Back Pain In Athletes
The lifetime incidence of mechanical back pain of some type or another is approximately 60% in human beings living in a western culture, with or without a sporting interest. While sportsmen can clearly suffer degenerative and mechanical problems unrelated to their sporting endeavours, there is a series of clinical syndromes and pathological processes that are seen specifically, but not exclusively in sportsmen.
Increasingly, in a leisureoriented culture, not only do these back pain problems afflict professional and top-level amateur sportsmen, but there are many recreational sporting injuries in the general population.
It is important to exclude significant underlying pathology in any patient or sportsman with back pain. The list of red flags popularized in the Clinical Standards Advisory Group document is a very useful guide to screening such patients for significant underlying pathology.
The clinician must always remember that non-spinal pathology such as retroperitoneal, abdominal and pelvic disease may present as back pain, and all of the sports-related syndromes are mechanical in nature triggered by activity and often relieved by rest.
In patients, in whom a significant red flag is identified, in particular pain worse or only at night, further appropriate investigation is mandatory. Assessment Diagnosis of the underlying cause of back pain in sportsmen can be difficult and although modern imaging techniques have greatly advanced the detection of more subtle lesions, more often than not a very accurate clinical history and careful physical examination will make the diagnosis.
The pattern of onset of the back pain and the chronicity of symptoms are important. Some sportsmen will be in high-risk sports and the history will reveal lack of protective conditioning rendering the sportsman vulnerable to overuse injury. Top-level professional sport, where the athlete is often expected BACK PAIN IN ATHLETES to achieve higher goals, may lead to extreme forces or ranges of movement being applied to the spinal column.
A training history and secondary information derived from the coach or trainer may be of help. The history is perhaps the most important part of the assessment in excluding significant underlying pathology such as malignancy or underlying infection. The location of the pain is aided by using a standard pain diagram and this allows a better differentiation of axial pain syndromes from radicular syndromes.
The general examination of the patient is no less important in sportsmen. Stigmata of systemic disease and abdominal and pelvic examination may be important in certain patient groups. Inspection of the spine may reveal the major step of high-grade spondylolisthesis, the tilt of an acute lumbar disc protrusion, the loss of sagittal profile, and flattening of the lumbar lordosis as seen in acute protective muscle spasm. Whilst most painful spinal structures are too deep for easy palpation, particularly in a muscular young patient, mid-line and paravertebral spinal tenderness should be noted. Spinal movements should be measured using Schober’s technique and observation of lumbo-pelvic rhythm during the flexion-extension arc should be made. Specific tests of sacroiliac joint pain should be made including pelvic shearing and flexion abduction external rotation (FABER) test.
The hip joints should be formally assessed and nerve root tension signs, including sciatic femoral stretch tests, with a full neurological assessment of the trunk and lower limbs are essential. Standard muscle and sensory charts are a useful tool to ensure completeness of a physical examination. Whilst rectal examination is mandatory in patients with a major spinal injury or any symptoms of a cauda equina compression, it should not be considered an appropriate investigation in young patient with simple mechanical pains. Unless a fracture is suspected, imaging and further investigations would very rarely be appropriate in the first 4-6 weeks following an acute low-back pain event or minor injury. Such investigations should be reserved where there is a major suspicion of underlying pathology or if symptoms are not resolving in this time frame.
Plain X-rays have largely been discredited as a useful investigation technique in low-back pain but provide very useful information on lumbar segmentation, and allow visualization of a spondylolysis or spondylolisthesis. At the very least this is a useful reference for discussion with the patient and to aid education in relation to the patient’s specific anatomy. The radiation dosage of oblique X-rays that were previously used for diagnosing spondylolysis is considered inappropriately high and a reverse gantry CT scan is both more sensitive and more accurate for diagnosing this particular condition. Soft-tissue structures including the intervertebral discs are best imaged on MRI scan and single photon emission computed tomography (SPECT) scanning is a very sensitive tool for diagnosing facet joint pathology facet fractures and stress fractures particularly in the region of the pars interarticularis.
In many athletes, the combination of all these investigations is required to put together the whole pathological picture. Provocative testing such as facet probing, nerve root injections, and discography are rarely indicated in this population, although they may be useful as an acute pain relieving modality. It is unlikely in patients who have such a chronic level of pain and disability that spinal fusion for axial pain is a consideration (and thereby require provocative injections as part of their preoperative work-up) are in a position to return to high-level sport whatever the outcome of their surgery.
Differential diagnosis in sports-specific back pain syndromes will be discussed later in this article. It is important to exclude significant underlying pathology in any patient or sportsman with back pain. The list of red flags popularized in the Clinical Standards Advisory Group document1 is a very useful guide to screening such patients for significant underlying pathology. The clinician must always remember that non-spinal pathology such as retroperitoneal, abdominal and pelvic disease may present as back pain, and all of the sports-related syndromes are mechanical in nature triggered by activity and often relieved by rest. In patients, in whom a significant red flag is identified, in particular pain worse or only at night, further appropriate investigation is mandatory.
Most sportsmen have a high level of self-knowledge and introspection, even more so than in the general population, and should be actively involved in decision making about various treatment options. There are very few gold standard treatments in managing back pain, there are multiple options and many vested interests.
Sportsmen should be protected from pressure to return too early to sport, either from their own ambition or from coaches, team-mates, friends and family. After acute pain treatment, multidisciplinary rehabilitation in an environment where other sportsmen are being treated is of great benefit, and the spinal surgeon, if involved at all, must maintain a holistic view of all the athlete’s needs.
Prolonged bed-rest for any spinal condition is a historical and inappropriate treatment. There is good evidence that overall function deteriorates rapidly with complete rest and that the important trunk and paravertebral muscles involved in spinal control become deconditioned and lose proprioceptive control. Rest should be appropriate and will largely entail restriction of sporting activity and occasionally, for example in an acute disc herniation, a few days complete rest at home short of strict bed-rest. Each day of bed-rest probably prolongs the rehabilitation phase by 1 week.
Although the main input from physiotherapists is in the rehabilitation phase of treatment, for acute soft-tissue injury, a full range of soft-tissue treatments including interferential, laser, ultrasound, deep frictions, massage and acupuncture may have a role to play. The ‘sports aware’ physiotherapist can introduce the principles of trunk control, pacing and graded return to sport even during the acute pain phase and setting specific goals this early is very helpful for top-level sportsmen.
A combination of oral non-steroidal anti-inflammatory medication, often in slow-release form, and an appropriate level of painkillers may be very beneficial in the early stages of acute back pain in sports. More chronic pain patterns requiring oral medication warrant further investigation and more definitive treatment. Sportsmen should be counselled against taking the occasional anti-inflammatory tablet, and assuming there are no gastrointestinal sideeffects, a course of at least 2 weeks is more appropriate.
The use of invasive treatments such as spinal injections should probably be avoided in acute situations. There is some evidence for a role for epidural injections, either of local anaesthetic or a combination of local anaesthetic and steroid, in patients with either an acute disc herniation or discogenic pain. In patients with persistent facet joint pain where the pain is proving a block to rehabilitation, facet injection offers a 50% chance of significant resolution of pain allowing such rehabilitation to progress. Repeated injection should be avoided in this particular patient group. It is considered very unwise for sportsmen to have injections in the spine before each sporting endeavour.
Surgery is rarely indicated in the majority of spinal conditions producing back pain in sportsmen. If indicated, such as in acute disc herniation with prolonged symptoms, proven and symptomatic spinal stenosis refractory to non-operative treatment, or axial pain with identified underlying instability such as in high-grade spondylolisthesis, surgery should be considered as part of holistic treatment where the emphasis is on rehabilitation and return to normal function and sports.
Surgery in isolation may alleviate pain, but will be a major obstacle to return to normal function. After a decompressive operation such as microdiscectomy or segmental decompression, it is entirely appropriate for sportsmen and their doctors to be considering return to top-level sport. Conversely, most spinal fusion techniques, particularly those involving the use of pedicle screw instrumentation, are likely to lead to a fixed, permanent deficit in paravertebral muscle function.
Although intensive rehabilitation and training may allow a return to high-level sport, it seems very unlikely that a return to maximum performance should be considered possible. There is an increase in the use of minimal access techniques such as laparoscopy, retroperitoneal endoscopy, and percutaneous posterior screw placement, and these may reduce the collateral damage to the important soft-tissue structures in the paravertebral area. Whilst there is emerging evidence that such techniques do allow early return to function, there is no convincing evidence that the ultimate functional outcome is significantly improved. Sportsmen undergoing spinal surgery must be aware of the options available and must also understand the significant potential complications and risks associated with spinal surgery.
Although major neurological disasters are rare following lumbar spine surgery, even a marginal change in nerve root function in L3, L4, L5 or S1 may profoundly disable a top-level athlete. It is also important for the surgeon undertaking reconstructive operations such as fusion to try and normalize the sagittal profile and recreate the lumbar lordosis.
Adherence to this biomechanical principle will anyway improve the likely fusion rate of surgery and that will optimize the subsequent functional capacity of the patient.