: Full pain-free motion Full strength Progressed through controlled sport-
specific activities
Sacroiliac Joint Dysfunction
Gradual onset Rule out infectious, inflammatory, or stress fracture Pain with extension, +FABER, + Gaenslen,
+Trendelenburg Xray if >3 weeks, MRI if needed, +/- labTreatment: Activity modification OMT/manual therapy PT with pelvic stabilization Oral analgesics Corticosteroid injection Bracing
SIJ Dysfunction
Osteoarthritis
OA Treatment
Keep Movin’ Low impact exercise Yoga, Pilates StretchingManage symptoms Heat Topicals Oral analgesics (acetaminophen, NSAIDs*) Supplements (glucosamine/chondroitin, turmeric)Physical Therapy maximize motion, strength Balance gait
Lumbar Strain
Disruption of muscle fibers within muscle belly or at the myotendinous junction
Pain 24-48 hours after injury With flexion +/-extension Unilateral muscle spasm +/- radiation to buttock Normal neuro exam Treat with PRICE, NSAIDs, and physical
therapy
Scoliosis
SHOULD NOT CAUSE BACK PAIN!!
Adolescent Idiopathic Scoliosis 2-4% 80-90% have a right-side thoracic
curve (convex to the right) ≥10 degrees with scoliometer
warrants x-ray
Adam’s Forward Bending TestRED FLAGS:
Left thoracic curve (convex to the left)
Severe pain Neurologic deficits Café au lait spots or
hairy patches
Riser Score: 1. Calculate risk of progression2. Guide treatment
Females have a 10% greater risk of curve progression!
Treatment and Referral Guidelines for Patients with Scoliosis
10 to 19 0 to 1 Radiography every six months, no referral
Observe
10 to 19 2 to 4 Radiography every six months, no referral
Observe
20 to 29 0 to 1 Radiography every six months, referral
Brace after 25 degrees
20 to 29 2 to 4 Radiography every six months, referral
Observe or brace*
29 to 40 0 to 1 Referral Brace
29 to 40 2 to 4 Referral Brace
> 40 0 to 4 Referral Surgery†
Cob Angle Risser Score Radiography/Referral Treatment
Horne JP, Flannery R, Usman S. Adolescent Idiopathic Scoliosis: Diagnosis and Management. Am Fam Physician. 2014 Feb 1;89(3):193-198.
“OTHER”
Infection Discitis or OsteomyelitisTumors Osteoid Osteoma, osteoblastoma, bone
cysts, Ewing sarcoma, osteogenic sarcoma, metastatic
Inflammation Seronegative spondyloarthropathiesAcute fractureCompression fractureVisceral pathology PyelonephritisCauda equina
Return to Play
Dependent Factors: Sport Age/Skeletal maturity Athlete/parents/coaches
Requirements: Pain-free motion with all activities Normal strength
Prevention
Good pre-participation evaluation Identify risk factors Prior injury Muscle weakness Inflexibility Begin general strength and fitness several
weeks prior to start of season Gradual increase in frequency and intensity Reduce amount of training and repetitive
motions during growth spurts
Core strengthening exercises
Stretching tight hamstrings and hip flexors
Teach proper technique
Postural corrections
Match athletes in size and strength
Take Home Points…
Muscle strain is a diagnosis of exclusion.
Identify the RED FLAGS.
Treatment should address flexibility and muscle imbalance.
Return to sport should be a gradual process.
References
1. Purcell L, Micheli L. Low Back Pain in Young Athletes. Sports Health. 2009 May; 1(3): 212-222.
2. Bono CM. Current concepts review: Low back pain in athletes. J Bone Joint Surg Am. 2004;86(2): 382-396.
3. Daniels JM, Pontius G. Evaluation of low back pain in athletes. Sports Health. 2011 Jul; 3(4): 336-345.
4. Horne JP, Flannery R, Usman S. Adolescent Idiopathic Scoliosis: Diagnosis and Management. Am Fam Physician. 2014 Feb 1;89(3):193-198.
5. Kujala UM,T.S. Lumbar mobility and low back pain during adolescence. A longitudinal three-year follow-up study in athletes and controls. Am J Sports Med. 1997. 363-368.
6. Green H, Cholewicki J, et al. A history of low back injury is a risk factor for recurrent back injuries in varsity athletes. Am J Sports Med. 2001;29(6):795-800.
7. Watkins RG. Lumbar disk injury in the athlete. Clin Sports Med. 2002;21(1):147-165.
8. Kim HJ, Green DW. Spondylosis in the adolescent athlete. Curr Opin Pediatr. 2011;23:68-72.
9. Gurd DP. Back pain in the athlete. Sports Med Arthrosc Rev.2011;19(1):7-16.