Low back pain in athletes

One of the more frequent reasons that a younger athletic patient, meaning anyone from the age of about 15 to 25, comes to see me in consultation is because they have severe activity related back pain that hasn’t responded to the usual treatments of rest, a couple of weeks of reduced activity, and over the counter anti-inflammatory pills. It’s a really challenging situation because in almost every case, the athlete can rest, rehabilitate, and get back to about 80% of their peak performance, but once they try to push it to become game ready, their pain returns.

Here’s a couple of actual examples of patient histories:

a 16 year old nationally ranked tennis player with plans to play Division 1 college tennis has been plagued by left sided back pain for the last 6 months. The pain is directly related to the number of overhead serves that he makes and to the number of sets that he plays. He has no pain at rest, no pain while cross-training, and no pain while playing at less than 80% of his full speed, hard hitting game. However, once he steps it up to match level play, after a few sets his back starts to seize up and he has had to withdraw from several tournaments.

a 17 year old competitive cross-country runner was cross training under the supervision of a strength and conditioning coach when she felt a sharp “pop” in her back while squatting with moderately heavy weights. Ever since, she has severe pain when sprinting, stair-climbing, or performing weighted lunges. The rest of the time she is basically normal. The injury happened over a year ago and in spite of rest, chiropractic massage, ice, and anti-inflammatories, she can’t sprint without her back seizing up.

I see similar histories up to about 25 years of age, so if this sounds familiar, keep reading.

Most of these patients have had plain X-rays of their spines before their visit, and many of them have had an MRI as well. Typically, these studies will demonstrate one of the following three conditions, in order of increasing severity:

1. a “stress reaction” in the pedicle of L5
2. spondylolysis or a “pars defect” of L5

or

3. spondylolisthesis at L5/S1

These findings are pretty common. For example, in a study of 19 competitive gymnasts attending a training camp that were selected basically at random and had MRI scans of their spine, spondylolysis was found in 3 of the 19 athletes, spondylolisthesis in 3 as well, and focal bone-marrow edema was found in both L3 pedicles in one gymnast. Since most of the patients are accomplished athletes to begin with, the usual prescription for six to eight weeks of physical therapy is rarely of much benefit. Most of the time they have already seen one or two trainers, conditioning coaches, or chiropractor-type practicioners before they come and see me, and they are usually pretty frustrated. Here are a couple of sample X-rays and MRI scans showing the findings that accompany them on their first visit.

These two slices of an MRI scan demonstrate a “stress reaction” in the pedicle of the vertebral body. The stress reaction shows up as white area in a part of the bone that normally has a darker appearance on MRI. This particular sequence of the MRI scan is formatted so that water shows up as a bright white signal and the presence of increased water content in this area is said to represent bony “edema”.

Edema is defined as “a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body”, and we see edema in the bone underneath the cartilage of arthritic joints, surrounding fractures, and in bone that has been bruised by hard impacts. Here are a couple of examples of bony edema.

The presence of bony edema is definitely a pathologic finding. Something is wrong with the musculoskeletal system in the immediate area and the bone is not happy. In this case, this MRI scan belonged to a 16 year old male football player who was working out with a conditioning coach who was having him squat very deeply with pretty heavy weight — on the order of 1.5 times his body weight — and his pain seemed to be due to hyperextension of the spine at the bottom of the squat.

Here is an example of a spondylolysis or a “pars defect” of L5. In this case there is a physical break in bone across the pars inter-articularis. The break is usually described by the radiologist as a defect, a lysis, or a stress fracture. All of these terms are synonymous, and they all indicate that there is a physical gap in the bone. Occasionally I will get a patient who comes to the office in a bit of a panic after being told that he or she has a “fractured spine”, but this is probably a bit too strong of a phrase to describe this finding accurately. The classic X-ray finding of a spondylolysis is known as the “scotty dog” sign. This sign describes the manner in which the spondylolysis defect can look (to someone with a very healthy imagination) like the collar on a scotty dog on the oblique views of the limbo-sacral junction. While the gap can be seen on plain X-ray, often a CT or an MRI scan is needed to really confirm that it is there, because the X-ray can be a little bit unclear. The reason why the use of the word “fracture” is not terribly appropriate here is because this is typically not an acute break, the gap in the bone is often filled with fibrous tissue, and there is usually some degree of residual stability to the vertebral body. Sometimes there is edema surrounding the defect, and sometimes not. Typically, patients with more severe back pain tend to have relatively more edema, but this is not a perfect relationship.

Finally, here is a case of spondylolisthesis at L5/S1. In this case the to halves of the vertebral body have started to move apart and the spondylolysis defect is noticeably larger. The overall alignment of L5 with respect to S1 has shifted, and L5 has slipped anteriorly with respect to S1. This finding is more common in females who tend to have more supple ligaments and presumably more flexible intervertebral disks, and it is more common in patients with more vertically oriented L5/S1 disk spaces, presumably because there are greater forces acting to displace L5 on S1 in patients with more lumbar lordosis and vertically oriented sacral endplates.

Let’s imagine that all three of these patients have pain only with strenuous athletic activity. Why? My opinion is that area where the stress reaction, pars defect, or spondylolisthesis occurs is placed under some sort of tension or stress ONLY when the spine is moved to the limits of its range of motion under the heavy loads of torque, muscular contraction, and athletic movement. For example, it’s not hard to imagine why the lumbar spine would be stressed during the twisting, lunging, and hitting motions of these competitive tennis players in ways that are fundamentally different than the stress imposed by the more mundane activities of daily life.

Will it heal? This seems to be the most frequent first-asked question once the diagnosis has been made, and the important thing that needs to be clarified what you meant by “healed”: less pain or a normal X-ray or MRI scan? When it comes to the actual findings on the X-rays or the MRI scan it’s hard to know for sure, but my opinion is that the stress reaction will probably subside and will not necessarily progress to a spondylolysis if the activity responsible for the pain is not a repetitive motion that the athlete plans to continue to perform. I think that once a spondylolysis has occurred, it is usually going to be a persistent defect and if there is any evidence of anterior displacement in the form of a spondylolisthesis bone certainly won’t bridge the gap or restore the alignment back to normal.

Should I use a bone stimulator? Unclear. Most patient’s will improve with some form of conservative treatment, so the gold standard supporting the use of a bone stimulator would be radiographic evidence of healing of the spondylolysis defect after treatment. As of 2013, there are no studies that have not been any published studies that have conclusively demonstrated that a bone stimulator results in radiographic healing in a large series of patients. In my practice, I leave the decision up to the athlete and the parents and to be perfectly frank, it usually comes down to a question of insurance coverage. If the family has good insurance and they are not terribly bothered about the cost, I have no problem recommending and prescribing a bone stimulator. However, it’s not something that I would push, especially if it was going to cause any financial hardship.

What about rehab? This is the most interesting part of the entire problem and the question that I think the most about. Here’s a short video on a competitive cross-fit athlete that successfully rehabilitated herself back to a very high level of functional movement after having an episode of back pain that appears to be due to a spondylolysis or spondylolisthesis.

I’ve been a big fan of Kelly Starrett for a number of years — mostly as a result of my own Crossfit experiences as a 40 year old + athlete, and I think he does an excellent job of explaining the body mechanics of a “stable” and “organized” spine and how this type of posture can reduce the stress and strains on the lumbar spine during functional movements. I’ve had a lot of good results with patients when I refer them to particular physical therapists who are skilled in coaching olympic weightlifters and who have a solid understanding of the protective effects of good posture and core strength and endurance. This is where I personally try to put most of my emphasis, but it’s hard to unlearn habits that work. For instance, in the case of the competitive tennis player who was case #1, his serve worked for him. He was able to achieve killer spin and power with dramatic hyperextension of his lumbar spine, and while his pars paid the price, so did his opponent. Unlearning that serve seems unlikely, but with a combination of cross training, postural education, and attempts to change his style of hitting, he has managed to reduce his pain to the point where he can play with a tolerable level of discomfort.

My advice is: spend the money on good coaching. The coast of california seems to have more Crossfit gyms than 7-11’s these days, and the increasing popularity of olympic weightlifting — with it’s attendant risks and benefits — has lead to a dramatic increase in the number of people in the local athletic community who really are knowledgeable about the ways to protect and stabilize the spine during functional movements under the loads imposed by athletics.

References:
1. Skeletal Radiol. 2006 Jul;35(7):503-9. Epub 2006 Mar 7.
Lumbar spine MRI in the elite-level female gymnast with low back pain.
Bennett DL, Nassar L, DeLano MC.
Source
University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Radiology, 200 Hawkins Drive, Iowa City, IA 52242, USA. lee-bennett@uiowa.edu
Abstract
OBJECTIVE:
Previous studies have shown increased degenerative disk changes and spine injuries in the competitive female gymnast. However, it has also been shown that many of these findings are found in asymptomatic athletic people of the same age. Previous magnetic resonance imaging (MRI) studies evaluating the gymnastic spine have not made a distinction between symptomatic and asymptomatic athletes. Our hypothesis is that MRI will demonstrate the same types of abnormalities in both the symptomatic and asymptomatic gymnasts.
DESIGN:
Olympic-level female gymnasts received prospectively an MRI exam of the lumbar spine. Each of the gymnasts underwent a physical exam by a sports medicine physician just prior to the MRI for documentation of low back pain. Each MRI exam was evaluated for anterior apophyseal ring avulsion injury, compression deformity of the vertebral body, spondylolysis, spondylolisthesis, degenerative disease, focal disk protrusion/extrusion, muscle strain, epidural mass, and bone-marrow edema.
PATIENTS:
Nineteen Olympic-level female gymnasts (age 12-20 years) were evaluated prospectively in this study. All of these gymnasts were evaluated while attending a specific training camp.
RESULTS:
Anterior ring apophyseal injuries (9/19) and degenerative disk disease (12/19) were common. Spondylolysis (3/19) and spondylolisthesis (3/19) were found. Focal bone-marrow edema was found in both L3 pedicles in one gymnast. History and physical exam revealed four gymnasts with current low back pain at the time of imaging. There were findings confined to those athletes with current low back pain: spondylolisthesis, spondylolysis, bilateral pedicle bone-marrow edema, and muscle strain.
CONCLUSIONS:
Our initial hypothesis was not confirmed, in that there were findings that were confined to the symptomatic group of elite-level female gymnasts.