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Low Back Pain in Athletes
A Simple Approach to Evaluation and Treatment
Dr. Jim SchillingAssistant Clinical Professor
Northern Arizona University
Definitions
• Low Back Pain (LBP): Pain between the 12th rib and inferior
gluteal folds.
• Acute: < 6 weeks
• Subacute: 6 weeks to 3 months
• Chronic: > 3 months
• Specific low back pain (SLBP): Degenerative conditions, tumor,
fractures, etc. (5-10%)
• Nonspecific low back pain (NSLBP): Back pain with no known
underlying pathology. (90-95%)(Krismer, 2007)1
Possible Pain Sources
• Innervated structures:
Vertebral periosteum
Ligaments
Fascia
Muscle
Intervertebral disc
Zygapophyseal joint (ZAJ)(Luoma, 2000)2
Other Possible Pain Sources
• 25% LBP could be referred from hip or SI joint pathology
(Sembrano, 2008)3.
• Nerve root (Bogduk, 2009)4
Epidemiology - Athletes
• LBP in athletes: 1 to >30% depending on sport (position),
training intensity and frequency.
• Most common prevalence: Wrestling, gymnastics, tennis, soccer,
rowing.
• Most common condition: Ligamentous sprains or muscle
strains.
• Persistent or recurrent symptoms: Degenerative disc disease or
spondylolytic stress lesions.Review: (Bono, 2004)5
Epidemiology - Athletes
• Highest frequency - Muscle strains:
• College athletes (4,790) 1968-1978. (Keene, 1989)6
• National Basketball Association 1988 – 1997. (Starkey,
2000)7
• College baseball 1988 – 2004. (Dick, 2007)8
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Epidemiology - Athletes
• Athletes at spine clinic:
• Adolescent (100):
• Spondylolysis or spondylolisthesis (47%)
• Disc (11%)
• Strain (6%)
• Adult (100):
• Spondylolysis or spondylolisthesis (5%)
• Disc (48%)
• Strain (27%)
(Micheli, 1995)9
Epidemiology - Athletes• Literature Review:
• Athlete epidemiology from 1951 to 2013:
• Degenerative disc disease
• Spondylolysis
(Mortazavi, 2015)10
• Muscle strain diagnosis:
• Made by exclusion: Localized tenderness, pain with strength or
stretch testing, (-) neurological findings and (-) imaging for
defined pathologies.
(Lawrence, 2006)11
ConclusionPrimary Source of LBP in Athletes
• Intervertebral disc
• Spondylolysis / Spondylolisthesis
Disc Lesion Mechanism
• Majority are posterior-lateral (Lurie, 2014)12
& occur at L4-5 , L5 – S1 (Wang, 2013)13
• Rotation & flexion pushes nucleus posterior-lateral
(Fazey, 2006)14
• Posterior-lateral anular tears may require anterolateral
bending. (Aultman, 2005)15
Mechanism of LBP in Athletes
• Cyclists: Pain with greater flexion & rotation occurring
in lower lumbar. (Burnett, 2004)16
• Baseball: Maximum axial rotation and acceleration: pitching;
near front foot contact; batting; after ball contact. Repetition of
axial rotation may cause anular tears. (Fleisig, 2013)17
• Tennis: Rotation and extension, cumulative load. (Campbell,
2013)18
• Golf: Lumbar axial rotation and contralateral side bending
through impact phase of swing creates excessive intervertebral
lateral shear resisted primarily by the disc. (Lindsay, 2014)19
Spondylolysis Mechanism
• Repeated lumbar flexion-extension or rotation with a
congenitally weak pars interarticularis.(Leone, 2011)20
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Evaluation
Clinical Examination
• Discogenic Pain: Centralization: A clinical phenomenon first
described by McKenzie during the mechanical assessment of patients
with LBP. The progressive retreat of distal referred or radicular
pain toward or to the lumbar midline. Commonly use end-range lumbar
extension movements. Sensitivity 92% and specificity 64% and
reliably differentiated discogenic from nondiscogenic pain using
discography. (Donelson, 1997)21
• Systematic Review: Centralization was the only clinical test
found to increase the likelihood of the disc as the source of pain.
(Hancock, 2007)22
Clinical Examination
• Discogenic pain: Slump Test: Found to have sensitivity for
disc herniation of sensitivity 83% and specificity 55% using CT or
MR imaging.(Stankovic, 1999)23
Clinical Examination
• Clinical Tests to Diagnose Lumbar Segmental Instability:
• Passive Lumbar Extension test: Found to have the highest
combined sensitivity 84% and specificity 90%, as well as the
highest +LR (8.8), suggesting that this test might be of use in
musculoskeletal and orthopedic clinical practice to diagnose
structural Lumbar segmental instability. The test is performed by
having the patient in the prone position, grabbing both ankles,
give slight traction to the legs and extend ~ 30cm. During this
maneuver, a positive test is based on an increase in pain with
extension that disappears on return to the starting position.
Systematic Review: (Alqarni, 2011)24
Passive Lumbar Extension test Clinical Examination
• Lumbar segment motion assessment:
• Passive accessory intervertebral motion (Anteroposterior
translation): Manual AP force applied to a single spinous process
in the lumbar spine causes motion of the entire lumbar region
assessed by dynamic MRI. (Kulig, 2004)25
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AP - Passive accessory intervertebral motion Clinical
Examination
• Lumbar segment motion assessment:
• Passive physiological intervertebral motion: Specific but not
a sensitive test for lumbar segmental instability and detection of
sagittal planar rotation or translation. (Abbott, 2005)26
Passive physiological intervertebral motion Clinical
Examination
• Spondolytic pain: Athletes with spondolytic LBP have tighter
hamstrings and increased sacral slope and pelvic incidence when
compared to athletes with nonspondolytic LBP. (Young, 2016)27
• Hamstring muscle-tendon unit does not influence lordotic
curve.
Lumbar Spondylolysis
• Review (Leone, 2011)20:
• Hereditary factor: Family member incidence up to 69%.
• Sport: Incidence up to 63%.
• Level: L5 vertebrae 95% of cases
• Clinical Findings: Pain with lumbar extension
Tight hamstrings
Often hyperlordotic
Step-off – Spondylolisthesis
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Clinical Examination
Tests for Lumbar Motor Control:
• Transversus abdominis isolation test: Prone; distal edge of
Pressure Biofeedback Unit (PBU) at ASIS; inflate to 70mmHg; draw-in
reducing pressure 6-10mmHg. (Richardson, 1995)28
• Lumbo-pelvic stability testing:
• Supine, active straight leg raise test (PBU)
• Supine, leg lowering test (PBU)
• Standing, Trendelenburg test(Corkery, 2014)29
Test for Drawing-In Maneuver
Clinical Examination
• Nerve root irritation: The straight leg raise test shows a
sensitivity of 97% and specificity of 53% for nerve root tension or
irritation using MR imaging. (Vroomen, 2002)30
Clinical Examination
• Muscle Strain: Isometric – Trunk side bend
• (Pain provocation with muscle strain)
Clinical Examination
• Sacroiliac Joint Pain Provocation Test:
• A cluster of tests: Distraction; Thigh Thrust; Gaenslen’s;
Compression; Sacral Thrust. Sensitivity of 91% and specificity of
83% was found using SI joint injections. (Laslett, 2003)31
Clinical Examination - Biomechanics
• Male professional tennis players (Vad, 2003)32 and golfers
(Vad. 2004)33 with LBP were more limited in lead-hip medial
rotation then asymptomatic.
• Hip function is one potential factor that might affect risk
for LBP in athletes who participate in rotation-related sports.
(Harris-hayes, 2009)34
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Yellow Flags
• Psychiatric Disorders: Anxious, depressed
• Socioeconomic Issues: Death in family, job loss(Ladeira,
2011)35
LBP – Red Flags
• Cauda Equina – Midline disc herniation on cauda equina nerve
roots. Bowel or bladder dysfunction, perianal sensory loss.
• Upper motor neuron lesion - Neural pathway above the anterior
horn cell (Spinal cord). (+) Babinski sign.
• Spinal tumor – Unexplained weight loss, thoracic pain, night
pain.
• Multiple Sclerosis – Paresthesia in both lower
extremities.
• Cord compression – Significant motor weakness, paresthesia in
both lower extremities.
• Aortic aneurism – Deep aching low back pain.
TreatmentRole of Lumbar Multifidus
• The data from this study support the hypothesis that the
superficialmultifidus contributes to the control of spine
orientation (Lordosis), and that the deep multifidus has a role in
controlling intersegmental motion.(Moseley, 2002)36
Role of Psoas Muscle
• Psoas and lumbar spine stability:
• L1-2 and L3-4 (Posterior force vector)
• L3-4 and L4-5 (In-line force vector)
• L5 - S1 (Anterior force vector)(Penning, 2000)37
• Psoas does not influence lordotic curve
Atrophy of Multifidus and Psoas
• A decrease in the cross-sectional area of multifidus and psoas
in patients with unilateral back pain was found using MR
imaging.(Barker, 2004)38
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Treatment – Intervertebral Disc
McKenzie Method
• Systematic review: McKenzie method is more effective than
passive therapy (ice, massage, education) for acute LBP. (Machado,
2006)39
Lumbar Disc Home Program
• Lumbar extension or lateral pelvic tilt in morning to
dehydrate disc.
• Standing low back extension: 10x after sitting.
• Disassociation with hip and lumbar motion.
• Walk ½ hour per day.
• Lumbar stabilization: Drawing-in maneuver → Core bracing.
• Ergonomics: Sitting – Lumbar roll (maintain lumbar extension)
&
elevate seat (assist lumbar extension).
Treatment – Motion Segment Instability
Motor Control
• Cricket players with LBP demonstrated a reduced ability to
perform the drawing-in maneuver and could not contract the
transversus abdominis independently of the other abdominal muscles.
(Hides, 2008)40
Motor Control
• Cricket players with LBP experienced a decrease in the amount
of contraction of the transversus abdominis and internal oblique
found with ultrasound after motor control training. They also
experienced an improvement in the ability to draw-in with training.
This indicates the amount of contraction is not as important as the
ability to contract these muscles independently of the other global
muscles. (Hides, 2010)41
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Motor Control
• Segmental stabilization exercises as described by Richardson
and Jull, 1992 were found to improve segmental stability using a
joint play grading scale and pain using a pressure pain threshold
technique with patients diagnosed with segmental instability.
(Kumar, 2011)42
Motor Control
• Drawing-in training: Re-education of deep trunk muscles,
transversus abdominis and multifidus by drawing-in abdominal wall
(umbilical and below: up-and-in to the spine) in prone and upright
positions. (Richardson, 1995)28
• Same as transversus abdominus isolation test
Lumbar Stabilization Mechanisms
• Drawing-in maneuver:
• Intra-abdominal pressure – Stiffening effect on lumbar
spine.
• Transversus abdominus-multifidus co-contraction - Causing
tension on the thoracolumbar fascia and a “corset effect.”
• Hoop tension – Increase in intracompartmental pressure within
the paraspinal space.(Schilling, 2008)43
Motor Control
• Exercises:
• The transversus abdominis had greatest activity with elbow-toe
exercise (Okubo, 2010)44 and even greater when using an unstable
surface (Imai, 2010)45 using fine wire electrodes.
• The lumbar multifidus had greatest activity with the back
bridge exercise. (Okubo, 2010)44
Elbow-Toe Exercise Local & Global Exercises
• Local segmental musculature appears to stabilize the spine at
the local level due to close proximity to the lumbar segments and
tonic contractility. Global musculature appears to stabilize the
spine globally through compressive loading of the spine through all
available segments and contribute greatly to gross motion. Both
appear to play distinct roles in spine stabilization. Our research
shows that initially training segmental musculature via core
stabilization exercises to provide active support directly to the
lumbar spine will increase spinal stability and decrease pain.
Global musculature can then be trained to provide further spinal
stability. (Haydt, 2016)46
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Global Stabilization
• Global core training:
• Beginner-intermediate-advanced progression
• Curl-up
• Birddog (Instability - Careful with extension)
• Side-bridge(McGill, 2009)47
Treatment – Spondylolysis • Unilateral defects heal 71.1% vs.
bilateral 18.1%.
• No difference in outcomes with or without bracing.
• Successful clinical outcomes in pain and function improvement
does not depend on healing of the lesion. (Klein, 2009)48
• Cessation of sport activity for 3 months:
To minimize intervertebral motion needed for osseous healing and
decrease risk of degenerative changes in ZAJ or disc. Patients who
stopped sports for a minimum of 3 months were 16.39 times more
likely to have excellent results than those who did not.
• Rigid Spine Brace:
A spine brace can reduce gross body movement, but is not
effective in controlling the lower lumbar segments to prevent
instability. (EL Rassi, 2013)49
Treatment – Nerve Root
• Patients with acute lumbar sciatica secondary to a disc
herniation reported reduced radicular pain and improved function
after 10 sessions in 2 weeks of lumbar mechanical traction
regardless if force was 50% or 10% of body weight. (Isner-Horobeti,
2016)50
Treatment of SI Joint Dysfunction
SI Joint Evidence
• Pain below PSIS (Majority literature)
• Athletic activities involving unilateral forceful movements:
Punting, hurdling, etc.
• A review of the literature has suggested that rotational and
translational movement
at the SI joint, determined by 3-D digitizing from
stereophotogrammetric analysis, is
minute and most likely sub-clinically detectable. (Goode, 2008)
51
• Although positional test results of the sacrum in relation to
the ilium changed from
asymmetrical to normal after manipulation, according to
stereophotogrammetric
analysis there was no alteration in position. (Tullberg,
1998)52
SI Joint Evidence
• Contraction of the transversus abdominis significantly
decreases laxity
or increases stiffness of the SI joint compared to lateral
abdominal
muscles with subjects in a prone position determined by
Doppler
imaging of vibrations. (Richardson, 2002)53
• Pelvic asymmetry appears very frequently and should be
regarded as
a physiologic adaptive alteration of the locomotor system to
transmission of asymmetrical mechanical loads. (Gnat,
2009)54
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SI Joint Stabilizer BeltTreatment of Chronic Low Back Pain
• Systematic review: Exercise programs consisting of
coordination or stabilization and strength or resistance are
effective in reducing CLBP. (Searle, 2015)55
• Meta-Analysis: Core stability exercise is more effective in
decreasing pain and improving function than general exercise in the
short-term, but no significant difference in the long-term. (Wang,
2012)56
Treatment of Chronic Low Back Pain
• Using psychosocial therapy (for example: biofeedback or
relaxation training) to change cognitive behaviors such as anxiety
associated with pain experiences. A review of the literature
suggests cognitive therapy is an effective component of the
over-all therapy of CLBP. (Gatchel, 2008)57
Summary:
Simple Low Back Pain Evaluation
• History: Sport/position , position of discomfort & relief
(disc pain can refer beyond knee)
• Observation: Trunk shift, Hyperlordosis, Step off
• Trunk movement: (PN provocation)
• Resistance: Isometric trunk side bend (PN provocation)
• Neural motor screen: Heel & toe raises, great toe
extension (L4 – S1)
• Special test: Pain above PSIS:
1. Discogenic: Centralization
2. Instability / Spondolytic: PLE
Pain below PSIS:
1. SI joint dysfunction: Laslett’s cluster of 5
Radiating pain:
1. Nerve root: SLR
• Instability – Refer for radiograph (oblique view) or bone
scan
Summary:
Simple Low Back Pain Treatment
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SLBP NSLBP
Spondolytic Disc
Cessation of Sport Segmental Stable
Re-stabilization Instability Segment
Re-stabilization McKenzie
Ergonomic
Sport specific core training
Sport specific functional training
Re-Stabilization
• Local: Lumbo-pelvic stability tests (Outcome measures)
Drawing-in training
Supine – limb movement
Elbow-toe exercise
Seated on unstable
Standing on unstable
• Global: McGill’s big 3 (Bracing)
Side-bridge
Birddog
Curl-up
McKenzie / Ergonomic
• McKenzie:
• Lumbar hyperextension
• Trunk shift
• Ergonomic:
• Seated with roll in lumbar
• Raise seat
• Walking
Radicular Pain
• Nerve root involvement (Radiating pain, + SLR):
• Mechanical traction (Any force)
Sacroiliac Joint Pain
• Below PSIS; Laslett’s SI joint PN provocation tests
• Drawing-in training
• SI joint belt
Chronic Low Back Pain
• Motor control: Drawing-in progression
• General resistance exercise
• Psychosocial therapy referral
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Core Training – Sport Specific
• Sports that involve trunk rotation:
• Seated Isometric trunk rotation
• Standing Isometric trunk rotation
Functional Training – Sport Specific
• Hip:
• Internal rotation of lead leg
• Biomechanics:
• Golf – Reduce rotation and side bend
• Rotational sports – Lumbar-pelvic unit
• Lumbar-hip disassociation:
• Trunk flexion at hips with lumbar rigid
This was meant to provide a simple, evidence-supported strategy
for the evaluation and
treatment of LBP in Athletes.
Questions?
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