A Case of Low Back Pain

A Case of Low Back Pain

Tina Gaston, ATC

Steadman Hawkins Sports SymposiumJune 7, 2013

History

• 14 year old male, right handed

• Football player: back up QB, WR, Safety

• Tae Kwon Do from 6 to 12 years old

• Church basketball

Presentation

• Low back pain intermittent through out TKD for 6 years

• Increase in low back pain after sprinting during spring football conditioning and throwing football

• no complaints of radiating symptoms

Observation

• Pain was always reported on Left side

• Muscle spasms on Left side only

• Point tenderness to Left of spinous process, L4/L5

• Full range of motion of lumbar and thoracic spine

• Pain with right rotation, throwing

Treatment

• Modified throwing activity

• Heat, ice and electrical stimulation for pain control

• Core strengthening

• Due to long history of back pain referred to Dr. Sease within 1 month of complaint

Differential Diagnosis

A) Strain

B) Disc herniation

C) Pars defect (spondylolysis)

D) UTI

E) Tumor

Matt Baird, MD


SpondylolysisDiagnosis & Management

Objectives

• Consider the complaint of low back pain in the athlete

• Briefly discuss the pathophysiology and diagnosis of spondylolysis (aka pars defect)

• Discuss treatment, specific rehabilitation techniques/protocols and RTP guidelines

Low Back Pain in Athletes• Epidemiology

– 10-15% of young athletes• 27% of Football players• 50% of artistic gymnasts• 86% of rhythmic gymnasts

– Incidence is quite different from the adult population

Low Back Pain in Athletes• Epidemiology

– Pars interarticularis injuries: 47% of young athletes (<18) with back pain vs 5% in adults

– Intervertebral Disc pathology: <11% in children vs 48% in adults

oocities.com

Low Back Pain in the Athlete

Take Home Point:

TAKE IT SERIOUSLY…

IT IS PROBABLY SOMETHING!!

Spondylolysis in the Athlete

Spondylolysis

• Definition – Stress fracture of the pars

interarticularis• Incidence

– 5% in North American Population• Age

– 0% at birth, reaches 5% by age 6• Sex

– 2-3 X more common in males – Spondylolisthesis more common in

females (2-4X)• Other Risk Factors

– Hyperlordosis– Genetics: 6X more common in

families with affected members

scottlaneycansell.wordpress.com

back.com

Spondylolysis

• Pathophysiology – Congenital vs Acquired– repetitive extension and rotation of lumbar spine– Rarely an acute injury– Most common at L5 (71-95%), followed by L4 (5-

23%)– Bilateral in as high as 89%

Spondylolysis

• Pathophysiology– What do we want to

avoid?

• Spondylolisthesis!– Slippage of one vertebra

over another– 15% of 1st graders with

spondylolysis progressed to spondylolisthesis (Frederickson, et al)

scoliosisassociates.com

triangledisc.com

Spondylolisthesis

• Grade 1: up to 25%• Grade 2: 26 to 50%• Grade 3: 51 to 75%• Grade 4: 76 to 100%• Grade 5: >100%

(spondyloptosis)

Stable

Unstable

agingspinecenter.com

Spondylolysis:Diagnosis

• History– Insidious onset of

extension-related LBP– Radicular symptoms are

occasionally reported– Pain with impact (tackling,

running, jumping)

bioathleticcenter.com


• Exam– Lumbar extension elicits pain

• Stork test – Masci, et al determined poor sensitivity and specificity with MRI/bone scan in 2006

– Hamstring Tightness (popliteal angle)

– Acquired scoliosis • Due to pain• C-shaped

– Gait disturbance• Crouched, short stride,

incomplete swing phase– Hyperlordosis, spasm

Pucell L, Michele L. Low back pain in young athletes. Sports Health. 2009; 1:212-222


• Radiographs– Lateral: slip, old pars fractures– Oblique: stress reaction of

pars • “neck of scotty dog”

– AP: other associated variants• Transitional vertebra, spina

bifida occulta (Steiner)

• Plain radiographs only identify 1/3 of defects– McTimony, 2003

• Do not let normal plain films reassure you

ajs.sagepub.com

ep.bmjjournals.com

sph.sagepub.com

Our Patient


• Advanced ImagingModality Pros Cons

CT with reconstruction

1. Most accurate bony defect

2. Osseous healing

1. Does not detect stress response

2. Ionizing radiation

SPECT 1. Stress reaction2. Distinguishes

acuity

1. Not as sensitive for detecting pars fracture

2. Radiation

MRI 1. Stress reaction2. Suggestive of

acuity3. IDs other

pathology4. No radiation

1. Not as sensitive for detecting pars fracture


• Advanced Imaging

– So what is the best test?• Established Literature: SPECT/CT• More recent literature: ? MRI

– “Magnetic resonance (MR) imaging should be used as the primary investigation for adolescents with back pain and suspected stress reactions of the lumbar pars interarticularis.”

• Leone et all, 2011 review article

Our Patient

Spondylolysis:Management

• Painless rest– No contact, extension, or

other painful activities

• Physical Therapy– Flexion-biased core

program

• Bracing?• TENS unit/bone stim?

kisersoandp.com


• Return to Play

– Hotly debated

– Pain free, FROM, normal strength and balance

– ~90% RTP by 5.5 months (Iwamoto, ‘01)– Average time out of sport: 3.9 months– Average time to full play: 5.2 months (Alvarez-Diaz, ‘11)

• EXPECT AT LEAST 3 MONTHS


• Follow up– Annual evaluation indicated through skeletal

maturity for those with pars defect– Repeat imaging dependent upon symptoms and

expectations– Goal is for fracture healing, but non-union does not

compromise outcome or RTP


• What if they don’t get better?– Failed >6 months of non-op

care– Pars Repair vs Fusion

• Candidate for pars repair if there is no slip/instability, and disc is normal

• Diagnostic pars injections may be used for treatment planning

Jenn Backs PT, DPT


SpondylolysisRehab & Return to Sport

Treatment Goals

Alleviate pain

Address risk factors to prevent further slip & instability

Pain-Free Return

Initial Injury

Return to

Sport

Initial Injury

Return to

Sport

Phase 1

Phase 2

Phase 3

Phase 4

• Biomechanical Factors– Lumbar Lordosis– Thoracic kyphosis– Flexibility

• Iliopsoas• Thoracolumbar Extensors

– Abdominal weakness

(McCleary 2007)

Risk Factors

Comprehensive Rehab Program Should Include…

Week 0-2

Minimize pain

Isolated muscle activation

Improve Flexibility

Improve Postural deficits

Phase 1 – Isolated Training

REST

• Cessation of aggravating activities

• Shortest time that healing is evident on serial imaging studies = 3 mos

(Standaert 2007)

ICE AND TENS

Minimize Pain

AVOID LUMBAR EXTENSION

Improve Flexibility/ROM

Improve Flexibility/ROM

Quadriceps Hip FlexorsThoracolumbar

Extensors

Isolated Muscle Activation

Transverse Abdominis

Multifidus

Muscle Activation

Transversus Abdominis

Stabilization of lumbar spine via attachment to thoracolumbar

fascia(Hides 2006)

Increase in intra-abdominal pressure

(Hodges 1996)

Muscle Activation

• Abdominal “Drawing-in” tension in anterior abdominal and posterior thoracolumbar fascia

(Hides 2006)

• More selective of TrA activation vs. posterior pelvic tilt

(Hodges 1996)

Training the TrA

Multifidus

Compressive force and segmental motion control

(Garet 2013)

Muscle Activation

• Significant IO and MT activity in poor sitting and standing posture

• TrA activation in erect postures vs. slumped sitting or sway back standing

(Reeve 2009)

Postural Re-Education

Pain ≤ 4/10

10 second TrA & MT activation

Good spinal stability with extremity movements

Oswestry < 30%

Progression to Phase 2

Week 3-8Minimize pain

Flexibility & ROM

Muscle Endurance

Integrate local muscle system

with global muscle system

Balance/dynamic activities

Phase 2 – Integrated Training

• Initiate gentle lumbar ROM as tolerated– Avoid Hyperextension

• Cardio endurance– Stationary Bike– Elliptical– Treadmill walking

Phase 2 Activities

Lumbar Spine = Fulcrum for extremity movements

Core Function = Provide stable base for extremity movement

Integrate Global with Local

LE Strength + Core Activation

Add Resistance Unstable Surfaces

Pain ≤ 2/10

Improving Core Stability

Full LE flexibility

LE strength = 4/5

Lumbar ROM WNL, no aberrant motion

Oswestry <20%


Week 9-12

Improve endurance/strength

Core control during dynamic functional movement patterns

Protected functional activities

Phase 3 – Dynamic Functional Training

Continue Progression from Phase 1 & 2

Improve Endurance/Strength

Dynamic Functional Movement Patterns

“Pre-Sport” Specific Activities

• Prone Double Leg Rasie

• Supine Chest Rasie

• Lateral Plank

• Prone Plank

• Supine DL Lowering

• Sorenson

Endurance Tests

0/10 Pain

5/6 endurance tests >30 seconds

Maintain LE flexibility

LE strength 4+/5

ODI <10%


Week 12-16

Maximize Strength and Endurance

Integrate sport specific activities

Prepare for return to sport and return

to play

Phase 4 – Return to Sport

Return to Sport

• Pain-free ROM, normal strength and conditioning, pain-free sport activities

(Cassas 2006)

• Sufficient cardio conditioning; full participation without symptoms

(Standaert 2005)

• Full, pain-free ROM; appropriate cardiorespiratory conditioning, sport specific activity without pain

(Standaert 2007)

• Painless spine ROM; unrestricted activity without pain

(Herman 2003)

What the Literature Says

Pain-free ROM

Cardiorespiratory Conditioning

Normal strength

Pain-free with sporting

What the Literature Says

Pain 0/10

5/6 endurance tests >60 seconds

LE and trunk strength 5/5

ODI <10%

RTS Criteria

●Diagnosis prior to overt fracture development

●Shorter symptom duration improved prognosis

●Therapeutic window limited at time of (+) bone scan

●Unilateral lesions more likely to heal

(Sys 2001)

Prognostic Factors

Our Case

• Rest

• Bracing

• Progressive therapy program

• Returned to play after 3 months

• Pain free throughout the following football season

Key Points

• Low back pain in athletes should be taken seriously

• Consider spondylolysis early and refer for prompt diagnosis

• Rest and step-by-step supervised rehab is the mainstay of treatment

• Return to play depends on the athlete’s ability to achieve certain goals at each stage of rehab– Expect at least 3 months

Thank You!

References• Alvarez-Diaz P, et al. Conservative treatment of lumbar spondylolysis in young soccer players.

Knee Surg Sports Traumatol Arthrosc. 2011 Dec;19(12):2111-4• d’Hemecourt PA, Gerbino II PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med.

2000;19:663-679.• Fredrickson BE, Baker D, et al. The natural history of spondylolysis and spondylolisthesis. JBJS.

1984;66(5):699-707.• Gregory PL, Batt ME, Kerslake RW, Webb JK. Single photon emission computerized tomography

and reverse gantry computerized tomography findings in patients with back pain investigated for spondylolysis. Clin J Sport Med. 2005;15:79-86.

• Hutchison MR. Low back pain in elite rhythmic gymnasts. Med Sci Sports Exerc. 1999;31:1686-1688.

• Iwamoto et al. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports. 2004.

• Kolt GS, Kirkby RJ. Epidemiology of injury in elite and subelite female gymnasts:a comparison of retrospective and prospective findings. Br J Sports Med. 1999;33:312-318

• Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lumbar spondylolysis: a review. Skeletal Radiology. 2011;;40(6):683-700.

• 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. Br J Sports Med. 2006;40:940-946.

• McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sport Med Rep. 2003;2:41-46.

• Pucell L, Michele L. Low back pain in young athletes. Sports Health. 2009; 1:212-222.• Semon RL, Spengler D. Significance of lumbar spondylolysis in college football players. Spine.

1981;6:172-174.• Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the

modified Boston brace. Spine. 1985;10:937-943.• Zetaruk M. Lumbar spine injuries. In: Micheli LJ. Purcell LK, eds. The Adolescent Athlete. New

York: Springer; 2007:109-140.

A Case of Low Back Pain

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