Rehabilitation for Low Back Pain
A Patient's Guide to Low Back Pain in Athletes
About 80 percent of the population suffers from a bout of low back pain at
some point in their life. However, some people are at higher risk for chronic
and acute back injuries due to their lifestyle. For obvious reasons, athletes
are at greater risk of sustaining a lumber (lower) spine injury due to physical
activity. Whether the sport is skiing, basketball, football, ice skating, soccer,
running, golf, or tennis, the spine undergoes a lot of stress, absorption of
pressure, twisting, turning, and even bodily impact. This strenuous activity
puts a strain on the back that can cause injury to even the finest and most
fit athletes. Though the entire spine is used when playing sports, it is estimated
that 5-10 percent of all athletic injuries are related to the lumbar (lower)
spine. Many cases of low back pain in athletes can be traced to a specific event
or trauma; others are brought about by repetitive minor injuries that result
Even though low back pain can often be treated without major disruption in
a person's life, athletes are often reluctant to seek medical help. Many of
them deny or minimize complaints in order to avoid consequences, such as: having
to decrease activity in order to recover, losing a position or being removed
from a team, missing a competition, or letting the team down. Others fear they
might lose their worth to the team. Some athletes simply do not want to bother
seeing a doctor for pain; they believe it will recover on its own.
Therefore, many athletes - from the weekend warrior to the elite professional
athlete - buck up their strength, pop some over-the-counter pain medication,
and tolerate the pain for the sake of the game and personal enjoyment. However,
avoiding medical help can lead to further and more serious injury. In some cases,
without medical help the anatomic damage could eventually lead to permanent
exclusion from sporting activities.
The majority of low back pain can be treated with conservative means. All athletes
who suffer from it should seek medical advice. The body's ability to be active
is worth preserving!
This document will cover:
- General lumbar spine anatomy
- Causes of lumbar injuries
- General guidelines
To best understand lumbar spine injuries, it helps to know some anatomy of
the overall spine, and more specifically, the lower spine.
Please review the document, entitled:
Common Causes of Low Back Pain in Athletes
There are many causes of low back pain. Here we will discuss the most common
causes in athletes: musculoligamentous strain, spondylolysis, spondylolisthesis,
and herniated nucleus pulposus.
The term "musculoligamentous strain" is just the medical term for describing
common "back strain". This term refers to all injuries of the lumbar spine's
soft tissue. Soft tissues are the muscles, nerves, ligaments, tendons, and blood
vessels around the spine. Musculoligamentous strains are probably the most common
sports injury. These injuries are diagnosed by exclusion, which means the diagnosis
is offered after all other causes of the pain are ruled out. These injuries
are usually self-limiting. In other words, they do not continue to spread and
get worse; they generally heal in time. Healing often happens even without getting
specific treatment for the area. Treatment generally focuses on education and
prevention of future strains, through proper conditioning, warm-up, and changes
in the way an activity is carried out.
Spondylolysis and Spondylolisthesis
So far, there is no definitive cause of spondylolysis. Most physicians agree
that the bone defect appears in children most likely due to a genetically weak
"pars interarticularis" teamed with repeated stress to the spine from various
physical activities during the major growth years. It is thought that spondylolysis
appears in younger and older adults as the result of excessive stress to the
spine and eventual stress fractures.
In athletes, spondylolysis is most commonly found in those who participate
in sports that have frequent hyperextension of the lumbar spine, such as: gymnastics,
pole-vaulting, and football. Weightlifters also have a higher incidence of the
disorder due to excessive stress on the spine.
Spondylolysis does not always produce noticeable symptoms. When it does, chronic
low back pain is the most common symptom. The pain can stem from mechanical
(structural) or compressive (pressure on nerves) pain. Initially, conservative
treatment is generally suggested.
Anti-inflammatory medications and stretching/strengthening exercises can reduce
the pain. If your spine specialist feels you may have a true stress fracture
from athletic activity, you may be placed in a back brace for 24 hours a day
for several months to allow the fracture to heal. You will then be gradually
weaned from the brace and allowed to return to full activity. Surgery is rarely
considered in such cases.
Spondylolysis can also lead to a condition closely related called "spondylolisthesis".
This condition occurs when the weakness caused by the spondylolysis causes one
vertebra to slip forward over the one below it. Most cases of spondylolysis
in athletes do not lead to vertebral slippage. However, if slippage does occur,
it may continue. This situation would require treatment that is more aggressive,
perhaps even surgery. The chance of progression is probably more worrisome in
teenagers than adults.
Many cases are non-symptomatic and do not cause any nerve problems. However,
sometimes the slipped vertebra can press into the space belonging to the spinal
canal. This leaves less room for the nerve roots. The neural pressure can lead
to low back, buttock, and leg pain, as well as numbness in the foot. If the
problem is severe, surgery may be suggested.
If you would like to learn more about spondylolysis and spondylolisthesis,
you may wish to review the document, entitled:
Herniated Nucleus Pulposus (HNP)
Because of excessive weight bearing and stress, athletes sometimes damage an
intervertebral disc. The intervertebral discs are flat, round "cushions" that
act as shock absorbers between each vertebra in your spine. There is one disc
between each vertebra. Each disc has a strong outer ring of fibers called the
annulus, and a soft, jelly-like center called the nucleus pulposus. The mushy
nucleus of the disc serves as the main shock absorber. The nucleus is made up
of tissue that is very moist because it has high water content. The water content
helps the disc act like a shock absorber - somewhat like a waterbed mattress.
The process of degeneration of the intervertebral disc causes many problems
in the spine. Everything you do during the day - once you stand upright - begins
to test the spine's ability to support your body weight. Athletes place more
pressure on the spine than the average person. Over time, repeated daily stresses
and minor injuries can add up and begin to affect the discs in the spine.
A herniated disc occurs when pressure to a disc's outer fibers (annulus) is
so great that it rips, and the nucleus ruptures out of its normal space. If
it rips near the spinal canal, the bulging disc can push out of its space and
into the spinal canal, placing inappropriate pressure on the spinal cord and
nerve roots. If a disc bulges a lot, or fragments into pieces that lie in the
canal, then irritation of the nerves can be severe.
The compression to the nerves caused by herniation can lead to feelings of:
numbness, pain, a change in reflexes, and/or tingling in the arms or legs. In
addition, if a disc ruptures, it releases chemicals that can irritate and inflame
the nerve roots, which leads to strong discomfort. Sometimes a herniated disc
is referred to as "slipped disc", though the disc does not actually slip.
Herniated discs are most common in the lumbar (lower) spine because it supports
more pressure than the thoracic (middle) or cervical (upper) parts of the spine.
In fact, a herniated lumbar disc often produces sciatica (the sciatic nerve
in the lumbar spine region connects with your legs). With sciatica, you will
feel numbness and pain down the back of the leg, side of the calf, and possibly
into the side of the foot, but not necessarily much back pain. The exact area
where you will feel numbness depends on the nerve root that is affected; the
numbness could be in the inner ankle, big toe, heel, outer ankle, outer leg,
or a combination of them. When the nerve roots' motor function is damaged by
disc herniation, you may also experience weakness in certain parts of the leg
Herniated discs can usually be treated without surgery. However, in rare cases
a herniated disc can be so large that it fills the entire spinal canal. When
the canal fills with disc material, it places enormous pressure on the nerves.
This can lead to paralysis of the muscles that control your bowels and bladder.
If you lose control over your bowels or bladder, contact your health care provider
immediately. The treatment of a herniated disc depends upon the symptoms and
degree of nerve irritation or dysfunction.
If you would like to learn more about herniated discs, you may wish to review
the document, entitled:
The adolescent athlete may also suffer from low back pain that is caused by
growth-related problems such as scoliosis and Scheuermann's kyphosis. These
problems may or may not be related to athletic activity, but they can affect
an athlete's ability to perform up to his or her standards.
Scheuermann's kyphosis is a developmental type of kyphosis. The vertebrae
are normally rectangular-shaped and stacked on top of one another like building
blocks with a soft cushion (disc) in between each one. If they wedge closer
together in a triangular shape, as with Scheuermann's kyphosis, it causes the
spine to curve more than normal. Sometimes this deformity is described as "round-back
posture" or "hunch-back".
For more information on Scheuermann's kyphosis, please review the document,
Scoliosis is a condition that is also related to growth. It appears usually
just as the teenage growth spurt of puberty begins and may progress through
the growth phase. In girls, this occurs earlier than in boys - about age 11
in girls and age 13 in boys. It is usually painless, but may cause back discomfort
with activity. The condition is genetic, which means it runs in families. It
is more common in girls than boys. If the condition progresses, it can be serious.
It may require treatment with a brace, or even surgery.
For more information on scoliosis, please review the document, entitled:
Athletes are not immune to the same problems that occur in the rest of the
population. This includes every type of back problem. It is sometimes hard for
an aggressive athlete to consider changing training schedules, or the fact that
a serious disease may exist. It is important to stay in tune with your body
and seek attention when symptoms do not go away in a timely fashion. Athletes
should be aware that such situations might require reducing or ceasing of athletic
activity until the problem is resolved.
In evaluating low back pain in athletes, your doctor will start by gathering
information about the current problem and a complete history of any additional
medical problems. Athletes tend to live with a certain amount of constant pain
of one type or another. This can cause them to ignore or minimize the severity
of their low back pain. They may also be used to dealing with more pain than
the average patient, so it may be harder to adequately assess their symptoms.
For these reasons, a thorough history of the athlete is needed.
Before developing a treatment plan, your physician will need to know:
- Your age
- Type of sport(s) and level of competition
- All past and current medical problems
- Location of the pain and where it spreads
- When the pain began, and the pain's relation to any specific trauma
- What brings on or relieves the pain
- Drug and medication use
Your health care provider will examine the entire spine. He or she will look
for: signs of unusual curves of the spine, a rib hump, a tilted pelvis, and
tilting of the shoulders. Your muscle strength will be tested, as well as reflexes,
sensation, and ability to perform specific movements. Finally, you may need
to undergo some tests if your provider feels there is need for more information.
For a complete discussion on how back problems are diagnosed and the tests
available, review to the document, entitled:
Treatment for low back pain in athletes is usually conservative, which refers
to non-surgical methods. These might include: anti-inflammatory medication,
physical therapy, and exercise. Athletes will understand that exercise is very
important in order to strengthen the abdominal, paraspinal, and pelvic musculature.
When muscles in these areas are stronger, they can take pressure off the spine
and help prevent back injuries. A physical therapist can help the patient develop
a beneficial routine of conditioning and rehabilitation that includes proper
warm-ups (such as back stretching exercises) and aerobic exercise.
For a discussion on the rationale behind many of the conservative treatment
recommendations made by spine specialists, please review the document, entitled:
Treatment for specific conditions can be found in the documents relating to
those problems. Feel free to search the site for additional information on specific
Copyright © 2003 DePuy Acromed.
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