The aging spine in sports

1. Masters athletes may experience low back pain from multiple sources. Masters athletes with discogenic back pain should avoid or modify sports with combined rotational and compressive forces; individuals with facet-mediated pain should avoid or modify sports with excessive extension and rotation. 2. Optimization of flexibility, strength, endurance, and core control is critical. Sports specific training, realistic goal setting, and counseling are of maximal importance. 3. Overall, the health benefits of continued sports and athletic participation outweigh the potential risks of spinal degeneration in middle-aged athletes. There is little correlation between radiographic appearance of the spine and symptoms; therefore, symptoms should serve as the primary guide when determining activity modifications. Overall, masters athletes should be encouraged to remain active and fit to enhance their quality of life and reduce the risk of cardiovascular disease.     

Current thinking: Return to play and transient quadriplegia

Athletes that participate in contact and collision sports assume risk of serious injury each time they take the field. For those athletes that have sustained an episode of transient quadriplegia, the decision of whether to return to competition can be a difficult one. Some athletes, realizing how close they may have come to permanent injury, may decide that further participation is not in their best interest. Others may be somewhat undecided, and some may want to return at all costs. As the treating physician, the goal is to identify those athletes who after a single episode of transient quadriplegia are at increased risk for further injury and consequently should discontinue participation in contact sports. Factors that may contribute to that determination include mechanism of injury, prior history of neurologic symptoms or injury, and anatomic features that may predispose to further injury such as disc herniation, fracture, or cervical stenosis.     

Hip muscle imbalance and low back pain in athletes: influence of core strengthening.

PURPOSE: The influence of a core-strengthening program on low back pain (LBP) occurrence and hip strength differences were studied in NCAA Division I collegiate athletes. METHODS: In 1998, 1999, and 2000, hip strength was measured during preparticipation physical examinations and occurrence of LBP was monitored throughout the year. Following the 1999-2000 preparticipation physicals, all athletes began participation in a structured core-strengthening program, which emphasized abdominal, paraspinal, and hip extensor strengthening. Incidence of LBP and the relationship with hip muscle imbalance were compared between consecutive academic years. RESULTS: After incorporation of core strengthening, there was no statistically significant change in LBP occurrence. Side-to-side extensor strength between athletes participating in both the 1998-1999 and 1999-2000 physicals were no different. After core strengthening, the right hip extensor was, on average, stronger than that of the left hip extensor (P = 0.0001). More specific gender differences were noted after core strengthening. Using logistic regression, female athletes with weaker left hip abductors had a more significant probability of requiring treatment for LBP (P = 0.009) CONCLUSION: The impact of core strengthening on collegiate athletes has not been previously examined. These results indicated no significant advantage of core strengthening in reducing LBP occurrence, though this may be more a reflection of the small numbers of subjects who actually required treatment. The core program, however, seems to have had a role in modifying hip extensor strength balance. The association between hip strength and future LBP occurrence, observed only in females, may indicate the need for more gender-specific core programs. The need for a larger scale study to examine the impact of core strengthening in collegiate athletes is demonstrated.     

Low back pain in athletes and non-athletes: a group comparison of basic pain parameters and impact on sports activity

Introduction

Low back pain (LBP) is a major health issue in athletes and non-athletes often accompanied by considerable restrictions in everyday functioning. Knowledge about differences between those groups regarding LBP parameters (intensity, duration, and disability) and their influence on daily life is still lacking. Hence, the present study aimed at the comparison of those LBP parameters between athletes and non-athletes and the impact of these factors on sports activity.

Methods

LBP patients receiving prescribed sport- or physiotherapeutic treatment (N = 264) completed a questionnaire battery to determine their LBP pain intensity, duration, chronification, disability, and changes in sports activity. The categorization into athletes and non-athletes was based on performance level. Uni- and multivariate analyses of (Co-) variance and nonparametric group comparisons were executed to analyze group differences.

Results

Disability was lower in the athlete’s group, especially concerning work ability (p < 0.05). Athletes rather continued with their sports activity despite LBP (p < 0.001). The interaction between age and difference in training volume showed that non-athletes (<29 years) reported a greater reduction of training volume from a pain free to a LBP phase compared to athletes in the respective age group.

Conclusions

The results imply that athletes with LBP perceive less impairment than non-athletes concerning disability and changes in training volume. Possible explanations can be inferred from different socialization processes and pain coping mechanisms among athletes. The outcomes contribute to the existing literature by adding specific knowledge about dissimilarities between athletes and non-athletes regarding the appraisal of LBP.

     

Eating disorders in the male athlete

Eating disorders do occur in male athletes. They are less prominent than in female athletes, and therefore in danger of being missed. The high-risk sports fall into the same categories as with females: aesthetic sports, sports in which low body fat is advantageous, such as cross-country and marathon running, and sports in which there is a need to "make weight", including wrestling and horse racing.Athletic involvement may foster the development of an eating disorder. Some male athletes, in their preoccupation with body image, will abuse anabolic steroids. While sports participation may contribute to the aetiology of an eating disorder, the converse is also true. Exercise may be used as therapy for some cases of eating disorder.In order to adequately treat eating disorders in the male athlete, it is first essential to identify cases. Psychoeducation of athletes, their families, coaches and trainers is an important first step. Counselling an athlete to pursue a sport appropriate to his body type, or to leave his sport behind altogether (an unpopular recommendation from a coach's perspective) can be important to treatment. Treatment of co-morbid psychiatric conditions is essential. Treatment can be structured using a biopsychosocial approach, and all appropriate modalities of therapy, including individual, family and group, as well as psychopharmacotherapy, where appropriate, should be applied.     

Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury

Traumatic osteitis pubis is a non-specific entity that relates to chronic groin injury and has recently been described as being akin to a pubic bone stress injury. It is uncertain whether or not reduction of hip joint range of motion occurs in traumatic osteitis pubis. The purpose of this study was to establish whether there is a reduction of hip range of motion in athletes who have chronic groin injury diagnosed as pubic bone stress injury. A case-control study was performed whereby 89 Australian Rules footballers underwent, with clinical history unknown, clinical and MRI examination of the groin region. Clinical criteria (pain with tenderness) and MR-criteria (pubic bone marrow oedema) were used for diagnosis of pubic bone stress injury. End-range internal and external rotation hip motion was measured using a goniometer. Athletes with and without symptoms were compared, as were athletes with current symptoms with athletes who had recovered from their groin pain episode. Chronic groin injury was diagnosed in 47 athletes with 37 having pubic bone stress injury. Thirteen athletes had previous groin injury. A reduction of internal and external hip range of motion was demonstrated in athletes with pubic bone stress injury (p < 0.05) and in athletes who had current symptoms compared to those who had recovered from their groin pain episode (p < 0.05). A reduction in hip range of motion was evident in athletes with chronic groin injury diagnosed as pubic bone stress injury. There may be a role for increasing hip range of motion in rehabilitation.     

Resistance band training or general exercise in multidisciplinary rehabilitation of low back pain? A randomized trial

Multidisciplinary biopsychosocial rehabilitation has been recommended for chronic low back pain (LBP ), including physical exercise. However, which exercise modality that is most advantageous in multidisciplinary biopsychosocial rehabilitation is unclear. In this study, we investigated whether multidisciplinary biopsychosocial rehabilitation could be more effective in reducing pain‐related disability when general physical exercise was replaced by strength training in the form of progressive resistance training using elastic resistance bands. In this single‐blinded (researchers), randomized controlled trial, 99 consenting adults with moderate‐to‐severe non‐specific LBP were randomized to three weeks of multidisciplinary biopsychosocial rehabilitation with either general physical exercise or progressive resistance band training and were then instructed to continue with their respective home‐based programs for nine additional weeks, in which three booster sessions were offered. The primary outcome was between‐group difference in change on the Oswestry Disability Index (ODI ) at 12 weeks. Due to early dropouts, data from 74 participants (mean age: 45 years, 57% women, mean ODI : 30.4) were obtained at baseline, 61 participants were followed‐up at 3 weeks, and 46 at 12 weeks. There was no difference in the change in ODI score between groups at 12 weeks (mean difference 1.9, 95% CI : −3.6, 7.4, P  = .49). Likewise, the change in secondary outcomes did not differ between groups, except for the patient‐specific functional scale (0‐10), which favored general physical exercise (mean difference 1.4, 95% CI : 0.1, 2.7, P  = .033). In conclusion, this study does not support that progressive resistance band training compared to general physical exercise improve outcomes in multidisciplinary biopsychosocial rehabilitation for patients with non‐specific LBP .     

The validity and reliability of the functional rating index for evaluating low back pain in athletes

The purpose of the present study was to determine the reliability and validity of the Functional Rating Index (FRI) for athletes with low back pain (LBP). In this cross‐sectional and prospective cohort study, the validated Persian FRI (PFRI) was tested in 100 athletes with LBP and 50 healthy athletes. From the athletes with LBP, data were recollected among 50 athletes with a 7‐day interval to examine test‐retest reliability. The content validity was excellent, and the athletes with LBP responded to all items with no floor or ceiling effects. The discriminative validity was supported by a statistically significant difference in PFRI total scores between the athletes with LBP and healthy athletes. The concurrent criterion validity was good (rho = 0.72). The construct, convergent validity was good (r = 0.83). The internal consistency reliability estimate was high (Cronbach's α = 0.90). Factor analysis demonstrated a single‐factor structure with an explained variance of 52.22%. The test‐retest reliability was excellent, indicated by an ICC_agreement of 0.97, and the agreement observed in the Bland and Altman plot demonstrated no systematic bias. It is concluded that the PFRI has excellent psychometric properties for assessing athletes with LBP.     

Back pain and MRI changes in the thoraco‐lumbar spine of young elite Mogul skiers

Athletes have a higher prevalence of LBP and spinal abnormalities on Magnetic Resonance Imaging (MRI) compared to non‐athletes. The objective of this study was to investigate the amount of spinal MRI abnormalities and the lifetime prevalence of low back pain (LBP) in 16 young elite Mogul skiers compared to 28 non‐athletes in the corresponding age in a cross‐sectional design. LBP was assessed by a questionnaire consisting of a part regarding previous or present back pain, the Oswestry disability index, and the EuroQol questionnaire. MRI examinations from Th5 to sacrum were conducted to evaluate spinal pathologies. The Mogul skiers had significantly more MRI abnormalities (like disc degeneration) in mean (7.25 vs 3.78, P < 0.023) compared to the controls. No significant difference was seen regarding the lifetime LBP prevalence between the groups (50% vs 42%, P = 0.555). No correlation could be found between disc degeneration and back pain in this study. Young elite Mogul skiers, compared to an age‐matched control group of non‐athletes, have an increased risk of developing spinal abnormalities potentially due to the different high loads that they are subjected to in their sport. Future relationship between the MRI abnormalities and LBP cannot be verified by this study design.     

Sports-related injuries of the elbow: an approach to MRI interpretation

MRI is a valuable tool for evaluating the athlete with elbow pain, particularly in those with nonlocalizable pain. MRI also is helpful in sorting out the cause of pain in athletes who may have acute trauma superimposed on tendinopathy or other chronic injuries from repetitive microtrauma. Even in athletes in whom the cause of pain confidently can be diagnosed clinically, MRI can document the injury severity, which can be helpful for estimating recovery time or in preoperative planning. By contributing to an accurate early diagnosis, MRI also can help minimize the time that athletes are away from their sports. The authors describe their approach to the MRI interpretation of elbow injuries in athletes, including osteochondral lesions, epicondylitis, and tears of the medial collateral ligament.     

The aetiology of sport injuries. A review of methodologies

Although participation in many sporting activities has increased dramatically in recent years, the study of injuries sustained during training or participation is still in its infancy. The most commonly used strategy is to describe the characteristics of a suitable case-series. This approach is relatively easy to implement, can be used to estimate the total morbidity load in a population, and can identify the relative frequency of various types of injury. However, the case series method cannot validly identify risk factors for injury or athletes at high risk; similarly, it cannot be used to estimate the absolute level of risk associated with sports participation. Finally, the population from which the injuries arose is often difficult to identify, and the series may not be representative of all injuries occurring in that population, and this may produce quite misleading results. In contrast, a variety of epidemiological designs may be employed to address questions of aetiology and to identify high risk groups of athletes. With careful attention to the underlying population denominators, one may estimate the relative or absolute risk of injury for athletes with given risk characteristics, defined by type and intensity of their participation in sports or by their individual physiology. This is achieved by inclusion of suitable control subjects in the epidemiological sample; these controls may be uninjured athletes or random samples of the general population. The comparison of injured and uninjured groups permits valid inferences to be drawn concerning risk factors, avoiding the many potential biases which affect inferences drawn from injured athletes only.     

Changes in lumbopelvic rhythm during trunk extension in adolescent soccer players

Many adolescent athletes experience low back pain (LBP). Its causative factors include lower limb muscle tightness and hip–spine incoordination. Hip–spine coordination [or lumbopelvic rhythm, LPR] can be used to assess lower-limb and spine functions. We assessed the presence/absence of LBP in adolescent soccer players before and after a six-month period and divided them into four groups: no LBP both before and after the period (NBP group); LBP before but not after (PN group); LBP after but not before (NP group); and LBP both before and after (LBP group). We used a 3D motion analysis system during trunk extension to measure the lumbar spine and hip ranges of motion (ROMs). On comparing the results obtained before and after the six-month period, lumbar spine ROM decreased in the NP group, hip ROM increased in the LBP group. From before to after the period, the linear prediction indicated that, when the hip extends by 1°, the lumbar spine extends by 3.5°–3.2° for the PN group and by 3.4°–2.8° for the NP group. The NP group extended their lumbar spine excessively compared with the hip before the period, which could cause LBP, but decreased the extension after the period. Lumbar extension relative to hip extension decreased in the PN group, which could decrease excessive load on the lumbar spine and eliminate LBP. These findings suggest that to prevent LBP in adolescent soccer players, it is important to restrict lumbar spine extension relative to hip extension.     

Magnetic resonance imaging-based interpretation of degenerative changes in the lower lumbar segments and therapeutic consequences

Intervertebral disc degeneration and facet joint osteoarthritis of the lumbar spine are, among others, well known as a cause of low back and lower extremity pain. Together with their secondary disorders they set a big burden on health care systems and economics worldwide. Despite modern imaging modalities, such as magnetic resonance imaging, for a large proportion of patients with low back pain (LBP) it remains difficult to provide a specific diagnosis. The fact that nearly all the lumbar structures are possible sources of LBP, may serve as a possible explanation. Furthermore, our clinical experience confirms, that imaging alone is not a sufficient approach explaining LBP. Here, the Oswestry Disability Index, as the most commonly used measure to quantify disability for LBP, may serve as an easy-to-apply questionnaire to evaluate the patient’s ability to cope with everyday life. For therapeutic purposes, among the different options, the lumbar facet joint intra-articular injection of corticosteroids in combination with an anaesthetic solution is one of the most frequently performed interventional procedures. Although widely used the clinical benefit of intra-articular steroid injections remains controversial. Therefore, prior to therapy, standardized diagnostic algorithms for an accurate assessment, classification and correlation of degenerative changes of the lumbar spine are needed.     

Management of the athlete with low back pain

The evaluation of an athlete with LBP using the classification system proposed by Delitto et al has been outlined. For outpatient orthopaedic practice, evidence in the literature is available documenting the reliability and the effectiveness of treatment guided by TBC. This classification system provides framework for the clinician to evaluate athletes with LBP because it investigates the presence of serious pathology, considers the severity of the disease process, and provides matched treatment based on the athlete's clinical presentation. When treating athletes with episodes of acute LBP, pain modulation and return to daily function are the primary treatment goals. When treating athletes with episodes of chronic LBP, return to sport and prevention of recurrence are the primary treatment goals.     

Association between lower back pain and lower extremity pain among young volleyball players: A cross-sectional study

BackgroundLower back pain (LBP), as well as lower extremity injuries, are major problems among young volleyball players. Nevertheless, only few studies have focused on the relationship between lower extremity injuries and LBP.ObjectiveThis study investigated the association between LBP and lower extremity pain, including knee and ankle pain, among young volleyball players.DesignCross-sectional study.SettingAmateur sports association.ParticipantsElementary and middle school-aged athletes (6–15 years of age).Main outcome measuresLBP and lower extremity pain.ResultsA total of 566 young volleyball players participated in this study. The point prevalence of LBP among young volleyball players was 9.5%. Using absence of lower extremity pain as a reference, the adjusted odds ratio (95% confidence interval) for LBP was 11.07 (5.64–21.71) in the presence of lower extremity pain.ConclusionsLBP is associated with Lower extremity pain among young volleyball players. Careful attention should be paid to lower extremity complaints to prevent and treat LBP among young volleyball players.     

Impact of retrowalking on pain,range of motion,muscle fatigability,and balance in collegiate athletes with chronic mechanical low back pain

Sport Sciences for Health - Low back pain (LBP) has been found to profoundly increase in athletes in the last decade. There are numerous treatment options available for LBP of which retrowalking...     

Development of a preliminary multivariable diagnostic prediction model for identifying active spondylolysis in young athletes with low back pain

AimsThe primary aim of this study was to develop a diagnostic cluster of common clinical findings that would assist in ruling out an active spondylolysis in adolescent athletes with low back pain (LBP).DesignRetrospective case-series.SettingHospital-based sports medicine clinic.PatientsOne thousand and twenty-five adolescent athletes with LBP (age 15.0 ± 1.8 years, 56% female) were reviewed. Active spondylolytic injuries were identified in 22% (n = 228) of these patients.Main outcome measurepresence or absence of active spondylolysis on advanced imaging.ResultsThrough logistic regression analysis, pain with extension (p < 0.001), difference between active and resting pain ≥3/10 (p < 0.001), and male sex (p = 0.002) were identified as significantly associated with active spondylolysis. The clinical cluster had a sensitivity of 88% (95% CI 83%–93%) to help rule out active spondylolysis. The negative likelihood ratio was 0.34 (95% CI 0.23–0.51) and the negative predictive value was 90% (95% CI 86%–93%). Diagnostic accuracy of the cluster was acceptable (area under the curve = 0.72 (95% CI 0.69, 0.76; p < 0.001).ConclusionThis study found a cluster of three patient characteristics that may assist in ruling out active spondylolysis in adolescent athletes with LBP.     

Lumbosacral transitional vertebral articulation: evaluation by planar and SPECT bone scintigraphy

It has been suggested that low back pain (LBP) may arise from lumbosacral transitional vertebral articulation (LSTVA) itself. It is known that bone scintigraphy is a valuable tool for the recognition of pain arising from bone and articular diseases. Therefore we aimed to show planar and SPECT bone scintigraphic findings of LSTVA and compare them with the LBP and X-ray findings. Twenty-eight patients (aged 20-63 years) in whom LSTVA had been identified radiographically were evaluated with planar bone scintigraphy, utilizing 99mTc methylene diphosphonate; and single photon emission computed tomography (SPECT) bone scintigraphy. Eighteen patients had LBP whereas 10 had not. There were 25 type IIA, one type IIB and two type IIIA LSTV articulation. On planar images, normal or non-focal minimally increased uptake superimposed on the upper sacroiliac joint was seen in patients without degenerative changes regardless of LBP whereas SPECT showed non-focal mild increased uptake on the area medial to the upper sacroiliac joint. Planar scans showed normal to non-focal mild, and mild-to-moderately increased uptake whereas SPECT demonstrated focal mild-to-moderately and markedly increased uptake in patients with degenerative changes without LBP and with LBP, respectively. The X-ray results showed an association of LBP degenerative changes, and the SPECT results showed a focal, markedly increased, uptake. We conclude that this focal, markedly increased, uptake may show the metabolically active degenerative changes of LSTV articulation and may help to reveal the pain arising from LSTVA. Therefore we propose that bone scintigraphy may be considered for the evaluation of patients with LBP thought to arise from LSTV articulation.     

Cuboid Syndrome

In brief: About 4% of the athletes with foot problems seen by the authors had cuboid syndrome. The authors say the syndrome is common but that many cases are not recognized or are misdiagnosed. In their experience, it occurs most often in pronated feet, and pain results from a partial displacement of the cuboid, which prevents its normal range of motion. The pain is relieved by manipulating the cuboid to restore its normal position. A cuboid pad or low-dye strapping help prevent recurrences. Orthotics may be necessary to correct excessive pronation of the feet.