Back to Sport. A Discussion on Low Back Pain in the Athlete SARAH L. KENNEDY, DO CAQSM

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1 Back to Sport A Discussion on Low Back Pain in the Athlete SARAH L. KENNEDY, DO CAQSM SIDELINE ORTHO & SPORTS 902 W. RANDOL MILL RD SUITE 120 ARLINGTON, TX

2 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.

4 Who gets it? THE YOUNG THE NOT SO YOUNG

5 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

6 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

7 Anatomy Anterior Column Vertebral bodies Epiphyseal growth plates Cartilaginous end plates Ring apophyses Posterior Column Neural arch Facet joints Spinous process Pars interarticularis Intervertebral discs ***Ossification of the posterior column progresses from anterior to posterior***

8 Down to the bones.

9 Ligamentous Attachments

10 The nerve

History *PPQRST including sport *Acute onset or gradual *Trauma *Repetitive hyperextension *Worse with extension *Pain with running or jumping *Radiation to buttock or thigh *Changes in training

11 History *PPQRST including sport *Acute onset or gradual *Trauma *Repetitive hyperextension *Worse with extension *Pain with running or jumping *Radiation to buttock or thigh *Changes in training *Diet *Prior h/o injury *Menstrual history *Family h/o HLA-B27, psoriatic arthritis, ankylosing spondylitis, Inflammatory BD Don t forget red flag questions: *Night time wakening *Fever *Night sweats *Unexplained weight loss *Morning stiffness *Malaise *Neurologic abnormalities *Bowel or bladder dysfxn

12 Physical Exam Observation of gait & posture Ataxia, antalgic, limp, Trendelenburg Symmetry of shoulders and pelvis Scoliosis, kyphosis, excess lordosis Skin abnormalities Hemangiomas, café-au-lait spots, hairy patches, skin dimples Range 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

13 Posture

14 Trendelenburg Testing Assess pelvic stability

15 Skin findings

16 Neurologic Exam

$(fractures, bone$ lesions) MRI (disc,

17 Diagnostics X-ray 3V (AP, lateral, oblique) CT scan (fractures, bone lesions) MRI (disc, nerve, etc.) Bone Scan with SPECT images

19 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

20 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.

21 Growth characteristics during the adolescent growth spurt for girls and boys Growth Characteristics Girls Boys Age at start 9-10 years years Age at maximum growth 12 years 14 years Age at which growth slows Age until growth continues Age at maximum height growth Purcell and Mitchell, 2009 >12 years >14 years years years years years

22 Ring Apophysis Repetitive flexion can lead to avulsion fractures!

$End-plate fractures of the$

23 Atypical (Lumbar) Scheuermann Sports involving rapid flex & ext (diving, rowing, and gymnastics) Flat back ( thoracic kyphosis and lumbar lordosis) Tight thoracolumbar fascia Xray: End-plate fractures of the lumbar vertebrae Schmorl nodes Vertebral apophyseal avulsions

24 Treatment Activity Modification NSAIDs Physical therapy Core stabilization Stretching Bracing 15 degrees of lordosis

weightlifting Pain with flexion Xray, CT scan Treat with

25 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

$portion, may predispose to stress fractures Spina bifida occulta may be a predisposing factor Most often at L5 and on$

27 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

28 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)

hamstrings and erector spinae and recent

29 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

30 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)

31 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

32 Spondylolisthesis Bilateral spondylolysis Lateral x-ray every 4-6 months until skeletally mature >50% or neurologic s/s refer 25% associated with disc herniation

33 Posterior Element Overuse Syndrome Signs and symptoms similar to spondylolysis with normal imaging Same treatment and return to play

34 The Not So Young Osteoarthritis Discogenic Spinal stenosis Strain Other

35 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.

36 Disc Pathology 48% of adults 11% of children L4-5 and L5-S1 most common

37 Disc Herniation Symptoms: Pain with flexion Associated back spasm Hamstring tightness +/- Buttock pain +/- Radicular symptoms PE: flexion +straight-leg raise, slump reflexes

38 Imaging X-ray to r/o bony lesion MRI if persistent >3 months or progressive 90% of patients improve with conservative treatment

39 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 sportspecific activities

$Sacroiliac Joint Dysfunction Gradual onset Rule out infectious, inflammatory, or stress fracture Pain with extension, +FABER, + Gaenslen, +Trendelenburg Xray if$

41 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, +/- lab Treatment: Activity modification OMT/manual therapy PT with pelvic stabilization Oral analgesics Corticosteroid injection Bracing

42 SIJ Dysfunction

43 Osteoarthritis

44 OA Treatment Keep Movin Low impact exercise Yoga, Pilates Stretching Manage 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

45 Lumbar Strain Disruption of muscle fibers within muscle belly or at the myotendinous junction Pain hours after injury With flexion +/-extension Unilateral muscle spasm +/- radiation to buttock Normal neuro exam Treat with PRICE, NSAIDs, and physical therapy

46 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

47 Adam s Forward Bending Test RED FLAGS: Left thoracic curve (convex to the left) Severe pain Neurologic deficits Café au lait spots or hairy patches

49 Riser Score: 1. Calculate risk of progression 2. Guide treatment Females have a 10% greater risk of curve progression!

50 Treatment and Referral Guidelines for Patients with Scoliosis Cob Angle Risser Score Radiography/Referral Treatment 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 Horne JP, Flannery R, Usman S. Adolescent Idiopathic Scoliosis: Diagnosis and Management. Am Fam Physician Feb 1;89(3):

OTHER Infection Discitis or Osteomyelitis

$spondyloarthropathies Acute fracture$

52 OTHER Infection Discitis or Osteomyelitis Tumors Osteoid Osteoma, osteoblastoma, bone cysts, Ewing sarcoma, osteogenic sarcoma, metastatic Inflammation Seronegative spondyloarthropathies Acute fracture Compression fracture Visceral pathology Pyelonephritis Cauda equina

53 Return to Play Dependent Factors: Sport Age/Skeletal maturity Athlete/parents/coaches Requirements: Pain-free motion with all activities Normal strength

54 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

55 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.

57 References 1. Purcell L, Micheli L. Low Back Pain in Young Athletes. Sports Health May; 1(3): Bono CM. Current concepts review: Low back pain in athletes. J Bone Joint Surg Am. 2004;86(2): Daniels JM, Pontius G. Evaluation of low back pain in athletes. Sports Health Jul; 3(4): Horne JP, Flannery R, Usman S. Adolescent Idiopathic Scoliosis: Diagnosis and Management. Am Fam Physician Feb 1;89(3): Kujala UM,T.S. Lumbar mobility and low back pain during adolescence. A longitudinal three-year followup study in athletes and controls. Am J Sports Med 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): Watkins RG. Lumbar disk injury in the athlete. Clin Sports Med. 2002;21(1): Kim HJ, Green DW. Spondylosis in the adolescent athlete. Curr Opin Pediatr. 2011;23: Gurd DP. Back pain in the athlete. Sports Med Arthrosc Rev.2011;19(1):7-16.

Sashil Kapur, MD Sports medicine fellow Lutheran General

Sashil Kapur, MD Sports medicine fellow Lutheran General 1 Spondy-what? Presentation Diagnosis Treatment Return to play 2 Very common musculoskeletal complaint 10-15% of children and adolescents Adults