Low back pain usually affects an athlete at some point. This pain can be from overuse or acute trauma. Complaints may range from mild to severe pain after a game or practice. Some injuries are characteristics of certain sports, such as:

Position, hours, and number of years played can influence overuse. Predominantly axial low back pain suggests so-called internal disk disruption from degenerative disk disease, also known as discogenic low back pain. Predominantly leg symptoms suggest radiculopathy from a herniated disk or degenerative nerve compression. Infections, tumors, and inflammatory arthritis more typically are suggested by nonmechanical back pain, such as night pain and pain at rest. Fever, malaise, and weight loss are additional red flag signs.

In 2015, Schroeder et al. studied the effect of pre-existing lumbar spine conditions on the careers of National Football League (NFL) athletes. They reviewed the medical evaluations and imaging of athletes at the NFL combine from 2003 to 2011. Prospective players with a pre-existing lumbar spine diagnosis were analyzed against healthy controls. This group found that players with a pre-existing lumbar spine diagnosis were less likely to be drafted. In addition, those who were drafted with a diagnosis of spondylolysis/spondylolisthesis had significantly shorter careers. In contrast, players with lumbar disk herniations did not exhibit a significant difference in career longevity.

Patients with a pre-existing lumbar spine diagnosis displayed no significant difference in graded performance compared to controls. Players who underwent operative management of lumbar disk herniations displayed no significant difference career longevity or graded performance compared to players treated nonoperatively. Two players in the study had undergone previous posterolateral lumbar fusion with instrumentation, both of whom went on to have successful careers without evidence of serious neurologic injuries at the time of the study. These results are similar to those that have been reported for athletes in the National Hockey League (NHL) and Major League Baseball (MLB) who had also gone on to have successful careers without neurologic compromise.

The work-up for an athlete with symptoms of low back pain with or without radiculopathy is similar to nonathlete patients. An accurate history and physical examination are essential. Key points to obtain from the history include:

Key points to assess during the physical examination include:

By history, examination, or investigative studies, the diagnostic work-up should first rule out the possibility of tumor, infection, and impending neurologic crisis, such as an unstable fracture. Excluding these conditions, if the main complaint is leg pain, plain x-rays and magnetic resonance imaging (MRI) should be obtained to reveal any nerve root compression from disk or bony structures. A noncontrast enhanced computed tomography (CT) can be obtained if the cause of pain remains unclear and an osseous source is suspected. A CT myelogram can be obtained if an MRI cannot be obtained. A single-photon emission computed tomography (SPECT) scan is particularly helpful for the detection of pars stress reactions, that is, characteristic bone activity that is present prior to frank pars fracture (spondylolysis). Currently available software can merge the CT and SPECT images together to illustrate such lesions (Fig. 9.1). Though less sensitive, an MRI can also show such stress reactions. Electromyography (EMG) and nerve conduction velocity (NCV) studies can help differentiate a peripheral nerve lesion from a radiculopathy, though it is not indicated for routine evaluation of back and leg pain.

In 2015, Schroeder et al. studied the effect of pre-existing lumbar spine conditions on the careers of National Football League (NFL) athletes. They reviewed the medical evaluations and imaging of athletes at the NFL combine from 2003 to 2011. Prospective players with a pre-existing lumbar spine diagnosis were analyzed against healthy controls. This group found that players with a pre-existing lumbar spine diagnosis were less likely to be drafted. In addition, those who were drafted with a diagnosis of spondylolysis/spondylolisthesis had significantly shorter careers. In contrast, players with lumbar disk herniations did not exhibit a significant difference in career longevity.

Patients with a pre-existing lumbar spine diagnosis displayed no significant difference in graded performance compared to controls. Players who underwent operative management of lumbar disk herniations displayed no significant difference career longevity or graded performance compared to players treated nonoperatively. Two players in the study had undergone previous posterolateral lumbar fusion with instrumentation, both of whom went on to have successful careers without evidence of serious neurologic injuries at the time of the study. These results are similar to those that have been reported for athletes in the NHL and MLB who had also gone on to have successful careers without neurologic compromise.