lumbar spine athletic

Not for reproduction or redistribution

Lumbar Spine: Athle2c Low Back Pain

Kyle Kiesel, PT, PhD, ATC Todd Arnold, MD


Point Prevalence of 14% One-year prevalence of 57% Lifetime prevalence of 66%

Prevalence

Kyle Kiesel, PT, PhD, ATC Todd Arnold, MD Lumbar Spine: Athletic Low Back Pain



Disc Pathologies

Spondylolysis and Spondylolisthesis Lumbar strains/sprains Sacral stress fractures Sacral iliac joint dysfunction



Diagnostics are more important in athletes with LBP

Low back pain in the general population is over diagnosed

In athletes, low back pain is under-diagnosed


Exam

Medical Screening Key Historical Factors Category Breathing Regional Interdependence Local Motor Control




Categorization

Categorization helps determine what type of treatment works best for the desired functional outcome

Categorization is effective in the general population


Stabilization Mobilization


Treatment Based Classification

Direction Specific


Treatment-Based Classification Approach

Athletic low back patients are classified into one of 4 treatment categories Based on key historic, demographic and physical exam

variables: Duration of symptoms Pain below the knee Current disability level Fear-avoidance level Pain intensity Movement characteristics Response to repeated movements




Four Treatment Categories

Extension oriented exercises Flexion oriented exercises Manual therapy for the spine/SIJD Motor control and strengthening program



3 Categories of Low Back Pain

Mobility/SIJD Extension Flexion


Flexion Oriented Pain



Diagnosis Flexion

Straight Leg Raise Test (sensitive only) Slump Test



Treatment

Extension Based Program Local Motor Control Regional Interdependence



Extension Oriented Pain




Diagnosis Extension

One-legged hyperextension test is neither specific or sensitive

Lumbar spinous process palpation test for diagnosis


Treatment and Prognosis

Depends on Imaging and Healing Goals Rehab Focus

Regional interdependence Excessive outer core activation Local motor control

Very good prognosis with favorable long-term data



Prognosis

Very good Long-term data are favorable




Mobility/SIJ Dysfunction


Diagnosis

1. CPR for Manipulation No pain below knee < 16 days duration < 19 FABQ Positive PA Glide > 35 Hip IR

2. Clear Closing Pattern Unilateral Restricted/Painful Side Bending and Extension



Diagnosis (cont.)

3. SIJ Test Cluster Distraction Thigh thrust Gaenslen Sacral thrust Compression (Any 3 tests +)

Sensitivity .91 Specificity .87 +LR 6.97



Treatment

Mobility Appropriate Manipulation Local Motor Control Regional Interdependence



Treatment (cont.)

SIJD Typically Muscle Energy Approach Local Motor Control Regional Interdependence



Prognosis

Generally very good Manage early to avoid recurrent events and associated

disability



Motor Control Training

Additional Clinical Testing Prone Instability Test Active Straight Leg Raise Test



1. Tester performs P-A glides over each lumbar segment for pain provocation Identify painful segments

2. Repeat P-A with hips extended (feet just off of the floor) Positive finding previously painful segments

become pain-free


Prone Instability Test


Active Straight Leg Raise Test (ASLR)

1. Subject is supine with legs 20 cm apart 2. Subject is asked to lift the leg 5 cm off the plinth 2-3 times each side

3. The test is considered positive if the subject reports that one leg feels more difficult or heavier to lift as compared to opposite side 4. Pain provocation is not part of this test

Kyle Kiesel, PT, PhD, ATC

Todd Arnold, MD Lumbar Spine: Athletic Low Back Pain



Discharge Testing

Functional Movement Screen Regional interdependence test Functional core test from upper and lower body Y-balance

test



Athletic Treatment Categories Category Diagnostic

Test Medical Management

Reset Reinforce

Flexion MRI NSAID Steroid dose pack Consider 1-2 day

complete rest Referral for

epidural injection

MSF quality focus TPDN:

- LM, RF, posterior chain - Breathing Local motor

control training LM Emphasis

Rest in acute phase, upload spine, consider corset, avoid sitting and flexion oriented activities

Multifidus taping

Mobility CPR/Closing Pattern

NSAIDS General L/S Manipulation

Gapping Manipulation

Mobility Exercise


Summary

Imaging is more important in athletes than the general public

Information on treatment categories and regional interdependence makes more informed decisions on prognosis and care




Chapter 2

Medical Diagnosis


Differential Diagnosis

Spondylolysis Scheuermanns Kyphosis Acute disc herniation Apophyseal ring fractures Discitis/vertebral osteomyelitis Neoplasms



Differential Diagnosis (cont.)

Referred pain Myelopathy Radiculopathy Somatic referred pain



Medical Screening Red Flags

Poor response to conservative care Unexplained change in bowel/bladder conditions Symptoms not consistent with mechanical cause of pain Blood in sputum Bilateral or unilateral radiculopathy Non healing sores or wounds Unexplained significant UE/LE weakness Progressive neurological deficits

UMN testing Clonus Babinski Hyperreflexia

UQS, LQS



Thoracic Spine Exam

Medical Screening Rule out viscerosomatic referred pain by checking for red

flags in history

Thoracic intervertebral disc lesion commonly caused by lifting, exercise, trauma,

degeneration, etc.

can mimic symptoms of visceral conditions



Lumbar Spine

Straight Leg Raise Test (sensitive only) MRI



Diagnosis Extension

One-legged hyperextension test is neither specific or sensitive

Lumbar spinous process palpation test for diagnosis Spondylolithesis test

Look for the step-off Specificity (85-100) sensitivity (60-88)




Treatment Extension

Conserva*ve treatment including bracing/rest/rehab Surgical treatment Outcome variables were

Healing Self-reported result Return to sport

Brace *me to a mean of 12 weeks (8-32)



Outcome Extension

Unilateral lesion Positive prognosis for healing up to 100%

Bilateral terminal lesion Healing as low as 0%

Return to Sport



Long term outcomes

No comparison studies Long term outcomes

Comparable to general population



Diagnosis Extension

Radiologic diagnosis MRI positive CT grading Early-progressive-terminal



Diagnostic Testing

Plain Radiographs Bone Scan MRI CT scan

Lumbar Spine: Athletic Low Back Pain

1

Bibliography

MedBridge Lumbar Spine: Athletic Low Back Pain

Kyle Kiesel, PT, PhD, ATC Todd Arnold, MD

T Bouras, P Korovessis, Management of spodylolysis and low grade apodylolesthesis in fine athletes: A comprehensive review. Eur J Orthop Surg Tramatol, DOI 10.1007/s00590-014-1560-7, November 2014. Charles H. Crawford, III, MD, et al., Current Evidence Regarding the Surgical and Nonsurgical Treatment of Pediatric Lumbar Spondylolysis: A Report from the Scoliosis Research Society Evidence-Based Medicine Committee. Spine Deformity 3 (2015) 30e44 Charles H. Crawford, III, MD, et al., Current Evidence Regarding the Etiology, Prevalence, Natural History, and Prognosis of Pediatric Lumbar Spondylolysis: A Report from the Scoliosis Research Society Evidence-Based Medicine Committee. Spine Deformity 3 (2015) 12e29 Alqarni, AM, Schneiders, AG, Cook, CE, Hendrick, PA, Clinical tests to diagnose lumbar spondylolysis and spodylolesthesis: A systematic review. Physical Therapy in Sports (2015) doi: 10.1016/j.ptsp.2014.12.005 Sairyo, Sakai,, Yasui, Conservative treatment of lumbar spondylolysis in childhood and adolescence: The radiological signs which predict healing. The journal of bone and joint surgery, Vol 91-B, No 2 February 2009 Dutton M. Orthopaedic: Examination, Evaluation, and Intervention 2nd ed. New York, NY: McGraw-Hill Companies, Inc.; 2008. 2. Kiesel KB, Underwood FB, Mattacola CG, Nitz AJ, Malone TR. A comparison of select trunk muscle thickness change between subjects with low back pain classified in the treatment-based classification system and asymptomatic controls. The Journal of orthopaedic and sports physical therapy. Oct 2007;37(10):596- 607. 3. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine. Jul 1 2003;28(13):1363-1371; discussion 1372. 4. Henry SM, Fritz JM, Trombley AR, Bunn JY. Reliability of a treatment-based classification system for subgrouping people with low back pain. The Journal of orthopaedic and sports physical therapy. Sep 2012;42(9):797-805. 5. Stanton TR, Fritz JM, Hancock MJ, et al. Evaluation of a treatment-based classification algorithm for low back pain: a cross-sectional study. Physical therapy. Apr 2011;91(4):496-509. 6. Bono CM. Low-back pain in athletes. The Journal of bone and joint surgery. American volume. Feb 2004;86-A(2):382-396. 7. Trainor TJ, Trainor MA. Etiology of low back pain in athletes. Current sports medicine reports. Feb 2004;3(1):41-46. 8.

Lumbar Spine: Athletic Low Back Pain

2

Brolinson PG, Kozar AJ, Cibor G. Sacroiliac joint dysfunction in athletes. Current sports medicine reports. Feb 2003;2(1):47-56. 11. Cassidy RC, Shaffer WO, Johnson DL. Spondylolysis and spondylolisthesis in the athlete. Orthopedics. Nov 2005;28(11):1331-1333. 14. Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. Use of the onelegged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. British journal of sports medicine. Nov 2006;40(11):940- 946; discussion 946. 11 15. Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. The Journal of orthopaedic and sports physical therapy. Jun 2007;37(6):290-302. 17. Capra F, Vanti C, Donati R, Tombetti S, O'Reilly C, Pillastrini P. Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. Journal of manipulative and physiological therapeutics. May 2011;34(4):231-238. 19. Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. Journal of pediatric orthopedics. Mar 2008;28(2):230-233. 21. Sundell CG, Jonsson H, Adin L, Larsen KH. Clinical examination, spondylolysis and adolescent athletes. International journal of sports medicine. Mar 2013;34(3):263-267. 22. Campbell RS, Grainger AJ, Hide IG, Papastefanou S, Greenough CG. Juvenile spondylolysis: a comparative analysis of CT, SPECT and MRI. Skeletal radiology. Feb 2005;34(2):63-73. 23. Garet M, Reiman MP, Mathers J, Sylvain J. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Sports health. May 2013;5(3):225-232. 25. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual therapy. Aug 2005;10(3):207-218.

DISCLAIMER: This handout is meant to be used as a general guide only. If you have specific questions, please discuss them with your provider.

Athletic Low Back Pain OverviewTHREE CATAGORIES OF BACK PAIN

FLEXIONDiagnostic Tool Reset ReloadMedical Management Reinforce Discharge Focus

MRI Rest in acute phase, unload spine, consider corset, avoid sitting and flexion oriented activities Multifidus taping

MSF quality focus TPDN - LM, RF, posterior chain - Breathing Local motor control training LM Emphasis

SLD symmetry YBT/FMS

NSAID Steriod Dose Pack Consider 1-2 day complete rest Referral for epidural injection

Lifts SLD symmetry TGU symmetry

EXTENSIONDiagnostic Tool Reset ReloadMedical Management Reinforce Discharge Focus

MRI CT post brace period

Activity modification avoiding loaded weight training (squats) and quad dominate activities Avoid stomach sleeping and prolonged standing

Hip and Thoracic extension Focus: TPDN - abdominals - RF - Iilacus - Psoas - Latissimus - Thoracic spine - Breathing - Control of HTS Local motor control training TrA focus

Lunge symmetry YBT/FMS

Rest/brace if acute lesion with goal of full healing. Obtain CT scan at 8 weeks To tolerance if chronic lesion NSAID are not recommended as they impede bone regeneration Can inject anesthetic next to pars (no steroid) and/or consider facet injection Healing is goal in acute lesion with much higher rate seen in unilateral

Flexion progression focus Chops TGU symmetry Maintain flexion rolling to manage HTS

SIJDDiagnostic Tool Reset ReloadMedical Management Reinforce Discharge Focus

Rule out extension lesion and + test cluster 3/5 provocative tests - Distraction - Thigh thrust - Gaenslen - Sacral thrust - Compression

Avoid excessive reciprocal movements Consider SI Belt

SIJ mobilization TPDN - Soleus (possible referral) - Abdominals - QL, TFL, LM Local motor control; focus on TrA/PF

YBT/FMS Consider SIJ injection (must be under fluoroscopy)

Flexion progression focus on symmetry; Chops, TGU and careful progression to SLD and lunges

LUMBAR SPINE: ATHLETIC LOW BACK PAIN: Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MD


POWERED BYPAGE 1

Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MDTHORACIC SPINE: SOCCER PLAYER

Management of the Cervical and Thoracic Spinewww.medbridgeeducation.com

RANGE OF MOTION TESTING

LUMBAR SPINE:

Soccer Player: Answers

Use this worksheet to mark down your findings as Dr. Kiesel and Dr. Arnold walk through each case study.

Front bend: Hamstring limitations Active straight leg test: No limitations FABER test: Negative Modified Thomas test: Positive test on the right Thoracic spine rotation: No limitations Closed Chain Dorsiflexion: Limited movement on the right ankle Findings: Hip and ankle concerns due to positive right thomas test and limited closed chain dorsiflexion on the right ankle


POWERED BYPAGE 1

Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MDTHORACIC SPINE: SOCCER PLAYER

Management of the Cervical and Thoracic Spinewww.medbridgeeducation.com

MEDICAL DIAGNOSIS

BONY LESION DIAGNOSIS

PHYSICAL THERAPY VISIT

LUMBAR SPINE:

Post-case: Answers

Use this worksheet to mark down your findings as Dr. Kiesel and Dr. Arnold walk through each case study.

Findings: Back pain, chest elevation causes more pain Red flags: None Concerns: Main concern is an extension lesion of a spondylolysis for someone that has had back pain for several months Solution: MRI (from physician)

Treatment: Brace, physical therapy

Breathing patterns: Need to detonify and work on core to improve breathing Regional interdependence: Dorsilflexion, hip extensions, neck dysfunction Log rolls: Isolated trunk rolls, muscle contraction patterns (the goal is for one muscle group to turn off while their counterparts are activated, segmental and smooth rolling Quadruped: Avoid extension, try to get flexion oriented control Half-kneeling: Hip extension, core function (balance and response)


POWERED BYPAGE 1

Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MDLUMBAR SPINE: FOOTBALL PLAYER

Lumbar Spine: Athletic Low Back Painwww.medbridgeeducation.com

CASE STUDY:

Football Player

CASE STUDY

Dr. Arnold gives background on the patient. He is a football player who had pain over the summer. It got better, and now the pain is much more manageable with no red flags. He had an MRI, which indicated 1-sided spondylolysis. Dr. Arnold removes the athlete from sport and braces him for 2 months, and will then order a CT scan. The process should take about 8 12 weeks to return to sport, and the patient will start PT in 2 weeks when pain is controlled.

A. Oblique view radiograph commonly used as the first imaging tool but can miss pars defect

B. Posterior view radiograph only lateral and oblique views are used to identify pars defects

C. Lateral view radiograph this is commonly used as a first imaging tool but is not as accurate as CT

D. Computed Tomography correct

A. Lamina incorrect

B. Pedicle incorrect

C. Pars interarticularis correct

D. Transverse process incorrect

1. In young athletes reporting insidious onset of extension based low back pain, your most-likely initial concern is regarding what diagnosis?

A. Lumbar disc herniation the athlete would likely report flexion-based LBP

B. Lumbar compression fracture This is not as likely with insidious onset

C. Lumbar pars defect correct: pars defects are a common cause of extension-based low back pain

D. Lumbar spinal stenosis this is a common cause of extension-based low back pain in older adults, not young athletes

2. The scottie-dog deformity seen on diagnostic imaging is used to diagnose lumbar spondylolysis. Which of the following is the most accurate to identify lumbar spondylolisthesis?

3. Spondylolysis is a defect that affects which portion of the vertebrae?

LUMBAR SPINE


POWERED BYPAGE 2

Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MDLUMBAR SPINE: FOOTBALL PLAYER


A. Extension this typically causes pain

B. Flexion correct: this typically relieves pain

C. Rotation this typically causes pain

D. Side bending this typically will not cause pain if the patient side bends away, but will not be as relieving as flexion

4. Athletes with spondylolysis will prefer to sleep, relax, and even complete exercises in which position/posture of the spine?

In physical therapy, Dr. Kiesel explains why he will emphasize local core training and breathing, especially in the beginning of rehab when the athlete is braced.

CASE STUDY:

Football Player

A. Low repetitions and long holds incorrect

B. Low repetitions and short holds incorrect

C. High repetitions and long holds incorrect

D. High repetitions and short holds correct

5. When training the local core in a patient who typically utilizes a high threshold strategy during movement and core activation, which is the most appropriate for Transversus Abdominis training initially?


POWERED BYPAGE 1

Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MDLUMBAR SPINE: SOCCER PLAYER


CASE STUDY:

Soccer Player with Low Back Pain

CASE STUDY

Todd introduces the patient who already had imaging, has had 6 months of low back pain and no previous history or known injury. She has had no improvement with treatment in training room and has a history of ankle sprains. Refer to the first part of the case video

A. Somatic correct

B. Neurogenic there is no numbness, tingling, etc.

C. Chemical Chemical pain is often stabbing, acute, etc.

D. Psychosomatic given the history, there are no signs or symptoms of psychosomatic pain disorders

1. Low back pain is a common complaint among athletes of all sport types and ages. A 22-year-old soccer player reports to your clinic with insidious onset of low back pain 6 months ago. She reports that her x-rays were negative for significant findings in the lumbar spine. She finds this confusing and questions if the pain is coming from somewhere other than her low back. Which of the following is not a possible cause of her pain?

A. Nerve root compression in the cervical spine correct: this could not refer pain to the lumbar spine

B. Undetected pars defect on plain radiograph it is likely that a pars defect can be missed on plain films

C. Muscular trigger point referral from the abdomen abdominal trigger points refer to the lumbar region

D. Hip mobility dysfunction by way of regional interdependence commonly, dysfunction in joints above and below the region of discomfort are common causes of pain

2. A 22 year-old female with a 6-month history of low back pain enters your clinic. During the subjective history, she describes the pain as deep and achy, and widespread across her back and posterior hips. You feel that her pain is likely in nature.

LUMBAR SPINE


POWERED BYPAGE 2

Kyle Kiesel, PT, PhD, ATC, Todd Arnold, MDLUMBAR SPINE: SOCCER PLAYER


A. Normal and symmetrical Y-Balance Test Lower Quarter all of the tests should be demonstrated, even the YBT-LQ as it demonstrates dynamic stability of the LE and core

B. At least a 2 push-up score on the Functional Movement Screen all of the tests should be demonstrated, push-up demonstrates good trunk control and core stability

C. Negative extension-clearing test on the Functional Movement Screen all of the tests should be demonstrated, the athlete should report no pain with lumbar extension for discharge

D. All of the above should be demonstrated prior to discharge correct

4. During discharge testing from physical therapy, an athlete being treated for low back pain should be able to demonstrate which of the following?

A. External Oblique all the answers can limit extension

B. Lattisimus Dorsi All the answers can limit extension

C. Rectus Abdominis All the answers can limit extension

D. Rectus Femoris All the answers can limit extension

E. All can limit extension correct

3. In patients with low back pain, it is important to address local core training to improve stabilization. However, it is equally important to address mobility deficits throughout the body that may negatively affect movement patterns. Which of the following can limit a standing multi-level extension pattern if there is restriction in that muscle?

Dr. Arnold refers the patient to Physical Therapy with Dr. Kiesel. The patients examination findings were as follows:

Multisegmental flexion: DN

Multisegmental extension: DP

Multisegmental rotation right: DP

Multisegmental rotation left: DN

Single leg stance right: DN

Single leg stance left: DN

Squat: DN

Positive right FABER

Negative ASLR for pain

Positive ASLR > 90 deg,

+ Thomas test for rectus & abduction

CASE STUDY:

Soccer Player with Low Back Pain

lumbar spine athletic

Documents

redistribution kyle

redistribution lumbar

atc todd arnold

md lumbar spine

pain treatment

prevalence kyle kiesel

pain diagnostics

categories of low