low back pain in volleyball players · 2018-06-05 · low back pain in volleyball players. low back...
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DR. CONNIE LEBRUN, MPE, CCFP(SEM), DIP SPORT MED, FACSMPROFESSOR, DEPARTMENT OF FAMILY PRACTICE FACULTY OF MEDICINE & DENTISTRY UNIVERSITY OF ALBERTAEDMONTON, ALBERTA, CANADA
Low Back Pain in Volleyball Players
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Low Back Pain in Volleyball
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272 competitive adolescent athletes involved in 31 different sports (158 males, 113 females, 15.4±2.0 years, body mass index [BMI] 20.3±2.4 kg/m2) enrolled in 10-month prospective clinical trial
Schmidt et al. 2014
LBP in Adolescents
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LBP in Adolescents
Schmidt et al., 2014
14 %
57 %
66 %
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LBP in Adolescents
Fig. 4 Relationship between existing (positive) and non-existing (negative) lifetime prevalence of LBP in the different sports (n = 272)
Schmidt et al., 2014
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LBP in Adolescents
• Retrospective cross-sectional study
• Students 18.5-24.5 years at Higher Institute of Sport and Physical Education of Sfax, Tunisia
– LBP reported by 879/5,958 of study participants (14.8%)
Triki et al., 2015
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LBP in Adolescents
• Prevalence of LBP significantly higher (p>0.001) in females (17.6%) than in males (12.5%)
Triki et al., 2015
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Risk Factors for LBP
• Repeated axial loading and hyperextension
• Misalignment of shoulders during serve or spike (smash)
• Repetitive hyperextension and rotation (spike and jump serve)
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Risk Factors for LBP
• Prolonged or frequent bending and twisting high loads or awkward postures
• Sudden and repetitive lumber flexion
• Repeated and heavy lifting (weight training?)
• Whole body vibrations
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Effects of Warm-up?
• Lumbar spine stiffness increased as a result of bench rest after a warm-up
• Effect seen in both spine extension and lateral bend axes but not in flexion or axial twist axes
• However - no decrease in stiffness associated with the active warm-up portion of the task was seen
Green et al. 2002
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Volleyball Injury Distribution
Reeser & Gregory 2015
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Spondylolysis/Spondylolisthesis
• Increased risk for developing stress fractures of the pars interarticularis of the vertebral bodies of the lower lumbar spine
Soler & Calderon 2000
• Most commonly the level of the fourth or fifth lumbar vertebral body (L5 > L4)
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Spondylolysis/Spondylolisthesis
• Kinematics of spiking and jump serving
• Risk for developing the condition (including beach volleyball players, track and field athletes, gymnasts, and weight lifters) ranges from: 1.5 to 8 times the 3–7% rate found among the general population
Soler & Calderon 2000
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Spondylolysis/Spondylolisthesis
• Full maturation of the bony pars does not occur until around the age of 25
• Spondylolysis more common during active growth spurts
• Iliopsoas inflexibility, thoracolumbar fascia tightness, abdominal weakness, and thoracic kyphosis
• Hamstring tightness
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Classification of Spondylolysis
Wiltse et al., 1975
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Spondylolysis/Spondylolisthesis
• Epidemiology:• Certain sports have a
significantly greater prevalence:– gymnastics (11–30%) – American football (20%)– weight lifting (23–30%) – wrestling (30–35%)
• Incidence of pars interarticularis defects in female gymnasts is 4X that of the general white female population
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Genetics and Spondylolysis
• Occurs in 15%-70% of first-degree relatives of individuals with the disorder
• Lysis is 2-3X more frequent in boys than girls, but slippage affects girls 2-3X more often than boys
• Prevalence is approximately 6% in the white population, a rate that is 2-3X higher than that in the black population
Soler & Calderon 2000
• In the Inuit population, the rate is as high as 25%
Hu et al. 2008
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Physical Examination
• Localized pain
• Worse with extension
• 1-legged hyperextension (“stork test”)
• Kemp test
– “quadrant” test
– extension-rotation test
• Sensitivity?
• Specificity?
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Spondylolisthesis
• Decreased lordosis
• Tight hip flexors
• Tight hamstrings
• Decreased SLR and popliteal angle
• “Step” deformity
From Cavalier et al., 2006
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Imaging for Spondylolysis/listhesis
• Xrays – AP, lateral, +/-obliques?
• Standing lateral –assess degree of slip
• Long term complications may occur in up to 25% of patients with spondylolysis:– Chronic LBP– Spondylolisthesis (15%)– Sciatica
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Spondylolisthesis
• Grade I - translation of up to 25%
• Grade II - 26% to 50%
• Grade III - 51% to 75%
• Grade IV - 76% to 100%
• Grade V - >100% (spondyloptosis)
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Bone Scan - Spondylolysis
• Technetium-99m (99mTc) methylene diphosphonate (MDP) bone scintigraphy
• Normal bone scan with pars defect is consistent with a healed (fibrous) process or non-union
• Prognostic value = sensitive tool for diagnosis of active spondylolysis
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Bone Scan - Spondylolysis
• Sensitivity of bone scan increased with use of single proton emission computed tomography (SPECT)
• Bone scan with SPECT
– Shows level of lesion
– Assess activity (i.e. potential for healing)
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• Single photon emission computed tomography (SPECT)/computed tomography (CT)
• Co-registered - fused image
• More precise localization of sites of abnormal bony uptake
• Identification of causes
• Identification of osseous abnormalities without associated abnormal radiotracer uptake
From Trout et al., 2015
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Vertebral Pedicle Fractures
From Trout et al., 2015
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Spinous Process Avulsions
From Trout et al., 2015
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Value of SPECT CT- “See” other things• Facet hypertrophy• Endplate apophyseal abnormalities• Degenerative disk disease• Endplate compression fracture• Persistent transverse process
ossification centre• Transverse process fracture• Transitional vertebra (+ back pain
= Bertolotti syndrome)• Sacral stress fracture• Sacroiliac joint syndrome• Diskitis and osteomyelitis• Benign or malignant tumor
From Trout et al., 2015
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CT for Bony Architecture
Reverse gantry oblique axialCampbell et al., 2005
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Radiation Doses
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What About MRI?• 39/40 pars defects seen on
CT and SPECT also had some degree of abnormality on MRI, but MRI correctly graded only 29
• Several subjects had MRI findings consistent with edema in the pars but no abnormalities on SPECT
• Limitations of MRI in terms of correctly grading the pars lesions were particularly apparent in patients with a pattern of findings on SPECT and CT indicating a stress reaction in the pars without a clear fracture line
Campbell et al., 2005
T-2 weighted imagesFrom Nakayama & Ehara 2015
MRI only identified 80% of lesions
Masci et al., 2006
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MRI Sequences
• Need sequences sensitive to bone marrow soft tissue edema for detection of the secondary bone marrow changes that come with a fatigue fracture:– Sagittal T1-weighted FSE
sequence
– Sagittal T2-weighted fat suppressed FSE and coronal T2-weighted
– Inversion recovery (STIR) sequences
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Suggested Imaging Protocol
From Campbell et al., 2005
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MRI Classification of Spondylolysis
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Early Progressive Terminal
Treatment of Spondylolysis
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Management of Spondylolysis
• Assessment of: – Flexibility (hamstrings)
– Lower limb alignment (including leg lengths)
– Foot structure (cavus vs flat feet)
– Motor function (strength imbalances)
• Flexibility training and dynamic lumbar spinal stabilization exercises
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Management of Spondylolysis
• Relative rest with appropriate activity modification x 3 months
• Bracing to minimize extension and resultant shear forces across the affected spinal segment?
• Only necessary for those individuals who remain symptomatic despite limiting their activity, or who require a physical/tactile reminder to avoid provocative activities
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Bracing & Biomechanics
• Bracing
– Controversial
– Differing views in literature
– Patients reported to heal with or without it
– If used, what type?
• Boston brace
• Soft brace?
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Use of Rigid Bracing
• Anti-lordotic modified Boston brace
• 23/24 hours
• 6 months with 6 month wean
• Stretching, strengthening
• Sports allowed in brace if no pain
• 52/67 (78%) excellent or good
Steiner & Micheli 1985
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Dianne Murray – Coach UBC Thunderbirds 1977/78 CIAU champs
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Bracing
• Bracing– With brace, 89% clinical
success– Without brace, 86% clinical
success– Not statistically significant,
p=0.75• Data imply bracing not
responsible for clinical improvement
• “Strong impetus to reconsider bracing as standard treatment”Klein et al., J Pediatr Orthop, 2009
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Management of Spondylolysis
• Athletes are allowed to return to sports when they have full, pain-free ROM, have achieved appropriate conditioning, spinal awareness, and sport-specific training, and can demonstrate sport-specific skills in a controlled environment without pain
Standaert & Herring 2007
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Management of Spondylolysis
• In general, rehabilitation requires 2-4 months to complete, resulting in a return to sports approximately 5-7 months after diagnosisStandaert & Herring 2007
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Need for Follow-up Imaging?
• Bilateral pars defects or unilateral defect in a very young athlete requires routine standing lateral radiographs every 6 to 12 months until skeletal maturity is reached
• Slip progression occurs during adolescent growth spurt
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Management of Spondylolysis
• Radiographicallydocumented pars interarticularisdefects that are “cold” on bone scanprobably representremote injuries and have little chance of bony union
• Treat to control pain, not achieve union
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Evidence-Based Outcomes
• Good evidence that when chronic bilateral pars defects exist – 43-74% will progress to isthmic spondylolisthesis
• Low likelihood for progression of spondylolisthesis, especially if the initial slip is < 30 %
• Unilateral, incomplete & early lesions can obtain bony union
• Short-term resolution is norm either with/without bony union
Crawford et al., 2014
Kreiner et al., 2016
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Indications for Surgery
• Classic indications for surgery:
– failure of comprehensive conservative treatment for > 6 months
– persistent back pain & pars non-union at 9–12 months (pars pseudoarthrosis)
• Increasing pain, worsening of preexisted neurological impairment and progressive olisthesis
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Surgery
• Posterolateral fusion with or without instrumentation
• L5 -S1 ‘‘in situ fusion’’ with autogenous iliac crest bone graft
• Direct repair for spondylolysis and spondylolisthesis < 3 mm with normal disc
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Degenerative Disc Disease
• Prevalence of disc alterations (including disc degeneration, bulging, and herniation) of 44% in volleyball players
Bartolozzi et al., 1991
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Beach Volleyball – Bondi Beach
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LBP in Professional Beach VB
• Cross-sectional study– 29 males
– Mean age 28 years
– Questionnaires, clinical examination and MRI
• 86% LBP during career
• 35% LBP in past 4 weeks
• 61% LBP in past 12 months
• No correlation between LBP and MRI changes
Külling et al. 2014
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LBP in Professional Beach VB
• 23/29 (79%) – at least 1 degenerated disc
– L4-5 (48%), L5-S1(52%)
– 5 players (17%) – both
• 6/29 (21%) spondylolysis
• 2/6 (33%) spondylolisthesis
• (5% in general population)
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Sacral Stress Fractures
• Insidious low-back, buttock, or vague pelvic pain
• Risk factors:– Insufficiency – normal loads
to abnormal bone
– Osteoporosis – Female Athlete Triad, RED-S
– Fatigue – abnormal loads to normal bone
– Recent increase in training intensity and deficient diet
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Examination –Sacral Stress Fractures
• Pain with single-leg hop
• Tenderness to palpation of the sacrum
• +’ve Flexion, ABduction, and External Rotation tests (FABER or Patrick’s)
• Negative SLR
• Normal neurologic examination
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Differential Diagnosis
• Sacroiliitis (inflammatory)
• Spondylolysis (pars defect)
• Piriformis pain
• SI joint dysfunction
• Back strain, radiculopathy
• Scoliosis, juvenile disc disorder, Scheuermann’skyphosis
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Sacral Stress Fractures Imaging
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Treatment of Sacral Stress Fractures
• WB as tolerated until able to ambulate without pain (10 to 14 days)
• Nonimpact cross-training for 6 to 8 weeks, then resumption of running or impact activity
• Correction of risk factors: pelvic obliquity, core strength, and presence of Female Athlete Triad/RED-S low energy availability
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Adapted Volleyball
• Adapted volleyball may be played by individuals with a variety of physical and mental impairments and disabilities including (but not limited to):
– limb amputation
– neuromuscular disorders
– hearing loss (deafness)
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Sitting Volleyballi. Smaller court (10 X 6m total
dimension, compared to 18 X 9m for the standing game)
ii. Lower net (1.15m for men/1.05m for women vs2.43m for men/2.24m for women in regular volleyball)
iii. Participants must remain “seated” during competition (the rule stipulates that it is obligatory for a player’s buttock or part of the athlete’s torso to remain in contact with the floor at all times)
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International Competition
• Sitting volleyball players must meet “minimum standard of disability”
• Classification defines their sport-specific level of functional limitation:
– level of amputation
– muscle strength
– joint range of motion
– differences in limb length
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International Standards
• Minimum team standards
• “Class allocation”
• Minimal disability (MD) and disabled (D)
• Only one out of six players on court may carry a “minimal disability” classification
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Lower Body Amputations and LBP• Amputations affect activation
of gluteal muscle group (namely gluteus medius) &creates Trendelenberg gait
• Constant lumbar side flexion toward amputated side during stance phase creates muscle tone through the paraspinals and quadratus lumborum
• Creates difficulty when trying to side bend the other way - i.e. an outside attacker who has to reach for an outside set
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Lower Body Amputations and LBP
• Decreased mobility in the hip on the amputated side due to tighter hip flexors, adductors, quads, lateral rotators and hamstrings
• This tightness in the hip creates even more problems when players go to sit on the ground
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Lower Body Amputations and LBP
• When players go to sit in the 'side saddle' position, and hips are not mobile enough to accommodate, they will strain through their low back
• Different effect depending on whether the amputation is on the same side of their dominant or hitting arm
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Adapted Beach Volleyball• Played with 3 players on a team:
– Sitting beach VB court - 4m X 4m
– Standing beach VB - 8m x 8m court
• Only 1 minimal disability athlete may be included per team (equivalent of a class A standing player)
• Remaining 2 players (no substitutions allowed) must be the equivalent to a standing class B or C rating
• Sitting & standing beach VB, standing indoor VB not in Paralympics
• Inaugural world championships in sitting & standing beach VB in 2016!
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