lbp in athletes

COPYRIGHT © 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Current Concepts Review

Low-Back Pain in AthletesBY CHRISTOPHER M. BONO, MD

Investigation 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 athlete’s 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 gymnast’s landing, a power-lifter’s heavy squat, or a boxer’sknockout punch. In static mode, it functions to help maintainan infielder’s stance, a cycler’s tuck, or a ballerina’s 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 >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.21

documented that 46% (thirty) of sixty-five adolescent ath-

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VOLUME 86-A · NU M B E R 2 · FE BR U A R Y 2004LOW-BA CK PAIN I N AT H L E TES

letes 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 specific

TABLE I Differential Diagnoses of Persistent Low-Back Pain in Athletes (in Approximate Order of Decreasing Frequency)

Spinal Diagnoses Nonspinal Diagnoses

Muscle strain/ligament sprain Intrapelvic, gynecologic conditions (e.g., ovarian cysts)

Degenerative disc disease Renal disease

Isthmic spondylolysis (no slip) Sacroiliac joint dysfunction

Isthmic spondylolisthesis

Facet syndrome

Ring apophyseal injury (adolescents)

Sacral stress fracture

Central disc herniation (without radiculopathy)

Sacralization of L5/tranverse process impingement16

Facet stress fracture16,62

Acute traumatic lumbar fracture16

Discitis/osteomyelitis

Neoplasm



conditioning 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 < 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 < 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 affected

the 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 O’Kane 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 either

TABLE II Three-Cycle System for Treatment of Nonradicular Low-Back Pain in Athletes as Described by Hopkins and White40

Cycle IA Immediate return to full activity; games and practices are not missed

Cycle IB Games and body contact are prohibited, practice is reduced by 75% (duration, intensity, frequency), nonsteroidal anti-inflammatory drugs, physical therapy optional, back to competition in four days

Cycle IC Games and body contact are prohibited, practice is reduced by 50%, nonsteroidal anti-inflammatory drugs, physical therapy optional, advance to Cycle B in four days

Cycle II Games and practice are prohibited, nonsteroidal anti-inflammatory drugs, two days of bed rest followed by physical therapy for abdominal strengthening for five days, advance to Cycle I

Cycle III Games and practice are prohibited, nonsteroidal anti-inflammatory drugs, two days of bed rest followed by physical therapy for abdominal and paraspinal strengthening, stationary bicycling, walking, or swimming



barefoot or wearing running shoes with padded insoles. Initialmuscle responses were later but the latency to maximal con-traction was shorter with shoe wear. On the basis of thesedata, the authors suggested that running shoes with insolesimproved the temporal synchronization between force trans-mission to the lumbar spine and paraspinal muscle responses.

Lumbar Strains and SprainsStrains occur by disruption of muscle fibers at various loca-tions within the muscle belly or musculotendinous junction37.Acute pain is most intense twenty-four to forty-eight hours af-ter injury. It is often associated with spasm that, after a coupleof days, may be localized to a so-called trigger point37. Recur-rent muscle strains are denoted by short asymptomatic peri-ods between episodes. Chronic strains are characterized bycontinued pain attributable to muscle injury. Patients withchronic back strains often undergo extensive radiographicworkups, with negative findings. Keene et al.38 found musclestrain to be the most common injury causing low-back pain in333 college athletes; 59% of the strains were acute and 41%were chronic. Micheli and Wood39 found that muscle strainwas the reason for low-back pain in 27% and 6% of 100 ado-lescent athletes and 100 adult athletes, respectively.

Sprains occur by subcatastrophic stretch of one or moreof the spinal ligaments. While some individual fibers may beinjured, the overall continuity of the ligament is maintained. Ifound no data delineating the exact tissue injury involved inlow-back sprains in athletes in my review of the literature. Al-though the nociceptive innervation of the spinal ligaments isill-defined, it is the presumed mode of pain transmission.Keene and Drummond37 thought that the interspinous process

ligament is the most commonly affected by sprains. The exactor relative prevalence of lumbar sprains has not been re-ported, to my knowledge.

Most practitioners recommend a short period of rest(one to two days) and intervals of icing in the acute phase aftera strain or sprain. Gentle and progressive stretching exercises,preferably under the direction of a qualified trainer or physicaltherapist, should follow. Unfortunately, I found no clinical se-ries in the literature documenting the effectiveness of a guidedrehabilitation program for lumbar sprains or strains in ath-letes. On the basis of their experience with athletic patients,some practitioners have adapted previously developed pro-grams for back pain typically used for nonathletes. A commonlink among these programs is the requirement that the indi-vidual be pain-free with nearly normal function (strength,

Fig. 2

Fig. 1

Anular tears (arrow) appear as regions of increased signal intensity

on magnetic resonance images through the intervertebral disc.

Lumbar disc degeneration is a common radiographic finding in ath-

letes. In this image of the lumbar spine of a seventeen-year-old high-

school football quarterback with a three-month history of back pain,

advanced changes can be appreciated at the L4-L5 and L5-S1 disc

spaces.



flexibility, and endurance) before returning to activity7,12,40,41.George and Delitto41 described a treatment-based classi-

fication system for low-back pain in athletes. Nonradicularlow-back pain was divided into six different syndromes (ex-tension, flexion, lumbar mobilization, sacroiliac mobiliza-tion, immobilization, and lateral shift syndromes) on the basisof exacerbating factors and presumed etiology. Treatment wasdirected at restricting painful postures and concentrated onexercising the back within a pain-free arc of motion. For ex-ample, extension syndrome, characterized by pain that wors-ened with flexion and improved with extension, is treatedwith extension exercise and restriction of flexion. According tothis method, the type of treatment is ultimately determined bythe ability of the practitioner to differentiate responses to vari-ous provocative maneuvers.

Hopkins and White40 described a three-cycle (level) sys-tem for rehabilitation after athletic low-back injuries. Each cy-cle differs in the relative degrees of rest, therapy, and timeuntil return to play. Cycle I is divided into subsets A, B, and C.A brief summary of their recommendations is outlined in Ta-ble II. More succinctly, Dreisinger and Nelson7 guided treat-ment by categorizing it simply as acute or chronic. Admittingthat acute injuries resolve quickly and usually spontaneously,the authors detailed recommendations for a short period ofdecreased activity and icing, administration of nonsteroidalanti-inflammatory drugs, and stretching followed by strengthtraining and return to sports activity. They recommended thatchronic cases be treated with trunk, back, and lower-extremityexercises to restore function.

Degenerative Disc DiseaseThe exact correlation between a degenerated intervertebral discand low-back pain remains elusive. High rates of radiographicfindings of degenerated discs in asymptomatic patients are evi-dence against an obligatory cause-and-effect relationship in thegeneral population42. Treatment of discogenic low-back pain inathletes is challenging.

Pathogenesis of Disc DegenerationWhile an in-depth discussion of the latest research concern-ing degenerative disc disease would not be appropriate for thisreview, the key mechanisms currently thought to produce andtransmit axial lumbar pain should be understood.

Stress within the anulus can produce tears within it43.Circumferential tears, representing delamination of the fiberswithin the tough outer ring, occur first. With continued stress,these can progress to radial tears. Radial tears can be detectedas a small zone of increased signal by magnetic resonance im-aging (Fig. 1) or as leakage of contrast medium within theposterior aspect of the anulus on a discogram. Next, nucleardesiccation and loss of proteoglycan ensue. At this stage, plainradiographs show mild decreases in disc space height; mag-netic resonance imaging can reveal decreased signal intensityin the disc on T2-weighted images. A diminished capacity ofthe disc to sustain loads places greater demands on the poste-rior facet joints, causing degeneration of the articular surfaces.

It has been proposed that, with time, advanced degenerativechanges, such as osteophyte formation in both the disc andthe facets, are an attempt at autostabilization.

Various components of the motion segment have beenimplicated as potential pain generators. Nociceptive microin-nervation of the posterior aspect of the anulus, anterior aspectof the anulus, and facet joints has been characterized in ana-tomical and histological studies44-46. Reproduction of a patient’stypical low-back pain with discography suggests that leakage ofintradiscal fluid or anular distention is involved in the produc-tion of back pain. Despite ever increasing amounts of informa-tion, substantial limitations of our diagnostic abilities related toan understanding of disc degeneration and back pain remain.

Disc Mechanics and SportsEvery sport places unique demands on the lumbar spine and,in turn, the intervertebral disc. Large forces are produced inthe disc during various athletic maneuvers. A golf swing, aprimarily torsional activity, produces 6100 and 7500 N ofcompressive force across the L3-L4 disc in amateur and pro-fessional players, respectively47. Hosea and Boland48 estimatedmaximal lumbar compressive forces to be about 6100 N inrowers. Similarly, fast bowling (or pitching) during cricket canplace large forces on the lumbar spine, which may be lessenedwith proper technique49. Elliott and Khangure49 found thatsmall-group coaching aimed at reducing the level of shoulderalignment counterrotation during cricket bowling decreasedthe prevalence and progression of disc degeneration as mea-sured with magnetic resonance imaging.

Gatt et al.50 measured forces in the L4-L5 motion seg-

Fig. 3

Defects from stress lesions can occur at various locations within the

vertebra: 1 = pedicle-body junction (previous site of neurocentral syn-

chondrosis), 2 = pedicle (retrosomatic), 3 = pars interarticularis (isth-

mic), 4 = retroisthmic, 5 = paraspinous process, and 6 = spinous

process (spina bifida). (Redrawn from: Johansen JG, McCarty DJ,

Haughton VM. Retrosomatic clefts: computed tomographic appear-

ance. Radiology. 1983; 148: 447. Reprinted with permission.)



ment during blocking maneuvers in five football linemen. Theaverage peak compressive load was >8600 N, with an averagepeak sagittal shear force of 3300 N. According to the authors,the magnitude of these forces exceeded the reported in vitroforces necessary to cause fatigue failure of the intervertebraldisc. These data suggest that football lineman are at risk forroutine repetitive disc microtrauma.

Cholewicki et al.51 measured forces in the L4-L5 motionsegment in fifty-seven competitive weight lifters. The averagecompressive loads were >17,000 N. In a similar study, Cappozzoet al.52 found that, when a person performed half-squat exerciseswith weights approximately 1.6 times body weight, compres-sive loads across the L3-L4 motion segment were about tentimes body weight (approximately 7000 N for an average 70-kgperson). Those investigators found that increasing lumbar flex-ion was the most influential factor affecting compressive loads.

Prevalence of Disc Degeneration in AthletesParticipation in sports appears to be a risk factor for the devel-opment of disc degeneration (Fig. 2). Sward et al.20 comparedradiographic changes in the lumbar spines of elite gymnastswith those in a randomly selected control group. Evidence ofdegenerative changes was noted in 75% (eighteen) of thetwenty-four athletes compared with 31% (five) of the sixteennonathletes. Eleven of the gymnasts demonstrated so-calledsevere disc degeneration, whereas none of the nonathletes did.However, the exact criteria for distinguishing severe fromnonsevere findings were not described. Ong et al.53 studied agroup of thirty-one Olympic athletes who presented with low-back pain and/or sciatica. Magnetic resonance imaging dem-onstrated that the disc signal progressively decreased fromcephalad to caudad, with L5-S1 being the most commonly af-fected level (in 35% [eleven] of the athletes). Disc bulges were

Fig. 4-B

Fig. 4-A

Preoperative T1-weighted magnetic resonance image of the lum-

bar spine of a fifteen-year-old female high-school football player

with spondylolisthesis. She complained of low-back pain for ap-

proximately one year before presentation but demonstrated no

neurologic symptoms or signs on physical examination.

Fig. 4-B Reduction was achieved through a poste-

rior approach with use of interbody distractors, fol-

lowed by a posterior lumbar interbody fusion with

use of titanium mesh cages packed with autograft

in the L5-S1 disc space. Reduction was maintained

with transpedicular screw fixation and posterolat-

eral fusion performed from L4 to S1. A postopera-

tive left footdrop resolved within one year. (Figures

courtesy of Steven R. Garfin.)



detected in 58% (eighteen) of the thirty-one participants.Comparing their data with previously published rates of ab-normalities in nonathletes, the authors concluded that discdegeneration was more common in Olympic athletes.

Disc degeneration appears to be influenced by the typeand intensity of the sport. Videman et al.4 demonstrated thatformer weight lifters have a higher rate of and more severe de-generative changes in the upper lumbar spine, whereas soccerplayers have findings almost exclusively in the L4 to S1 levels.While degenerative findings were most common in weight lift-ers, this group did not have a higher rate of back pain. In a studyof Italian volleyball players, Bartolozzi et al.8 found that, of nine-teen athletes who used proper technique and did not overtrain,21% (four) had degenerative changes, whereas, of twenty-sixwho used improper technique and overtrained, sixteen (62%)had such changes. The frequency of symptoms in these twogroups was not reported. Sward et al.22 found male gymnasts tohave a higher rate of back pain and a greater number of radio-graphic degenerative changes than competitors in other sports.

Some studies have suggested an association betweenspecific imaging findings and the likelihood of back pain.Lundin et al.14 prospectively examined initial and ten-year follow-up radiographs of a group of athletes. The radiographic find-ing that most strongly correlated with low-back pain wasdecreased disc-space height, regardless of whether it was de-tected on the initial or follow-up examination. Furthermore,the greater the number of levels involved, the more likely theathlete was to have had low-back pain. Sward et al.20 foundthat decreased signal intensity within the disc on magneticresonance imaging correlated with low-back pain in both ath-letes and nonathletes. They also found that an abnormal ver-tebral configuration (defined as an increased anteroposteriordiameter, presumably from osteophyte formation) correlatedwith the occurrence of low-back pain. Comparing findings onbaseline and follow-up magnetic resonance imaging in thirty-one girl athletes, Kujala et al.21 noted that six of eight who hadlow-back pain had a new radiographic abnormality, the mostcommon of which was a ring apophyseal injury. Ogon et al.54

found that severe anterior end-plate degeneration was associ-ated with a greater risk of low-back pain in 120 adolescentelite skiers. Videman et al.4 reported that former elite athleteswith a history of at least monthly low-back pain had signifi-cantly higher scores for disc degeneration on magnetic reso-nance imaging than did those who had pain less frequentlythan twice a year (p = 0.04). Importantly, low-back pain wasmore strongly predicted by life dissatisfaction, neuroticism,hostility, extroversion, and poor sleep quality.

Nonoperative TreatmentNonoperative modalities are the mainstays of treatment ofdiscogenic low-back pain in the athlete. Various rehabilitationprotocols have been suggested specifically for this condition.However, I am not aware of any published clinical trials evalu-ating or comparing results in athletes.

Cooke and Lutz13 detailed a five-stage rehabilitation pro-tocol for the treatment of discogenic lumbar pain in athletes.

Stage I (early protected mobilization) consists of a brief periodof rest followed by various therapeutic modalities (applicationof heat or ice, nonsteroidal anti-inflammatory drugs, soft-tissue mobilization, and epidural injection). Once pain is con-trolled, the athlete begins an early exercise program to restorelumbar and lower-extremity range of motion. Stage II (dy-namic spinal stabilization) focuses on co-contraction exercisesof the abdominal and lumbar extensor muscles to stabilize theinjured motion segment. Isometric exercises (contraction ofthe muscles without changing the length of the muscle) helpto retrain muscles to maintain a mechanically neutral posi-tion. Stage III focuses on strengthening of the lumbar muscles.Importantly, initial strength gains are derived from improve-ments in neuromuscular firing as opposed to muscle fiber hy-pertrophy. In Stage IV, the athlete returns to sports activity.Plyometric exercises (resisted stretch of a muscle, or eccentriccontraction, followed by an explosive concentric contraction)are recommended in this stage. The authors’ criteria for re-turning to sports were (1) a full painless range of motion, (2)the ability to maintain a neutral spine position during sport-specific exercises, and (3) a return of muscle strength, endur-ance, and control. Stage V includes institution of a maintenanceprogram with regular home and warm-up exercises.

Fig. 5

Substantial pain relief after infiltration of the pars with a local anes-

thetic suggests that the spondylolytic lesion is the primary pain

source. In this oblique fluoroscopic image, the so-called Scotty dog

appearance of the posterior aspect of the vertebral arch can be ap-

preciated. The needle tip is in contact with the superior articular

process of L4 (the back of the dog’s head), with contrast medium

visible along the posterior surface of the pars interarticularis. A

thin haze of contrast medium can be appreciated within the defect

itself (the collar around the dog’s neck).



Young et al.12 stressed the importance of active participa-tion of the physical therapist in continually modifying the ther-apeutic regimen as the athlete progresses. They also stressed theimportance of not relying solely on an algorithmic approach torehabilitation. Therapy goals are pain reduction and decreasingthe length of symptomatic episodes. This is achieved by (1) tar-geting abnormal skeletal shifts and posture, (2) reducing abnor-mally high muscle tone in spastic regions, and (3) reinforcing acomfortable body position, which is more often lumbar exten-sion in patients with discogenic pain. Focus is placed on ad-dressing tight extraspinal muscles, such as the hamstrings, hipflexors, hip rotators, hip extensors, and abdominals.

Minimally Invasive TreatmentThe role of therapeutic spinal injections for the treatment oflow-back pain remains controversial. Regardless of a lack ofproven efficacy, epidural steroid injections remain a popularminimally invasive treatment for discogenic low-back pain.There have been no studies analyzing the efficacy of these tech-niques in athletes, to my knowledge. As the role of intradiscalelectrothermal therapy in the treatment of chronic low-backpain in nonathletes is still highly controversial, its applicabilityto athletes is unknown. At my institution, this modality has hada nearly 100% failure rate in athletes.

Surgical OptionsOperative treatment of discogenic low-back pain resultingfrom degenerative disc disease currently consists of variousmethods of fusion. While the anecdotal experience of a num-ber of surgeons suggests that fusion can be successful in se-lected athletes, I am not aware of any published seriesdocumenting clinical results in this patient population. Ex-trapolating recommendations for nonathlete patients55 to ath-letes indicates that the surgical indications for lumbar fusionshould include (1) pain correlated with positive findings onimaging studies (e.g., magnetic resonance imaging), (2) con-tinuous symptoms for at least four to six months despite ac-tive nonoperative treatment, and (3) localized midline spinaltenderness that corresponds to the radiographic level of dis-ease. The role of provocative discography remains controver-sial. However, reproduction of the patient’s symptoms duringtesting of the intended level of fusion, along with negative re-sponses at adjacent control levels, is considered by some55,56 tobe an important surgical criterion.

Various methods of lumbar fusion have been advocatedfor the treatment of chronic disabling axial back pain from de-generative disc disease. These include posterolateral, anteriorinterbody, posterior interbody, transforaminal interbody, andcircumferential (anterior and posterior) fusion techniques,

Fig. 6-A

Figs. 6-A and 6-B Images of a twenty-two-year-old college baseball player with a one-year history of persistent low-back pain exacerbated by

extension that was not responsive to nonoperative treatment. Fig. 6-A A plain lateral lumbar radiograph revealed an obvious L4 pars defect

without spondylolisthesis. Preoperative magnetic resonance imaging did not demonstrate any evidence of disc degeneration. Fig. 6-B Three

months after a direct pars repair with iliac crest autograft stabilized with a pedicle screw-rod-hook construct, the pars lesion appeared healed.

Although the patient reported resolution of pain and participated in recreational sports, she did not return to competitive athletics because of

financial reasons.

Fig. 6-B



with or without instrumentation. A review of the available lit-erature suggests that interbody fusion techniques result inhigher fusion rates and possibly better clinical outcomes thando posterolateral fusions57-60. Currently, most surgeons whoperform lumbar fusion for discogenic low-back pain prefer aninterbody technique rather than a posterolateral fusion alone.This reflects an increasingly popular belief that the disc itself isthe main pain generator. Thus, notwithstanding generallyhigher fusion rates with the former procedure, the critical dif-ference between interbody and posterolateral arthrodesesmight be disc excision.

The clinical results of interbody fusion for the treatmentof back pain have varied, although no reports have specificallyaddressed the results in athletes, to my knowledge. Good orexcellent results have been reported in between 80% and100% of cases56-61. There is little or no information concerningthe optimal time at which the athlete should return to sportsactivity after lumbar fusion16. Conservatively, however, theathlete should not return until there is radiographic evidenceof a solid fusion, complete or nearly complete resolution ofpain, and restoration of competitive-level measured func-tional parameters, such as strength, flexibility, and endurance.

SpondylolysisSpondylolysis refers to a defect within the bone of the poste-rior part of the neural arch. While spondylolyses can developat various sites62-64, the most common region to be affected isthe isthmus of bone between the cephalad and caudad articu-lar processes (Fig. 3). This region, more familiarly known asthe pars interarticularis, is most commonly affected at L5 (in85% to 95% of cases) and L4 (in 5% to 15%)65. While the exactetiology of isthmic spondylolysis is not known, it is widely be-lieved to be a stress fracture caused by repetitive loading66-68, al-though there may be other contributing factors69-71. Theprevalence of spondylolysis in the general population has beenestimated to be between 3% and 6%72-74. Supporting a me-chanical etiology is the fact that the highest prevalence hasbeen reported in Alaskan Eskimos who sustain crouching pos-tures for long periods of time while skinning whale blubber75.Most cases are asymptomatic. About one-quarter of symp-tomatic cases are associated with spondylolisthesis74.

The prevalence of spondylolysis in athletes is variable. Ingeneral, the prevalence is not higher than that in the generalpopulation76. However, some sports appear to be associatedwith a higher prevalence. In a study of 3132 competitive ath-letes, Rossi and Dragoni77 reported a rate of 43% in divers,30% in wrestlers, and 23% in weight lifters. In a study of 3152competitive athletes, Soler and Calderon76 documented a prev-alence of 27% in throwing athletes, 17% in gymnasts, and17% in rowers. Micheli and Wood39, in a study of 100 adoles-cent athletes and 100 adult athletes who presented with backpain, found that the adolescents had a higher rate of spon-dylolysis (47%) than did the adults (5%). Incidentally, thesepercentages were nearly reversed for the prevalence of degen-erative disc disease. In some of the earliest reports of spon-dylolysis in athletes, young female gymnasts had been

identified to be at particular risk. Jackson et al.11 evaluated 100female gymnasts with radiographs because of back pain.Eleven (11%) demonstrated bilateral spondylolytic pars de-fects, and six of them had a grade-I slip. Although these preva-lences appear substantially lower than those reported morerecently, this is likely a result of improvements in radiographicassessment and increased awareness.

Pain is usually confined to the low back. If the pain radi-ates, it does so to the buttocks or the back of the thigh and ismore commonly from hamstring tightness than from radicu-lopathy. Pain is aggravated by extension of the lumbar spine,which is often elicitable during examination. Inspection candemonstrate exaggerated lumbar lordosis from increased sacralinclination without a slip (a possible predisposing factor forslippage78) or from spondylolisthetic deformity. With higher-grade spondylolisthesis, the buttocks can appear heart-shapedand a midline step-off between the spinous processes can bepalpated. Point tenderness on palpation of the affected spinousprocess can be present in cases of spondylolysis alone. Straight-leg raising can demonstrate hamstring tightness, but usually itdoes not reproduce radicular pain that extends below the knee.The single-leg hyperextension test described by Jackson et al.11 isa useful provocative test. It entails the patient standing on oneleg while simultaneously extending the low back. This shouldproduce pain on the side of the standing leg in a patient with asymptomatic ipsilateral spondylolytic lesion. To my knowledge,the reliability, sensitivity, and specificity of this test have notbeen analyzed. Neurologic examination usually reveals normalfindings.

ImagingImaging of an athlete with low-back pain and suspectedspondylolysis begins with a series of plain anteroposterior, lat-eral, and oblique lumbar radiographs. A coned-down lateralradiograph of the lumbosacral junction produces a clearer im-age of the posterior bone structures than does a standard lat-eral radiograph. Approximately 85% of defects are appreciableon this view. The oblique radiograph is useful to detect defectsin that plane73. Left and right oblique radiographs should bemade. Spondylolisthesis, or slipping, is graded on a lateral ra-diograph according to the Myerding79 system, with grade I in-dicating <25%; grade II, 25% to 50%; grade III, 50% to 75%;and grade IV, 75% to 100%. Rarely, spondylolisthesis (gradeV) occurs (Fig. 4-A).

When plain radiographs of a patient with persistentsymptoms reveal negative findings, a bone scan, computerizedtomography scan, single-photon-emission computed tomogra-phy scan, or magnetic resonance imaging scan can be made. Abone scan detects areas of bone turnover; i.e., bone deposition.Uptake can represent impending stress fractures, also known asstress reactions67. Jackson et al.67 utilized bone scans to detectstress reactions in thirty-seven young athletes. Importantly, ini-tial bone scans were negative in seven athletes who subsequentlyhad positive uptake within the pars on repeat examination onemonth later. Single-photon-emission computed tomographyhas been touted as the most sensitive test to detect a pars lesion.



Bellah et al.80 performed plain radiography, bone scans, andsingle-photon-emission computed tomography scans for 162adolescent athletes with low-back pain. In thirty-nine of seventy-one patients, the single-photon-emission computed tomogra-phy scan demonstrated increased uptake in the pars articulariswhen bone scans were negative. Whenever the bone scan waspositive, the single-photon-emission computed tomographyscan was also positive. The utility of single-photon-emissioncomputed tomography for differentiating between symptomaticand asymptomatic pars lesions has also been studied. In a seriesof nineteen patients with radiographically confirmed lesions,Collier et al.81 found that single-photon-emission computed to-mography scanning showed positive findings in eleven of thir-teen symptomatic patients but in none of six asymptomaticpatients. Additional prospective studies using single-photon-emission computed tomography scans are needed to demon-strate more clearly their ability to predict symptoms.

Computed tomography scans are more sensitive thanplain radiographs. Spondylolytic lesions demonstrate a char-acteristic appearance that resembles an arthritic facet joint atthe level of the pedicle on axial images. Some believe com-puted tomography to be the most sensitive test for spondylo-lysis82,83. Congeni et al.82 used computed tomography images todifferentiate chronic nonhealing and acute-healing fractures.In their group of forty athletes with back pain, all had positivebone scans. Forty-five percent had a chronic lesion demon-strated by computed tomography, 40% had an acute lesion,and 15% had no obvious lesion on computed tomography.Unfortunately, the radiographic criteria for chronic and acutelesions were not detailed, and the authors did not attempt tocorrelate findings with prognosis.

The role of magnetic resonance imaging in detecting orclassifying spondylolysis is unclear. In a recent study, increasedbone edema (hypointensity) within the pars on T1-weightedimages in seven symptomatic patients with initially negativecomputed tomography scans was associated with the subse-quent development of a detectable pars defect84. After fracture-healing, as demonstrated by follow-up computed tomographyat five months, the findings on the magnetic resonance imaginghad normalized. Kujala et al.9 prospectively followed a group ofyoung athletes with low-back pain who had initial and follow-up bone scans as well as magnetic resonance imaging. Impor-tantly, the magnetic resonance image was negative for eightpatients who had a positive bone scan. Notably, the magneticresonance imaging was performed with a low-field unit, andonly standard T1 and T2-weighted image sequences were made.The investigators suggested that higher-strength magnets, simi-lar to those currently available, with fat-suppression and STIR(short tau inversion recovery) sequences might increase sensi-tivity. To my knowledge, there have been no comparisons ofmagnetic resonance imaging and single-photon-emission com-puted tomography for the diagnosis of spondylolysis.

Natural History and Risk of ProgressionMuschik et al.85 assessed the risk of slip progression associatedwith observational care and an early return to sports. Of

eighty-six young athletes with either spondylolysis or spondy-lolisthesis followed for an average of five years, thirty-three(38%) had progression or development of a slip. The slips in-creased by an average of only 10.5%, and, unexpectedly, sevenathletes had a 9% decrease in the amount of slip.

Ikata et al.86 compared the radiographs and magnetic res-onance imaging scans of seventy-seven adolescent athletes withhigh-grade isthmic spondylolisthesis with those of eighty-eightadolescent athletes with spondylolysis alone. Slips in youngerpatients were more likely to progress. Furthermore, the authorsfound wedging of the L5 vertebra and rounding of the superiorend plate of S1 in all patients who had a slip but in none of thepatients who did not. It was not clear if these morphologicalchanges were a cause or result of spondylolisthesis.

Nonoperative TreatmentThe majority of athletes with spondylolysis or pars stress reac-tions respond favorably to nonoperative treatment. Usually thistreatment includes a brief period of rest followed by physical re-habilitation. The role and best type of external immobilizationcontinue to be debated. Most authors67,87-90 have agreed that ath-letes can return to play when they are pain-free, regardless ofwhether there is radiographic evidence of pars healing.

Jackson et al.67 treated a group of young athletes withpars stress reactions by limiting movements or activities thataggravated pain. This treatment was individualized to eachathlete, and none discontinued playing sports. The treatmentincluded a short period of initial bed rest. While the authorsreported using a form-fitting brace intended to limit hyperex-tension of the lumbar spine, they did not report the durationof use or the criteria for discontinuation of such treatment.

Blanda et al.87 reported the results of nonoperative careof sixty-two athletes with symptomatic spondylolysis. Defectswere documented by radiographs and, when radiographs werenegative, by bone scans. Treatment included restriction of ac-tivity and bracing for two to six months. No sports or exercisewas permitted during the entire treatment period, and therewas no description of rehabilitative exercises. Notably, thebrace was designed to maintain lumbar lordosis. Fifty-two pa-tients (84%) were reported to have an excellent result; eight(13%), a good result; and two (3%), a fair result. The rate ofradiographic healing (independent of clinical outcome) washigher for unilateral defects (78% [eighteen] of twenty-threesuch defects healed) than bilateral defects (8% [three] ofthirty-seven healed). The fact that eight patients underwent aposterolateral fusion because of the development of presum-ably asymptomatic or minimally symptomatic slip progres-sion is of concern, since 98% of patients had either a good oran excellent result with regard to pain relief after bracing. Theaverage duration of follow-up was 4.2 years, with a minimumof two years. While the authors concluded that nonoperativecare with lordotic bracing was an effective treatment, it ap-pears that this approach might predispose to the developmentof spondylolisthesis.

In the same study, twenty athletes were treated for spon-dylolisthesis with the same protocol. Twelve had a grade-I slip;



six, grade-II; and two, grade-III. Eighteen had pars defects, andtwo had an elongated pars. Seventeen (85%) had an excellentresult, and one each had a good, fair, or poor result. Interpreta-tion of these findings is obfuscated by the fact that the majority(twelve) of the twenty patients eventually underwent postero-lateral fusion for progression of the slip (five), persistent pain(five), or a neurological deficit (two). The average duration offollow-up was 3.2 years, with a minimum of two years. Again,these data suggest reconsideration of the proposed regimen ofnonoperative care including lordotic bracing.

Steiner and Micheli88 used a modified, overlapping braceto treat sixty-seven young athletes with symptomatic spondy-lolysis or grade-I spondylolisthesis. The antilordotic brace wasdesigned to hold the lumbar spine in relative flexion (in dis-tinction to that used by Blanda et al.87). Seventy-eight percent(fifty-two) of the patients demonstrated a good or excellentresult with no pain and returned to full sports activity. Nine(13%) had continued mild pain, and six (9%) underwent aposterolateral fusion for pain relief. The average duration offollow-up was 2.5 years.

In a later study from the same institution, d’Hemecourtet al.89 evaluated the results of antilordotic brace treatment inseventy-three young athletes with spondylolysis or grade-Ispondylolisthesis. Importantly, thirty-three patients had nega-tive findings on plain radiographs and computed tomographyimages but had detectable pars lesions on either a bone scan ora single-photon-emission computed tomography scan. Thetreatment regimen included brace wear for twenty-threehours per day for six months followed by a weaning period ofseveral months. A physical therapy program with a focus onflexion exercises was also instituted. Athletes returned tosports as early as four to six weeks after the initiation of treat-ment if they (1) had no pain with extension on physical exam-ination, (2) had worn the brace full-time, and (3) remainedpain-free. Results were very similar to those in the previousstudy88, with fifty-six (77%) of the athletes having a good orexcellent result. In this series, the fate of the remaining 23%(seventeen) of the patients was not detailed; it was not re-ported whether they eventually underwent surgery.

Sys et al.90 documented the results of nonoperative treat-ment of twenty-eight elite athletes (age range, twelve totwenty-seven years) with a pars lesion. All patients had nega-tive findings on plain radiographs. Bone scans, single-photon-emission computed tomography, and computed tomographywere used to confirm the diagnosis. Treatment included brac-ing for a mean of sixteen weeks and subsequent follow-up foran average of thirteen months. A second computed tomogra-phy scan was made at the time of final follow-up to assesshealing of the defect. Results were subcategorized according towhether the patient had a unilateral, bilateral, or so-calledpseudobilateral defect. (A pseudobilateral defect was definedas asymmetrical signal within the pars bilaterally, indicating aconfirmed unilateral lesion with a questionable or developingcontralateral one.) All eleven unilateral lesions and five ofthe nine bilateral lesions healed. However, none of the eightpseudobilateral lesions had healed at the time of final follow-

up. Independent of healing, 82% (twenty-three) of the ath-letes had an excellent outcome, 11% (three) had a good out-come, and 7% (two) had a fair result. The rate of return tosports activity did not differ among the three groups. The au-thors concluded that an unhealed defect does not preclude agood clinical result or a return to athletic pursuits.

Operative TreatmentAfter failure of extensive nonoperative measures, surgical inter-vention can be considered. Indications for early surgical man-agement are a neurologic deficit related to spondylolisthesis, aprogressive slip, or a grade-III or higher-grade slip at presenta-tion, as such a lesion is associated with a high likelihood of fur-ther spondylolisthesis11. These indications are independent oflow-back pain. Operative techniques for these problems includedecompressive laminectomy and various methods of fusion.Solid fusion is more difficult to achieve in high-grade slips,which has led to interest in combined anterior and posteriorprocedures, vertebrectomy and fusion, or spanning bone-graftstruts placed through a transpedicular posterior approach91-93.

Fusion

Posterolateral fusion, with or without instrumentation, canbe an effective means of relieving low-back pain in patientswith recalcitrant spondylolysis or spondylolisthesis. Unfortu-nately, there is little clinical information regarding athletes.Thorough searches of the English-language literature did notreveal any dedicated series of athletes. Within a report onnonoperative care, Blanda et al.87 reported that nine of twelvepatients had an excellent result after posterolateral fusion forspondylolisthesis. However, only five of the operations wereperformed for pain relief and these results were not analyzedseparately.

Recently, interbody fusion for isthmic spondylolisthesisin adult patients has been reported more frequently94-98. Despitehigher fusion rates and better maintenance of sagittal align-ment, these methods have not been demonstrated to have clini-cal advantages compared with posterolateral fusion94,97. The roleof this surgical technique for the treatment of adult athletes re-mains unclear. With the exception of patients in whom reduc-tion of a high-grade slip has been elected (Fig. 4-B), adolescentathletes are not usually candidates for interbody fusion.

I found no data concerning the appropriate time afterwhich an athlete may return to sports following lumbar fusionfor spondylolysis or spondylolisthesis. In my opinion, the cri-teria should be similar to those for an athlete’s return follow-ing nonoperative care: the athlete should be pain-free andhave nearly normal function (strength, flexibility, and endur-ance) along with the added requirement of a solid fusionradiographically7,12,40,41.

Direct Pars Repair

More frequently reported in the literature are the results of di-rect pars repair in athletes99-103. Surgery is indicated for persis-tent pain from the defect itself that has failed to resolve after atleast six months of nonoperative care. While low-grade slips



(less than grade II) are not absolute contraindications, surgi-cal repair for those slips remains controversial104. A positive re-sponse (nearly complete pain relief) to an infiltrative injectioninto the pars defect (Fig. 5) seems to be a good predictor of apositive outcome independent of the presence of a low-gradeslip or mild disc degeneration104-106. Preferably, the disc shouldnot demonstrate evidence of degeneration. Persistent painthat is not relieved by injection is more likely to originate fromthe intervertebral disc and might be treated better by othermethods.

Various fixation methods have been used successfully,including wiring, interfragmentary screws, pedicle screw-rodconstructs, and pedicle screw-rod-hook constructs99,102,104,105,107.Biomechanical evidence suggests that pedicle screw-rod-hookconstructs allow the least motion across the defect site (Figs.6-A and 6-B). A critical portion of the repair, regardless of fix-ation type, is resection of the fibrous tissue within the defect,decortication to a bleeding surface, and ample autogenousbone-grafting.

Debnath et al.100 performed a prospective study of twenty-two competitive athletes (fifteen to thirty-four years of age)treated with a direct pars repair by either Scott wiring (passedaround the transverse process and spinous process in a figure-of-eight pattern) or the Buck (translaminar interfragmentary)screw technique. All patients had defects documented by eithersingle-photon-emission computed tomography or computedtomography. Two of the three patients treated with Scott wiringdid not have healing of the defect, had revision to a posterolat-eral fusion, and did not return to sports. The other patienttreated with Scott wiring had a healed defect but did not returnto sports. In contrast, eighteen of the nineteen patients who un-derwent Buck screw fixation returned to sports, after an averageof seven months, and demonstrated significant improvementsin the Oswestry disability index and Short Form-36 scores (p <0.001 for both). The numbers were too small to allow anymeaningful statistical comparison between the two techniques,although the clinical failures in all three patients with the Scottwiring are troubling.

Nozawa et al.103 documented the outcomes of a wiringtechnique in twenty competitive young athletes (average age,23.7 years old). Bone healing was reported in all patients, andthe Japanese Orthopaedic Association scores were signifi-cantly improved at up to an average of 3.5 years postopera-tively (p < 0.0001). Furthermore, all patients returned to thesame sport, but not all returned to the same level of competi-tion. It is difficult to reconcile these contrasting findings withthose of Debnath et al.100.

Other investigators have reported surgical results in rec-reational athletes. Gillet and Petit102 reported the results oftreatment with a rod-screw construct in ten patients. Six hadan excellent result, returning to participation in recreationalsports. One patient each reported a good and fair result. Twopatients were considered to have a failure of treatment, andone of them later underwent interbody fusion. No postopera-tive brace was used. Although the authors stated that they as-sessed union with plain radiographs and tomograms, they did

not report the healing rate. In a study of a similar patient pop-ulation, Roca et al.99 reported that thirteen of fifteen patientswere able to return to recreational sports activities one year af-ter translaminar screw repair.

Sacral Stress FractureStress fractures of the sacrum are an uncommon cause of low-back pain in athletes. The prevalence is unknown. Althoughsuch fractures appear to be more common in female ath-letes10,17,108, they have been reported in male athletes as well18.These fractures almost exclusively affect running athletes in-volved in sports such as cross-country, track, or marathon10,18.

The presentation commonly includes an insidious on-set of asymmetric low-back or gluteal pain that develops overa period of weeks, usually with no history of an acute incident.Physical findings are paramedian point tenderness of one sideof the sacrum or sacroiliac joint. The faber test (figure-of-fourtest of the lower extremity) can be positive on the ipsilateralside. Delvaux and Lysens18 described a “hopping test” in whichpain is reproduced by bouncing on the leg on the affected side.In the one case that they reported, this sign was negative afterthe fracture healed. The flamingo test (patient standing on theipsilateral leg) may also be positive.

Female patients should be questioned about eating hab-its and menstrual history to rule out the so-called terribletriad in women athletes. A positive history of amenorrhea oran eating disorder should prompt a bone mineral density test.If this reveals a decreased bone density in association with asacral lesion, an insufficiency fracture, rather than a stressfracture, is more likely. Treatment of the underlying cause ofosteoporosis should be initiated in conjunction with psycho-logical counseling.

Plain radiographs usually reveal negative findings, ne-cessitating advanced imaging studies for diagnosis. Magneticresonance imaging, computed tomography, single-photon-emission computed tomography, and bone scans can be diag-nostic. Johnson et al.10 used various combinations of thesetests to detect lesions. In all cases in which magnetic resonanceimaging was performed, it confirmed the presence of a frac-ture that was detectable on bone scan. In both of their case re-ports, Shah and Stewart108 and Featherstone17 used magneticresonance imaging alone to confirm the diagnosis.

Treatment is always nonoperative, consisting of rest andprotected or non-weight-bearing. This is followed by progres-sive mobilization, weight-bearing, and activity as symptomspermit. The overall prognosis is favorable, with the athletes re-turning to sports activity in an average of about one and a halfmonths108. The athlete should be adequately rehabilitated be-fore returning to full activity. Most patients, however, reportpersistent mild or intermittent pain10.

Christopher M. Bono, MDDepartment of Orthopaedic Surgery, Boston University Medical Center, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118. E-mail address: [email protected]



The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to pro-vide such benefits from a commercial entity. No commercial entity

paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charita-ble or nonprofit organization with which the author is affiliated or associated.

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