Joseph Lee, MD
Injuries to the back are prevalent among athletes. It is estimated that 9 percent of all sport-related injuries involve lower-back pain. In the United States, 50 to 80 percent of the general population will have at least one episode of lower-back pain in their lifetime. In professional sports, lower-back pain is the most common reason that athletes miss a game, match, or contest. Over 90 percent of incidents of back pain are self-resolving (i.e., they heal themselves), so the exact incidence of mid-back (thoracic) and lower-back (lumbar) spine disorders in athletes cannot be determined.
Pain related to the mid and lower back can be caused by muscles, ligaments, discs, nerves, joints, bone, or organs. The spinal column is made up of the spinal bones called vertebrae, which are separated by gel-filled discs known as intervertebral discs. Approximately 33 vertebrae (12 thoracic and 5 lumbar) and 23 intervertebral discs comprise the spinal column. Similar to a jelly donut, the intervertebral disc is made of a central gelatinous material called the nucleus pulposus, which is surrounded by a fibrous band of connective tissue along the periphery called the annulus fibrosis. Discs function as shock absorbers for the spine and prevent direct bone-on-bone contact of the vertebrae. The spinal column is covered by various soft tissues, including muscles, tendons, ligaments, and fascia.
In this chapter, we consider the major causes of back pain related to common injuries in athletes. To maximize performance and minimize injury, athletes should understand the basic diagnostic criteria and preliminary treatment options.
Lumbar Sprain or Strain
Lumbar Degenerative Disc Disease
Annular Tears and Disc Herniations
Transverse Process Fracture
Spinal Compression Fracture
Spinal Burst Fracture
Spondylolysis and Spondylolisthesis
Facet Joint Pain
LUMBAR SPRAIN OR STRAIN
A sprain is a ligament injury caused by overstretching or tearing a ligament. A strain is a muscle injury involving overstretching or tearing of the muscle fibers. Pain from a sprain or strain is a result of the tissue being stressed beyond its pliable range. A sprain or strain can occur in almost any sport, from a contact sport such as rugby to a noncontact sport such as bowling. The lumbar and thoracic regions of the spine contain many layers of ligaments and muscles, so it is often difficult to determine the exact ligament or muscle in which the sprain or strain has occurred, but it is commonly treated in the same way. A sprain or strain is the most common cause of mid- and lower-back pain in the athlete and is most commonly seen in individuals 20 to 40 years of age.
Symptoms of a lumbar sprain or strain generally occur during an athletic event and worsen over a 24-hour period. An increase in discomfort is often felt the day after the inciting injury. The most common symptoms are pain, stiffness, and spasm in the lower back accompanied by occasional radiating pain into the buttock. In this case, the pain radiating into the buttock is called referred pain and would not be caused by nerve irritation (sciatica). Tenderness is usually felt in a small area of the lower back. Pain is exacerbated by certain activities or motions, including bending or arching the back, and is typically improved by sitting or lying down.
The largest muscles of the back, known as the erector spinae, run longitudinally (lengthwise) along the spinal column and aid with extension (bending backward) of the spine. Other major muscles, such as the multifidi group, sit deeper, are adjacent to the vertebrae, run laterally, and aid mostly with rotation and stability of the spine. The smallest and deepest muscles of the spine run within shorter lengths and, for the most part, provide stability to the region along with the ligaments. The muscles of the abdominal wall and the deeper iliopsoas muscles are responsible for anterior stability and flexion. In general, no X-rays are necessary for the first month if the injury is not traumatic or significant.
The initial treatment for any sprain or strain includes applying ice to the painful area three or four times daily. Each time, the ice should be applied in five-minute intervals—five minutes on and five minutes off—for approximately 30 to 60 minutes. If the athlete has no allergies or previous gastrointestinal sensitivity to such medications, an over-the-counter anti-inflammatory such as ibuprofen and an analgesic such as acetaminophen might be useful to alleviate pain and discomfort. These steps will assist in reducing inflammation and pain. In general, relative rest—that is, avoiding activities that exacerbate the pain—is preferred to bed rest. A physician should be consulted if pain does not improve within 48 hours or if there is loss in sensation in the buttocks area, sensory loss, weakness in the lower limbs, or loss of bowel or bladder control.
Once serious injuries are ruled out, other treatments such as a more potent prescription anti-inflammatory medication, muscle relaxants, physical therapy, osteopathic manipulation, chiropractic treatment, medical massage, and acupuncture may be added to speed the recovery process. Physical therapy focuses on stretching exercises for the lower-back and leg muscles to restore a normal lumbar curvature and strengthen the lumbar muscles that contribute to core. Ice, ultrasound, and electrical stimulation may be used as needed to reduce pain and inflammation. Exercises that focus on strengthening the core (thoracic, lumbar, pelvic, abdominal) muscles can further stabilize the spine and help prevent future injuries.
Return to Action
Once full range of motion and simple activities of daily living can be accomplished without pain, the athlete may return to cross-training and sports activity, with pain as the limiting factor. Return to competitive play typically occurs three to six weeks after the injury.
A muscle contusion, commonly called a bruise, occurs frequently in the lumbar and thoracic area, especially in contact or high-impact sports. Contusions occur as a result of direct, focal trauma to the soft tissues. This can occur in contact sports such as rugby, American football, basketball, soccer, boxing, or martial arts; during a fall; or when an athlete accidentally runs into a hard object or surface while playing a noncontact sport. The force of the blunt trauma, if great enough, causes injury to the soft tissue stemming from rupture of the cells. Sometimes that can result in local pooling of blood called a hematoma.
While pain from a lumbar sprain or strain (see p. 201) peaks after about 24 to 48 hours, the localized pain from a contusion progressively worsens over the course of a few days. Pain is generally described as dull and nonradiating and is exacerbated by touching the area. Look for evidence of a bruise (black and blue discoloration called an ecchymosis) and tenderness in a specific area or signs of redness. X-rays or other imaging can rule out more serious injuries such as a fracture (see p. 211) or organ damage such as spleen rupture that can occur as more serious complications of the trauma.
The treatment regimen is similar to the treatment for lumbar sprains or strains and includes relative rest, heat and ice, and anti-inflammatory medications as needed initially. If the contusion or tenderness does not abate within a few days, consult a physician for further evaluation. Also, be aware that organ injury can mimic back pain from the spine. A collapsed lung and kidney contusion are prime examples; the athlete may feel discomfort in the flank area (in the lower back below the bottom of the rib cage) or in the chest. Physician consultation is critical if pain does not subside within a few days or in the case of accompanying symptoms such as abdominal pain or difficulty breathing.
Return to Action
Following a contusion, athletes may return to exercising once they have normal range of motion of the back and are pain free. Typically, return to play takes longer for an athlete involved in a contact sport than for an athlete in a noncontact sport. If there is no suspicion of flank injury (i.e., organ injury), return to sport may occur in three to six weeks. If there is a significant flank injury and organ damage is suspected, the athlete may be out for several months as determined by the physician.
LUMBAR DEGENERATIVE DISC DISEASE
Degenerative disc disease (DDD) is a general term that refers to mechanical and structural changes to an intervertebral disc that can result in disc degeneration as the body naturally ages. It is not an actual disease process, because these are normal changes that occur over time in the general population. Degenerative disc disease leads to the discs drying out, causing them to lose their flexibility and sometimes flatten, resulting in increased stress on the adjacent vertebrae. Over time, this can cause bone spurs to form, facet joints to become more arthritic, and ligaments to thicken.
There have been multiple theories to explain the potential cause(s) of DDD. Although sports activities can potentially aggravate pain from DDD, they do not cause it. Recent literature suggests that genetics play a stronger role in the condition than environmental factors. People who have had a prior disc injury are at greater risk for having discs that deteriorate and become painful.
Findings of DDD on imaging studies are generally asymptomatic and are considered to be incidental findings that do not require treatment. The degree of degeneration noted on imaging has also not been shown to correlate well with the degree of symptoms. Those athletes who develop symptomatic DDD can experience pain in the lower back that is often nonspecific and difficult to pinpoint. If the disc degeneration results in pressure on a spinal nerve in the back, it can result in symptoms of sciatica (see p. 208). X-rays and magnetic resonance imaging (MRI) can show signs of DDD, but, as noted earlier, these do not necessarily correlate well with symptoms.
Various methods can treat symptomatic lumbar DDD. If a short rest and mild analgesic or anti-inflammatory medications do not alleviate symptoms, a physician might place the athlete on oral steroids to reduce inflammation. The athlete is then reevaluated within a week, or sooner if pain or neurologic symptoms are noted.
If there are no special concerns, the athlete may begin a course of physical therapy that focuses on extension-based exercises to reduce pressure on the disc. Lower-back (core) strengthening and stretching should help restore normal function. When symptoms start to improve, the athlete may gradually start to exercise as well. The most important factor in treating this condition is athlete education and maintenance of a core strengthening and flexibility program.
Return to Action
The progression of therapy is guided by the athlete’s pain and ability to tolerate activity. The athlete with symptomatic lumbar DDD can be prone to occasional bouts of back pain and thus needs to regularly perform core strengthening, lower-back and lower-extremity stretching, and extension strengthening exercises to minimize recurrence of pain. All exercises for lumbar DDD, including Pilates and yoga, should be performed with caution. Avoid excesses of range of motion that might lead to aggravation. Modify yoga and Pilates to avoid forceful flexion exercises.
ANNULAR TEARS AND DISC HERNIATIONS
Annular tears and disc herniations are injuries to the intervertebral disc of the spine. Because they can be found on imaging in people with and without spinal pain, it can be difficult to determine whether imaging findings indicate an acute and symptomatic finding.
Annular tears are caused by disruption of the annulus fibrosis (the outer disc layer) without a frank disc herniation. A disc herniation is an injury to the disc in which the gel comes out of the disc through a portion of the annular layer that can no longer contain the gel, and can cause pain from the disc itself (known as disc pain) due to chemical irritation and inflammation or from pinching of a spinal nerve. There are two basic mechanisms of disc- related pain. One relates to chemical irritation caused by the various liquids inherent within the disc’s internal milieu. These liquids help nourish and protect the disc, but when they escape its housing, they cause irritation to surrounding soft tissue and nerves. The other mechanism for pain production is direct mechanical pressure of the disc material onto adjacent structures including nerves.
Herniated discs in the lumbar spine are rather common in athletes, particularly in those between the ages of 20 to 35 years. Annular tears and disc herniations are commonly seen in sports involving heavy lifting, twisting, and torqueing movements, and flexion injuries. Athletes in throwing sports and twisting sports such as tennis, golf, American football, and baseball (pitching), for example, are at increased risk for such injuries. Sports and activities that require extreme range of motion such as gymnastics and yoga also pose an increased risk for such injuries.
Athletes with disc pain generally experience localized, non-radiating lower back pain. Because sitting increases pressure on a spinal disc, athletes with a symptomatic annular tear or herniated disc are typically more comfortable standing rather than sitting. Positions that put more pressure on the disc, such as sitting or bending, typically worsens the pain. Activities that take pressure off the disc, such as lying down, might improve symptoms. No neurologic deficits (weakness, loss of sensation, or leg pain) are noted with disc pain. However, a disc herniation may result in sciatica (see p. 208), which can give symptoms of pain, numbness, or tingling (or more than one of these) radiating down the leg, as well as possible focal muscle weakness due to inflammation or compression (or both) of a spinal nerve. Much as with any injury, athletes tend to compensate by leaning on the nonpainful side.
Most discomfort related to a disc herniation is likely caused by inflammation rather than direct pressure of a disc on a spinal nerve. If an athlete has back pain radiating into the legs with associated weakness, or if any of certain cardinal warning signs are present, a physician should evaluate the athlete as soon as possible because these symptoms indicate radicular pain (sciatica) and may signify a significant spinal nerve injury. The cardinal warning signs include loss of bladder or bowel control, intractable pain, and progressive loss of neurologic function, that is, significant and rapidly progressive weakness.
If symptoms of back pain persist and a disc herniation is suspected, an MRI is recommended. However, the appearance of the spine on MRI does not necessarily correlate with symptoms or the degree of disability. Many people who have herniated discs found on an MRI are not symptomatic. Magnetic resonance imaging is often too sensitive and picks up things that are not clinically significant. But when symptoms do correlate with the findings on MRI, there is a likely association between the disc herniation and symptoms. Discography, in which a needle is inserted into the suspect disc and a mixture of fluid containing dye is injected into the disc to reproduce the patient’s pain, has been utilized to diagnose disc pain, but its use has been limited due to the high rate of false-positive results.
Treatment for a symptomatic annular tear or acute disc herniation is similar to that for lumbar DDD (see p. 204). If relative rest and anti-inflammatory medications do not alleviate symptoms, an oral steroid taper may be considered. The athlete is then reevaluated within a week, or sooner if pain or neurologic symptoms worsen. Symptoms of concern include the cardinal warning signs mentioned earlier. If any of these occur, the athlete should immediately consult a spine surgeon or neurosurgeon.
If there are no special concerns, the athlete may begin a course of physical therapy that focuses on extension-based exercises to reduce pressure on the disc. Lower-back (core) strengthening and stretching should help restore normal function. When symptoms start to improve, the athlete may gradually start to exercise as well. If symptoms fail to improve and there is persistent pain and dysfunction, an epidural steroid injection under X-ray guidance (fluoroscopy), along with continued physical therapy, may be considered. If the athlete still shows no improvement with this conservative treatment, surgery might be considered to remove part of the disc that is compressing the nerve.
In the rare event that an injured athlete has a sudden onset of bowel or bladder incontinence or saddle anesthesia (numbness in the buttock region), emergency evaluation of the patient with an emergent MRI, steroids, and possible emergency surgery may be indicated. This is a sign of a serious neurologic condition in which the herniated disc has compressed a significant portion of the nerves in the spinal canal that supply innervation to the lower parts of the body. The only treatment in this instance is rapid surgical decompression of the disc. Early surgery is advocated with this condition because it can lead to progressive and permanent neurologic deficits such as paralysis.
Return to Action
Return to sport-related activity depends on the symptoms. The athlete should be pain free and should have undergone physical therapy including progressive cross-training, strengthening, and a return-to-sports program. The athlete needs to continue performing a home exercise program created by the physical therapist with the aim of strengthening the core muscles, maintaining flexibility, and relieving pressure from the spine to reduce the chance of recurrence of the symptoms. With conservative treatment for disc pain, the athlete can resume competition in approximately six to eight weeks. With surgical decompression, the athlete is usually out for the season or for at least three months.
Sciatica refers to a spinal nerve that is inflamed and compressed, resulting in lower-back pain radiating into the leg, numbness, tingling, muscle weakness, or some combination of these. It is, in fact, not the sciatic nerve located lower down in the body that is being pinched. The common cause is a herniated disc pressing on (“pinching”) a particular spinal nerve. In older athletes, it can result from spinal stenosis, which is a focal narrowing of the spinal canal. Sciatica pain radiates into the leg in a particular pattern. In addition to pain, it can also result in focal muscle weakness, as well as numbness and tingling.
Magnetic resonance imaging is generally the best imaging test to identify the specific source of the sciatica. However, not all findings on an MRI will be relevant to a patient’s condition. It is important that the imaging findings match up with an athlete’s symptoms. If spinal imaging does not clearly identify clear, focal etiology of the patient’s spinal symptoms and yet sciatica is still suspected, an electromyographic study may be considered.
If an athlete has acute, severe back pain radiating into the legs with significant weakness, or if any of certain cardinal warning signs are present, the athlete should be medically evaluated immediately to rule out a significant spinal nerve injury. Cardinal warning signs for which immediate medical evaluation (i.e., at a hospital emergency room) is warranted include loss of bladder or bowel control, intractable pain, and progressive loss of neurologic function, that is, significant and rapidly progressive weakness.
If symptoms of a pinched nerve persist despite a course of conservative care, an MRI of the spine is recommended. It is important that a person’s symptoms correlate with specific findings on MRI. For instance, if the athlete has lower-back pain radiating into the right leg and the MRI findings include a focal disc herniation to the left side, that finding would not match with the person’s symptoms and would not likely indicate the source of the symptoms.
There are various treatment options for sciatica. If rest and a mild analgesic such as an anti-inflammatory do not alleviate symptoms, a physician might place the athlete on an oral steroid taper to reduce inflammation. The athlete may begin a course of physical therapy that focuses on core strengthening and stretching, which should help restore normal function. Medical massage may also be beneficial to loosen hypertonic tissues and to help mobilize inflammatory fluids from the area. When symptoms start to improve, the athlete may gradually return to exercising as well. If symptoms fail to improve and are persistent, an X-ray–guided epidural steroid injection may also be considered. If the athlete still shows no improvement with this conservative treatment, surgery might be considered to relieve the pressure on the pinched nerve.
In the rare event that any of the cardinal warning signs occur (bladder or bowel incontinence, intractable pain, significant and rapidly progressive weakness), the athlete should immediately consult a spine surgeon. As noted earlier, these are signs of potential serious neurologic injury in which the nerves in the spinal canal may be compromised and can lead to a spinal cord injury. The only treatment in this clinical situation is emergency surgical decompression. Early surgery is advocated in this condition because it can lead to progressive and permanent neurologic deficits such as paralysis.
Return to Action
Similar to the situation with symptomatic disc pain, return to sport-related activity depends on the symptoms. The athlete should be pain free and should have undergone a physical therapy program that includes core flexibility and core strengthening exercises, progressive cross-training, and a return-to-sports program. The athlete should continue a monitored exercise program. With conservative treatment for a pinched nerve, the athlete can resume competition in approximately six to eight weeks. With surgical decompression, the athlete is usually out for the season or for at least three months.
TRANSVERSE PROCESS FRACTURE
The transverse process is a bony protrusion extending off each side of the vertebra. A transverse process fracture typically results from injuries involving high-energy trauma, such as from direct blunt trauma (a violent football tackle), forceful sideways side bending, or avulsion of the transverse process due to a forceful pull by the psoas muscle. These injuries are common in contact or collision sports, especially those in which contact is made on the back, such as American football, rugby, and hockey, as well as in falls that occur in ice skating and horseback riding.
Transverse process fractures are stable fractures that usually have no neurologic symptoms. Physical examination typically reveals tenderness over the fractured area, and a bruise is sometimes apparent. Pain may adversely affect spinal motion. The high-energy impact that caused the fracture may also be sufficient to cause serious internal organ damage. This potential organ injury depends on the level of the spine fracture. If it occurs in the mid-back region (thoracic spine), the lungs, aorta, or pancreas may be affected. A fracture in the lower mid-back may put the kidney at risk. Direct organ injury from transverse process fractures is rare. Nonetheless, it is crucial to assess any signs of abdominal discomfort. Ask if the athlete has difficulties breathing, which may signify a lung injury, or pain with urination (e.g., blood in the urine), which may be caused by kidney injury (see p. 194). X-rays can detect these fractures, but they also often miss such injuries and do not rule out other potential associated internal organ injuries. If the diagnosis is questionable or internal organ injury is suspected, a computed tomography (CT) scan is recommended.
The treatment regimen for an uncomplicated transverse process fracture typically consists of ice, analgesics, a soft brace, and subsequent physical therapy. The goals of physical therapy are to reduce pain, restore motion, and improve flexibility and core strength.
Return to Action
Once pain is managed well enough that the athlete is able to move, begin gradual reconditioning. As pain subsides, the athlete can start sport-specific exercises with the goal of regaining complete range of motion and returning to participation once pain free. Clearance to resume participation is withheld if organ damage is present. The healing of the fracture takes approximately six to eight weeks for young athletes and up to three months for weekend warriors and older athletes.
SPINAL COMPRESSION FRACTURE
A spinal compression fracture is a fracture of the vertebral body that results in compression of the bone. It is caused in athletics by significant trauma that suddenly flexes the thoracic or lumbar spine. When the force is great enough, the vertebral body can collapse upon itself. Fortunately, such fractures of the spine are not common in sports. Sports in which you might see these injuries include tackling sports such as rugby and American football; falling sports such as horseback riding, gymnastics, and track and field; and sports that involve high-velocity crashes in which athletes might land in a flexed position (skiing or cycling). In older athletes with a history of bone loss or athletes with conditions that result in bone loss such as osteopenia or osteoporosis, compression fractures can occur even with milder trauma that would normally not result in fracture or any trauma at all in a young athlete. It should be noted that osteoporosis and osteopenia do not occur only in older individuals; they can be seen in younger people as well, such as in female endurance athletes.
The athlete with a compression fracture has constant, severe pain that is made worse with nearly any motion but especially with flexion. Usually, no neurologic deficits are seen after a compression fracture unless there is a retropulsed bone fragment (a fragment that travels into the spinal canal) that impinges on the spinal cord or spinal nerves. In the event that neurologic injury is suspected, such as paralysis of the arms or legs during the trauma, or other neurologic findings such as numbness, tingling, or weakness in the legs, the athlete should be immediately immobilized and sent to a hospital emergency room for a comprehensive spine evaluation to rule out spinal cord injury. Diagnosis of a compression fracture is made by X-ray. If neurologic injury is suspected, an MRI of the lumbar spine would be indicated.
Spinal compression fractures are typically treated conservatively with analgesics for pain control, 6 to 12 weeks of bracing, and subsequent physical therapy. Cementing procedures done for compression fractures such as balloon kyphoplasty or vertebroplasty have not been shown in the medical literature to be more effective than conservative care and are generally not recommended. Surgery is indicated in rare cases, notably when neurologic compromise has resulted from the fracture.
Return to Action
Rehabilitation focuses on returning to activity without pain. Core muscle strengthening and reconditioning exercises should be included. For noncontact sports, athletes can probably return to play within 12 weeks if they have obtained full range of motion without pain. For contact sports, athletes should be advised of the risks of a repeat fracture and must weigh the risk-to-benefit ratio. Repeat fractures or further collapse of the vertebrae could cause postural changes and lead to painful conditions in the future. If “weak” bones are suspected, a recommendation by the athlete’s physician for osteoporosis testing via bone density testing may be suggested.
SPINAL BURST FRACTURE
Burst fractures are caused by a combination of axial (vertical) loading and flexion of the spine. In a burst fracture, the force of the trauma causes the vertebra to burst apart like a smashed pretzel rather than to collapse upon itself as is seen with a compression fracture. Because of the type of fracture, a fragment of bone might lodge itself in the spinal canal. This is most severe when a bone fragment is propelled into the spinal canal and injures the spinal cord. Athletes at risk are those who play sports in which high-force blows to the spine occur or there is a significant risk of falls from an elevated height. Rock climbers, horseback riders, American football players (especially those who might get thrown airborne or who tackle with their head down), ski jumpers, and cliff divers are all at risk of sustaining a burst fracture.
Treat on-the-field spinal injuries with great care and caution. These injuries should be viewed as medical emergencies. Any indication of weakness of the arms or legs or acute spine pain caused by trauma warrants immediate immobilization on a spine board by trained professionals and immediate transfer to a hospital emergency room. A burst fracture that propels bone into the spinal canal will likely result in a spinal cord injury, which can cause paralysis of both legs (for thoracic and lumbar burst fractures), as well as bowel and bladder incontinence.
Once at the emergency room, an athlete with a spinal cord injury will likely receive high-dose intravenous steroids, immediate MRI, and surgical evaluation. If a spinal cord injury has occurred and surgery is performed, the athlete will likely require intensive inpatient rehabilitation to recover to the best functional level that neurologic impairment allows. When appropriate, a rehabilitation counselor, physical therapist, or physiatrist can recommend a program for disabled athletes. Such programs are available in larger communities.
Return to Action
Recovery from surgery depends on the degree of nerve injury and can vary from full recovery to permanent paralysis. Healing occurs for up to 12 months, and continued rehabilitation most often is ongoing for several years or a lifetime. High-impact and high-risk sports are usually not permitted after these injuries.
SPONDYLOLYSIS AND SPONDYLOLISTHESIS
Spondylolysis (pars fracture) is a stress fracture in the posterior part of the vertebra known as the pars interarticularis. The injury is caused by repetitive hyperextension (bending backward) of the lumbar spine and is common in teenage athletes whose bones have not fully matured. It is commonly seen in sports that involve repetitive twisting and loading of the spine, such as gymnastics, wrestling, American football, and tennis. It is more common in females than males. It most often occurs at the lowest two lumbar segments (L4 and L5).
Spondylolisthesis (slippage) refers to a slippage of one vertebral body over the one below it. There are various types of spondylolistheses. In athletes, it is usually caused by stress fractures (specifically a pars stress fracture) on both sides of a vertebral body, which can allow the vertebra to slip forward.
Symptoms of spondylolysis are generally described as dull, lower-back pain, occasionally radiating into the buttocks. Physical examination tends to reveal pain with extension with no evidence of neurologic deficits. Spondylolysis must be suspected in any young athlete with extension-based pain who does not respond to conservative treatment, including analgesia and therapy, within a short time. Early evaluation of spondylolysis is crucial to prevent further damage. Because X-rays of the spine might not reveal findings early enough, a bone scan is often recommended if spondylolysis is suspected. Alternatively, high-field MRI and spiral CT scans can be helpful if a pars stress fracture is suspected and X-ray and bone scan tests are negative.
Spondylolisthesis does not typically result in pain. However, it can result in sciatica due to spinal nerve root irritation or compression (or both) because of the bony slippage. Spondylolisthesis can be detected on a plain X-ray. Flexion and extension views are needed to assess if the degree of slippage changes with spinal motion, which would be indicative of an instability at that spinal level and is believed to be a much greater source of pain. An MRI of the lumbar spine is helpful if there are sciatica symptoms or spinal stenosis. Spondylolistheses are graded from I to V, with each number representing further slippage of a vertebra with respect to the one directly below it. Surgical treatment is considered in grades III, IV, and V or if the athlete continues to experience pain radiating into the legs despite conservative treatment, or for a symptomatic, unstable spondylolisthesis.
Athletes with an acute spondylolysis will be braced in an orthotic that prevents spinal extension until they are pain free for at least six weeks. The duration of treatment depends on whether symptoms are acute or chronic, the degree of pain, and whether there is a stress reaction or fracture.
Athletes for whom the problem is not caught early on might eventually develop chronic episodic recurring pain from spondylolysis itself or spondylolisthesis that causes nerve compression. These athletes will be treated with analgesics or anti- inflammation drugs (or both), muscle relaxants, and opioids, if needed. Physical therapy should focus on core stabilization, neutral spine pelvic floor strengthening, and biomechanics. Epidural steroid injections may be indicated in those who have persistent sciatica symptoms.
Return to Action
An athlete recovering from spondylolysis or spondylolisthesis is not allowed to participate in sports but may perform low-impact aerobic exercises such as bicycling with the brace. Physical therapy entails aerobic exercises as well as stretching of the lower-extremity muscles and core strengthening. Maintaining the routine core strengthening exercises as instructed by the physical therapist is important in preventing recurrent symptoms. Return to athletic participation after a diagnosis of acute spondylolysis or spondylolisthesis can range from 3 to 12 months, depending on the progress of healing and stability of the spine as assessed on follow-up X-rays. Return to sport is usually limited to a level of participation that does not exacerbate pain.
FACET JOINT PAIN
A spinal joint is known as a facet joint or a zygapophyseal joint. Facet joints are located on the posterior and lateral aspects of the spine, and they connect the posterior or rear portion of the adjacent vertebrae. Facet joint pain is caused by inflammation or arthritis of the facet joint. The facet joint is a true synovial joint, and when injured or inflamed can become swollen. Athletes at risk for injuring facet joints are those who perform rotational movements, such as golfers, tennis players, and baseball pitchers.
Athletes generally complain of localized lower-back pain exacerbated by extension and rotation and relieved by flexion. Pain often radiates into the buttock on the same side. However, facet joint pain is not easily identified on clinical exam. In suspected cases, diagnosis can be confirmed by a diagnostic facet joint injection or a diagnostic medial branch block, which blocks the nerves that supply sensation to the facet joint with an anesthetic agent.
Initially treat facet joint pain with ice, analgesics, and anti-inflammatory medication. The athlete should avoid activities that cause pain. Physical therapy that focuses on strengthening the core muscles and stretching the leg muscles should be undertaken. Ultrasound, ice, and moist heat can be used to control pain. Avoid spinal extension in the early stages, but introduce it as symptoms are controlled. The athlete needs to learn to use core muscles during activity to prevent hyperextension of the spine during motion and to avoid straining the facet joints. In cases in which these treatments do not resolve the pain, other procedures must be considered, including interventional spinal procedures such as fluoroscopic-guided facet injection or blocking and ablating the nerves that supply the injured joint.
Return to Action
Athletes may return to sport once there is no exacerbation of pain in practice and sport-specific training, and core muscles have strengthened. This can occur in a relatively short period of time (two to three weeks) if only a synovitis is present, but may take much longer (three months or more) if there are bony changes in the facet joint. Athletes with chronic facet pain may choose to continue to play sports but will need to modify their activity. If an athlete is willing to put up with a mild flare of pain for a day after sport and the condition is not deteriorating, there is no real health risk in continuing. Chronic patients sometimes preload with over-the-counter anti-inflammatory medications before an athletic contest, which is not recommended; chronic use of anti-inflammatories can lead to adverse side effects such as gastritis or stomach ulcers and potential kidney damage. Anti-inflammatories may also mask symptoms, allowing the athlete to continue participating with the risk of causing further damage.
*The author would like to acknowledge the contribution of Stuart Kahn and Arjang Abbasi to this chapter.