Non-Operative Approach to Back Pain in the Athlete

Non-Operative Approach to Back Pain in the Athlete
Amity Rubeor, DO
248
Non­Operative Approach to Back Pain in the Athlete
VCU Sports Medicine Update in Primary Care
December 4, 2011
Amity Rubeor, DO
Assistant Professor (clinical)
Brown Family Medicine Residency I have no actual or potential conflict of interest in relation to this program or presentation
Incidence of Back Pain in Athletes
More likely to have a “pathoanatomical
” cause
More likely to have a “pathoanatomical” cause
– Spondylolysis
– Spondylolisthesis
– Herniated disc
Majority of cases etiology is hard to identify
Evidence supporting specific treatments is sparse 249
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What we all think of…
Back Pain in the Athlete: Etiologies
Adolescents
Soft Tissue
– Lordotic low back pain
Vertebral Complex
– Posterior Elements of spine
Spondylolysis
Pedicle stress fracture
– Anterior Element of spine
Scheuermann Disease
Vertebral Apophyseal Injury
Adults
Soft Tissue
– Musculoligamentous strain/sprain
Vertebral Complex
– Posterior Elements of spine
Facet Syndrome
– Anterior Elements of spine
Herniated Disc
Sacroiliac Joints
Sacroiliac Joints
Back Pain in the Athlete: Etiologies
Adolescents
Soft Tissue
– Lordotic low back pain
Vertebral Complex
– Posterior Elements of spine
Spondylolysis
Pedicle stress fracture
– Anterior Element of spine
Scheuermann Disease
Vertebral Apophyseal Injury
Adults
Soft Tissue
– Musculoligamentous strain/sprain
Vertebral Complex
– Posterior Elements of spine
Facet Syndrome
– Anterior Elements of spine
Herniated Disc
Sacroiliac Joints
Sacroiliac Joints
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2
Back Pain in the Athlete:
Conservative Treatment
Physical therapy
– Core stability
– McKensie technique
Spinal Manipulation
– Chiropractic medicine
– Osteopathic Manipulative Medicine
Traction
Medications
Overview
Etiologies
– Key history components
– Special tests
Imaging
Treatment
Musculoskeletal Back Strain
Common cause of back pain in the athlete
Irritation and/or “micro‐
Irritation and/or “micro‐rupture” in the paraspinal muscles
Can be acute or chronic
Gurd DP. Back Pain in the young athlete. Sports Med Arthr Rev 2011, 19:7‐16
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Musculoskeletal Back Strain: History
c/o: tightness, limited ROM, “burning” or “achy pain”
PQRST: short interval pain after an event
Video games? Back pack? – Those playing > 2 hours of video games per day – A backpack or the amount of weight in a back pack
Training schedule–
Training schedule– recently increased?
Musculoskeletal Back Strain:
Exam
Standing
– Taught paraspinal
Taught paraspinal muscles (“cords”)
– Limited forward bending
– Increased lumbar lordosis
Increased lumbar lordosis
– Negative stork test
Gait
Seated: taught paraspinal
Seated: taught paraspinal muscles
Supine: increased lumbar lordosis
Supine: increased lumbar lordosis
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Musculoskeletal Back Strain:
Imaging and Treatment
Plain Xrays: negative
Rest and ice
Massage
Spinal Manipulation
– Chiropractic
– Osteopathic
– Other
Physical Therapy
Musculoskeletal Back Strain:
Spinal Manipulation
2008 Cochrane Review1
– More effective than sham therapies
– No more effective that physical therapy or analgesics
Theorized effective by Flynn et al2…
– No symptoms distal to knee
– Duration of symptoms < 16 days
– Lumbar hypomobility
Lumbar hypomobility
1: Assendelft WJJ et al. Spinal manipulative therapy for low‐back pain (review). The Cochrane Collaboration 2008
2: Hebert J et al. Clinical prediction for success of interventions for managing low back pain. Clin in Sports Med 2008; 27: 463‐479
Musculoskeletal Back Strain:
Physical Therapy
McKensie technique:
– Repeated end‐
Repeated end‐range movements
– Centralization: movement in direction that relieves pain or paresthesias
relieves pain or paresthesias
– Extension is a common exercise movement in athletes
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Lordotic Low Back Pain
Also known as Posterior Element Overuse Syndrome
Axial skeleton grows quickly
Soft tissue (thoracolumbar fascia) grows slowly
TIGHTNESS in ligaments and muscles
Stress on spine
Lordotic Low Back Pain
“Constellation” of conditions…
– Muscle‐
Muscle‐tendon units
– Ligaments
– Facet Joints
Tight hamstrings can complicate lordotic LBP by increasing the lordotic curve
Normal extensor to flexor ratio is 1.3 to 1.0
Purcell L, Micheli L. Low back pain in young athletes. Sports Health: A multidisciplinary approach 2009;1: 212
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Lordotic Low Back Pain:
History
c/o: achy pain, limited ROM
PQRST: gradual onset, crescendo
Age: growth spurt
Activity: high intensity, stability
Lordotic Low Back Pain:
Exam
Standing
– Paraspinal muscle spasm and point tenderness
– Hyperlordotic
– Hamstring spasm
– Negative Stork test
Gait
Seated: paraspinal spasm and point tenderness
Supine: increased lordosis
increased lordosis
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Lordotic Low Back Pain
Traction apophysitis may occur – iliac crest – spinous process
– anterior vertebral ring apophysis Impingement of adjacent spinous processes can occur, forming a pseudarthrosis
– Baastrup's syndrome
Lordotic Low Back Pain:
Imaging and Treatment
Plain x‐
Plain x‐rays: negative
Rest, ice
Massage
Osteopathic Manipulation
Physical Therapy: –
–
–
–
Thoracolumbar and peripelvic stretching
Core stabilization
Flexion exercises
Balance of extensors to flexors: 1.3 to 1.0 ratio
Lordotic Low Back Pain:
Physical Therapy
Functional deficits of the trunk muscles
May effect stability of lower back
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Back Pain in the Athlete: Etiologies
Adolescents
Soft Tissue
– Lordotic low back pain
Vertebral Complex
– Posterior Elements of spine
Spondylolysis
Pedicle stress fracture
– Anterior Element of spine
Scheuermann Disease
Vertebral Apophyseal Injury
Adults
Soft Tissue
– Musculoligamentous strain/sprain
Vertebral Complex
– Posterior Elements of spine
Facet Syndrome
– Anterior Elements of spine
Herniated Disc
Sacroiliac Joints
Sacroiliac Joints
Anterior Elements of the Spine
Purcell L, Micheli L. Low back pain in young athletes. Sports Health: A multidisciplinary approach 2009;1: 212
257
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Scheuermann Disease
Rounding of the thoracic or lumbar spine
– Anterior wedging of 1 to 3 vertebrae
– Lumbar disease: overuse (flexion) in athletes
Characterized by…
– Endplate irregularity or fracture
– Nuclear herniations (Schmorl’s nodes)
– Possible vertebral apophyseal avulsions
Scheuermann Disease:
History
c/o: poor posture, sharp pain with bending forward
PQRST: worse with sitting or activity
Males>females
Sports: rapid flexion and extension
– Diving, gymnastics
– Rowing
– Football: offensive lineman Scheuermann Disease:
Exam
Standing
– Decreased lordosis
Decreased lordosis
– Decreased kyphosis
Decreased kyphosis or “flat back”
– Pain with forward flexion
Gait
Seated: paraspinal spasm
Supine: tight hamstrings
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Scheuermann Disease:
Imaging/Treatment
Plain Xrays
Rest, activity modification
Physical Therapy
– Core stability
– Extension exercises
Lordotic bracing
Vertebral Apophyseal Injury
Apophysis fuses to vertebral body at 17 years
Approximately 50%: acute trauma
– Avulsion fracture with a disc herniation
– Most common at the inferior apophysis of L4
Repetitive microtrauma
Repetitive microtrauma
– Repetitive flexion
– Traction
Sassmannshausen G, Smith BG: Back pain in the young athlete. Clin Sports Med 2002, 21:121
121–
–132.50.
G, Smith BG: Back pain in the young athlete. Clin
Sports Med 2002, 21:
Vertebral Apophyseal Injury: History
c/o: can present like a herniated disc
PQRST: worse with coughing, sneezing
Sport: repetitive flexion and extension
– Volleyball, wrestling
– Weight lifting
Age
.
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Vertebral Apophyseal
Vertebral Apophyseal Injury:
Exam
Standing: limited flexion and extension
Gait: difficulty with heal and toe walk
Seated: normal neuro exam
Supine: positive contralateral
positive contralateral straight leg raise
Vertebral Apophyseal Injury:
Imaging/Treatment
MRI may be inadequate to differentiate between bone and disc material
– X‐ray or CT may reveal a small avulsion fracture
Rest
Core stabilization Surgical excision of the avulsed fragment in a vertebral ring apophyseal injury
Back Pain in the Athlete: Etiologies
Adolescents
Soft Tissue
– Lordotic low back pain
Vertebral Complex
– Posterior Elements of spine
Spondylolysis
Pedicle stress fracture
– Anterior Element of spine
Scheuermann Disease
Vertebral Apophyseal Injury
Adults
Soft Tissue
– Musculoligamentous strain/sprain
Vertebral Complex
– Posterior Elements of spine
Facet Syndrome
– Anterior Elements of spine
Herniated Disc
Sacroiliac Joints
Sacroiliac Joints
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Gurd DP. Back Pain in the young athlete. Sports Med Arthr Rev 2011, 19:7
DP. Back Pain in the young athlete. Sports Med Arthr
Rev 2011, 19:7‐‐16
Hebert J et al. Clinical prediction for success of interventions for managing low back pain. Clin
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