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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.