Introduction
- Christopher J. Durall, PT, DPT, MS, SCS, LAT, CSCS
- Brian K. Allen, DO
Epidemiology
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Lumbar spine injuries in athletes are relatively common and most of these are thought to be strains (partial or complete tears of muscle-tendon units) and/or sprains (partial or complete tears of ligamentous/capsular/discal tissues).
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Among collegiate athletes, men’s wrestling, football, and women’s gymnastics have the highest rates of low back injury, with an occurrence of 0.36 to 0.49 injuries per 1000 athlete exposures. Approximately 80% of these are thought to be lumbar strains or sprains.
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Among high school athletes, 7% to 13% of all sports injuries are lower back injuries, of which muscle strains account for roughly 60%.
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Low back injuries are the most common type of injury in competitive weightlifters, affecting approximately 23% of these individuals. Roughly 82% of these injuries are believed to be strains/tendonitis or sprains.
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Low back pain is the most common musculoskeletal problem reported by both amateur and professional golfers, and most of these injuries are thought to be strains or sprains.
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The majority of low back injuries occur during competition, although women’s basketball, volleyball, and field hockey have higher rates of low back injury during practice.
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Among football players, linemen seem to be more vulnerable to low back injury compared with other positions.
Pathophysiology
Intrinsic Factors
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History of previous back injury or back surgery, obesity, structural deformity (e.g., scoliosis, spondylolysis, hypermobility, leg-length inequality) all appear to elevate risk of future low back sprain/strain.
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Reduced trunk extensor muscle endurance has been found to be a risk factor for nonspecific LBP.
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Lack of adequate trunk muscle endurance, in general, may lead to increased loading of the passive low-back structures (ligaments, capsules, discs), which may increase the risk of future lumbar sprain.
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Contrary to popular belief, a correlation between lumbar mobility/flexibility and low back symptomatology has not been conclusively demonstrated, at least in gymnasts.
Extrinsic Factors
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Improper technique/biomechanics leading to excessive tissue loading
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Excessive training/participation resulting in cumulative overload
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Intense training/participation (aggressiveness, “win at all costs” syndrome, etc.).
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Sports-specific demands/biomechanics (e.g., extension loading in gymnasts and football lineman)
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Involvement in impact sports (e.g., football) appears to be a risk factor for lumbar strain/sprain due to loading and repetition demands of these activities.
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Sports that require repetitive end-range of motion loading (e.g., hyperextension in gymnastics), are associated with a greater risk of lumbar strain/sprain. Weightlifting, as a sport, or as a performance-enhancing modality for other sports, increases the load on the spine and, thus, the potential for injury.
Traumatic Factors
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Sudden forceful tensile loading (e.g., twisting, bending)
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Muscular overexertion, with either movement or sustained positioning (strains)
Classic Pathological Findings
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Identifiable pathological findings are rare with lumbar strains/sprains.
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Reactive muscle spasm and/or muscular trigger points may be present in some individuals.
Clinical Presentation
History
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The athlete may or may not recall a specific mechanism of injury (e.g., fall).
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Some athletes may report recent increases in training frequency and/or intensity.
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Pain of a lower lumbar sprain or strain generally originates in the lower back and upper buttocks, although it may refer into surrounding areas, including the thighs. The pain is usually movement-related and may be provoked only when the athlete moves in a particular way. Because of this mechanical pain, the athlete may complain of loss of function, such as an inability to turn, twist, or bend normally.
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The athlete may report painful muscle spasms.
Physical Examination
Abnormal Findings
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Trunk active range of motion is typically reduced, presumably due to pain from loading injured tissues ( Figure 18-1 ).
FIGURE 18-1
Trunk active range of motion is typically reduced following a lumbar strain/sprain, presumably because of pain from loading injured tissues.
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Gait may be mildly antalgic during the acute phase of injury to avoid loading injured tissues.
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Palpation of the muscles in the lumbar area may reveal local tenderness, trigger points, and/or spasm.
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Edema, erythema, and elevated skin temperature may be apparent when the injured tissues are superficial.
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With a lumbar sprain, passive posterior-to-anterior “springing” of vertebrae adjacent to affected ligaments/capsule/disc is usually provocative.
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Contraction or palpation of affected muscles is provocative with a lumbar strain, whereas passive posterior-to-anterior “springing” of the lumbar vertebrae is usually not provocative.
Pertinent Normal Findings
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Structural deformities (e.g., sciatic list, “step-off” deformity) should be absent.
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Neurological symptoms (e.g., myotomal weakness, lower extremity reflex aberrations, dermatomal sensory changes) should be absent.
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Pain should not markedly intensify with lumbar extension. (If it does, consider spondylolysis, particularly in young athletes whose sport or position requires repetitive extension, such as gymnasts or football linemen).
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Radicular symptoms (narrow band of pain radiating into legs), particularly those below the knee, should be absent with lumbar sprains/strains.
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The straight-leg raising test may provoke mild low back pain but should not produce leg symptoms below the knee.
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Tests for sacroiliac dysfunction (e.g., posterior thigh thrust, gapping) should be negative.
Imaging
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Imaging is usually not appropriate for lumbar strain/sprain injuries, unless the injury is the result of recent significant trauma.
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Plain radiography may be appropriate to rule out avulsion fractures when pain is localized to tendon-bone interface.
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Imaging should be considered in patients with severe, unremitting pain or neurological findings; pain that developed after an acute traumatic event or pain that persists longer than 6 weeks.
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Imaging should be considered earlier in young athletes because early identification of acute spondylolisthesis can influence outcomes.
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Anteroposterior, lateral, 45° right and left oblique views and collimated lateral views of the lumbar spine should be obtained.
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CT, MR, or scintography may be appropriate for select patients to rule out other potential causes of back pain, such as fracture, infection, tumor, or involvement of spinal nerve roots.
Differential Diagnosis
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Visceral injury/disease (e.g., renal disease, pyelonephritis)
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Vascular disease (e.g., abdominal aortic aneurysm)
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Lumbosacral disc injuries
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Lumbosacral facet syndrome
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Lumbosacral instability
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Lumbosacral radiculopathy
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Lumbosacral spine acute fracture
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Lumbosacral spondylolisthesis
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Lumbosacral spondylolysis
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Piriformis syndrome
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Early discitis before onset of fever
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Rheumatic disease: white blood cell count, erythrocyte sedimentation rate, and human leukocyte antigen assay for HLA-B27 may be used to assess for underlying rheumatic disease.
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Sacroiliac joint injury
Treatment
Nonoperative Management
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Oral, topical, or injectable analgesics
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Oral, topical, or injectable antiinflammatories
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Muscle relaxants
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Pain/symptom modulating modalities (e.g., sensory electrical stimulation, cryotherapy)
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Spinal mobilization (nonthrust) or manipulation (thrust)
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Therapeutic massage/soft tissue mobilization
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Relative rest
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Therapeutic exercise
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Aquatic therapy
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Patient education (e.g., warm-up routines appear to have a positive effect on preventing low back injuries in golfers if they are at least 10 minutes long)
Guidelines for Choosing Among Nonoperative Treatments
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Pain/symptom modulating modalities should be considered during the acute phase of injury. Once the athlete is able to tolerate active treatment, these should be discontinued or used sparingly to minimize iatrogenic effects of exercise or spinal mobilization/manipulation.
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Muscle relaxants: Medication such as Skelaxin and Flexeril has no direct effect on the muscle motor unit. Their mechanism of action is through modifying the central nervous system response to painful stimuli. They do work synergistically with pain medication allowing lower doses of pain medication to have the same pain relieving effect.
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Spinal mobilization (nonthrust) or manipulation (thrust) should be considered in the acute or sub-acute period for athletes with low-to-moderate levels of symptom irritability when the following variables are satisfied: symptom duration less than 16 days, low work-related fear-avoidance belief scores, lumbar hypomobility, hip internal rotation range of motion at least 35° on one or both sides, no symptoms distal to the knee.
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Relative rest: Most athletes who experience a lumbar strain or sprain will require a period of reduced or modified activity, including removal from competition. Symptom-limited alternative activities and exercises should be encouraged to minimize deconditioning.
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Low-level therapeutic exercise should begin as soon as possible after the injury to avoid the deleterious effects of immobilization. The intensity, duration, and complexity of therapeutic exercise should be increased over time in accordance with the athlete’s symptomatic and objective improvement.
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Patients who are intolerant of land exercise may tolerate aquatic therapy. Many land exercises can be replicated in a pool, with the benefits of reduced spinal weightbearing (via buoyancy), and increased spinal stabilization (via hydrostatic pressure).
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The majority of lumbar strains/sprains will be self-limiting and resolve within 6 weeks regardless of the type of treatment.
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Most athletes can return to full unrestricted play after sufficient resolution of pain and restoration of range of motion and strength.
Surgical Indications
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There are no absolute indications for surgery with lumbar strain/sprains
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
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See general guidelines in the preceding.
Aspects of Clinical Decision Making When Surgery Is Indicated
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Lumbar strains/sprains are typically benign in nature, transient and self-limiting. Failure to respond to conservative management within 4 to 6 weeks may warrant referral for further specialized testing.
Evidence
Multiple Choice Questions
- QUESTION 1.
Which collegiate sports have the highest rates of low back injury?
- A.
Golf and competitive weightlifting (i.e., powerlifting)
- B.
Men’s wrestling, football, women’s gymnastics
- C.
Men’s rugby and women’s field hockey
- D.
Soccer and tennis
- A.
- QUESTION 2.
Which of the following factors have been shown to increase risk of lumbar spine injury?
- A.
History of previous back injury
- B.
Inadequate lumbar flexibility
- C.
Inadequate stretching before activity
- D.
Lack of motivation
- A.
- QUESTION 3.
Which of the following is NOT a typical/common finding in patients with lumbar strain/sprain?
- A.
Ankle dorsiflexor weakness
- B.
Decreased trunk range of motion
- C.
Mildly antalgic gait
- D.
Muscle spasms and/or muscular trigger points
- A.
- QUESTION 4.
Which of the following statements is correct?
- A.
Imaging is not usually appropriate following a lumbar strain or sprain unless the injury occurred recently.
- B.
Imaging is not usually appropriate following a lumbar strain or sprain unless the injury occurred during football practice or competition.
- C.
Imaging is not usually appropriate following a lumbar strain or sprain unless the injury occurred during gymnastics practice or competition.
- D.
Imaging is not usually appropriate following a lumbar strain or sprain unless the injury is the result of recent significant trauma.
- A.
- QUESTION 5.
Which of the following statements is NOT correct?
- A.
Most athletes who experience a lumbar strain or sprain will require a period of reduced or modified activity, including removal from competition.
- B.
Most athletes suffering from a lumbar strain or sprain will require spinal surgery.
- C.
Some athletes who have sustained a lumbar strain or sprain will benefit from pain modulating modalities.
- D.
Some athletes who have sustained a lumbar strain or sprain may be appropriate for spinal manipulation treatment.
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Epidemiology)
- QUESTION 2.
Correct answer: A (see Pathophysiology)
- QUESTION 3.
Correct answer: A (see Clinical Presentation)
- QUESTION 4.
Correct answer: D (see Clinical Presentation)
- QUESTION 5.
Correct answer: B (see Treatment)
Nonoperative Rehabilitation of Lumbar Spine Strains and Sprains
- Christopher J. Durall, PT, DPT, MS, SCS, LAT, CSCS
- Brian K. Allen, DO
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Consider the unique requirements of the athlete’s sport in addition to the identified deficits when prescribing exercises.
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Maintain or improve sport-specific fitness/conditioning via cross-training.
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Athlete must be able to adequately control lumbar spine and pelvis throughout ranges of motion required by the sport.
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Return to full, unrestricted activity should be predicated on symptom response to activity.
Phase I (weeks 1 to 2)
Protection
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Bracing (e.g., lumbar corset) is not recommended for lumbar sprains or strains because of a lack of proven efficacy and concerns over the deleterious effects of prolonged immobilization on connective tissue integrity. Nonetheless, there are anecdotal reports of patients with severe low back pain benefiting from transient use of bracing with activities of daily living. For this reason, any lumbar bracing should be discontinued as soon as possible.
Management of Pain and Swelling
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Sensory electrical stimulation, moist heat, or cryotherapy may be used to reduce pain and swelling.
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Unlike peripheral joints, anecdotal evidence suggests that superficial heating may be beneficial for treating acute spine pain.
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Fatiguing motor-level electrical stimulation or ultrasound combined with motor-level electrical stimulation may be effective for reducing muscle spasm or for deactivating muscle trigger points.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
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The presence of the following variables may increase the likelihood of success with lumbar manipulation or mobilization: symptom duration less than 16 days, low work-related fear-avoidance belief scores, lumbar hypomobility, hip internal rotation range of motion (ROM) at least 35° on one or both sides, and no symptoms distal to the knee.
Soft Tissue Techniques
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Deep massage or ischemic compression may be used for trigger points or muscle spasms.
Stretching and Flexibility Techniques for the Musculotendinous Unit
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Gentle lumbar spine self-mobilization exercises should be initiated as soon as possible in a pain-free ROM to limit the adverse effects of immobilization and to stimulate the synthesis and proper alignment of collagen. These exercises can be performed in supine (e.g., knee to chest, posterior pelvic tilting), prone (e.g., prone press-ups), or quadruped (e.g., weight shifting/rocking in different directions) ( Figure 18-2 ).
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Athletes who feel better in lumbar extension may tolerate extension activities/exercises, whereas those who feel better in lumbar flexion should be encouraged to try various flexion activities/exercises. Outcomes for LBP tend to be better when treatment is matched to the patient’s directional preference, and worse when the patient is given a directionally opposite treatment.
FIGURE 18-2
Weight shifting in quadruped. From a quadruped position, slowly shift weight forward, backward, left, right, or along a diagonal to increase trunk range of motion.
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Stretching exercises should be included for the hip flexors, rotators, adductors, quadriceps, gastrocnemius/soleus, and hamstring muscles ( Figure 18-3 ).
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Hip/leg stretching exercises should be performed with abdominal bracing (see description that follows) while maintaining a neutral (i.e., mid-ROM) lumbar spine to avoid symptom exacerbation.
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