Lumbar Spine Injuries in Athletes of All Ages Cindy J. Chang M.D. - - PowerPoint PPT Presentation
Lumbar Spine Injuries in Athletes of All Ages Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Clinical Professor of Orthopaedics and Family and Community Medicine 11/19/17 Objectives Understand how an effective history and physical
11/19/17
UCSF Primary Care Sports Medicine Clinical Professor of Orthopaedics and Family and Community Medicine
§ Understand how an effective history and physical exam can lead you to a focused differential diagnosis for low back pain § Develop treatment plans for the most common causes of low back pain in your athlete population
11/19/17 2
■ With a good history…you should arrive at the correct diagnosis
90% of the time
u Or at least a confident top 3 differential!
■ With a good history, and comfortable knowledge of basic
anatomy…it will make your exam focused, quick and efficient
◆ And give you more time to chart…
■ With a good history, and comfortable knowledge of basic anatomy,
you will not need to palpate until the END of the exam…
◆ Or you risk your patient not letting you finish the exam!
11/19/17 3
§ Stock gowns/sheets and paper shorts in the room § Be able to get to both sides of the exam table § Have a step stool handy
11/19/17 4
bladder
11/19/17 5
§ Location - Point to where the pain is
11/19/17 6
‒ Onset (O) ‒ Location ‒ Duration ‒ Character (Q) ‒ Aggravating/Alleviating (P) ‒ Radiation (R) ‒ Timing (T) ‒ Severity (S)
11/19/17 7
§ History of cancer § Progressive motor or sensory deficit § Prolonged steroid use, IV drug use § Major trauma § Numbness in groin/saddle § Bilateral leg weakness § Fever and chills § Unrelenting severe pain with rest or at night § Loss of bowel or bladder function
11/19/17 8
Henschke N et al. Cochrane Database Syst Rev 2013
11/19/17 9
§ Increased ligamentous laxity/greater mobility of spine
§ Immature joints and ossification centers
11/19/17 10
Basu S. Neurol 2012
§ 31 prs of nerves § C7 nerve exits b/w 6th and 7th cervical vertebrae § L4 nerve exits b/w 4th and 5th lumbar vertebrae
Lee MWL et al, Clin Anat 2008
§ Superficial
‒ Spinalis ‒ Longissimus ‒ Iliocostalis § Deep
group ‒ Multifidus ‒ Rotatores ‒ Intertransversarius
§ Observation:
motion § Sitting:
sensation, strength § Supine:
Hip flexor tightness § Prone:
femoral nerve stretch, passive extension hips/spine; Hamstring/ glut max strength, L5 reflex § Standing:
exten; one legged extension, Gillet test (pelvic motion); feet, gait, heel/toe walk, functional testing
11/19/17 16
§ Younger
§ Older
18
Massel DH and Singh K. Instr Course Lect 2017
1. Age—22 professional soccer player 2. Date of injury/symptom onset--ACUTE 3. Injury Mechanism:
CONTINUE PLAY 4. Symptoms: Mechanical/Other
BLADDER FXN. SWELLING AT SITE OF TRAUMA
5. Symptoms: Pain/Numbness/Tingling
6. Modifying/Other Factors
§ Observation: DISCOMFORT, IN PAIN § Sitting: LOCAL PAIN WITH SLUMP TEST, NO RADIATION. NL
§ Supine:
§ Prone:
§ Standing:
§ Sudden extreme twisting or side-bending movement, or direct impact
§ Majority treated conservatively, no surgery needed § Stabilization not needed § Gradual introduction of movement and PT/rehab § Full return to activity expected
Nagasawa DT et al. World Neurosurg 2017
1. 50 YO OVERWT FEMALE CARPENTER 2. Date of injury/symptom onset: 2 DAYS AGO 3. Injury Mechanism:
AND TWISTED FOR A BALL 4. Symptoms:
BLADDER OK
5. Symptoms: Pain/Numbness/Tingling
6. Modifying/Other Factors
§ Observation: STIFFNESS. DISCOMFOFT WITH MOVEMENT § Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH § Supine: NEG SLR, HIP FROM W/O PAIN § Prone:
§ Standing:
ERECT POSITION; SLOW GAIT, HEEL/TOE WALK OK
§ Acute sudden movement or action § Overuse from poor posture, mm strength, endurance § Common and self- limiting § Treatment:
patterns
no resolution
e.g. walking in proper shoewear
Traeger A et al. CMAJ 2017
1. Age, occupation, etc.: 51 YO LESS OVERWT CARPENTER 2. Date of injury/symptom onset: 2 MONTHS AGO 3. Injury Mechanism:
WORKOUT, INCREASING RUNNING MILEAGE ON TREADMILL 4. Symptoms: STIFF, WEAK, BOWEL/BLADDER OK
5. Symptoms: Pain/Numbness/Tingling
6. Modifying/Other Factors
COUGH/SNEEZE
§ Observation: STANDING WHEN YOU ENTER ROOM § Sitting:
FOOT; ê STRENGTH 4/5 L GREAT TOE EXTENSION, L ANKLE DF; 5-/5 L ANKLE PF § Supine:
§ Prone:
§ Standing:
16 ON L; NO ATROPHY
§ Subspecialty referral for any weakness, loss of reflexes
increasing pain unresponsive to meds § Physical therapy; Posture/positions of comfort; Weight loss § NSAID alternating with acetaminophen every 3 hrs
600 ibu @ 1400, etc. § Other meds individualized
Traeger A et al. CMAJ 2017
1. Age: 30 YO MALE PROGRAMMER TRAINING FOR SF MARATHON 2. Date of injury/symptom onset: OFF AND ON X 2 MONTHS 3. Injury Mechanism:
INTERVALS 4. Symptoms: Mechanical/Other
5. Symptoms: Pain/Numbness/Tingling
6. Modifying/Other Factors
LESS TIME STRETCHING
§ Observation: NO DISCOMFORT § Sitting: NEG SLUMP, NL SENS/STRENGTH/REFLEXES § Supine:
§ Prone:
PASSIVE HIP EXTENSION § Standing:
ROTATION), GAIT NL
§ Evaluate hip flexors, quads, ITB
§ Anterior rotation
and adductors as femur moves forward during sprinting but pelvis does not posteriorly rotate § Posterior rotation
‒ Rule out rheum d/o if very tender over SI joint, warm, AM pain/stiffness, resolution with NSAID ‒ Physical Therapy
Peebles R and Jonas CE. CSMR 2017
1. Age: 15 YO HS FB PLAYER, RHD 2. Date of injury/symptom onset: GRADUAL X 2-3 MO 3. Injury Mechanism:
the line, lifts weights 4. Symptoms: Mechanical/Other: TIGHT, NO SWELLING
5. Symptoms: Pain/Numbness/Tingling
(SLEEPS ON STOMACH) 6. Modifying/Other Factors
§ Observation: MOVES EASILY § Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH, (-) CVAT § Supine:
TIGHT BILAT
TIGHT HIP FLEXORS § Prone:
HIP
EXTENSION § Standing:
ROT, EXTENSION
§ AP/Lateral
– Localizes uptake to posterior vertebral elements – Hot vs. Cold
– Assess age and healing
Ledonio CGT et al. Spine Deform 2016
rotated, low back hyperextended
Panteliadis P et al. Global Spine J 2016
§ Exercise daily § Practice correct posture § Lift correctly § Sleep properly § Avoid prolonged position § Achieve and maintain a healthy weight