Low Back Pain in Athletes

Athletes are at greater risk of sustaining a lumber (lower) spine injury due to physical activity. Whether the sport is skiing, basketball, football, gymnastics, soccer, running, golf, or tennis-the spine undergoes a lot of stress, absorption of pressure, twisting, turning, and even bodily impact. This strenuous activity puts stress on the back that can cause injury to even the finest and most fit athletes.

Though the entire spine is used when playing sports, it is estimated that five to ten percent of all athletic injuries are related to the lumbar spine. Many cases of low back pain in athletes can be traced to a specific event or trauma; others are brought about by repetitive minor injuries.

It is sometimes hard for an aggressive athlete to consider changing training schedules. It is also hard to accept the fact that a serious disease may exist. All athletes who suffer from low back pain should seek medical advice. Some situations might require reducing or ceasing athletic activity until the problem is resolved. The body’s ability to be active is worth preserving.

Learn about low back pain in athletes including

• how the spine is affected
• what generally causes low back pain in athletes
• how a diagnosis is made
• what treatment options are available

In order to understand your symptoms and treatment choices, it is helpful to start with a basic understanding of the anatomy of the low back. This includes becoming familiar with the various parts that make up the lumbar spine and how they work together.

Even though low back pain can sometimes be treated without major disruption to a person’s life, athletes are often reluctant to seek medical help. Many of them deny or minimize complaints in order to avoid consequences, such as: having to decrease activity in order to recover, losing a position or being removed from a team, missing a competition, or letting the team down. Some athletes simply do not want to bother seeing a doctor for pain; they hope it will recover on its own.

Many athletes-from the weekend warrior to the elite professional athlete-buck up their strength, pop some over-the-counter pain medication, and tolerate the pain for the sake of the game and personal enjoyment. But avoiding medical help can lead to further and more serious injury. Without medical help, the anatomic damage can sometimes lead to permanent exclusion from sporting activities.

There are many causes of low back pain. The most common causes in athletes are back strain, spondylolysis, spondylolisthesis, and herniated discs.

Back Strain

The medical term used to describe common back strain is musculoligamentous strain. This term refers to all injuries of the lumbar spine’s soft tissue. Soft tissues are the muscles, nerves, ligaments, tendons, and blood vessels around the spine. These are probably the most common types of sports injuries. Back strains are diagnosed by exclusion, which means the diagnosis is offered after all other causes of pain are ruled out. These injuries are usually self-limiting. In other words they do not continue to spread and get worse; they generally heal in time.

Spondylolysis and Spondylolisthesis

A crack in the bony ring of the spinal column is called spondylolysis. If the crack occurs on both sides of the bony ring, the spine is free to slip forward, a condition called spondylolisthesis. So far there is no definitive cause of spondylolysis. Most physicians agree that the bone defect appears in children mainly due to sports activities that put repeated stress on the pars interarticularis. The spondylolysis appears in younger and older adults as the result of excessive stresses on the spine, eventually causing a stress fracture.

Spondylolysis in athletes is most commonly found in those who participate in sports that have frequent hyperextension of the lumbar spine, such as gymnastics, pole-vaulting, and football. Weightlifters also have a higher incidence of the disorder due to excessive stress on the spine.

Spondylolysis does not always produce noticeable symptoms. When it does, chronic low back pain is the most common symptom. The pain can stem from mechanical (structural) or compressive (pressure on nerves) pain.

Spondylolisthesis occurs when the weakness caused by the spondylolysis causes one vertebra to slip forward over the one below it. Most cases of spondylolysis in athletes do not lead to vertebral slippage. But if slippage does occur it may continue. This situation requires more aggressive treatment-perhaps even surgery. The chance of progression is probably more worrisome in teenagers than adults.

Many cases are non-symptomatic and do not cause any nerve problems. Sometimes the slipped vertebra can press into the space of the spinal canal. This leaves less room for the nerve roots. The neural pressure can lead to low back, buttock, and leg pain, as well as numbness in the foot. Surgery may be suggested if the problem is severe.

Herniated Discs

Many sports produce high amounts of pressure on the spine. Over time, these repeated stresses add up and begin to affect the discs in the spine.

A herniated disc occurs when pressure to a disc’s outer fibers (annulus) is so great that it rips, and the nucleus ruptures out of its normal space. If it rips near the spinal canal, the bulging disc can push out of its space and into the spinal canal, placing inappropriate pressure on the spinal cord and nerve roots. If a disc bulges substantially, or fragments into pieces that lie in the canal, then irritation of the nerves can be severe.

The compression to the nerves caused by herniation can lead to feelings of numbness, pain, a change in reflexes, and tingling in the arms or legs. In addition, if a disc ruptures, it releases chemicals that can irritate and inflame the nerve roots, which leads to extreme discomfort. Sometimes a herniated disc is referred to as “slipped disc,” though the disc does not actually slip.

Other Causes

Adolescent athletes may also suffer from low back pain that is caused by growth-related problems, such as scoliosis and Scheuermann’s kyphosis. These problems may or may not be related to athletic activity. But they can affect an athlete’s ability to perform up to his or her standards.

Scoliosis

Scoliosis is a condition that is related to growth. It appears usually just as the teenage growth spurt of puberty begins and may progress through the growth phase. The growth spurt begins at about age 11 in girls and age 13 in boys. Scoliosis is usually painless, but it may cause back discomfort with activity. The condition is genetic, which means it runs in families. It is more common in girls than boys. If the condition progresses, it can be serious. It may require treatment with a brace, or even surgery.

Scheuermann’s Kyphosis

Scheuermann’s kyphosis is a developmental type of kyphosis. The vertebrae are normally rectangular-shaped and stacked on top of one another, like building blocks, with a soft cushion (disc) in between each one. If they wedge closer together in a triangular shape, as with Scheuermann’s kyphosis, it causes the spine to curve more than normal. Sometimes this deformity is described as “round-back posture” or “hunch-back.”

In evaluating low back pain in athletes, your doctor will start by gathering information about the current problem and a complete history of any additional medical problems. Athletes tend to live with a certain amount of constant pain. This can cause them to ignore or minimize the severity of their pain. They may also be used to dealing with more pain than the average patient, which sometimes makes it harder to adequately assess their symptoms. This is why a thorough history of the athlete is needed.

Before determining a diagnosis and developing a treatment plan, your physician will need to know

• your age
• the type(s) of sport(s) and level of competition in which you are involved
• all past and current medical problems
• the location of the pain and where it spreads
• when the pain began, along with the pain’s relation to any specific trauma
• what brings pain on or relieves it
• about any drug or medication use

Physical Exam

Your doctor will examine your entire spine looking for signs of unusual curves, a rib hump, a tilted pelvis, and tilting of the shoulders. Your muscle strength will be tested, as well as your reflexes, sensation, and ability to perform specific movements. You may have to undergo further tests if your doctor feels there is need for more information.

Conservative Treatment

The majority of low back pain in athletes can be treated with conservative means. Treatments will vary depending on the cause of pain. Back strains may simply require a short period of limited activity, medication, and ice applications. When symptoms ease, athletes are usually able to resume their sport activity gradually, applying concepts of proper conditioning and warm ups.

Athletes with spondylolysis and spondylolisthesis may require the use of a brace, along with rigorous avoidance of the sport activity. The brace is commonly prescribed for three months, after which athletes gradually return to their sports activities. The treatment for a herniated disc depends on the symptoms and degree of nerve irritation or dysfunction. Herniated discs can usually be treated without surgery.

Medication

Your doctor may prescribe anti-inflammatory medications to reduce pain and swelling.

Ice

If the injury just happened, your doctor may instruct you to apply ice to the sore area. Cold packs are typically applied for 15 to 20 minutes. Some doctors recommend the use of contrast applications. This is accomplished by alternating cold and hot packs every five minutes over the sore area.

Specific Rest

Immediately after a back injury, rest is often all your back needs to feel better. Rest is used to take the pressure off your spine and the muscles around it. You should rest in a comfortable position on a firm mattress. Doctors usually advise against bed rest for more than two days. Staying in bed longer than two days can weaken key muscles of the trunk. In most cases of sudden back pain, the sooner you start moving again, the sooner your back pain will improve.

Bracing

If a spine specialist feels you may have a true stress fracture from athletic activity, you might be placed in a back brace (24 hours a day) for several months to allow the fracture to heal. You will then be gradually weaned from the brace and allowed to return to full activity. Surgery is rarely considered for these problems.

Physical Therapy

Your doctor may have you work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you get back to optimal performance with sport activities.

Athletes understand that exercise is very important in order to strengthen the abdominal, paraspinal, and pelvic muscles. Strong muscles in these areas can take pressure off the spine and help prevent back injuries. A physical therapist can help a patient develop a beneficial routine of conditioning and rehabilitation that includes proper warm-ups (such as back stretching exercises) and aerobic exercise.

The goals of physical therapy are to help you

• apply proper conditioning, warm-ups, and cool downs
• use proper technique in your sport activity
• choose appropriate equipment for your sport
• maximize your flexibility and core strength
• learn ways to manage your condition

ESI

An epidural steroid injection (ESI) is usually reserved for more severe pain from nerve root irritation due to a herniated disc. The steroid injections are a combination of cortisone (a powerful anti-inflammatory steroid) and a local anesthetic that are given through the back into the epidural space. It is not usually suggested unless conservative treatments are not helping and surgery is fast becoming an option. An ESI is only successful in reducing the pain from a herniated disc in about half the cases.

Surgical Treatment

Spondylolysis and Spondylolisthesis

Surgical treatment for spondylolysis and spondylolisthesis is necessary only in the event that conservative treatments fail to keep your pain at a tolerable level. The surgery must address the presence of mechanical and compressive symptoms.

Nerve pressure may require surgical decompression, called decompressive laminectomy of the lumbar spine. In order to free up or “decompress” the nerves, the surgeon must remove a section of bone from the back of the spine (lamina). The surgeon may also have to remove a portion of the facet joints. The lamina and facet joints normally provide stability in the spine. Removal of either or both can cause the spine to become loose and unstable. When this occurs, doctors will include fusion. Likewise, patients needing surgery for spinal instability due to spondylolisthesis typically require lumbar fusion.

Herniated Disc

Surgical treatment for a herniated disc depends on several factors such as your specific problem and your surgeon’s experience.

• Laminotomy and Discectomy
• Microdiscectomy
• Endoscopic Discectomy