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Disclosure  I have no conflict of interest in relation to this Lumbar Spine Injuries in presentation Athletes of All Ages  Ossur Americas: presented an independent lecture on knee Cindy J. Chang, M.D. osteoarthritis UCSF Clinical Professor Primary Care Sports Medicine Depts. of Orthopaedics and Family & Community Medicine 12/14/18 2 Lumbar Spine Injuries in Athletes of All Ages Objectives Facts What % of adults in US have had LBP lasting at least 1 day over the past 3 1.  Discriminate between the months? 15%, 20%, or 25%? common etiologies of low back pain through an effective history Which one is NOT included in first-line treatment for chronic LBP, and exam, and appropriate 1. acupuncture, NSAIDs, Tai chi, or yoga? ancillary studies.  Develop treatment plans Opioids are considered second-line pharmacological therapy for chronic including non-pharmacologic and 3. back pain, True or False? pharmacologic approaches for the most common causes of low back pain in your athlete Acute low back pain generally resolves with which of the following? 4. time, rest, heat, and/or massage? population Which one has the strongest evidence supporting its benefit in chronic LBP? 5. 90% will recover within 6 wks NSAIDs, mm relaxants, BZDs, corticosteroids? Deyo RA et al Spine 2006; Qaseem A et al Ann Int Med 2017 3 Lumbar Spine Injuries in Athletes of All Ages 4 Lumbar Spine Injuries in Athletes of All Ages 1

Low Back Pain – History Facts What % of adults in US have had LBP lasting at least 1 day over the past 3 1. (OLDCARTS vs OPQRST) months? 15%, 20%, or 25% ? Which one is NOT included in first-line treatment for chronic LBP, 1.  O nset (O) – date of injury acupuncture, NSAIDs , Tai chi, or yoga?  L ocation – point to where the pain is  D uration – acute or chronic Opioids are considered second-line pharmacological therapy for chronic 3. back pain, True or False ?  C haracter (Q) – burning, sharp, dull, achy  A ggravating/ A lleviating (P) – provokes/palliates Acute low back pain generally resolves with which of the following? 4.  R adiation (R) – come from or go anywhere else time , rest, heat , and/or massage ?  T iming (T) – constant, at night, with activity  S everity (S) – grade pain Which one has the strongest evidence supporting its benefit in chronic LBP? 5. NSAIDs , mm relaxants, BZDs, corticosteroids? Deyo RA et al Spine 2006; Qaseem A et al Ann Int Med 2017 5 Lumbar Spine Injuries in Athletes of All Ages 6 Lumbar Spine Injuries in Athletes of All Ages Low Back Pain – History Red Flags ( MS OLDCARTS vs OPQRST)  History of cancer  M echanism  Progressive motor or sensory deficit  S ymptoms  Prolonged steroid use, IV drug use  O nset (O) – date of injury  Major trauma  L ocation – point to where the pain is  Bilateral leg weakness  D uration – acute or chronic  Fever and chills  C haracter (Q) – burning, sharp, dull, achy  Unrelenting severe pain with rest or at night  A ggravating/ A lleviating (P) – provokes/palliates  Numbness in groin/saddle  R adiation (R) – come from or go anywhere else  Loss of bowel or bladder function  T iming (T) – constant, at night, with activity  S everity (S) – grade pain Henschke N et al. Cochrane Database Syst Rev 2013 7 Lumbar Spine Injuries in Athletes of All Ages 8 Lumbar Spine Injuries in Athletes of All Ages 2

Facts Facts  What % of LBP in adolescents have no clear identifiable  What % of children who presented to the ED with back cause? pain had a pathological cause of the pain? 44% 49% A. 2.3% A. 25% B. 5.5% B. 50% C. 10.1% 23% C. 66% 24% 20% D. 24.8% 17% 13% D. 80% 10% 2.3% 5.5% 10.1% 24.8% % % % % 5 0 6 0 2 5 6 8 Yang S et al J Ped Ortho 2017 Brooks TM et al Ped Emerg Care 2018 9 Lumbar Spine Injuries in Athletes of All Ages 10 Lumbar Spine Injuries in Athletes of All Ages Facts Facts 1. What is the annual prevalence of LBP in college 1. What is the annual prevalence of LBP in college students? 20%, 30%, or 40%? students? 20%, 30%, or 40% ? - stressful psychosocial variables of feeling very sad, exhausted, and overwhelmed were associated with the prevalence of LBP 2. Significant differences in diagnosis and surgery rates - Most LBP represents a pain condition , NOT spinal problem exist between African Americans and whites with occupational low back injuries , True or False? 1. Significant differences in diagnosis and surgery rates exist between African Americans and whites with occupational 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 Kennedy et al JACH 2008; Chibnail et al Spine 2006 11 Lumbar Spine Injuries in Athletes of All Ages 12 Lumbar Spine Injuries in Athletes of All Ages 3

LS Spine – Bones, Joints, and Discs 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 13 Lumbar Spine Injuries in Athletes of All Ages 14 Lumbar Spine Injuries in Athletes of All Ages LS Spine - Nerves LS Spine - Nerves  Dermatomes  Myotomes  31 pairs of - L1/L2 – Hip flexion nerves - L3/L4 – Knee extension  C7 nerve - L4 – Ankle dorsiflexion exits above - L5 – Great toe 7 th cervical dorsiflexion vertebrae - S1 – Ankle  L5 nerve plantarflexion exits below 5 th lumbar vertebrae 15 Lumbar Spine Injuries in Athletes of All Ages 16 Lumbar Spine Injuries in Athletes of All Ages 4

LS Spine - Nerves LS Spine - Muscles  Dermatomes  Superficial Thoracic group - Abdominal group - Erector Spinae group -  Spinalis  Longissimus  Iliocostalis  Deep Transversospinal group -  Multifidus  Rotatores  Intertransversarius Lee MWL et al, Clin Anat 2008 17 Lumbar Spine Injuries in Athletes of All Ages 18 Lumbar Spine Injuries in Athletes of All Ages LS Spine - Muscles Lumbar Spine – A systematic exam  Observation : - Tenderness LS spine, SI joints; femoral nerve - abrasions, bruising, stretch, passive extension comfort, motion hips/spine; Hamstring/glut  Sitting : max strength, L5 reflex - slump test, L4 and S1  Standing: reflexes, sensation, - ROM: flex, ext, sidebend, strength rot/ext; one legged  Supine/Sidelying : extension, Gillet test - SLR, Hip ROM /pain, (pelvic motion); feet, gait, Hamstring/Hip flexor heel/toe walk, functional tightness, L5 reflex testing  Prone : 19 Lumbar Spine Injuries in Athletes of All Ages 20 Lumbar Spine Injuries in Athletes of All Ages 5

Lumbar Spine – A systematic exam Common Lumbar Spine Injuries in Athletes  Observation :  Supine/Sidelying :  Younger  Older - abrasions, bruising, - SLR, Hip ROM /pain, comfort, motion Hamstring/Hip flexor - Mechanical low back - Lumbosacral strain pain tightness, L5 reflex - Herniated disc  Standing: - Spondylolysis  Prone : - Degenerative disc - ROM: flex, ext, sidebend, - Spondylolisthesis rot/ext; one legged - Tenderness LS spine, SI extension, Gillet test joints; femoral nerve - Herniated disc (pelvic motion); feet, gait, stretch, passive extension heel/toe walk, functional hips/spine; Hamstring/glut testing max strength, L5 reflex  Sitting : slump test, L4 and S1 reflexes, sensation, strength Massel DH and Singh K. Instr Course Lect 2017 21 Lumbar Spine Injuries in Athletes of All Ages 22 Lumbar Spine Injuries in Athletes of All Ages Case #1- History Case #1 - Exam 50 YO OVERWT CARPENTER  Observation: STIFFNESS, DISCOMFORT W/ MOVING Mechanism of injury: PLAYING VB AT FAMILY REUNION AND n  Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH TWISTED FOR A BALL  Supine: NEG SLR, HIP FROM W/O PAIN Symptoms: STIFFNESS n  Prone: Onset – ACUTE, 2 DAYS AGO - - NO CENTRAL SPINE OR BONY PAIN Location – ENTIRE LOW BACK - - TENDER BILAT PARASPINAL MM ON PALP Duration – 2 DAYS - - NEG FEMORAL NERVE STRETCH, HAM/GLUT MAX Character – BURNING - STRENGTH 5/5 Aggravating/Alleviating –MOTION/ICE, IBUPROFEN, -  Standing: KNEES TO CHEST - ROM: STIFF/PAIN ESP FF W/ SPASM, PAIN WHEN Radiation – NONE - RETURNING TO ERECT POSITION Timing –CONSTANT DURING DAY , NO PAIN AT NIGHT - - SLOW GAIT, HEEL/TOE WALK OK Severity - 4/10 PAIN, NO WEAKNESS, NO RED FLAGS - 23 Lumbar Spine Injuries in Athletes of All Ages 24 Lumbar Spine Injuries in Athletes of All Ages 6