Lbp in Athletes

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<p>COPYRIGHT 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED,8:Current Concepts ReviewLow-Back Pain in AthletesBY CHRISTOPHER M. BONO, MDInvestigation performed at the Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, orrecurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stresslesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; how-ever, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease thatis recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusionin selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participa-tion in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appearsto be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, inde-pendent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars inter-articularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes andallow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such astrack or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobiliza-tion, physical therapy, and return to sports in one to two months, when the pain has resolved.An athletes lower spine usually performs demanding and ex-treme tasks without problems. The highly mobile lumbarspine and its associated muscles and ligaments, vernacularlycalled the low back, are an important but underrecognizedsource of great dynamic power during a golf or baseball swing,a gymnasts landing, a power-lifters heavy squat, or a boxersknockout punch. In static mode, it functions to help maintainan infielders stance, a cyclers tuck, or a ballerinas arabesque.Not infrequently, the low back is revealed, by pain and dys-function, to be one of the most common reasons for missedplaying time by professional athletes1-3.Published rates of low-back pain in athletes range from1% to &gt;30%4-6 and are influenced by sport type, gender, trainingintensity, training frequency, and technique7-10. Although mostcases are self-limited, many athletes have persistent symp-toms8,11-14. Degenerative disc disease and spondylolysis are themost common structural abnormalities associated with low-back pain in athletes. However, despite these patients beinghighly motivated to return to activity, a specific pain generatoris not always found, which often makes diagnosis and treatmentchallenging15. Thus, awareness of less common causes of low-back pain in athletes, such as sacral or facet stress fractures, isimportant10,16-18.EpidemiologyIt is important to remember that low-back pain is a symp-tom, not a diagnosis. Most often, it is not associated with anunderlying structural abnormality7,15. One must consider thiswhen interpreting epidemiological reports of low-back pain.The lifetime prevalence of low-back pain in the general adultpopulation is estimated to be 85% to 90%19. Between 2% and5% of people report low-back pain that occurs at least onceper year19.With conflicting reports, it is not clear whether ath-letes are at higher risk for low-back pain. According to onestudy, the lifetime prevalence of low-back pain in wrestlers(59%, nineteen of thirty-two) was significantly higher thanthat of age-matched controls (31%, 223 of 716)6. Sward etal.20 found a significantly higher rate of low-back symptomsin elite gymnasts (79%, nineteen of twenty-four) than in acontrol group (38%, six of sixteen). Likewise, Kujala et al.21documented that 46% (thirty) of sixty-five adolescent ath-,8, THE JOURNAL OF BONE &amp; JOI NT SURGERY J BJ S. ORGVOLUME 86-A NUMBER 2 FEBRUARY 2004LOW-BACK PAI N I N ATHLETESletes reported low-back pain compared with 18% (six) ofthirty-three nonathletes. In contrast, Videman et al.4 foundthat low-back pain was less common in former elite athletes(present in 275 [29.3%] of 937) than it was in nonathletes(273 [44.0%] of 620).Back pain is a common reason for lost playing time bycompetitive athletes. McCarroll et al.1 reported that low-backpain accounted for loss of playing time by 30% (forty-four) of145 college football players. Hainline2 found that 38% of pro-fessional tennis players reported low-back pain as the reasonfor missing at least one tournament. Ninety percent of all tourinjuries in professional golfers involve the neck or back3.Low-back pain is more common in some athletes thanin others. In a prospective study, Lundin et al.14 found thatwrestlers had the highest rate of severe low-back pain (54%,fifteen of twenty-eight), while rates were lower for tennis andsoccer players (32%, nine of twenty-eight, and 37%, eleven ofthirty, respectively). Granhed and Morelli6 found the lifetimeprevalence of low-back pain to be 59% (nineteen of thirty-two) in wrestlers compared with 23% (three of thirteen) inheavyweight lifters. Competitive male and female rowers had a15% and 25% prevalence of low-back pain, respectively, in arecent study5. In comparison with other athletes, gymnasts ap-pear to be among the most likely to report severe back pain22.Hutchinson23 found that six of seven elite rhythmic gymnastsreported low-back pain over a seven-week period.Differential DiagnosisAlthough this article focuses on the more common disordersthat cause low-back pain in athletes, the evaluating practitio-ner should consider a broad differential diagnosis at presenta-tion in order to avoid missing less frequent sources ofsymptoms (Table I).Lumbar Flexibility and Risk Factors for Back PainWarm-up exercises are routinely performed prior to practiceand competition to minimize the risk of injury. For the lowback, a major focus is increasing flexibility, which in turn mightimprove the muscles and ligaments responses to demands. De-spite the widespread use and acceptance of warm-up exercises,there are few data demonstrating that they can decrease theprevalence of low-back pain or the risk of injury in athletes. Athletes frequently have a period of rest between warm-up and play. Interested in the effects of this common scenario,Green et al.24 measured lumbar range of motion in twenty-sixvolleyball players prior to activity, immediately after a standard-ized warm-up regimen, and after a standardized warm-up fol-lowed by thirty minutes of rest. Although flexion and rotationwere not affected, the lumbar spines were stiffer in extension af-ter rest than they were immediately after warm-up. Flexibilityimmediately after warm-up was not significantly different frompre-warm-up values. These data suggest that bench rest afterwarm-up exercises can have a detrimental effect on lumbar flex-ibility. However, the link between the observed degrees of in-creased stiffness and the subsequent risk of lumbar injuryremains unclear. These findings also call into question the com-monly held belief that warm-up can improve low-back flexibil-ity, and they suggest that the ability of warm-up to preventinjury, if indeed real, might be due to another mechanism.In support of these findings is the observation by Kujalaet al.25, in a three-year longitudinal study, that specifically tar-geted training did not increase maximal lumbar extension inadolescent athletes. The authors concluded that aggressive at-tempts at increasing lumbar flexibility could unnecessarilystress structures, such as the intervertebral discs or pars inter-articularis. In contrast, Kibler and Chandler26 found a specificTABLE I Differential Diagnoses of Persistent Low-Back Pain in Athletes (in Approximate Order of Decreasing Frequency)Spinal Diagnoses Nonspinal DiagnosesMuscle strain/ligament sprain Intrapelvic, gynecologic conditions (e.g., ovarian cysts)Degenerative disc disease Renal diseaseIsthmic spondylolysis (no slip) Sacroiliac joint dysfunctionIsthmic spondylolisthesisFacet syndromeRing apophyseal injury (adolescents)Sacral stress fractureCentral disc herniation (without radiculopathy)Sacralization of L5/tranverse process impingement16Facet stress fracture16,62Acute traumatic lumbar fracture16Discitis/osteomyelitisNeoplasm,8 THE JOURNAL OF BONE &amp; JOI NT SURGERY J BJ S. ORGVOLUME 86-A NUMBER 2 FEBRUARY 2004LOW-BACK PAI N I N ATHLETESconditioning program to be effective in increasing the lumbarrange of motion in fifty-nine tennis players. The occurrence ofback pain was not measured in either study. These data indi-cate that, with proper training, lumbar flexibility in competi-tive athletes reaches a plateau that should be maintained byregular stretching but attempts to push beyond that point inan effort to enhance performance might be detrimental.Others have studied the impact of flexibility on low-backpain. Kujala et al.27 prospectively examined lumbar flexibility ina group of adolescent athletes and nonathlete controls. Neithergroup had had previous low-back pain. Importantly, lumbarmeasurements were not performed during episodes of pain.While no differences were detected between male athletes(hockey and soccer players) and controls, female athletes (gym-nasts and figure skaters) had a greater overall range of motion(p = 0.014) and range of motion of the low lumbar levels (p =0.036) than did female nonathletes. Furthermore, a decreasedrange of motion of the low lumbar levels and decreased maxi-mal extension were predictive of low-back pain in women:those within the lowest quartile had 3.4 times the chance of hav-ing pain lasting more than one week. In a study of 116 top maleSwedish athletes, Sward et al.28 evaluated lumbar mobility, in ad-dition to various other anthropometric features, in relation toback pain. While wrestlers and gymnasts were more flexible andsoccer players were less flexible, there was no correlation be-tween spinal flexibility and back pain, with the numbers avail-able. This finding is in sharp contrast to the findings of Kujala etal.27. Curiously, the strongest predictor of pain was a low sacralinclination angle (p &lt; 0.05), although this did not differ amongthe different sports.A correlation between lower-extremity function and therisk of low-back pain has been extensively studied. In a pro-spective examination of 257 college athletes playing varioussports, Nadler et al.29 correlated the prevalence of low-backpain with findings related to the lower extremity. Of fifty-seven athletes with a lower-extremity overuse syndrome or ac-quired ligamentous laxity, fourteen (25%) had low-back pain(p &lt; 0.001). Neither decreased flexibility of the lower extremi-ties or limb-length discrepancy was a risk factor for back pain.However, the primary outcome measure was treatment forlow-back pain, and this could have led to an underestimationof the prevalence of low-back pain and it could have affectedthe statistical analyses. In a later study, Nadler et al.30 linkedside-to-side differences in maximum hip extension with theonset of low-back pain in female athletes. As was the case forthe previously discussed studies assessing low-back flexibilityand back pain, it is not clear whether reversing these so-calledrisk factors could decrease the chance of low-back injury. Incontrast to the findings of Nadler et al., Twellaar et al.31 foundno influence of lower-extremity flexibility on the occurrenceof low-back pain in 136 physical education students.A history of low-back pain is the greatest predictor offuture occurrences in athletes. Greene et al.32 found, in a pro-spective investigation of 679 college athletes, that those whoreported prior low-back injury had three times the risk forsubsequent episodes compared with those without prior pain;also, those who had active back pain at the start of the studyhad six times the risk for subsequent episodes compared withthose without prior pain. Supporting these findings was theobservation by OKane et al.33 that 57.1% (eighty-nine) of 156competitive rowers with a history of preexisting low-back painhad subsequent occurrences, whereas 36.6% (613) of 1673rowers without such a history had pain. Possibly because ofadaptive measures, rowers with a history of pain before theirrowing careers were less likely to quit the sport because of low-back symptoms.Equipment variables can influence the risk for low-back pain. Quinn and Bird34 found that the saddle type influ-enced the prevalence of low-back pain in 108 equestrians. Useof a traditional (or general purpose) saddle was associatedwith a 33% and 72% prevalence of pain in men and women,respectively. In comparison, a Western (deep-seated) saddlewas associated with rates of only 6% and 33%, respectively. Itwas speculated that the added cushioning and stability pro-vided by the Western saddle was the critical factor. Salai etal.35 studied the influence of seat angle on the pelvic-lumbarextension angle in recreational cyclists and found lumbar hy-perextension to be a risk factor for low-back pain. Adjustingthe seat to a neutral lumbar position alleviated back pain in70% of the cyclists.Footwear can affect force transmission to the low back,which may be important in the understanding of low-backpain in running athletes. Ogon et al.36 compared lumbarparaspinal myoelectric responses in athletes running eitherTABLE II Three-Cycle System for Treatment of Nonradicular Low-Back Pain in Athletes as Described by Hopkins and White40Cycle IA Immediate return to full activity; games and practices are not missedCycle IB Games and body contact are prohibited, practice is reduced by 75% (duration, intensity, frequency), nonsteroidal anti-inflammatory drugs, physical therap...</p>