eMedicine Specialties > Sports Medicine > Spine
Lumbar Disk Problems in the Athlete
Updated: Oct 12, 2007
Introduction
Background
Low back pain (LBP) is one of the most common reasons for missed playing time in professional athletics, as well as a leading reason for healthcare provider visits. When evaluating patients with LBP, lumbar disc problems should be considered.
Frequency
United States
At-risk sports for lumbar disc problems include activities that require frequent flexion, extension, and rotation of the spine. An example is gymnastics, in which disc degeneration is seen in up to 75% of participants that present with back pain.1 Disc degeneration is significantly more common in elite athletes (75%) compared with nonathletes (31%).2
Lumbar disc herniation accounts for only 4% of back pain cases3; symptomatic disc herniations are more common in adults (48%) than adolescent athletes (11%). Acute disc herniations commonly occur in individuals between the ages 30 and 55 years4; however, athletes between ages 20 and 35 years are at the greatest risk for disc injury,5 and the L4-L5 and L5-S1 levels are most commonly affected.
Functional Anatomy
The vertebrae are separated by vertebral discs that are composed of a gel substance (nucleus pulposus) surrounded by outer collagen fibers, which are arranged in a crossed manner (annulus fibrosis). These discs are further supported by the anterior and posterior longitudinal ligaments. Together, the vertebral disc complex resists spinal compression.
During axial rotation of the spine, the annular fibers are placed at a mechanical disadvantage. Furthermore, in forward flexion, the anterior vertebral endplates approximate, increasing the pressure of the disc posteriorly. The most common disc herniation is directed posteriorly toward the foraminal window, where the nerve roots exit the spinal canal. As such, a common mechanism of herniation in athletes is combined flexion, rotation, and compression of the spine. Football, wrestling, hockey, gymnastics, tennis, and golf are some sports in which this injury mechanism commonly occurs.
In the presence of a disc herniation, forward flexion worsens the herniation. In extension, the opposite occurs. The posterior vertebral endplates approximate, forcing the disc anteriorly, to reduce the herniation.
The anatomic structures that have been implicated as pain generators include the vertebral discs, nerve roots, ligaments, zygapophysial joints (z-joints), sacroiliac joints, and the musculature. Some studies suggest that discogenic pain secondary to annular disruption is the most common cause of LBP6; vascularized granulation tissue with innervation along a torn annulus fibrosis is thought to be the cause. Inflammatory factors caused by the leakage of nuclear material from annular tears can delay intradiscal tissue healing. These factors include matrix metalloproteinases (MMPs), phospholipase A2 (PLA2), cyclooxygenase (COX), prostaglandins, nitric oxide (NO), cytokines, interleukins, and macrophages.
Classifications of disc herniations
- Disc protrusion describes a bulged annulus that has not ruptured. In this scenario, there is no contact between the nucleus and the extradiscal space.
- Disc extrusion describes a ruptured annulus with some expelled nucleus that remains attached to the disc.
- Sequestered disc or complete prolapse describes a nucleus that is expelled from the disc and is no longer attached.
Sport-Specific Biomechanics
In cycling, an incorrect seat position may predispose an individual to disc herniation. Running can cause wear and tear to the vertebral discs secondary to the repetitive trauma that is involved. Well-cushioned shoes and more forgiving training surfaces are thought to protect against disc injury.
Former elite weight lifters and soccer players have been noted to have a higher incidence of degenerative disc disease (DDD) — as noted on magnetic resonance imaging (MRI) studies — but these findings have not been correlated with increased pain in the affected athletes.5
(See also the eMedicine articles Lumbar Degenerative Disk Disease [in the Physical Medicine and Rehabilitation section], Degenerative Disk Disease [in the Orthopedic Surgery section], and Degenerative Lumbar Disc Disease in the Mature Athlete [in the Sports Medicine section].)
Clinical
History
The following symptoms should be noted with regard to the patient's pain:
- Intensity (The severity of pain does not always correlate with the extent of the herniation.)
- Character or quality (eg, sharp, dull, achy, or burning)
- Location (Before irritation of the nerve root occurs, pain may be limited to the lower back without radicular symptoms.)
- Percentage of back to leg pain
- Onset (ie, sudden or insidious)
- Duration
- Exacerbating and relieving factors (eg, sitting, standing, lying, ambulating, or during Valsalva maneuver)
- Radiation (eg, dermatomal pattern)
- Morning stiffness (This is usually limited to 20-30 min with discogenic pain vs 2-3 h with arthritis.4)
- Constitutional symptoms (eg, weight loss, fever, or nausea)
- Remote or recent trauma
- Recent change in training routine
- Younger or older patients (younger than age 20 y or older than 50 y)
- History of previous malignancy
- Fever/chills
- Weight loss
- Night symptoms
- History of intravenous/injection (IV) drug use
- Immunosuppressed patients
- Saddle anesthesia (eg, possible cauda equina syndrome)
- Recent bowel or bladder dysfunction, particularly urinary retention
- Severe progressive neurologic deficit
Typical symptoms of nerve root compression are pain and paresthesias that follow a dermatomal pattern, and findings may include lower-extremity muscle weakness.
Cauda equina syndrome can occur in the presence of significant central disc herniation. This is considered a surgical emergency, and patients should be referred for evaluation without delay.
(See also the eMedicine articles Cauda Equina Syndrome [in the Emergency Medicine section] and Cauda Equina Syndrome [in the Orthopedic Surgery section].)
Physical
It is important to observe the patient's ambulation, posture, affect, gait, and need of assistive devices. Asymmetries in the patient's neck, shoulders, back, hips, and legs can also be helpful in the evaluation of LBP. Lumbar shift (ie, list) is commonly seen with disc herniation, and the list is usually away from the side of the pain.4
The spinous process and interspinous ligaments should be palpated, and any step-off deformity should be noted.
Range-of-motion assessment should include the following:
- Flexion – This motion tends to produce pain with disc herniation and ligamentous injury.
- Extension – This motion tends to produce pain with facet disease, spinal stenosis, spondylolysis, and DDD. (See also the eMedicine articles Lumbar Facet Arthropathy, Spinal Stenosis and Neurogenic Claudicati on, Lumbar Spondylolysis and Spondylolisthesis [in the Physical Medicine and Rehabilitation section]; Lumbosacral Facet Syndrome [in the Sports Medicine section]; and Spondylolisthesis, Spondylolysis, and Spondylosis [in the Orthopedic Surgery section].)
- Axial Rotation and lateral bending
Through light touch and pinprick testing of the medial (L4), dorsal (L5), and lateral or plantar (S1) aspect of the foot, the most likely affected nerve roots are tested. Most herniations occur medial to the dorsal root ganglion (DRG), which is a bipolar neuron. Therefore, it is possible for distal sensory testing to remain normal despite abnormal motor testing.
Motor testing includes having the patient squat, as well as walk on the heels and toes. Manual muscle testing is commonly measured according to the Oxford scale, as follows:
- 0– No movement
- 1– Trace contraction without joint movement
- 2– Joint motion with gravity eliminated
- 3– Joint movement against gravity
- 4– Movement against gravity and some resistance
- 5 – Normal strength
Repeat testing can fatigue the muscles and may allow the clinician to distinguish subtle weakness(es) on examination. The muscles to be tested include the following:
- Iliopsoas (L2-L3)
- Quadriceps (L3-L4)
- Hamstring (L5-S1)
- Tibialis anterior(L4-L5)
- Extensor hallucis longus (L5)
- Posterior tibialis (S1-S2)
- Patellar (L3-L4)
- Medial hamstring (L5) – Perform with the patient prone.
- Achilles (S1) – This reflex may be difficult to elicit. The calf must be relaxed and the foot slightly dorsiflexed. A diminished Achilles reflex is a common finding of radiculopathy.
- Upper motor neuron testing is performed through Babinski and clonus testing.
The straight-leg raise (SLR) is performed with the patient supine as the examiner elevates the lower extremity. This test is considered to be positive if the patient's symptoms are reproduced between 30-70º of elevation. Pain at 60º is 95% sensitive for an L5-S1 radiculopathy.4 Pain at greater than 70º of elevation is more consistent with lumbar facet or sacroiliac pain.4 Performing a seated SLR gives fewer false-positive results,8 and the test is more commonly positive in adults relative to children. (See also the eMedicine article Sacroiliac Joint Injury.)
The distribution of pain with SLR testing can predict anatomic location of a lesion 88.5% of the time.9 The majority of lesions (95%) occur at the L4-L5 or L5-S1 disc space, affecting primarily the L5 and S1 nerve roots. S1 typically produces more leg pain than back pain and travels down the buttock region, posterior thigh, along posterolateral calf and heel, and into the lateral foot, and fourth and fifth toes. L5 typically affects the lateral aspect of the leg, the medial dorsal aspect of the foot, and the plantar aspect of the great toe.
The crossed straight-leg raise (CSLR) test is an SLR test performed on the asymptomatic limb. The CSLR is considered positive if it reproduces pain that radiates down the symptomatic extremity. This test is less sensitive (25%) than the SLR, but it is more specific (90% vs 40%). A positive CSLR is suggestive of a large herniation and predicts minimal improvement with nonoperative treatment.4
The slump test is performed with the patient seated at the edge of the examination table. The cervical, thoracic, and lumbar spine is flexed as the examiner passively extends the patient's leg. If pain occurs, the patient is asked to extend the neck. Relief of pain with cervical extension suggests neural tension radiculopathy; if the pain is not relieved, it suggests the cause of the pain is from stretching muscle fibers.The femoral nerve tension sign (femoral stretch test) evaluates higher lumbar disc radiculopathy (L2-L3). The test is performed with the patient in the prone position; the physician flexes the patient's knee to 90º, as well as extends the hip while keeping the patient's pelvis on the examination table. Although the validity of this test has not been well documented,4 it is thought that tension on the femoral nerve can reproduce anterior thigh radicular symptoms.
A hip examination is necessary because disc herniation may present with radicular symptoms to the anterior thigh and groin. These pain findings may be falsely attributed to L1-L3 nerve impingement. Hip range of motion should be evaluated, particularly internal rotation testing, which commonly elicits pain in cases in which there is intra-articular hip pathology.
The Waddell test maneuvers are a series of maneuvers (total flexion, extension, lateral flexion, palpation, supine SLR test, bilateral active SLR, active sit-up) that help the to clinician differentiate between those patients with LBP who have significant structural deformities (including fractures, surgical scars) or permanent neurologic deficits and those who do not.
The Waddell tests should be employed when nonorganic causes of pain are suspected in cases that include the following:
- Tenderness that is out of proportion to the examination
- Contradictory findings between the seated and supine SLR tests
- Pain with maneuvers that normally do not cause pain, such as light axial pressure to the cervical spine or gentle axial rotation
- Reduced pain response with distraction
- Disturbance that is not correlated with dermatomal distribution
- Overreaction during the examination
Causes
- Poor training technique and overtraining are frequent causes of disc herniation.
- Activities that involve chronic combined flexion and rotation with compression can lead to radial tears of the annulus fibrosis and gradual posterior disc bulging.
- Chronic changes such as calcification and osteophyte formation of the vertebrae can also lead to disc problems.
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Further Reading
Keywords
athletes and back pain, low back pain and sports, strained back, back is out, herniated disc, slipped disc, herniated nucleus pulposus, HNP, ruptured disc, degenerative disc disease, DDD, lumbago, mechanical low back pain, LBP, lumbar disc problems
