Espondiloptose em atleta

The adolescent athletes are at greater risk of low back pain and structural spine injuries. Spondylolysis is responsible for the majority of back pain cases in young athletes, rarely occurring in adults. We report a case of a 13‐year‐old judo female athlete, who came to our service with 5 months of progressive low back pain during training which was initially attributed to mechanical causes, without any further investigation by imaging methods. At admission, the patient had lumbar deformity, antalgic posture and bilaterally positive unipodalic lumbar hyperextension maneuver. After a research which showed spondyloptosis, the patient underwent surgery. In this article, we discuss, based on this case report, the diagnostic approach to low back pain in young athletes, since the complaint of chronic back pain can be a marker of a structural lesion that may be permanent and bring irreversible functional loss.     

Lumbar spine injuries in pediatric and adolescent athletes

During the past two decades, there has been a significant increase in sports participation by pediatric athletes. Spinal injuries thus have become a great concern. The unique nature of the pediatric spine should be well-recognized and low back pain in a pediatric athlete should therefore be taken seriously and evaluated thoroughly. In this review article, sports-related lumbar spine problems will be covered including overuse injuries, spondylolysis, pars stress fractures, spondylolysthesis, and lumbar disc herniation. Early identification of these problems will eventually minimize these injuries.     

Fatigue stress fractures of the pelvis: a rare cause of low back pain in female athletes

Stress fracture of the pelvis represents one rare differential diagnosis among the manifold causes of low back pain in female athletes. We report a case of fatigue stress fracture of the pelvis in a 24-year-old female athlete as an unusual differential diagnosis of low back pain that should be taken into consideration. According to the literature the incidence of low back pain in athletes ranges from 1% to 30% and is influenced by sport type, gender, training intensity, training frequency and technique. In some cases, no specific pain generator is found, which makes diagnosis and treatment difficult. The frequency of the injury and the treatment options are discussed, based on published studies.     

Low-back pain in athletes

While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, or recurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; however, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease that is recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusion in selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participation in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appears to be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, independent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars interarticularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes and allow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such as track or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobilization, physical therapy, and return to sports in one to two months, when the pain has resolved.     

Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up

This study is a prospective, consecutive, 3-year cohort study of women with back pain in an index pregnancy. The aim was to describe the physical status and disability among women with back pain 3 years after delivery. Pain was identified as lumbar back pain, posterior pelvic pain or combined lumbar as well as posterior pelvic pain. Previous studies have established that all three types of pain can be reduced by structured physiotherapy during pregnancy, and the beneficial effect may last for several years. Though it is known that some women have residual pain for a long time, the relative incidence of the three pain types and their degree of disability associated with each have never been reported. Neither has any study presented findings of a physical examination of women 3 years post partum with a focus on the type of pain. All women who were registered as having experienced back pain during an index pregnancy were interviewed by mail 3 years post partum. Women who had residual back pain filled in an additional questionnaire and were physically examined. Out of 799 pregnant women, 231 had some type of back pain during the index pregnancy, and 41 women had pain 3 years later. Women with combined lumbar and posterior pelvic pain were significantly more disabled ( P<0.05) and had significantly lower endurance in the lumbar back and hip abduction muscles ( P<0.01). Some 5% of all pregnant women, or 20% of all women with back pain during pregnancy, had pain 3 years later. The key problem may be poor muscle function in the back and pelvis.     

Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections

BACKGROUND: Adductor dysfunction is a condition that can cause groin pain in competitive athletes, but the source of the pain has not been established and no specific interventions have been evaluated. We previously defined a magnetic resonance imaging protocol to visualize adductor enthesopathy. The aim of this study was to elucidate, in the context of adductor-related groin pain in the competitive athlete, the role of the adductor enthesis (origin), the relevance of adductor enthesopathy diagnosed with magnetic resonance imaging, and the efficacy of entheseal pubic cleft injections of local anesthetic and steroids. METHODS: We reviewed the findings in a consecutive series of twenty-four competitive athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. Magnetic resonance imaging was performed to assess the adductor longus origin for the presence or absence of enthesopathy. Seven patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and seventeen patients (Group 2) had enthesopathy confirmed on magnetic resonance imaging. All patients were treated with a single pubic cleft injection of local anesthetic and steroid into the adductor enthesis. At one year after this treatment, the patients were assessed for recurrence of symptoms. RESULTS: On clinical reassessment five minutes after the injection, all twenty-four athletes reported resolution of the groin pain. At one year, none of the seven patients in Group 1 had experienced a recurrence. Sixteen of the seventeen patients in Group 2 had a recurrence of the symptoms (p < 0.001) at a mean of five weeks (range, one to sixteen weeks) after the injection. CONCLUSIONS: A single entheseal pubic cleft injection can be expected to afford at least one year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan; however, it should be employed only as a diagnostic test or short-term treatment for a competitive athlete with evidence of enthesopathy on magnetic resonance imaging.     

Defect in the articular process of the lumbar facet

Bone defect in the lumbar articular facet is rarely noted, and only a few reports on its clinical course have been presented. We report on seven cases with lumbar inferior facet defect whose symptoms were mimicking spondylolysis. We have found three types of the defect shape on radiographs: linear, blunt, and irregular. There were five cases with linear type, one with blunt, and one with irregular. All patients had persistent low back pain, especially when doing physical activity or sports, but no one had history of major trauma or accident. Injection of a small amount of anesthetic temporarily alleviated the low back pain. The low back pain in six patients was controlled with conservative treatments, such as bracing or medication; bone union was especially gained in one case. However, a volleyball player's pain could not be controlled conservatively, and removal of the bone fragment was performed. It is considered that facet defect is not as rare as presumed, and more attention should be paid to it as a source of low back pain.     

Upper-extremity rehabilitation: conditioning and orthotics for the athlete and performing artist

Rehabilitation of athletes or musicians with hand injuries begins immediately after injury. Accurate diagnosis of the injury and tissues involved is followed by specific acute and rehabilitative therapies to correct the injury and determine any biomechanical changes that may have occurred. Medication and physical methods aid in decreasing inflammation and pain. Mobility is progressively restored, with the aid of appropriate heating modalities, as soon as signs and symptoms allow. Proprioception and neuromuscular coordination are then retrained. This is followed by balanced muscle strength training. Finally, sport-specific endurance and biomechanical skills are developed. Emotional aspects of the injury may be dealt with by investigating the physical and emotional stresses of the performance, and discussing them with the patient. Some patients may also be helped by psychologic counseling. Orthotics may be used to decrease swelling, decrease pain, and inhibit unwanted motion. Some variations allow for progressive range of motion and strength building. Attention to these details maximizes the chances of successful return to performance in the athlete or performing artist with a hand injury.     

The current approach to the medical diagnosis of low back pain.

A small number of patients who present with low back pain will have an underlying medical disorder as the source of their pain. Patients who fail to respond to conservative management with controlled physical activity and nonnarcotic analgesics should have a thorough re-evaluation to detect possible sources of nonmechanical pain. Symptoms of fever, weight loss, recumbency pain, morning stiffness, acute severe pain, or colicky back pain represent specific entry points into the algorithm for diagnosis of back pain from underlying systemic illnesses. These patients will generally require a plain roentgenographic examination with subsequent scintography, MRI, CT, laboratory work, and biopsy as indicated by any positive findings during the diagnostic work-up. Therapy for individuals with nonmechanical low back pain is directed at the specific medical disorder that is the cause of their symptoms.     

The outcome of lumbar discectomy in elite athletes

STUDY DESIGN: An outcomes assessment of 14 elite college athletes who had undergone lumbar disc surgery was performed using the SF-36, a validated questionnaire that assesses quality of life. OBJECTIVES: To determine the outcomes and results of lumbar disc surgery in an elite group of athletes and compare the results with those in the general population and in age-matched control subjects. SUMMARY OF BACKGROUND DATA: Lumbar disc surgery is reported to be a highly successful procedure with excellent results. The outcome in elite athletes has not been assessed and compared with population norms and age-matched control subjects. METHODS: Fourteen athletes from schools in the National Collegiate Athletic Association with a mean age of 20.7, underwent lumbar discectomy for radiculopathy refractory to conservative treatment. Ten had a single-level microdiscectomy, three a two-level microdiscectomy, and one a percutaneous discectomy. Patients were evaluated at a mean follow-up of 3.1 years, underwent a detailed clinical evaluation, and filled out the SF-36 questionnaire. RESULTS: All 14 patients had improvement of pain with elimination of the radicular component, took less medication than before surgery, and returned to recreational sports. Nine patients, all with a single level microdiscectomy, returned to varsity sports. Five athletes prematurely retired from competitive sports because of continued symptoms. Three of the athletes who retired underwent two-level procedures, and one had a percutaneous discectomy. SF-36 scores for bodily pain, physical role, and social and mental health roles were significantly lower in those athletes who retired. Patient scores were also compared with those in a group of noninjured age-and sport-matched college athletes. There were no differences between injured and noninjured athletes, but both groups had scores significantly lower than normal values in an age-matched group for bodily pain, physical role, general health, and social function. CONCLUSIONS: All patients were satisfied with their surgeries, were greatly improved, and were pain free in activities of daily living. For a single-level microdiscectomy, the success rate in elite athletes is excellent, with 90% of athletes able to return to a high level of competition. Two-level disease may be associated with a less favorable outcome.     

Anterior and combined anteroposterior fusion for lumbar disc pain. A preliminary study.

This article reports on a study of 51 consecutive patients (83 lumbar discs) with back pain who underwent anterior interbody lumbar fusion or combined anterior and posterior fusion at the same operation during a 2-year period. All patients met the criteria for diagnosis of a painful internal disc disruption and/or failed back syndrome and have had a lengthy trial of conservative treatment consisting of rest, physical therapy, back support, nonsteroidal anti-inflammatory drug therapy, and guarded activity; this treatment was often supplemented by epidural cortisone injections, pain management, and functional rehabilitation. Patients with prolonged back pain who failed with conservative care after a minimum of 12 months of severely disabling symptoms were selected for surgery on the basis of a positive dynamic discogram reproducing their exact pain and demonstrating a morphologically degenerative disc (internal disc disruption). For the purpose of this study, patients were categorized into three groups and followed up for 15-36 months after the operation. There were no deaths or major complications, and the overall success in achieving measurable diminution of preoperative pain was 80%. This article discusses preliminary conclusions on the efficacy and safety on anterior and anteroposterior fusion for lumbar disc pain.     

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy

There is no convincing medical evidence to support the routine use of lumbar fusion at the time of a primary lumbar disc excision. There is conflicting Class III medical evidence regarding the potential benefit of the addition of fusion in this circumstance. Therefore, the definite increase in cost and complications associated with the use of fusion are not justified. Patients with preoperative lumbar instability may benefit from fusion at the time of lumbar discectomy; however, the incidence of such instability appears to be very low (< 5%) in the general lumbar disc herniation population. Patients who suffer from chronic low-back pain, or are heavy laborers or athletes with axial low-back pain, in addition to radicular symptoms may also be candidates for fusion at the time of lumbar disc excision. Patients with a recurrent disc herniation have been treated successfully with both reoperative discectomy and reoperative discectomy combined with fusion. In patients with a recurrent lumbar disc herniation with associated spinal deformity, instability, or associated chronic low-back pain, consideration of fusion in addition to reoperative discectomy is recommended.     

Spondylolysis and spondylolisthesis in the child and adolescent athlete

Spondylolysis and spondylolisthesis are common causes of low back pain in the competitive athlete. Repetitive loading of the lumbar spine results in stress reactions and spondylytic defects of the pars interarticularis. Spondylolysis and lesser degrees of spondylolisthesis frequently respond to activity restrictions, bracing (in specific situations), and physiotherapy. Spinal fusion is indicated for spondylolysis and spondylolisthesis that remain painful despite nonoperative measures and progressive, high-grade spondylolisthesis. Return-to-play guidelines are made for each athlete individually based on his or her specific diagnosis, response to treatment, and sporting activity.     

Painful lumbar spondylolysis among pediatric sports players: a pilot MRI study

Introduction  

For children and adolescents who are very active athletes, fresh lumbar spondylolysis is the main pathologic cause of lower back pain (LBP). However, regarding the terminal-stage spondylolysis (pars defect), there have been few studies to clarify the pathomechanism of LBP. The purpose of this study is to clarify the cause of LBP associated with pars defects in athletes. This is the first report showing a possible pathomechanism of LBP in active athletes with painful pars defect.     

Spondylolysis in the female gymnast.

In a roentgenographic analysis of the lumbar spine of 100 young female gymnasts engaged in high-level competition, the incidence of pars interarticular defects was 11 per cent; 6 per cent had spondylolisthesis. This is 4 times higher than their non-athletic female peers. It appears that the female athlete may have the same incidence of pars interarticularis defects as the male performing similar activities. Pars defects developing in association with athletic activities may be distinct from those developing in early childhood. A negative lumbosacral roentgenographic series does not completely rule out a developing pars defect. Bone scintography offers an additional tool for evaluating early stress reaction in the pars, and suggests that if the athlete restricts vigorous activity, some will heal without progressing to roentgenographically detectable defects. Low back pain in the young gymnast should be a warning sign. Close scrutiny of pars interarticularis in these young athletes will reveal a high incidence of developing defects.     

A 14-year-old competitive, high-level athlete with unilateral low back pain: case report

Objective:

To detail the presentation of a male adolescent competitive high-level soccer player with left sided low back pain that occurred while playing soccer. This case will outline the importance of early detection, risk of progression and management of active spondylolysis in adolescent athletes.

Clinical Features:

The patient initially presented to a chiropractic sport specialist with left sided low back pain (9/10 on numeric pain scale rating) while kicking soccer balls with his left leg of one month duration. He was initially diagnosed with mechanical low back pain and successfully treated for acute pain management including removal from sport specific training and competition, soft tissue therapy and advice to rest. The chief complaint returned however, when the athlete resumed training and competition. A plain film imaging report suggested only postural alterations in an otherwise normal study of the lumbar spine. Computed tomography images taken three months later revealed a fracture at the left L5 pars interarticularis.

Summary:

The early detection of spondylolysis combined with an effective plan of management including rest and conservative therapy with a progressive return to play may allow competitive athletes to resume participation at an elite level.     

Lumbar position sense and the risk of low back injuries in college athletes: a prospective cohort study

Background  

Impaired proprioception in the lumbar spine has often been reported in people with low back pain. However, no prospective studies exist to assert the cause and effect of this association. We hypothesized that athletes with a history of low back injury (LBI) would demonstrate poorer lumbar position sense (PS) than athletes without a history of LBI, and that this deficit would be a risk factor for future LBI.     

Editorial Commentary: Why the Mind Matters in Anterior Cruciate Ligament Injury Recovery: Psychological Readiness and Return to Sport

Following anterior cruciate ligament injury and surgery, it is important that we prepare athletes to return to sport not only from a physical perspective but also a psychological one. Typically, we are concerned for an athlete who has low confidence or high anxiety. However, can being too psychologically ready to return to sport also be a bad thing? While the optimal psychological profile will vary from person to person, evidence is emerging that more extreme responses may have detrimental consequences and increase the risk of further injury.     

Adolescent lumbar disc herniation in a Tae Kwon Do martial artist: a case report

Lumbar disc herniations are rare in children. The etiology and clinical picture may be different in children than in adults. Conservative management is the treatment of choice. Tae Kwon Do is a Korean martial art which is notorious for its high fast kicks. Tae Kwon Do will be an official Olympic sport in the year 2000. Low back pain is occasionally reported by Tae Kwon Do athletes but there are no reported cases in the literature on disc herniation in a Tae Kwon Do athlete. A case report is presented to illustrate clinical presentation, diagnosis, radiological assessment and conservative management of lumbar disc herniation in children.     

Posterior Glenohumeral Instability: Diagnosis and Management

Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients’ symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.