Disclosure I have no conflict of interest in relation to this - - PowerPoint PPT Presentation

1

12/14/18

Cindy J. Chang, M.D.

UCSF Clinical Professor Primary Care Sports Medicine

• Depts. of Orthopaedics and Family & Community Medicine

Lumbar Spine Injuries in Athletes of All Ages

Lumbar Spine Injuries in Athletes of All Ages 2

Disclosure

• I have no conflict of interest

in relation to this presentation

• Ossur Americas:

presented an independent lecture on knee

• steoarthritis

Lumbar Spine Injuries in Athletes of All Ages 3

Objectives

• Discriminate between the

common etiologies of low back pain through an effective history and exam, and appropriate ancillary studies.

• Develop treatment plans

including non-pharmacologic and pharmacologic approaches for the most common causes of low back pain in your athlete population

90% will recover within 6 wks

Lumbar Spine Injuries in Athletes of All Ages 4

Facts

1.

What % of adults in US have had LBP lasting at least 1 day over the past 3 months? 15%, 20%, or 25%?

1.

Which one is NOT included in first-line treatment for chronic LBP, acupuncture, NSAIDs, Tai chi, or yoga?

3.

Opioids are considered second-line pharmacological therapy for chronic back pain, True or False?

4.

Acute low back pain generally resolves with which of the following? time, rest, heat, and/or massage?

5.

Which one has the strongest evidence supporting its benefit in chronic LBP? NSAIDs, mm relaxants, BZDs, corticosteroids?

Deyo RA et al Spine 2006; Qaseem A et al Ann Int Med 2017

2

Lumbar Spine Injuries in Athletes of All Ages 5

Facts

1.

What % of adults in US have had LBP lasting at least 1 day over the past 3 months? 15%, 20%, or 25%?

1.

Which one is NOT included in first-line treatment for chronic LBP, acupuncture, NSAIDs, Tai chi, or yoga?

3.

Opioids are considered second-line pharmacological therapy for chronic back pain, True or False?

4.

Acute low back pain generally resolves with which of the following? time, rest, heat, and/or massage?

5.

Which one has the strongest evidence supporting its benefit in chronic LBP? NSAIDs, mm relaxants, BZDs, corticosteroids?

Deyo RA et al Spine 2006; Qaseem A et al Ann Int Med 2017

Lumbar Spine Injuries in Athletes of All Ages 6

Low Back Pain – History (OLDCARTS vs OPQRST)

• Onset (O) – date of injury
• Location – point to where the pain is
• Duration – acute or chronic
• Character (Q) – burning, sharp, dull, achy
• Aggravating/Alleviating (P) – provokes/palliates
• Radiation (R) – come from or go anywhere else
• Timing (T) – constant, at night, with activity
• Severity (S) – grade pain

Lumbar Spine Injuries in Athletes of All Ages 7

Low Back Pain – History

(MS OLDCARTS vs OPQRST)

• Mechanism
• Symptoms
• Onset (O) – date of injury
• Location – point to where the pain is
• Duration – acute or chronic
• Character (Q) – burning, sharp, dull, achy
• Aggravating/Alleviating (P) – provokes/palliates
• Radiation (R) – come from or go anywhere else
• Timing (T) – constant, at night, with activity
• Severity (S) – grade pain

Lumbar Spine Injuries in Athletes of All Ages 8

Red Flags

• History of cancer
• Progressive motor or sensory deficit
• Prolonged steroid use, IV drug use
• Major trauma
• Bilateral leg weakness
• Fever and chills
• Unrelenting severe pain with rest or at night
• Numbness in groin/saddle
• Loss of bowel or bladder function

Henschke N et al. Cochrane Database Syst Rev 2013

3

Facts

• A. 25%
• B. 50%
• C. 66%
• D. 80%

Lumbar Spine Injuries in Athletes of All Ages 9

• What % of LBP in adolescents have no clear identifiable

cause?

Yang S et al J Ped Ortho 2017

2 5 % 5 % 6 6 % 8 %

13% 44% 23% 20%

Facts

• A. 2.3%
• B. 5.5%
• C. 10.1%
• D. 24.8%

Lumbar Spine Injuries in Athletes of All Ages 10

• What % of children who presented to the ED with back

pain had a pathological cause of the pain?

Brooks TM et al Ped Emerg Care 2018

2.3% 5.5% 10.1% 24.8%

49% 24% 10% 17%

Lumbar Spine Injuries in Athletes of All Ages 11

Facts

• 1. What is the annual prevalence of LBP in college

students? 20%, 30%, or 40%?

• 2. Significant differences in diagnosis and surgery rates

exist between African Americans and whites with

• ccupational low back injuries, True or False?

Kennedy et al JACH 2008 Chibnail et al Spine 2006

Lumbar Spine Injuries in Athletes of All Ages 12

Facts

• 1. What is the annual prevalence of LBP in college

students? 20%, 30%, or 40%?

• stressful psychosocial variables of feeling very sad, exhausted,

and overwhelmed were associated with the prevalence of LBP

• Most LBP represents a pain condition, NOT spinal problem
• 1. Significant differences in diagnosis and surgery rates

exist between African Americans and whites with

• ccupational low back injuries, True or False?
• May explain why A-A receive lower workers’ compensation

medical expenditures, disability ratings, and settlement awards

Kennedy et al JACH 2008; Chibnail et al Spine 2006

4

Lumbar Spine Injuries in Athletes of All Ages 13

LS Spine – Bones, Joints, and Discs

Lumbar Spine Injuries in Athletes of All Ages 14

LS Spine – Pediatric Bones, Joints, and Discs

• Increased ligamentous laxity/greater

mobility of spine

• spinal columns more elastic than spinal cord
• Immature joints and ossification centers
• Facet joints more shallow and horizontal
• Vertebral bodies wedge-shaped
• Less developed spinous process

Basu S. Neurol 2012

Lumbar Spine Injuries in Athletes of All Ages 15

LS Spine - Nerves

• 31 pairs of

nerves

• C7 nerve

exits above 7th cervical vertebrae

• L5 nerve

exits below 5th lumbar vertebrae

Lumbar Spine Injuries in Athletes of All Ages 16

LS Spine - Nerves

• Dermatomes
• Myotomes
• L1/L2 – Hip flexion
• L3/L4 – Knee extension
• L4 – Ankle dorsiflexion
• L5 – Great toe

dorsiflexion

• S1 – Ankle

plantarflexion

5

Lumbar Spine Injuries in Athletes of All Ages 17

LS Spine - Nerves

• Dermatomes

Lee MWL et al, Clin Anat 2008

Lumbar Spine Injuries in Athletes of All Ages 18

• Superficial
• Thoracic group
• Abdominal group
• Erector Spinae group
• Spinalis
• Longissimus
• Iliocostalis
• Deep
• Transversospinal group
• Multifidus
• Rotatores
• Intertransversarius

LS Spine - Muscles

Lumbar Spine Injuries in Athletes of All Ages 19

LS Spine - Muscles

Lumbar Spine Injuries in Athletes of All Ages 20

Lumbar Spine – A systematic exam

• Observation:
• abrasions, bruising,

comfort, motion

• Sitting:
• slump test, L4 and S1

reflexes, sensation, strength

• Supine/Sidelying:
• SLR, Hip ROM /pain,

Hamstring/Hip flexor tightness, L5 reflex

• Prone:
• Tenderness LS spine, SI

joints; femoral nerve stretch, passive extension hips/spine; Hamstring/glut max strength, L5 reflex

• Standing:
• ROM: flex, ext, sidebend,

rot/ext; one legged extension, Gillet test (pelvic motion); feet, gait, heel/toe walk, functional testing

6

Lumbar Spine Injuries in Athletes of All Ages 21

Lumbar Spine – A systematic exam

• Observation:
• abrasions, bruising,

comfort, motion

• Standing:
• ROM: flex, ext, sidebend,

rot/ext; one legged extension, Gillet test (pelvic motion); feet, gait, heel/toe walk, functional testing

• Sitting: slump test, L4 and

S1 reflexes, sensation, strength

• Supine/Sidelying:
• SLR, Hip ROM /pain,

Hamstring/Hip flexor tightness, L5 reflex

• Prone:
• Tenderness LS spine, SI

joints; femoral nerve stretch, passive extension hips/spine; Hamstring/glut max strength, L5 reflex

Lumbar Spine Injuries in Athletes of All Ages 22

Common Lumbar Spine Injuries in Athletes

• Younger
• Mechanical low back

pain

• Spondylolysis
• Spondylolisthesis
• Herniated disc
• Older
• Lumbosacral strain
• Herniated disc
• Degenerative disc

Massel DH and Singh K. Instr Course Lect 2017

Lumbar Spine Injuries in Athletes of All Ages 23

Case #1- History

50 YO OVERWT CARPENTER

n

Mechanism of injury: PLAYING VB AT FAMILY REUNION AND TWISTED FOR A BALL

n

Symptoms: STIFFNESS

• Onset – ACUTE, 2 DAYS AGO
• Location – ENTIRE LOW BACK
• Duration – 2 DAYS
• Character – BURNING
• Aggravating/Alleviating –MOTION/ICE, IBUPROFEN,

KNEES TO CHEST

• Radiation – NONE
• Timing –CONSTANT DURING DAY

, NO PAIN AT NIGHT

• Severity - 4/10 PAIN, NO WEAKNESS, NO RED FLAGS

Lumbar Spine Injuries in Athletes of All Ages 24

Case #1 - Exam

• Observation: STIFFNESS, DISCOMFORT W/ MOVING
• Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH
• Supine: NEG SLR, HIP FROM W/O PAIN
• Prone:
• NO CENTRAL SPINE OR BONY PAIN
• TENDER BILAT PARASPINAL MM ON PALP
• NEG FEMORAL NERVE STRETCH, HAM/GLUT MAX

STRENGTH 5/5

• Standing:
• ROM: STIFF/PAIN ESP FF W/ SPASM, PAIN WHEN

RETURNING TO ERECT POSITION

• SLOW GAIT, HEEL/TOE WALK OK

7

Lumbar Spine Injuries in Athletes of All Ages 25

Case #1 - Exam

Lumbar Spine Injuries in Athletes of All Ages 26

Diagnosis – Muscle strain

• Acute sudden movement or action
• Overuse from poor posture, mm

strength, endurance

• Common and self-limiting
• Treatment:
• Ice/Heat
• Proper posture and movement

patterns

• Active daily exercise, e.g. walking in

proper shoewear

• Physical Therapy
• Weight management
• NSAIDS/MM relaxers

Traeger A et al. CMAJ 2017

Lumbar Spine Injuries in Athletes of All Ages 27

Case #2- History

50 YO LESS OVERWT CARPENTER

• Mechanism of injury: UNSURE; 3 MO AGO BEGAN MEDICINE BALL

AB WORKOUT, INCREASING RUNNING MILEAGE ON TREADMILL

n

Symptoms: STIFF, WEAK

• Onset –GRADUAL
• Location – LOW BACK, L BUTTOCKS
• Duration – X 2 MONTHS
• Character –ACHY @ NIGHT; SHARP/BURNING @ DAY
• Aggravating/Alleviating –COUGH,SNEEZE/ICE,HEAT,NSAIDS

TEMPORARY ONLY

• Radiation – LEFT OUTER LEG TO TOES
• Timing –CONSTANT DURING DAY, OCCAS AT NIGHT
• Severity - 4/10 PAIN WORSENING TO 8/10, NO RED FLAGS

Lumbar Spine Injuries in Athletes of All Ages 28

Case #2 - Exam

• Observation: STANDING WHEN YOU ENTER ROOM
• Standing:
• ROM: PAINFUL FF TO 45 DEG; R SIDEBEND
• ABLE TO TOE WALK; HARDER L HEEL WALK; NO

ATROPHY

• Sitting: + SLUMP,  SENSATION FIRST WEBSPACE, 

STRENGTH 4/5 L GREAT TOE DORSIFLEXION

• Supine: + L SLR AT 45 DEG, L HIP FROM BUT PAIN W/ ER
• Prone:
• + TENDER L4-5 > L5-S1, L SI JOINT
• NEG FEMORAL N STRETCH TEST
• L HAM/GLUT MAX 4+/5, ABSENT L L5 REFLEX

8

Lumbar Spine Injuries in Athletes of All Ages 29

Testing L5 Reflex

Lumbar Spine Injuries in Athletes of All Ages 30

Disc and nerve root relationship

Lumbar Spine Injuries in Athletes of All Ages 31

Disc and nerve root relationship

Lumbar Spine Injuries in Athletes of All Ages 32

Case #2: Imaging

9

Lumbar Spine Injuries in Athletes of All Ages 33

Case #2: Imaging

Lumbar Spine Injuries in Athletes of All Ages 34

Case #2 Dx – L4-5 disc herniation

Lumbar Spine Injuries in Athletes of All Ages 35

Case #2 Dx – L4-5 disc herniation

• Subspecialty referral for any weakness, loss of reflexes
• Emergent care if loss of bowel/bladder, saddle anesthesia, increasing pain

increasing pain, unresponsive to meds

• Physical therapy; Posture/positions of comfort; Activity

modifications, Ergonomics, Weight loss

• NSAID alternating with acetaminophen every 3 hrs
• E.g., 600 mg ibu @ 0800, 1000 mg acetam @ 1100, 600 ibu @ 1400, etc.
• Other meds individualized
• E.g., prednisone, gabapentin, TCA, narcotics

Traeger et al, CMAJ 2017; Holve and Barkan, JABFM 2008; Goldberg et al, JAMA 2015; Eskin et al, JEM 2014

Lumbar Spine Injuries in Athletes of All Ages 36

Dx – L4-5 disc herniation

• Interventions
• Epidural corticosteroid injections vs placebo for leg pain

(mean difference, -6.2 [95% CI, -9.4 to -3.0]) and for disability (-3.1 [CI, - 5.0 to -1.2]) in the short term (< 3 mos)

• In patients with a herniated disk confirmed by imaging and leg

symptoms persisting for at least six weeks, surgery was superior to non-operative treatment in relieving symptoms (15.0

[95% C.I., 11.8 - 18.1]) and improving function (14.9 [95% C.I., 12.0 - 17.8])

• 4-year rate of reoperation was 10%

Pinto et al. Ann Intern Med 2012; Weinstein et al, Spine 2008

10

Lumbar Spine Injuries in Athletes of All Ages 37

Dx – L4-5 disc herniation  chronic LBP

• Medications
• NSAIDs should be recommended (Strength: Strong)
• Opioids may be considered but should be avoided if possible

(Strength: Weak)

• Antidepressants should not be routinely used (Strength: Strong)
• Corticosteroids pooled results of two trials (overall and leg pain -12.2,

95% C.I. -20.9 to -3.4) but only short term (< 8 wks)

• Trial of gabapentin (pain -26.6, 95% C.I. -38.3 to -14.9) only short term

benefits

White et al. Spine 2011; Pinto et al. BMJ 2012

Lumbar Spine Injuries in Athletes of All Ages 38

Lumbar intradiscal pressures

Nachemson A. Clin Ortho Rel Research 1966

Lumbar Spine Injuries in Athletes of All Ages 39

Case #3 - History

15 YO HS/CLUB VB PLAYER, RHD

• Mechanism of injury: UNSURE, HURTING ALL SUMMER;

WORSE WITH SPIKING

• Symptoms: TIGHTNESS
• Onset – GRADUAL
• Location – LOW BACK, MORE RIGHT SIDED
• Duration – 2-3 MOS, LASTS 24 HR AFTER VB
• Character – DULL TO SHARP
• Aggravating/Alleviating – SPIKING/NSAIDS, 1 WK OFF
• Radiation – NONE
• Timing –DURING AND AFTER VB, HURTS AT NIGHT

(SLEEPS ON STOMACH)

• Severity – 4/10 PAIN

Lumbar Spine Injuries in Athletes of All Ages 40

Case #3 - Exam

• Observation: MOVES EASILY
• Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH,

(-) CVAT

• Supine:
• NEG SLR, HIP FROM, HAM TIGHT BILAT
• + THOMAS TEST BILAT FOR HIP FLEXORS
• Prone:
• + TENDER L5-S1 LEVEL, R>>L
• + PAIN PASSIVE EXTENSION R HIP
• + PAIN ACTIVE BACK EXTENSION
• Standing:
• ROM: PAIN W/ R SIDEBEND, R ROT/EXTENSION
• PAIN 1-LEG EXTENSION R>>L

11

Lumbar Spine Injuries in Athletes of All Ages 41

Case #3 - Exam

Lumbar Spine Injuries in Athletes of All Ages 42

Case #3 Radiographs

• AP/Lateral

Lumbar Spine Injuries in Athletes of All Ages 43

Case #3: Additional Radiographs Needed?

– Oblique views

• Can see “Scottie Dog”

Beck NA et al. JBJS Am 2013

Lumbar Spine Injuries in Athletes of All Ages 44

Case #3: Additional Imaging

• Bone Scan with SPECT

– Localizes uptake to posterior vertebral elements – Hot vs. Cold

• Thin cut CT

– Assess age and healing of fracture

• MRI
• STIRS sequences

Ledonio CGT et al. Spine Deform 2016

12

Lumbar Spine Injuries in Athletes of All Ages 45

PROCEDURE

AVG ADULT RADIATION DOSE = TO NATURAL BACKGROUND RADIATION

CXR 0.1 mSv 10 days XR Spine 1.5 mSv 6 months CT Spine 6 mSv 24 months Bone Scan 6.3 mSv 25 months

http://www.radiologyinfo.org/en/info.cfm?pg=safety-xray

Radiation Exposure: Avg exposure 3 mSv/year from nature 0.03 mSv/year RT airplane flight

Mettler FA, et al Radiology 2008

Lumbar Spine Injuries in Athletes of All Ages 46

Case #3: MRI vs CT

Lumbar Spine Injuries in Athletes of All Ages 47

Case #3 Dx – Spondylolysis

• Treatment controversial
• Rest
• +/- Bracing
• Physical therapy
• Trunk stabilization and LE

flexibility

• Typical: hip flexors tight, pelvis

ant rotated, low back hyperextended

• RTP when pain free and strong
• Complications
• Non-Union Chronic Pain
• Spondylolisthesis

Panteliadis P et al. Global Spine J 2016

Lumbar Spine Injuries in Athletes of All Ages 48

Facet Joint Dysfunction

• Inflammation, sprain, degeneration
• Active ROM
• Flexion = “opening”
• Extension = “closing”
• Lumbar facet joints “open” on right

side with left lateral flexion and left rotation

• Lumbar facet joints “close” on right

side with right lateral flexion and right rotation

13

Lumbar Spine Injuries in Athletes of All Ages 49

Imaging



Lumbar Spine Injuries in Athletes of All Ages 50

Case #4 - History

25 YO PROGRAMMER, TRAINING FOR MARATHON

• Mechanism of injury: UNSURE
• Symptoms: TIGHTNESS L HAM, L LOW BACK
• Onset – GRADUAL
• Location – L PROX HAM, BUTTOCKS
• Duration – 2 MOS
• Character – SHARP, ACHY
• Aggravating/Alleviating –SITTING; SPRINTING; STAIRS/

STRETCHING

• Radiation – NONE
• Timing –INTERMITTENT, NO NIGHT PAIN. NO PAIN DURING

CAMPING WKEND

• Severity – 0-3/10 PAIN, NO WEAKNESS/RED FLAGS

Lumbar Spine Injuries in Athletes of All Ages 51

Case #4 - Exam

• Observation: NO DISCOMFORT
• Sitting: NEG SLUMP, NL SENS/STRENGTH/REFLEXES
• Supine:
• NEG SLR, HIP FROM, NEG FABER
• + THOMAS TEST ON LEFT - TIGHT HIP FLEXOR
• Prone:
• + TENDER L SI JOINT
• NT OVER PROX HAM TENDON
• NEG PAIN W/ PASSIVE HIP EXTENSION, KNEE FLEX
• Standing:
• ROM: TIGHTNESS IN PROX HAM W/ FF
• + GILLET TEST ON L (+ ANT ROTATION)
• GAIT NL

Lumbar Spine Injuries in Athletes of All Ages 52

Thomas Test

• Evaluate iliapsoas, rectus femoris, ITB

14

Lumbar Spine Injuries in Athletes of All Ages 53

Thomas Test

• Evaluate iliapsoas, rectus femoris, ITB

Lumbar Spine Injuries in Athletes of All Ages 54

Gillet Test

Lumbar Spine Injuries in Athletes of All Ages 55

Gillet Test

Lumbar Spine Injuries in Athletes of All Ages 56

Anterior rotation of pelvis

15

Lumbar Spine Injuries in Athletes of All Ages 57

Case #4 Dx: Left SI Joint Dysfunction

• Anterior rotation
• Tight hip flexor, tight ITB, Weak glut
• Excessive stretch on hamstring and

adductors as femur moves forward during sprinting BECAUSE pelvis does not posteriorly rotate

• Posterior rotation
• Tight piriformis/glutes, Weak hip flexor
• Rule out rheum d/o if tender over SI

joint, warm, AM pain/stiffness, good resolution with NSAID

• Physical Therapy

Peebles R and Jonas CE. CSMR 2017

Lumbar Spine Injuries in Athletes of All Ages 58



Lumbar Spine Injuries in Athletes of All Ages 59

Prevent Back Pain with a Healthy Lifestyle

• Exercise daily—but avoid overload!
• Practice correct posture
• Lift correctly--including lifting weights
• Sleep properly
• Avoid prolonged positions
• Achieve and maintain a healthy weight

There is usually not a quick fix

90% will recover within 6 wks

Lumbar Spine Injuries in Athletes of All Ages 60

Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand.

• Chinese proverb

“A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment.”

• Author unknown

16

Thank you!