INJURY CLINIC
Sports Medicine 12(6): 394-406. 1991 0112-1642/91/0012-0394/$06.50/ 10 © Adis International Lim ited. All rights reserved. SPOl70
Low Back Pain in Young Athletes A Practical Approach Jack Harvey and Suzanne Tanner Sections of Sports Medicine, The Orthopaedic Center of the Rockies, Fort Collins, Colorado, and University of Colorado Health Sciences Center, Denver, Colorado, USA
Contents 395 396 396 396 396 396 396 397 397 397 397 398 398 398 399 399
399 399 400 400 400 401 401 401 401 402 402 404 405 405 405 405
Summary I. Predisposing Conditions I. I Growth Spurt 1.2 Training Errors I.3 Improper Technique 1.4 Poor Equipment I.5 Leg-Length Inequality 1.6 Poor Fitness 2. Diagnostic Entities 2.1 Contusion 2.2 Fractures 2.3 Sprain/Strain 2.4 Lumbar Facet Syndrome 2.5 Spondylolysis/Spondylolisthesis 2.6 Sacroiliac Disorder 2.7 Disc Herniation 2.8 Spinal Disorders Simulating Athletic Injury 3. Diagnostic Tests 3.1 Radiographs 3.2 Bone Scan 3.3 Computed Tomography 3.4 Magnetic Resonance Imaging 4. Psychological Counselling 5. First Aid and Rehabilitation 5.1 Immediate Treatment 5.2 Range-of-Motion and Strengthening Exercises 5.3 Back Exercises 5.4 Conditioning Programmes 5.5 Return to Activity 5.6 Strength Training Equipment 5.7 Protective Devices 5.8 Maintenance Conditioning Programme
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Summary
395
Lumbar spine pain accounts for 5 to 8% of athletic injuries. Although back pain is not the most common injury, it is one of the most challenging for the sports physician to diagnose and treat. Factors predisposing the young athlete to back injury include the growth spurt, abrupt increases in training intensity or frequency, improper technique, unsuitable sports equipment, and leg-length inequality. Poor strength of the back extensor and abdominal musculature, and inflexibility of the lumbar spine, hamstrings and hip flexor muscles may contribute to chronic low back pain. Excessive lifting and twisting may produce sprains and strains, the most common cause of low back pain in adolescents. Blows to the spine may create contusions or fractures. Fractures in adolescents from severe trauma include compression fracture, comminuted fracture, fracture of the growth plate at the vertebral end plate, lumbar transverse process fracture, and a fracture of the spinous process. Athletes who participate in sports involving repeated and forceful hyperextension of the spine may suffer from lumbar facet syndrome, spondylolysis, or spondylolisthesis. The large sacroiliac joint is also prone to irritation. The signs and symptoms of disc herniation in adolescents may be more subtle than in adults. Disorders simulating athletic injury include tumours and inflammatory connective tissue disease. Often, however, a specific diagnosis cannot be made in the young athlete with a low back injury due to the lack of pain localisation and the anatomic complexity of the lumbar spine. A thorough history and physical examination are usually more productive in determining a diagnosis and guiding treatment than imaging techniques. Diagnostic tests may be considered, though, for the adolescent athlete whose back pain is severe, was caused by acute trauma, or fails to improve with conservative therapy after several weeks. Radiographs, bone scanning, computed tomography, and magnetic resonance imaging may help identify, or exclude serious pathology. Fortunately, the majority of cases of low back pain in adolescents respond to conservative therapy. Immediate treatment of an acute injury, such as a sprain or strain, includes cryotherapy, electrogalvanic stimulation, anti-inflammatory medications and gentle exercises. Prolonged bed rest should be avoided since atrophy may occur rapidly. Strong analgesics are also usually contraindicated, except for sleep, since they mask pain and may allow overvigorous activity. Early strengthening exercises include the Williams flexion exercises and/or McKenzie extension exercises. Both exercise motions may often be prescribed. Athletes with an acute disc herniation, however, should only perform extension exercises initially. Athletes with spondylolysis, spondylolisthesis and facet joint irritation should initially be limited to flexion exercises. Brief sessions of walking, pool walking or jogging, and upright cycling may be started when tolerated to maintain aerobic conditioning. The proper timing for an athlete to return to activity depends on the demonstration of functional skills necessary to perform a specific sport. The final component of a young athletes' back rehabilitation programme includes a long term stretching, and back and abdominal strengthening programme.
Although a low back injury is not the most common athletic injury, it may be one of the most disabling. Back pain is reported to occur in 85% of the general population but in only 5 to 8% of the athletic population. Both acute traumatic and overuse injuries occur and may be more frequent in certain sports. Contact and collision sports such as American football, rugby and wrestling provide opportunity for blunt trauma, sprains and strains. Overuse injuries from repeated lumbar hyperextension may be found in gymnastics, volleyball and
rowing. The sports physician needs to be able to evaluate these problems and formulate a plan of treatment and rehabilitation. The lumbar spine links the lower extremities and the torso. This important link is responsible for the coordinated transfer of power through the body in most sports. Although most athletes are in good general physical condition, one cannot assume that athletes have spent much time strengthening and stretching their low back and abdomen. Injuries are often due to poor conditioning of the spine, poor
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biomechanics or the repetitive stresses placed on the spine by the nature of the sport. Acute excessive force placed on the spine may also cause injury. Disc disease is occasionally encountered. Finally, athletes are not immune to the degenerative processes that affect all spines. The sports physician faced with an athlete experiencing lumbar pain should exclude serious spine disorders, institute first aid and start a rehabilitation programme to expedite the athlete's return to the sport. On occasion the physician will have to decide if the athlete may practise or play while still experiencing back pain. What is needed is a quick and easy way to establish the correct diagnosis when faced with the athlete with a painful back. This allows the proper selection of therapeutic techniques. Unfortunately, no such system of diagnostics exists. In fact, the frustration or absolute dislike some physicians feel toward treating back pain is because back pain is very difficult to diagnose and thus properly treat. However, the vast majority of back pain does resolve. In fact, the correct diagnosis in acute low back pain is established only 2% of the time in the immediate period! If the pain persists for 6 weeks, the diagnostic accuracy climbs to 15% and to 30% at 3 months (Nachemson et al. 1987). With this very low probability of acutely establishing a correct diagnosis, the sports physician's time is best spent ruling out serious spine disorders such as disc herniation. Following this, a reliance on sound first aid and rehabilitation principles outlined in this paper will stand the physician in good stead. Finally, it is reassuring to know that two-thirds of the injured are relatively symptom-free and able to function in work or sports in 2 weeks and 88% are doing well by 6 weeks (Nachemson 1988). The challenge facing the sports physician is mostly to not do anything to retard the athlete's recovery and try to maintain the athlete's fitness during the injury.
1.1 Growth Spurt During this phase, if the paraspinous tissues do not grow at the same rate as bone, the resultant tight lumbodorsal fascia and hamstrings stress the spine, predisposing to back pain. Emphasis on maintaining flexibility will mitigate this situation (Clancy 1979; Hochschuler 1990). 1.2 Training Errors Abrupt increases in training intensity or frequency are often cited in association with the onset oflow back pain in adolescents. Too much weight lifted with the military press manoeuvre in a weightlifter may precipitate low back pain. A teenage dancer may suddenly switch from a lay-off period, when she was only taking classes 2 hours a day, to a schedule of rehearsing for 10 to 12 hours a day. This dramatic increase in back stress can injure ligaments, muscles and tendons (Micheli 1983). 1.3 Improper Technique Improper technique may contribute to low back strain. A lineman, for example, who blocks an opponent while maintaining an erect posture may suffer a hyperextension injury. Excessive lordosis in a dancer performing an arabesque or lifting a partner may produce low back pain (Micheli 1983). 1.4 Poor Equipment An improper bicycle fit, for example, may predispose a cyclist to low back pain. Seat height which is too high may cause excessive pelvic rocking, which may lead to increased muscular activity and fatigue (Hochschuler 1990). Excessive distance between the seat and handlebars causes a cyclist to ride in a hyperiordotic position and may strain the back.
1.5 Leg-Length Inequality
1. Predisposing Conditions Factors predisposing the young athlete to back injury are both intrinsic and extrinsic.
Leg-length discrepancies cause an unequal transmission offorce across the spine during weightbearing activities. This is further accentuated when
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the athlete moves quickly and the stress transmitted through the spine is amplified by acceleration of the body mass (Hochschuler 1990). There is controversy as to the relative difference necessary to be clinically meaningful. In the general population, a sample of authors felt that a minimum of lcm difference is needed before intervention is required. Others, including those who have studied the effects in athletes specifically, tend to consider differences of 4mm and up to be important (Hochschuler 1990). 1.6 Poor Fitness There is no conclusive evidence that cardiovascular fitness, as measured by maximum oxygen uptake, decreases the risk for back injury (Hochschuler 1990), but it is difficult to separate aerobic capacity from muscular endurance, strength, flexibility and body composition. Like guy wires supporting a telephone pole (Foster & Fulton 1991), the abdominal and back extensor muscles increase stability of the spine during sporting activities. Weakness ofthe erector spinae may contribute to low back pain. The normal ratio of trunk extension strength to trunk flexion strength is 1.3: I. In patients with low back pain this ratio is substantially reduced (Foster & Fulton 1991). Inflexibility of the hamstrings increases lumbar lordosis (Hochschuler 1990). Pelvic mobility is essential in bending and lifting activities, and tightness of the hip flexor muscles may limit pelvic movement and cause excessive strain on the lumbar spine (Foster & Fulton 1991). Tightness of the hip extensor muscles may reduce lumbar lordotic curve, making the spine less resilient to axial loading (Foster & Fulton 1991).
2. Diagnostic Entities Although the adolescent athlete is exposed to minor trauma more frequently than the nonathlete, the athlete is generally in better physical condition and has more developed supporting struc-
397
tures of the spine. Therefore, the majority of back injuries in adolescents are minor. Specific entities are listed below, but the diagnosis of low back pain in adolescents is complicated by the nonspecificity of pain in many cases (Pelz 1989). Even if the specific structure injured is not identified, the majority of cases of low back pain in adolescents resolve with conservative therapy. 2.1 Contusion A bruise from a direct blow may be visible. 2.2 Fractures Injured athletes with lumbar spine fractures do not always present with neurological deficits. Fractures in adolescent athletes include the following: Compression fracture is the most common traumatic lesion of the lumbar spine. This injury is caused by acute flexion of the spine such as occurs in a fall from a height or by a heavy weight striking the shoulders. This fracture occurs primarily at the anterior vertebral body, which is the weakest site in the lumbar vertebrae due to the lack of horizontal traheculations. Athletes who sustain a calcaneal fracture from a fall from height should be questioned to determine if back pain is present. They may also have a vertebral compression fracture (Harris & Harris 1981). Comminuted fracture of the lumbar spine is much less common than the simple compression fracture. It is usually caused by a severe abrupt flexion force which drives one vertebral body or its adjacent intervertebral disc into the superior plate of the next lower body. Posterior fragments may be driven posteriorly, producing cord compression or injury. The intervertebral disc is always injured with this fracture (Harris & Harris 1981). Young athletes can develop fractures of the growth plate at the vertebral endplate in which the nucleus pulposis herniates into the vertebral body. Since the cartilaginous endplate is weaker that the
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nucleus pulposis, excessive compressive forces can cause the endplate to fracture (Hochschuler 1990). The lumbar transverse processes may fracture due to a direct blow, a sudden, strong contraction by the psoas and quadratus lumborum, or as the result of forceful movements of the trunk avulsing the attachments of the muscles (Hochschuler 1990). In one study of 4 football players with transverse process fractures, all were either offensive halfbacks or offensive ends (Bowerman & McDonnell 1975). Transverse process fractures may be overlooked radiographically. AJracture o/the spinous process may occur from a direct blow (Hochschuler 1990). 2.3 Sprain/Strain Looking at the natural history of low back pain in adolescents, it seems likely that most cases of acute low back pain are caused by sprains or strains from lifting or twisting. Mild to moderate acute low back pain in adolescents usually heals quickly, as is the case when sprains and strains occur in other body parts (Nachemson 1988). A 'sprain' is an injury to a ligament and a 'strain' refers to inflammation, microtears, or tears of the muscle, tendon, or musculotendinous junction. It is often difficult to differentiate the exact structure injured. Sprain/strain mechanisms can be grouped into 3 categories, defined as follows: l. Acute injury: a sudden overloading of musculotendinous units, as might occur in sprinting or kicking. 2. Chronic or overuse injury: a repeated overload and/or frictional resistance, which occurs in endurance training or other highly repetitive action. 3. Acute injury imposed on chronic injury (Hochschuler 1990). 2.4 Lumbar Facet Syndrome The facet syndrome is a painful irritation of the posterior elements of the lumbar spine. There is potential risk to neural elements as they exit
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through the intervertebral foramen from capsular swelling (Hochschuler 1990). Athletes who participate in sports involving repeated and forceful hyperextension of the lumbar spine suffer a higher incidence of lumbar facet syndrome; such sports include American football, gymnastics, diving, power lifting, and golf. Tennis players, especially during a serve, and male dancers who lift their partners are also at risk (Hochschuler 1990). The classic facet syndrome is characterised by local paralumbar tenderness, pain on hyperextension, normal neurological examination, and hip, buttock or back pain with straight leg raising. Pain may occur when assuming an upright position following forward flexion of the lumbar spine. Pain may be referred to multiple areas, including the groin, the greater trochanter, and to the posterior thighs as far as the knee. Generally, the pain is relieved by rest and made worse by movement (Hochschuler 1990). 2.5 Spondylolysis/Spondylolisthesis These terms are derived from the Greek. 'Spondylo' means vertebra, '-lysis' means crack or fracture, and '-olisthesis' means sliding down an incline. Spondylolysis is a bony defect affecting the pars interarticularis (a segment near the junction of the pedicle and the lamina) that usually affects the LS vertebral body. Spondylolysis may progress to spondylolisthesis, an anterior slippage of a vertebra (usually LS) [Cacayorin et al. 1987]. In the athlete, the lytic defect is thought to be due to repetitive hyperextension maneouvres. In gymnastics, fatigue overloading of the neural arch occurs from back walkovers and performing dismounts in lumbar extension. Lumbar rotation during throwing sports, diving and wrestling can cause unilateral spondylolysis to develop (Hochschuler 1990). The incidence of spondylolysis in selected sports is listed in table I. Athletes will usually note chronic dull aching pain of the lumbosacral spine that is exacerbated by manoeuvres requiring hyperextension, or rotation with the back in a hyperlordotic position. Dur-
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Table I.
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Incidence of spondylolysis in selected sports (Rossi
1988) Sport
Incidence of spondylolysis (%)
Diving Weightlifting Wrestling Gymnastics Track and field General population
63.3 36.2 33.0 32.0 22.5 5.0
ing the physical examination, extension of the back or hip will exacerbate pain (Hochschuler 1990). In the skeletally immature athlete, close observation for progression to and of spondylolisthesis is advised. Wiltse has found the greatest amount of slippage occurring between the ages of 9 and 14 years, but seldom after that (Wiltse et al. 1974). Once the patient is skeletally mature progression is rare (Hochschuler 1990). 2.6 Sacroiliac Disorder The sacroiliac joint is one of the largest, yet least mobile, articulations in the body. Acute lesions of the sacroiliac joint generally require a sudden forceful injury as might occur in motor racing, American football, soccer, rugby, hockey, basketball and baseball. A misstep by a runner whose heel strike is made with the knee locked will transmit high loads to the pelvis, or one with a leg-length discrepancy may precipitate a sacroiliac lesion (Hochschuler 1990). Symptoms commonly include pain in any area of the low back, buttocks or posterior thigh. Localised tenderness over the sacroiliac joint with asymmetry of intrapelvic movement is found on examination. Tender and asymmetric landmarks at the symphysis pubis may be evident (Hochschuler 1990). 2.7 Disc Herniation Disc herniation is a focal protrusion of the nucleus pulposus through a defect in the annulus fibrosus, most commonly occurring in its postero-
lateral portion. Disc herniation occurs in the regions of greatest mobility; thus, it is common in the lumbar region, especially at the L5 to SI and L4 to L5 levels (92%). Disc herniation is usually precipitated by trauma or lifting a heavy object and may be accompanied by a snapping sensation. Pain and radiculopathy may occur suddenly or gradually. In adolescents, however, the presenting signs may be confined to hamstring and back inflexibility (Hochschuler 1990). 2.8 Spinal Disorders Simulating Athletic Injury
2.8.1 Tumours Primary bone tumours may cause pain. Nocturnal pain is the characteristic presentation of osteoid osteoma. It most frequently occurs in an adolescent or young adult male. In the spine, typically the posterior elements are involved. The pain may be initially relieved by salicylates. Another tumour that clinically presents with unusually severe pain is osteoblastoma. commonly involving the vertebral appendages (Cacayorin et al. 1987).
2.8.2 Inflammatory Connective Tissue Disease In young runners complaining of persistent sacroiliac pain, a positive bone scan and HLA B27 in association with dramatic response to anti-inflammatory medication should suggest the diagnosis of ankylosing spondylitis (Hochschuler 1990).
3. Diagnostic Tests A thorough history and physical examination are usually more productive in determining a diagnosis and guiding treatment than imaging techniques. There is often no specific anatomic defect visible by imaging techniques. The diagnostic tests listed below may be considered in the adolescent athlete whose back pain is severe, was caused by acute trauma, or fails to improve with conservative therapy after several weeks.
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3.1 Radiographs The rate of plain film revealing abnormal findings is very low and the cost is high. In 1984, over 7 million were obtained in the United States at a cost of more than $500 million, and the incidence of unexpected positive findings has been reported to be as low as 1 in 2500 cases (Nachemson 1976; Pelz 1989; Scavone et al. 1981). The most common surgically remediable cause of low back pain, disc herniation, cannot be seen on plain films. This overused form of examination is not innocuous: the standard anteroposterior, lateral and oblique views deliver 11 rad to the skin, one of the highest doses of any radiological examination to the gonads (Pelz 1989). Trauma constitutes the main reason that would prompt an athlete to undergo radiographic evaluation. Anteroposterior and lateral radiographs of the lumbar spine and pelvis are initially the only projections required. Plain films allow detection of fractures and subluxations (Cacayorin et al. 1987). In the anteroposterior projection, lumbar transverse process fractures may be vertically situated across the base of the transverse process, or they may consist simply of avulsion of the tip of the process. Because the psoas muscle arises in part of the lumbar transverse processes, a haematoma may diffuse into the fascial plane adjacent to the muscle, thereby obliterating radiographic identification of the fracture. The absence of the normal psoas shadow may be the most prominent finding in instances of fracture of the lumbar transverse processes (Harris & Harris 1981). In the lateral view, a compression fracture may consist simply of buckling of the superior plate, anterior wedging, or loss of stature of a vertebral body, depending on the magnitude of flexion force impacted (Harris & Harris 1981). A coned down lateral 'spot' projection, with the x-ray beam centred between the surfaces of the lumbosacral space, allows proper evaluation of the width of the lumbosacral space. The lumbosacral space is depicted as being falsely narrowed on the routine lateral roentgenogram due to divergence of the x-ray beam (Harris & Harris 1981).
Oblique radiographs are often necessary to identify a defect in the pars interarticularis indicative of spondylolysis. This presents as a lytic defect or increased density in the neck of the Scotty dog. Hyperextension, hyperj1exion and bending views may be useful to detect subtle malalignment of the spine not evident on routine views. They may be helpful in assessing the degree of vertebral movement with spondylolisthesis. 3.2 Bone Scan The radionuclide bone scan is a sensitive modality for detecting early inflammatory or malignant processes the spine. Although very sensitive, the test is nonspecific, time-consuming, and produces poor anatomic localisation. Comparison of oblique radiographs and the bone scan may be helpful in identifying spondylolysis and its stage. Rothman defined 4 stages of the natural history of spondylolysis: I. acute fracture; II. healing fracture; III. unhealed fracture; and IV. healed fracture. Until spondylolysis occurs, repetitive microstress may be radiographically invisible, but detectable on bone scan. A stage II fracture should be discernible on lumbar spine radiographs and bone scans. A stage III fracture is visible on plain radiographs, but the bone scan is likely to be negative. Stage IV lesions may not be recognised as such. Thickening of the pars interarticularis may be visible on radiographs (Shalen 1990) and the bone scan is negative. Bone scans may also be used to screen for tumours or infection in unusual cases. 3.3 Computed Tomography Computed tomography (CT) is superior to plain films in defining the extent of a spinal fracture. Major disadvantages of CT scanning are the high radiation dose (approximately 10 rad to the skin for a 3-level study of the lumbar region) and the limited field of view (Pelz 1989).
Low Back Pain in Young Athletes
3.4 Magnetic Resonance Imaging Experience is rapidly accumulating with the use of magnetic resonance imaging (MRI) in the investigation of low back pain. MRI currently provided the most accurate morphological evaluation of the intervertebral disc (Pelz 1989) and there is no radiation exposure. Boden has shown that findings of abnormalities on magnetic resonance images must be strictly correlated with clinical signs and symptoms due to the high incidence of bulging and degenerated lumbar intervertebral discs seen even in asymptomatic subjects. In his study, magnetic resonance imaging was performed on 67 individuals who had never had low back pain, sciatica or neurogenic claudication. About one-third of the subjects were found to have a substantial abnormality. Of those less than 60 years old, 20% had a herniated nucleus pulposis. There was degeneration or bulging of a disc at at least 1 lumbar level in 35% ofthe subjects between 20 and 39 years old (Boden et al. 1990).
4. Psychological Counselling Adolescent athletes with injuries severe enough to limit sports participation are likely to show shock, disbelief, and denial regarding the extent of their spinal injury. They may have difficulty trusting the physician and appear to be in a rush to return to sports. The skilled practitioner should be able to help the athlete set and achieve workable goals, to assist the athlete in moving from self-pity and hopelessness to acceptance and adaptation, and to be creative in terms of helping the adolescent define themselves and their value to others in ways independent of physical performance (Hochschuler 1990).
5. First Aid and Rehabilitation 5.1 Immediate Treatment The pain and spasm that accompany acute injury to the lumbar spine can begin immediately or may develop in the hours that follow practice or the game. Occasionally the spasm doesn't present
401
until the following morning. Anticipation of this debilitating pain and spasm and prompt application of ice to the back for 45 to 60 minutes will preempt much of the discomfort. If spasm starts to set in, then electrogalvanic stimulation or microcurrent applications can supplement the cryotherapy. Strict bed rest or maintaining a single position for a prolonged period of time (i.e. sitting for hours in a car or plane) are to be avoided as this promotes back spasm. The athlete should be encouraged to move the back through a relatively pain-free range of motion and walk each hour for 5 minutes. Only in the most severe cases of pain and spasm should bed rest be allowed and then for a maximum of 24 to 36 hours. Further periods of bed rest do not produce better recovery rates and allow atrophy of injured muscles and deconditioning (Deyo et al. 1986). Cryotherapy should be repeated frequently during the 36 to 48 hours following the injury as should the motion. As the spasm starts to subside, motion through the painfree range should be advanced to gentle stretching. Use pain and subsequent return of spasm to judge how rapidly this stretching should be progressed. Although some studies have shown that medications do not expedite the resolution of back pain per se, it is our feeling that the use of anti-inflammatory medications which do have some mild to moderate analgesic effect promote rehabilitation acutely. Strong analgesics should be avoided or only used to allow sleep. Strong analgesics may cause the rehabilitation programme to progress too rapidly by decreasing the athlete's pain and allowing overvigorous stretching and exercising. Therefore, we recommend using oral anti-inflammatory medications and recently have been impressed with the new injectable anti-inflammatory ketorolac tromethamine. The anti-inflammatory medications are used regularly during the first 3 to 7 days and then as needed over the next couple of weeks. Other means of pain control such as transcutaneous nerve stimulation, trigger point injection or acupuncture have been successful in some studies (Ohnmeiss et al. 1990). The popularity of chiropractic treatment among many athletes cannot be easily dismissed. Manipulation has been
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shown to provide temporary pain relief and reduction of spasm in medical studies (Ohnmeiss et al. 1990). As far as these entities are concerned, we encourage the sports physician to utilise the modalities with which he or she is most familiar. These other entities should be employed under the guidance of a competent consultant. Finally, it should be apparent to the physician that one particular modality may not give reliably good results in all cases. These instances may be the best place to use the above-listed adjunctive therapies. 5.2 Range-of-Motion and Strengthening Exercises After the acute period, we move from first aid to the beginning of the athlete's rehabilitation. This phase may also be the most appropriate starting point for the athlete with chronic pain or an overuse back injury that lacks the severe pain and muscle spasm described above. A couple of days after an acute traumatic injury or on the initial day of an overuse injury, it is important to determine which motion, flexion or ex-
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5.3 Back Exercises There are several series of back exercises that can be employed during the rehabilitation period. Depending on the pathology and as dictated by the athlete's tolerance, one set or a combination of these exercises can be used. Our preference is to try to exercise both flexors and extensors unless extension or flexion is contraindicated. Extension exercises are contraindicated initially in athletes with spondylolysis, spondylolisthesis and facet joint dysfunction. Flexion exercises should be avoided in athletes with acute disc herniation. The Williams back series are the most common flexion exercises and have several variations (fig. 1). One must remember that a single set of 10 repetitions may not be a great enough workload for the athletic abdomen. High repetition and mUltiple sets may be required. As the athlete progresses, increased intensity can be added by using weights or the therapist's manual resistance. Minor postexercise discomfort should resolve with the application of heat (hot tub), ice or massage. Persistence of pain or development of spasm indicates that the programme was advanced too vigorously.
tension, causes the least pain and start some easy
The McKenzie back extension exercises (fig. 2)
strengthening exercises. These may be isometrics done at one or several positions or isotonics through a comfortable range of motion. The therapist may find that fairly vigorous isoto nics are tolerated in the midrange of the motion while lesser intensities are needed at the extremes of motion. The patient's pain should be the guide as to the intensity and progression of the exercises. The therapy pool offers a nice environment for the initiation of exercises. The buoyancy of the water unloads the spine so that only a fraction of the athlete's weight is stressing the spine in 1 to 1.3m of water. Resistance exercises can be performed with the extremities without the need to hold weights. Hand paddles, exercise boot or bells (Hydrotone, Oklahoma
have been a mainstay in the treatment of disc disease for at least a decade (McKenzie 1981). Again, for the athlete the recommendation of a set of 10 may be inadequate. Good results are often obtained by repeating these exercises throughout the day. We have found these to be especially useful in the bicyclist who maintains a flexed period often for hours during training. The cyclist dismounts every 40 minutes and performs a set of extension exercises while training. During competition hyperextension exercises can be performed on the bike while upright. It is also helpful to counsel the athlete with degenerative disc disease to exercise early in the morning while the disc is maximally hydrated and at maximum height (White & Malone
City) and fins all can add resistance for the wor-
1990).
kout. Water also has the advantage of allowing diagonal movements so that proprioceptive neural facilitation patterns can be added to the therapy programme as the athlete progresses.
Many sports require repetitive flexion, extension, rotation or combinations of these motions. This in itself may promote excessive micromotion at the discs and facet joints. This results in overuse
403
Low Back Pain in Young Athletes
1. Pelvic tilt. Ue on your back with knees bent, feet flat on floor. Flatten the small of your back against the floor. without pushing down with the legs. Hold for 5 to 10 seconds.
2. Knee to chest. Ue on your back with knees bent and feet flat on the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the knee and repeat with the other knee.
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3. Double knee to chest. Begin as in the prevIous exercise. After pulling right knee to chest. pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly lower one leg at a time.
4. Partial sit-up, stra ight version. Do the pelvic tilt (exercise 1) and, while holding this position. slowly curl your head and shoulders ofl the floor. Hold briefly. Return slowly to the starting position.
Fig. 1. Examples of Williams flexion exercises.
1. Prone lying. Ue on your stomach with arms along your sides and head turned to one side. Maintain this position for 5 to 10 minutes.
2. Prone lying on elbows. Lie on your stomach with your weight on elbows and forearms and your hips touching the floor or mat. Relax your low back. Remain in this position 5 to 10 minutes. If thiS causes pain, repeat exercise 1. then try again.
3. Prone press-ups. Ue on your stomach with palms near your shoulders, as If to do a standard push-up. Slowly push your shoulders uP. keepIng your hips on the surface and letting your back and stomach sag. Slowly lower your shoulders. Repeat 10 limes.
4. Progressive extension with pillows. Ue on your stomach and place a pillow under your chest . After several minutes, add a second pillow. If this does not hurt, add a third pillOW after a few more minutes. Stay in this poSition up to 10 minutes. Remove pillows one at a time over several minutes.
Fig. 2. Examples of McKenzie extension exercises.
404
Sports Medicine 12 (6) 1991
symptoms and with time degenerative disease and even arthritis. This phenomenon is also seen in the athlete that has very strong limb muscles, but has not invested any time in conditioning the lumbar spine. The result is again an unstable spine with increased microtrauma and symptoms. Because of this problem, spine stabilisation exercises that utilise the co-contraction of flexors, extensors and rotators are taught to splint the spine during activity. These exercises are first taught in a very simple form in a supine or prone position and progressed to standing and moving position (fig. 3). Finally, the athlete is taught to use the techniques while training and competing. Although these exercises
Supine exercises Lie on your back with knees bent and feet flat on the floor.
Abdominal pelvic tilt TlQhten your stomach muscle so that your low back gently presses against the floor. Hold this contraction for 10 seconds, countifIQ out loud. and then slowly relax. Repeat. Lower extremity activities Perform an abdominal pelvic tilt so that your low back gently presses against floor. Maintaining the pelvic tilt: 1. Slowly lift your toes. and then your heel of one foot up and down from the floor. Repeat with other foot. 00 not let your low back lift from the floor as you lift your toes. Repeat. 2. Slowly move knees apart and together. Repeat. movifIQ the knees further apart each time. as long as your lower back does not lift from the floor. Repeat. 3. Slowly lift one foot up and down approximately 2.5 to Scm from the floor, and then repeat with the other foot . 00 not let your low back lift from the floor as you lift your foot. Repeat. 4. Slowly lift one foot 2.5 to Scm off \he floor. Extend the leg, keepifIQ \he foot 2.5 to Scm from the floor. Extend the leg as far as you can. not letting your low back lift from the floor. Replace the foot on the floor and repeat with the other leg. Repeat.
Fig. 3.
Examples of spinal stabilisation exercises.
are more difficult to teach the athlete and require several hands-on sessions with a trained therapist, we have found them to be extremely valuable in rehabilitation of the athlete with chronic back pain or for prevention of recurrence in the athlete with an initial episode of low back pain. 5.4 Conditioning Programmes An aerobic exercise programme may be started simultaneously with a resistance programme. Many therapists feel that a good conditioning programme is essential for rehabilitation of back injuries. It is also useful in that it helps initiate spinal stabilis-
Upper extremity activities Assume the 4-point position , maintaining a straight low back: 1. Uft up one arm straight . thumb pointing toward the ceiling. next to your ear. Be sure that your body does not twist . Hold 10 seconds. counting out loud. then lower the arm and repeat with your other arm. Repeat .
Lower extremity activities Assume the 4-point position , maintaining a straight low back: 1. Slide one leg out behind you so that the foot and knee lift off the floor 10 to 1 Scm. Your foot and knee should remain at the same level and the knee should remain slightly bent. Be sure that your body does not twist. Hold for 10 seconds. countifIQ out loud. and retum to startifIQ position . Repeat with your other leg. Repeat.
Combined upper and lower extremity activities Assume the 4-point poSition . maintaining a straight low back : 1. Ult up one arm straight. thumb pointing toward the ceilifIQ . next to your ear. Slide the opposite leg out behind you so that the foot and knee lilt off the floor 10 to IScm. Be sure that your body does not twist. Hold for 10 seconds. counting out lOUd. and retum to start· ifIQ poSition . Repeat on the other side with your opposite arm and leg. Repeat.
Low Back Pain in Young Athletes
ation by the muscles. Initially, the activity should be one that is tolerated with a minimum of discomfort and can be performed for a minimum of 20 minutes per day, and if possible the activity should be an integral part of the sport in which the athlete participates. The concept of specificity of training makes it desirable that the athlete initiate activity that mimics their sport as soon as possible if it does not aggravate the injury. Aerobic activities that are usually well tolerated initially are walking, pool walking or jogging, upright cycling and the use of stair-stepping machines. As the athlete's symptoms resolve, jogging or running, cycling and swimming are permitted. Cross-country skiing or mimicking the cross-country motions in the shallow end of a pool with weights improves spinal stabilisation and coordination between lower extremity and torso movement. Finally, activities that require stop and start and rapid change of direction manoeuvres (ball and racquet sports) are slowly added if required for the athlete's return to sport. 5.5 Return to Activity As the athlete's symptoms resolve and progress through the rehabilitation programme, training of specific functional activities related to return to sport need to be initiated. At first activities with isolated flexion-extension, lateral bending or rotation should be used. Combined motions are more stressful to the discs and need to be introduced gradually. As the athlete returns to sport, the physician needs to be on the alert to activities within the sport that may cause a recurrence or aggravate present symptoms. Portions of practice may need to be eliminated, modified or reduced in repetition or intensity to keep the athlete healthy. Prolonged practice sessions may be too stressful for the recently injured athlete and coaches need to be counselled to limit practice sessions. Remember, practice doesn't make perfect, perfect practice makes perfect! A big question is often when to return the athlete to practice or play. At present there is no test that gives doctor, coach or athlete the answer. The
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best indicator is a successful graduation within the back rehabilitation programme and the demonstration of the functional skills necessary to perform the sport. If this can be demonstrated without the need for rest periods or the constant application of ice or modalities, the prognosis is good. However, the stresses of all-out competition and prolonged intense training may cause low back pain to recur. If the recurrences are minor and infrequent, training is permitted. Frequent or severe recurrence mandates extensive evaluation and more aggressive therapy or consideration of resigning from the sport. 5.6 Strength Training Equipment Recently isokinetic equipment has become available to test and exercise the spine. Only now are data for normal values becoming available for some movements. Complex movements such as combined flexion, bending and rotation produce so much data that interpretation is far from a science. It is our opinion that not enough experience is available to use isokinetic devices to determine readiness for return to play. Also, the benefits of solely using these devices for rehabilitation of back injuries is unproven. Isokinetics has become an important aspect of limb rehabilitation, but much needs to be learned before the same can be said for back rehabilitation. 5.7 Protective Devices Protective devices may be useful in some instances. Braces that limit hyperextension in the gymnast, the weight lifter's belt and the football flak jacket all have their place. Prolonged use of these devices may allow the athlete to continue in their sport. 5.8 Maintenance Conditioning Programme The final phase of the athlete's back rehabilitation programme is the design and implementation of a maintenance programme. Too often as the athlete gets well and returns to sport the stand-
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ard weight room exercises are continued, but the back and abdominal rehabilitation exercises are neglected. Since recurrence rates of back pain are 40 to 60%, it is important for the athlete to participate in a long term programme. Instruction on proper sitting and standing posture should also be provided. In conclusion, it is often difficult for the sports physician to establish a definitive diagnosis in a young athlete with lower back pain. After excluding the common serious problems with careful history, examination and appropriate radiographs, therefore, an aggressive first aid and rehabilitation programme is likely to allow the athlete to return to the playing field.
References Boden SD, Davis DO, Dina TS, et aI. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. Journal of Bone and Joint Surgery 72 (3): 1990 Bowerman JW, McDonnell EI. Radiology of athletic injuries football. Radiology 117: 33-36, 1975 Cacayorin E, Hochlauser L, Petro OR. Lumbar and thoracic spine pain in the athlete: radiographic evaluation. Clinics in Sports Medicine 6 (4): 767-783, 1987 Clancy WO. Symposium: low back pain in athletes. American Journal of Sports Medicine 7 (6): 361-368, 1979 Deyo RA, et al. How many days bed rest for acute low back pain? A randomized clinical trial. New England Journal of Medicine 215: 10-64, 1986 Foster DN, Fulton MN. Back pain and the exercise prescription. Oinics in Sports Medicine 10: 197-209, 1991
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Harris JH, Harris WHo The radiology of emergency medicine, 2nd ed., Williams and Wilkins, 1981 Hochschuler SH. The spine sports, Hanley and Belfus, Philadelphia, 1990 McKenzie RN. The lumbar spine, pp. 49-80, Spinal Publishing Ltd, Waikanae, New Zealand, 1981 Micheli U. Back injuries in dancers. Clinics in Sports Medicine 2 (3): 473-484, 1983 Nachemson A. The lumbar spine: an orthopaedic challenge. Spine I: 59-71, 1976 Nachemson A. Exercise, fitness and back pain. In Exercise fitness and health, pp. 533-540, Human Kinetics Press, Champaign, III, 1988 Nachemson A, Spitzer WO, et al. Scientific approaches to the assessment and management of activity-related spinal disorders. A monograph for clinicians: report of the Quebec Task Force on Spinal Disorders. Spine 12 (Suppl. I): SI-S59, 1987 Ohnmeiss DD, et aI. Nonsurgical treatment of sports-related spine injuries. In Hochschuler (Ed.) The spine in sports, Hanley and Belfus, Inc. Philadelphia, pp. 241-266, 1990 Pelz DM. Radiologic investigation of low back pain. Canadian Medical Association Journal 140 (I): 289-295, 1989 Rossi F. Spondylolysis, spondylolisthesis and sports. Journal of Sports Medicine and Physical Fitness 18 (4): 317-340, 1988 Scavone J, Latchaw R, Rohrer O. Use of lumbar spine films: statistical evaluation at a university teaching hospital. Journal of the American Medical Association 246: 1105-1108, 1981 Shalen PRo Radiographic evaluation of thoracolumbar sports-related injuries. In Hochschuler (Ed.) The spine in sports, pp. 221-240, Hanley and Belfus, Inc., 1990 White TL, Malone TR. Effects of running on intervertebral disc height. Journal of Sports Physical Therapy 12: 139-146, 1990 Wiltse LL, Widell EH, Hackson DW. Fatigue fracture: the bone lesion in isthmic spondylolisthesis. Journal of Bone and Joint Surgery 57-22, 1974
Correspondence and reprints: Dr Jack Harvey. Orthopaedic Center of the Rockies, 2500 East Prospect Road, Fort Collins, CO 80524, USA.
Sports Medicine 12(6): 394-406. 1991 0112-1642/91/0012-0394/$06.50/ 10 © Adis International Lim ited. All rights reserved. SPOl70
Low Back Pain in Young Athletes A Practical Approach Jack Harvey and Suzanne Tanner Sections of Sports Medicine, The Orthopaedic Center of the Rockies, Fort Collins, Colorado, and University of Colorado Health Sciences Center, Denver, Colorado, USA
Contents 395 396 396 396 396 396 396 397 397 397 397 398 398 398 399 399
399 399 400 400 400 401 401 401 401 402 402 404 405 405 405 405
Summary I. Predisposing Conditions I. I Growth Spurt 1.2 Training Errors I.3 Improper Technique 1.4 Poor Equipment I.5 Leg-Length Inequality 1.6 Poor Fitness 2. Diagnostic Entities 2.1 Contusion 2.2 Fractures 2.3 Sprain/Strain 2.4 Lumbar Facet Syndrome 2.5 Spondylolysis/Spondylolisthesis 2.6 Sacroiliac Disorder 2.7 Disc Herniation 2.8 Spinal Disorders Simulating Athletic Injury 3. Diagnostic Tests 3.1 Radiographs 3.2 Bone Scan 3.3 Computed Tomography 3.4 Magnetic Resonance Imaging 4. Psychological Counselling 5. First Aid and Rehabilitation 5.1 Immediate Treatment 5.2 Range-of-Motion and Strengthening Exercises 5.3 Back Exercises 5.4 Conditioning Programmes 5.5 Return to Activity 5.6 Strength Training Equipment 5.7 Protective Devices 5.8 Maintenance Conditioning Programme
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Summary
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Lumbar spine pain accounts for 5 to 8% of athletic injuries. Although back pain is not the most common injury, it is one of the most challenging for the sports physician to diagnose and treat. Factors predisposing the young athlete to back injury include the growth spurt, abrupt increases in training intensity or frequency, improper technique, unsuitable sports equipment, and leg-length inequality. Poor strength of the back extensor and abdominal musculature, and inflexibility of the lumbar spine, hamstrings and hip flexor muscles may contribute to chronic low back pain. Excessive lifting and twisting may produce sprains and strains, the most common cause of low back pain in adolescents. Blows to the spine may create contusions or fractures. Fractures in adolescents from severe trauma include compression fracture, comminuted fracture, fracture of the growth plate at the vertebral end plate, lumbar transverse process fracture, and a fracture of the spinous process. Athletes who participate in sports involving repeated and forceful hyperextension of the spine may suffer from lumbar facet syndrome, spondylolysis, or spondylolisthesis. The large sacroiliac joint is also prone to irritation. The signs and symptoms of disc herniation in adolescents may be more subtle than in adults. Disorders simulating athletic injury include tumours and inflammatory connective tissue disease. Often, however, a specific diagnosis cannot be made in the young athlete with a low back injury due to the lack of pain localisation and the anatomic complexity of the lumbar spine. A thorough history and physical examination are usually more productive in determining a diagnosis and guiding treatment than imaging techniques. Diagnostic tests may be considered, though, for the adolescent athlete whose back pain is severe, was caused by acute trauma, or fails to improve with conservative therapy after several weeks. Radiographs, bone scanning, computed tomography, and magnetic resonance imaging may help identify, or exclude serious pathology. Fortunately, the majority of cases of low back pain in adolescents respond to conservative therapy. Immediate treatment of an acute injury, such as a sprain or strain, includes cryotherapy, electrogalvanic stimulation, anti-inflammatory medications and gentle exercises. Prolonged bed rest should be avoided since atrophy may occur rapidly. Strong analgesics are also usually contraindicated, except for sleep, since they mask pain and may allow overvigorous activity. Early strengthening exercises include the Williams flexion exercises and/or McKenzie extension exercises. Both exercise motions may often be prescribed. Athletes with an acute disc herniation, however, should only perform extension exercises initially. Athletes with spondylolysis, spondylolisthesis and facet joint irritation should initially be limited to flexion exercises. Brief sessions of walking, pool walking or jogging, and upright cycling may be started when tolerated to maintain aerobic conditioning. The proper timing for an athlete to return to activity depends on the demonstration of functional skills necessary to perform a specific sport. The final component of a young athletes' back rehabilitation programme includes a long term stretching, and back and abdominal strengthening programme.
Although a low back injury is not the most common athletic injury, it may be one of the most disabling. Back pain is reported to occur in 85% of the general population but in only 5 to 8% of the athletic population. Both acute traumatic and overuse injuries occur and may be more frequent in certain sports. Contact and collision sports such as American football, rugby and wrestling provide opportunity for blunt trauma, sprains and strains. Overuse injuries from repeated lumbar hyperextension may be found in gymnastics, volleyball and
rowing. The sports physician needs to be able to evaluate these problems and formulate a plan of treatment and rehabilitation. The lumbar spine links the lower extremities and the torso. This important link is responsible for the coordinated transfer of power through the body in most sports. Although most athletes are in good general physical condition, one cannot assume that athletes have spent much time strengthening and stretching their low back and abdomen. Injuries are often due to poor conditioning of the spine, poor
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biomechanics or the repetitive stresses placed on the spine by the nature of the sport. Acute excessive force placed on the spine may also cause injury. Disc disease is occasionally encountered. Finally, athletes are not immune to the degenerative processes that affect all spines. The sports physician faced with an athlete experiencing lumbar pain should exclude serious spine disorders, institute first aid and start a rehabilitation programme to expedite the athlete's return to the sport. On occasion the physician will have to decide if the athlete may practise or play while still experiencing back pain. What is needed is a quick and easy way to establish the correct diagnosis when faced with the athlete with a painful back. This allows the proper selection of therapeutic techniques. Unfortunately, no such system of diagnostics exists. In fact, the frustration or absolute dislike some physicians feel toward treating back pain is because back pain is very difficult to diagnose and thus properly treat. However, the vast majority of back pain does resolve. In fact, the correct diagnosis in acute low back pain is established only 2% of the time in the immediate period! If the pain persists for 6 weeks, the diagnostic accuracy climbs to 15% and to 30% at 3 months (Nachemson et al. 1987). With this very low probability of acutely establishing a correct diagnosis, the sports physician's time is best spent ruling out serious spine disorders such as disc herniation. Following this, a reliance on sound first aid and rehabilitation principles outlined in this paper will stand the physician in good stead. Finally, it is reassuring to know that two-thirds of the injured are relatively symptom-free and able to function in work or sports in 2 weeks and 88% are doing well by 6 weeks (Nachemson 1988). The challenge facing the sports physician is mostly to not do anything to retard the athlete's recovery and try to maintain the athlete's fitness during the injury.
1.1 Growth Spurt During this phase, if the paraspinous tissues do not grow at the same rate as bone, the resultant tight lumbodorsal fascia and hamstrings stress the spine, predisposing to back pain. Emphasis on maintaining flexibility will mitigate this situation (Clancy 1979; Hochschuler 1990). 1.2 Training Errors Abrupt increases in training intensity or frequency are often cited in association with the onset oflow back pain in adolescents. Too much weight lifted with the military press manoeuvre in a weightlifter may precipitate low back pain. A teenage dancer may suddenly switch from a lay-off period, when she was only taking classes 2 hours a day, to a schedule of rehearsing for 10 to 12 hours a day. This dramatic increase in back stress can injure ligaments, muscles and tendons (Micheli 1983). 1.3 Improper Technique Improper technique may contribute to low back strain. A lineman, for example, who blocks an opponent while maintaining an erect posture may suffer a hyperextension injury. Excessive lordosis in a dancer performing an arabesque or lifting a partner may produce low back pain (Micheli 1983). 1.4 Poor Equipment An improper bicycle fit, for example, may predispose a cyclist to low back pain. Seat height which is too high may cause excessive pelvic rocking, which may lead to increased muscular activity and fatigue (Hochschuler 1990). Excessive distance between the seat and handlebars causes a cyclist to ride in a hyperiordotic position and may strain the back.
1.5 Leg-Length Inequality
1. Predisposing Conditions Factors predisposing the young athlete to back injury are both intrinsic and extrinsic.
Leg-length discrepancies cause an unequal transmission offorce across the spine during weightbearing activities. This is further accentuated when
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the athlete moves quickly and the stress transmitted through the spine is amplified by acceleration of the body mass (Hochschuler 1990). There is controversy as to the relative difference necessary to be clinically meaningful. In the general population, a sample of authors felt that a minimum of lcm difference is needed before intervention is required. Others, including those who have studied the effects in athletes specifically, tend to consider differences of 4mm and up to be important (Hochschuler 1990). 1.6 Poor Fitness There is no conclusive evidence that cardiovascular fitness, as measured by maximum oxygen uptake, decreases the risk for back injury (Hochschuler 1990), but it is difficult to separate aerobic capacity from muscular endurance, strength, flexibility and body composition. Like guy wires supporting a telephone pole (Foster & Fulton 1991), the abdominal and back extensor muscles increase stability of the spine during sporting activities. Weakness ofthe erector spinae may contribute to low back pain. The normal ratio of trunk extension strength to trunk flexion strength is 1.3: I. In patients with low back pain this ratio is substantially reduced (Foster & Fulton 1991). Inflexibility of the hamstrings increases lumbar lordosis (Hochschuler 1990). Pelvic mobility is essential in bending and lifting activities, and tightness of the hip flexor muscles may limit pelvic movement and cause excessive strain on the lumbar spine (Foster & Fulton 1991). Tightness of the hip extensor muscles may reduce lumbar lordotic curve, making the spine less resilient to axial loading (Foster & Fulton 1991).
2. Diagnostic Entities Although the adolescent athlete is exposed to minor trauma more frequently than the nonathlete, the athlete is generally in better physical condition and has more developed supporting struc-
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tures of the spine. Therefore, the majority of back injuries in adolescents are minor. Specific entities are listed below, but the diagnosis of low back pain in adolescents is complicated by the nonspecificity of pain in many cases (Pelz 1989). Even if the specific structure injured is not identified, the majority of cases of low back pain in adolescents resolve with conservative therapy. 2.1 Contusion A bruise from a direct blow may be visible. 2.2 Fractures Injured athletes with lumbar spine fractures do not always present with neurological deficits. Fractures in adolescent athletes include the following: Compression fracture is the most common traumatic lesion of the lumbar spine. This injury is caused by acute flexion of the spine such as occurs in a fall from a height or by a heavy weight striking the shoulders. This fracture occurs primarily at the anterior vertebral body, which is the weakest site in the lumbar vertebrae due to the lack of horizontal traheculations. Athletes who sustain a calcaneal fracture from a fall from height should be questioned to determine if back pain is present. They may also have a vertebral compression fracture (Harris & Harris 1981). Comminuted fracture of the lumbar spine is much less common than the simple compression fracture. It is usually caused by a severe abrupt flexion force which drives one vertebral body or its adjacent intervertebral disc into the superior plate of the next lower body. Posterior fragments may be driven posteriorly, producing cord compression or injury. The intervertebral disc is always injured with this fracture (Harris & Harris 1981). Young athletes can develop fractures of the growth plate at the vertebral endplate in which the nucleus pulposis herniates into the vertebral body. Since the cartilaginous endplate is weaker that the
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nucleus pulposis, excessive compressive forces can cause the endplate to fracture (Hochschuler 1990). The lumbar transverse processes may fracture due to a direct blow, a sudden, strong contraction by the psoas and quadratus lumborum, or as the result of forceful movements of the trunk avulsing the attachments of the muscles (Hochschuler 1990). In one study of 4 football players with transverse process fractures, all were either offensive halfbacks or offensive ends (Bowerman & McDonnell 1975). Transverse process fractures may be overlooked radiographically. AJracture o/the spinous process may occur from a direct blow (Hochschuler 1990). 2.3 Sprain/Strain Looking at the natural history of low back pain in adolescents, it seems likely that most cases of acute low back pain are caused by sprains or strains from lifting or twisting. Mild to moderate acute low back pain in adolescents usually heals quickly, as is the case when sprains and strains occur in other body parts (Nachemson 1988). A 'sprain' is an injury to a ligament and a 'strain' refers to inflammation, microtears, or tears of the muscle, tendon, or musculotendinous junction. It is often difficult to differentiate the exact structure injured. Sprain/strain mechanisms can be grouped into 3 categories, defined as follows: l. Acute injury: a sudden overloading of musculotendinous units, as might occur in sprinting or kicking. 2. Chronic or overuse injury: a repeated overload and/or frictional resistance, which occurs in endurance training or other highly repetitive action. 3. Acute injury imposed on chronic injury (Hochschuler 1990). 2.4 Lumbar Facet Syndrome The facet syndrome is a painful irritation of the posterior elements of the lumbar spine. There is potential risk to neural elements as they exit
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through the intervertebral foramen from capsular swelling (Hochschuler 1990). Athletes who participate in sports involving repeated and forceful hyperextension of the lumbar spine suffer a higher incidence of lumbar facet syndrome; such sports include American football, gymnastics, diving, power lifting, and golf. Tennis players, especially during a serve, and male dancers who lift their partners are also at risk (Hochschuler 1990). The classic facet syndrome is characterised by local paralumbar tenderness, pain on hyperextension, normal neurological examination, and hip, buttock or back pain with straight leg raising. Pain may occur when assuming an upright position following forward flexion of the lumbar spine. Pain may be referred to multiple areas, including the groin, the greater trochanter, and to the posterior thighs as far as the knee. Generally, the pain is relieved by rest and made worse by movement (Hochschuler 1990). 2.5 Spondylolysis/Spondylolisthesis These terms are derived from the Greek. 'Spondylo' means vertebra, '-lysis' means crack or fracture, and '-olisthesis' means sliding down an incline. Spondylolysis is a bony defect affecting the pars interarticularis (a segment near the junction of the pedicle and the lamina) that usually affects the LS vertebral body. Spondylolysis may progress to spondylolisthesis, an anterior slippage of a vertebra (usually LS) [Cacayorin et al. 1987]. In the athlete, the lytic defect is thought to be due to repetitive hyperextension maneouvres. In gymnastics, fatigue overloading of the neural arch occurs from back walkovers and performing dismounts in lumbar extension. Lumbar rotation during throwing sports, diving and wrestling can cause unilateral spondylolysis to develop (Hochschuler 1990). The incidence of spondylolysis in selected sports is listed in table I. Athletes will usually note chronic dull aching pain of the lumbosacral spine that is exacerbated by manoeuvres requiring hyperextension, or rotation with the back in a hyperlordotic position. Dur-
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Table I.
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Incidence of spondylolysis in selected sports (Rossi
1988) Sport
Incidence of spondylolysis (%)
Diving Weightlifting Wrestling Gymnastics Track and field General population
63.3 36.2 33.0 32.0 22.5 5.0
ing the physical examination, extension of the back or hip will exacerbate pain (Hochschuler 1990). In the skeletally immature athlete, close observation for progression to and of spondylolisthesis is advised. Wiltse has found the greatest amount of slippage occurring between the ages of 9 and 14 years, but seldom after that (Wiltse et al. 1974). Once the patient is skeletally mature progression is rare (Hochschuler 1990). 2.6 Sacroiliac Disorder The sacroiliac joint is one of the largest, yet least mobile, articulations in the body. Acute lesions of the sacroiliac joint generally require a sudden forceful injury as might occur in motor racing, American football, soccer, rugby, hockey, basketball and baseball. A misstep by a runner whose heel strike is made with the knee locked will transmit high loads to the pelvis, or one with a leg-length discrepancy may precipitate a sacroiliac lesion (Hochschuler 1990). Symptoms commonly include pain in any area of the low back, buttocks or posterior thigh. Localised tenderness over the sacroiliac joint with asymmetry of intrapelvic movement is found on examination. Tender and asymmetric landmarks at the symphysis pubis may be evident (Hochschuler 1990). 2.7 Disc Herniation Disc herniation is a focal protrusion of the nucleus pulposus through a defect in the annulus fibrosus, most commonly occurring in its postero-
lateral portion. Disc herniation occurs in the regions of greatest mobility; thus, it is common in the lumbar region, especially at the L5 to SI and L4 to L5 levels (92%). Disc herniation is usually precipitated by trauma or lifting a heavy object and may be accompanied by a snapping sensation. Pain and radiculopathy may occur suddenly or gradually. In adolescents, however, the presenting signs may be confined to hamstring and back inflexibility (Hochschuler 1990). 2.8 Spinal Disorders Simulating Athletic Injury
2.8.1 Tumours Primary bone tumours may cause pain. Nocturnal pain is the characteristic presentation of osteoid osteoma. It most frequently occurs in an adolescent or young adult male. In the spine, typically the posterior elements are involved. The pain may be initially relieved by salicylates. Another tumour that clinically presents with unusually severe pain is osteoblastoma. commonly involving the vertebral appendages (Cacayorin et al. 1987).
2.8.2 Inflammatory Connective Tissue Disease In young runners complaining of persistent sacroiliac pain, a positive bone scan and HLA B27 in association with dramatic response to anti-inflammatory medication should suggest the diagnosis of ankylosing spondylitis (Hochschuler 1990).
3. Diagnostic Tests A thorough history and physical examination are usually more productive in determining a diagnosis and guiding treatment than imaging techniques. There is often no specific anatomic defect visible by imaging techniques. The diagnostic tests listed below may be considered in the adolescent athlete whose back pain is severe, was caused by acute trauma, or fails to improve with conservative therapy after several weeks.
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3.1 Radiographs The rate of plain film revealing abnormal findings is very low and the cost is high. In 1984, over 7 million were obtained in the United States at a cost of more than $500 million, and the incidence of unexpected positive findings has been reported to be as low as 1 in 2500 cases (Nachemson 1976; Pelz 1989; Scavone et al. 1981). The most common surgically remediable cause of low back pain, disc herniation, cannot be seen on plain films. This overused form of examination is not innocuous: the standard anteroposterior, lateral and oblique views deliver 11 rad to the skin, one of the highest doses of any radiological examination to the gonads (Pelz 1989). Trauma constitutes the main reason that would prompt an athlete to undergo radiographic evaluation. Anteroposterior and lateral radiographs of the lumbar spine and pelvis are initially the only projections required. Plain films allow detection of fractures and subluxations (Cacayorin et al. 1987). In the anteroposterior projection, lumbar transverse process fractures may be vertically situated across the base of the transverse process, or they may consist simply of avulsion of the tip of the process. Because the psoas muscle arises in part of the lumbar transverse processes, a haematoma may diffuse into the fascial plane adjacent to the muscle, thereby obliterating radiographic identification of the fracture. The absence of the normal psoas shadow may be the most prominent finding in instances of fracture of the lumbar transverse processes (Harris & Harris 1981). In the lateral view, a compression fracture may consist simply of buckling of the superior plate, anterior wedging, or loss of stature of a vertebral body, depending on the magnitude of flexion force impacted (Harris & Harris 1981). A coned down lateral 'spot' projection, with the x-ray beam centred between the surfaces of the lumbosacral space, allows proper evaluation of the width of the lumbosacral space. The lumbosacral space is depicted as being falsely narrowed on the routine lateral roentgenogram due to divergence of the x-ray beam (Harris & Harris 1981).
Oblique radiographs are often necessary to identify a defect in the pars interarticularis indicative of spondylolysis. This presents as a lytic defect or increased density in the neck of the Scotty dog. Hyperextension, hyperj1exion and bending views may be useful to detect subtle malalignment of the spine not evident on routine views. They may be helpful in assessing the degree of vertebral movement with spondylolisthesis. 3.2 Bone Scan The radionuclide bone scan is a sensitive modality for detecting early inflammatory or malignant processes the spine. Although very sensitive, the test is nonspecific, time-consuming, and produces poor anatomic localisation. Comparison of oblique radiographs and the bone scan may be helpful in identifying spondylolysis and its stage. Rothman defined 4 stages of the natural history of spondylolysis: I. acute fracture; II. healing fracture; III. unhealed fracture; and IV. healed fracture. Until spondylolysis occurs, repetitive microstress may be radiographically invisible, but detectable on bone scan. A stage II fracture should be discernible on lumbar spine radiographs and bone scans. A stage III fracture is visible on plain radiographs, but the bone scan is likely to be negative. Stage IV lesions may not be recognised as such. Thickening of the pars interarticularis may be visible on radiographs (Shalen 1990) and the bone scan is negative. Bone scans may also be used to screen for tumours or infection in unusual cases. 3.3 Computed Tomography Computed tomography (CT) is superior to plain films in defining the extent of a spinal fracture. Major disadvantages of CT scanning are the high radiation dose (approximately 10 rad to the skin for a 3-level study of the lumbar region) and the limited field of view (Pelz 1989).
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3.4 Magnetic Resonance Imaging Experience is rapidly accumulating with the use of magnetic resonance imaging (MRI) in the investigation of low back pain. MRI currently provided the most accurate morphological evaluation of the intervertebral disc (Pelz 1989) and there is no radiation exposure. Boden has shown that findings of abnormalities on magnetic resonance images must be strictly correlated with clinical signs and symptoms due to the high incidence of bulging and degenerated lumbar intervertebral discs seen even in asymptomatic subjects. In his study, magnetic resonance imaging was performed on 67 individuals who had never had low back pain, sciatica or neurogenic claudication. About one-third of the subjects were found to have a substantial abnormality. Of those less than 60 years old, 20% had a herniated nucleus pulposis. There was degeneration or bulging of a disc at at least 1 lumbar level in 35% ofthe subjects between 20 and 39 years old (Boden et al. 1990).
4. Psychological Counselling Adolescent athletes with injuries severe enough to limit sports participation are likely to show shock, disbelief, and denial regarding the extent of their spinal injury. They may have difficulty trusting the physician and appear to be in a rush to return to sports. The skilled practitioner should be able to help the athlete set and achieve workable goals, to assist the athlete in moving from self-pity and hopelessness to acceptance and adaptation, and to be creative in terms of helping the adolescent define themselves and their value to others in ways independent of physical performance (Hochschuler 1990).
5. First Aid and Rehabilitation 5.1 Immediate Treatment The pain and spasm that accompany acute injury to the lumbar spine can begin immediately or may develop in the hours that follow practice or the game. Occasionally the spasm doesn't present
401
until the following morning. Anticipation of this debilitating pain and spasm and prompt application of ice to the back for 45 to 60 minutes will preempt much of the discomfort. If spasm starts to set in, then electrogalvanic stimulation or microcurrent applications can supplement the cryotherapy. Strict bed rest or maintaining a single position for a prolonged period of time (i.e. sitting for hours in a car or plane) are to be avoided as this promotes back spasm. The athlete should be encouraged to move the back through a relatively pain-free range of motion and walk each hour for 5 minutes. Only in the most severe cases of pain and spasm should bed rest be allowed and then for a maximum of 24 to 36 hours. Further periods of bed rest do not produce better recovery rates and allow atrophy of injured muscles and deconditioning (Deyo et al. 1986). Cryotherapy should be repeated frequently during the 36 to 48 hours following the injury as should the motion. As the spasm starts to subside, motion through the painfree range should be advanced to gentle stretching. Use pain and subsequent return of spasm to judge how rapidly this stretching should be progressed. Although some studies have shown that medications do not expedite the resolution of back pain per se, it is our feeling that the use of anti-inflammatory medications which do have some mild to moderate analgesic effect promote rehabilitation acutely. Strong analgesics should be avoided or only used to allow sleep. Strong analgesics may cause the rehabilitation programme to progress too rapidly by decreasing the athlete's pain and allowing overvigorous stretching and exercising. Therefore, we recommend using oral anti-inflammatory medications and recently have been impressed with the new injectable anti-inflammatory ketorolac tromethamine. The anti-inflammatory medications are used regularly during the first 3 to 7 days and then as needed over the next couple of weeks. Other means of pain control such as transcutaneous nerve stimulation, trigger point injection or acupuncture have been successful in some studies (Ohnmeiss et al. 1990). The popularity of chiropractic treatment among many athletes cannot be easily dismissed. Manipulation has been
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shown to provide temporary pain relief and reduction of spasm in medical studies (Ohnmeiss et al. 1990). As far as these entities are concerned, we encourage the sports physician to utilise the modalities with which he or she is most familiar. These other entities should be employed under the guidance of a competent consultant. Finally, it should be apparent to the physician that one particular modality may not give reliably good results in all cases. These instances may be the best place to use the above-listed adjunctive therapies. 5.2 Range-of-Motion and Strengthening Exercises After the acute period, we move from first aid to the beginning of the athlete's rehabilitation. This phase may also be the most appropriate starting point for the athlete with chronic pain or an overuse back injury that lacks the severe pain and muscle spasm described above. A couple of days after an acute traumatic injury or on the initial day of an overuse injury, it is important to determine which motion, flexion or ex-
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5.3 Back Exercises There are several series of back exercises that can be employed during the rehabilitation period. Depending on the pathology and as dictated by the athlete's tolerance, one set or a combination of these exercises can be used. Our preference is to try to exercise both flexors and extensors unless extension or flexion is contraindicated. Extension exercises are contraindicated initially in athletes with spondylolysis, spondylolisthesis and facet joint dysfunction. Flexion exercises should be avoided in athletes with acute disc herniation. The Williams back series are the most common flexion exercises and have several variations (fig. 1). One must remember that a single set of 10 repetitions may not be a great enough workload for the athletic abdomen. High repetition and mUltiple sets may be required. As the athlete progresses, increased intensity can be added by using weights or the therapist's manual resistance. Minor postexercise discomfort should resolve with the application of heat (hot tub), ice or massage. Persistence of pain or development of spasm indicates that the programme was advanced too vigorously.
tension, causes the least pain and start some easy
The McKenzie back extension exercises (fig. 2)
strengthening exercises. These may be isometrics done at one or several positions or isotonics through a comfortable range of motion. The therapist may find that fairly vigorous isoto nics are tolerated in the midrange of the motion while lesser intensities are needed at the extremes of motion. The patient's pain should be the guide as to the intensity and progression of the exercises. The therapy pool offers a nice environment for the initiation of exercises. The buoyancy of the water unloads the spine so that only a fraction of the athlete's weight is stressing the spine in 1 to 1.3m of water. Resistance exercises can be performed with the extremities without the need to hold weights. Hand paddles, exercise boot or bells (Hydrotone, Oklahoma
have been a mainstay in the treatment of disc disease for at least a decade (McKenzie 1981). Again, for the athlete the recommendation of a set of 10 may be inadequate. Good results are often obtained by repeating these exercises throughout the day. We have found these to be especially useful in the bicyclist who maintains a flexed period often for hours during training. The cyclist dismounts every 40 minutes and performs a set of extension exercises while training. During competition hyperextension exercises can be performed on the bike while upright. It is also helpful to counsel the athlete with degenerative disc disease to exercise early in the morning while the disc is maximally hydrated and at maximum height (White & Malone
City) and fins all can add resistance for the wor-
1990).
kout. Water also has the advantage of allowing diagonal movements so that proprioceptive neural facilitation patterns can be added to the therapy programme as the athlete progresses.
Many sports require repetitive flexion, extension, rotation or combinations of these motions. This in itself may promote excessive micromotion at the discs and facet joints. This results in overuse
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Low Back Pain in Young Athletes
1. Pelvic tilt. Ue on your back with knees bent, feet flat on floor. Flatten the small of your back against the floor. without pushing down with the legs. Hold for 5 to 10 seconds.
2. Knee to chest. Ue on your back with knees bent and feet flat on the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the knee and repeat with the other knee.
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3. Double knee to chest. Begin as in the prevIous exercise. After pulling right knee to chest. pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly lower one leg at a time.
4. Partial sit-up, stra ight version. Do the pelvic tilt (exercise 1) and, while holding this position. slowly curl your head and shoulders ofl the floor. Hold briefly. Return slowly to the starting position.
Fig. 1. Examples of Williams flexion exercises.
1. Prone lying. Ue on your stomach with arms along your sides and head turned to one side. Maintain this position for 5 to 10 minutes.
2. Prone lying on elbows. Lie on your stomach with your weight on elbows and forearms and your hips touching the floor or mat. Relax your low back. Remain in this position 5 to 10 minutes. If thiS causes pain, repeat exercise 1. then try again.
3. Prone press-ups. Ue on your stomach with palms near your shoulders, as If to do a standard push-up. Slowly push your shoulders uP. keepIng your hips on the surface and letting your back and stomach sag. Slowly lower your shoulders. Repeat 10 limes.
4. Progressive extension with pillows. Ue on your stomach and place a pillow under your chest . After several minutes, add a second pillow. If this does not hurt, add a third pillOW after a few more minutes. Stay in this poSition up to 10 minutes. Remove pillows one at a time over several minutes.
Fig. 2. Examples of McKenzie extension exercises.
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Sports Medicine 12 (6) 1991
symptoms and with time degenerative disease and even arthritis. This phenomenon is also seen in the athlete that has very strong limb muscles, but has not invested any time in conditioning the lumbar spine. The result is again an unstable spine with increased microtrauma and symptoms. Because of this problem, spine stabilisation exercises that utilise the co-contraction of flexors, extensors and rotators are taught to splint the spine during activity. These exercises are first taught in a very simple form in a supine or prone position and progressed to standing and moving position (fig. 3). Finally, the athlete is taught to use the techniques while training and competing. Although these exercises
Supine exercises Lie on your back with knees bent and feet flat on the floor.
Abdominal pelvic tilt TlQhten your stomach muscle so that your low back gently presses against the floor. Hold this contraction for 10 seconds, countifIQ out loud. and then slowly relax. Repeat. Lower extremity activities Perform an abdominal pelvic tilt so that your low back gently presses against floor. Maintaining the pelvic tilt: 1. Slowly lift your toes. and then your heel of one foot up and down from the floor. Repeat with other foot. 00 not let your low back lift from the floor as you lift your toes. Repeat. 2. Slowly move knees apart and together. Repeat. movifIQ the knees further apart each time. as long as your lower back does not lift from the floor. Repeat. 3. Slowly lift one foot up and down approximately 2.5 to Scm from the floor, and then repeat with the other foot . 00 not let your low back lift from the floor as you lift your foot. Repeat. 4. Slowly lift one foot 2.5 to Scm off \he floor. Extend the leg, keepifIQ \he foot 2.5 to Scm from the floor. Extend the leg as far as you can. not letting your low back lift from the floor. Replace the foot on the floor and repeat with the other leg. Repeat.
Fig. 3.
Examples of spinal stabilisation exercises.
are more difficult to teach the athlete and require several hands-on sessions with a trained therapist, we have found them to be extremely valuable in rehabilitation of the athlete with chronic back pain or for prevention of recurrence in the athlete with an initial episode of low back pain. 5.4 Conditioning Programmes An aerobic exercise programme may be started simultaneously with a resistance programme. Many therapists feel that a good conditioning programme is essential for rehabilitation of back injuries. It is also useful in that it helps initiate spinal stabilis-
Upper extremity activities Assume the 4-point position , maintaining a straight low back: 1. Uft up one arm straight . thumb pointing toward the ceiling. next to your ear. Be sure that your body does not twist . Hold 10 seconds. counting out loud. then lower the arm and repeat with your other arm. Repeat .
Lower extremity activities Assume the 4-point position , maintaining a straight low back: 1. Slide one leg out behind you so that the foot and knee lift off the floor 10 to 1 Scm. Your foot and knee should remain at the same level and the knee should remain slightly bent. Be sure that your body does not twist. Hold for 10 seconds. countifIQ out loud. and retum to startifIQ position . Repeat with your other leg. Repeat.
Combined upper and lower extremity activities Assume the 4-point poSition . maintaining a straight low back : 1. Ult up one arm straight. thumb pointing toward the ceilifIQ . next to your ear. Slide the opposite leg out behind you so that the foot and knee lilt off the floor 10 to IScm. Be sure that your body does not twist. Hold for 10 seconds. counting out lOUd. and retum to start· ifIQ poSition . Repeat on the other side with your opposite arm and leg. Repeat.
Low Back Pain in Young Athletes
ation by the muscles. Initially, the activity should be one that is tolerated with a minimum of discomfort and can be performed for a minimum of 20 minutes per day, and if possible the activity should be an integral part of the sport in which the athlete participates. The concept of specificity of training makes it desirable that the athlete initiate activity that mimics their sport as soon as possible if it does not aggravate the injury. Aerobic activities that are usually well tolerated initially are walking, pool walking or jogging, upright cycling and the use of stair-stepping machines. As the athlete's symptoms resolve, jogging or running, cycling and swimming are permitted. Cross-country skiing or mimicking the cross-country motions in the shallow end of a pool with weights improves spinal stabilisation and coordination between lower extremity and torso movement. Finally, activities that require stop and start and rapid change of direction manoeuvres (ball and racquet sports) are slowly added if required for the athlete's return to sport. 5.5 Return to Activity As the athlete's symptoms resolve and progress through the rehabilitation programme, training of specific functional activities related to return to sport need to be initiated. At first activities with isolated flexion-extension, lateral bending or rotation should be used. Combined motions are more stressful to the discs and need to be introduced gradually. As the athlete returns to sport, the physician needs to be on the alert to activities within the sport that may cause a recurrence or aggravate present symptoms. Portions of practice may need to be eliminated, modified or reduced in repetition or intensity to keep the athlete healthy. Prolonged practice sessions may be too stressful for the recently injured athlete and coaches need to be counselled to limit practice sessions. Remember, practice doesn't make perfect, perfect practice makes perfect! A big question is often when to return the athlete to practice or play. At present there is no test that gives doctor, coach or athlete the answer. The
405
best indicator is a successful graduation within the back rehabilitation programme and the demonstration of the functional skills necessary to perform the sport. If this can be demonstrated without the need for rest periods or the constant application of ice or modalities, the prognosis is good. However, the stresses of all-out competition and prolonged intense training may cause low back pain to recur. If the recurrences are minor and infrequent, training is permitted. Frequent or severe recurrence mandates extensive evaluation and more aggressive therapy or consideration of resigning from the sport. 5.6 Strength Training Equipment Recently isokinetic equipment has become available to test and exercise the spine. Only now are data for normal values becoming available for some movements. Complex movements such as combined flexion, bending and rotation produce so much data that interpretation is far from a science. It is our opinion that not enough experience is available to use isokinetic devices to determine readiness for return to play. Also, the benefits of solely using these devices for rehabilitation of back injuries is unproven. Isokinetics has become an important aspect of limb rehabilitation, but much needs to be learned before the same can be said for back rehabilitation. 5.7 Protective Devices Protective devices may be useful in some instances. Braces that limit hyperextension in the gymnast, the weight lifter's belt and the football flak jacket all have their place. Prolonged use of these devices may allow the athlete to continue in their sport. 5.8 Maintenance Conditioning Programme The final phase of the athlete's back rehabilitation programme is the design and implementation of a maintenance programme. Too often as the athlete gets well and returns to sport the stand-
406
ard weight room exercises are continued, but the back and abdominal rehabilitation exercises are neglected. Since recurrence rates of back pain are 40 to 60%, it is important for the athlete to participate in a long term programme. Instruction on proper sitting and standing posture should also be provided. In conclusion, it is often difficult for the sports physician to establish a definitive diagnosis in a young athlete with lower back pain. After excluding the common serious problems with careful history, examination and appropriate radiographs, therefore, an aggressive first aid and rehabilitation programme is likely to allow the athlete to return to the playing field.
References Boden SD, Davis DO, Dina TS, et aI. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. Journal of Bone and Joint Surgery 72 (3): 1990 Bowerman JW, McDonnell EI. Radiology of athletic injuries football. Radiology 117: 33-36, 1975 Cacayorin E, Hochlauser L, Petro OR. Lumbar and thoracic spine pain in the athlete: radiographic evaluation. Clinics in Sports Medicine 6 (4): 767-783, 1987 Clancy WO. Symposium: low back pain in athletes. American Journal of Sports Medicine 7 (6): 361-368, 1979 Deyo RA, et al. How many days bed rest for acute low back pain? A randomized clinical trial. New England Journal of Medicine 215: 10-64, 1986 Foster DN, Fulton MN. Back pain and the exercise prescription. Oinics in Sports Medicine 10: 197-209, 1991
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Harris JH, Harris WHo The radiology of emergency medicine, 2nd ed., Williams and Wilkins, 1981 Hochschuler SH. The spine sports, Hanley and Belfus, Philadelphia, 1990 McKenzie RN. The lumbar spine, pp. 49-80, Spinal Publishing Ltd, Waikanae, New Zealand, 1981 Micheli U. Back injuries in dancers. Clinics in Sports Medicine 2 (3): 473-484, 1983 Nachemson A. The lumbar spine: an orthopaedic challenge. Spine I: 59-71, 1976 Nachemson A. Exercise, fitness and back pain. In Exercise fitness and health, pp. 533-540, Human Kinetics Press, Champaign, III, 1988 Nachemson A, Spitzer WO, et al. Scientific approaches to the assessment and management of activity-related spinal disorders. A monograph for clinicians: report of the Quebec Task Force on Spinal Disorders. Spine 12 (Suppl. I): SI-S59, 1987 Ohnmeiss DD, et aI. Nonsurgical treatment of sports-related spine injuries. In Hochschuler (Ed.) The spine in sports, Hanley and Belfus, Inc. Philadelphia, pp. 241-266, 1990 Pelz DM. Radiologic investigation of low back pain. Canadian Medical Association Journal 140 (I): 289-295, 1989 Rossi F. Spondylolysis, spondylolisthesis and sports. Journal of Sports Medicine and Physical Fitness 18 (4): 317-340, 1988 Scavone J, Latchaw R, Rohrer O. Use of lumbar spine films: statistical evaluation at a university teaching hospital. Journal of the American Medical Association 246: 1105-1108, 1981 Shalen PRo Radiographic evaluation of thoracolumbar sports-related injuries. In Hochschuler (Ed.) The spine in sports, pp. 221-240, Hanley and Belfus, Inc., 1990 White TL, Malone TR. Effects of running on intervertebral disc height. Journal of Sports Physical Therapy 12: 139-146, 1990 Wiltse LL, Widell EH, Hackson DW. Fatigue fracture: the bone lesion in isthmic spondylolisthesis. Journal of Bone and Joint Surgery 57-22, 1974
Correspondence and reprints: Dr Jack Harvey. Orthopaedic Center of the Rockies, 2500 East Prospect Road, Fort Collins, CO 80524, USA.
