Lumbar Spine Problems in Elite Athletes

Lumbar Disc Herniation

The spinal column is made up of rectangular-shaped bones, called vertebrae, stacked on top of each other. The lower segment of the spinal column is called the lumbar spine. Each of the spinal vertebrae is separated by a cushion of tissue called the intervertebral disc. This disc helps to absorb energy and, at the same time, allows for motion between adjacent vertebrae.

The intervertebral disks are susceptible to injury and are not well equipped for self-repair. The disc has a very limited blood supply, making damage to the disc material often something the body has difficulty healing on its own.

One common type of disc damage is called a herniation. When a herniation occurs, some of the intervertebral disc material is pushed away from its normal boundary and can press up against the nerve roots and spinal cord. The most common symptoms of intervertebral disc herniation are signs of nerve irritation such as pain, numbness, and weakness extending down the lower extremity. Back pain is not the most common symptom of a disc herniation.

While most lumbar disc herniations are mild, some lumbar disc herniations can be a very serious problem. If the disc is pressing on the central portion of the lumbar spinal nerves, there are two conditions, called cauda equina syndrome and conus medullaris syndrome, that can occur. These are important problems to diagnose, since the results of treatment become much worse when there are delays in surgical treatment. Symptoms of these conditions may include the inability to control bowel or bladder function and numbness around the genitals. While these conditions are very rare complications of a disc herniation, they are ones that need to be diagnosed quickly and treated efficiently.

Nonsurgical treatment is effective for more than 90 percent of athletes who sustain a lumbar disc herniation. Often, oral anti-inflammatory medications can help relieve symptoms of acute inflammation. Physical therapy is a typical treatment that is important to help restore core and back muscle strength and hopefully prevent further problems down the road. If symptoms become difficult to control, an epidural steroid injection may also be used and often has effective results.

Surgical treatment is typically reserved for athletes who do not improve after a minimum of 6 weeks of nonsurgical treatment. Interestingly, studies have not shown any significant difference in length of time to return to athletics, length of athletic career, or overall results of treatment of a lumbar disc herniation when comparing surgical and nonsurgical treatment. As a result, most patients, even elite athletes, should start with nonsurgical treatment. Regardless of treatment type, about 90 percent of athletes returned to their pre-injury level of activity.

Degenerative Disc Disease

Degenerative disc disease is a very common problem, both in the athletic and nonathletic populations. A normal intervertebral disc is composed largely of water and is something like a spongy cushion. A degenerative disc loses much of its water volume and becomes more rigid, absorbing less energy with normal movements.

The most important factors in the development of degenerative disc disease appear to be aging and genetic predisposition. Older athletes are much more prone to developing degenerative disc disease, and those who have a family history of degenerative discs of the spine are much more likely to have this condition. However, there is a notion that aggressive sports activities can also contribute to the development of early signs of degenerative disc disease.

Degenerative disc disease is typically diagnosed in athletes who complain of back pain via imaging studies, possibly including X-rays and MRIs. Most athletes who are diagnosed with degenerative disc disease can be managed with nonsurgical treatment. The typical treatment consists of physical therapy focused on core and lumbar spine strengthening. The goal is to improve the strength of the muscles surrounding the spine to better off-load the damaged lumbar discs.

There is little evidence to support the use of other treatments. Alternative treatments such as acupuncture, chiropractic treatment, massage, and others have been used historically, but there is little evidence to suggest that these alter the long-term prognosis. Many athletes swear by these treatments, and most are very safe to perform. Each athlete may be slightly different, and it is reasonable to try these different treatment options to find the right one for you.

Surgical treatment is generally not helpful for people with degenerative disc disease and typically is reserved for athletes who are unable to return to sports after a minimum of 6 months (if not much longer) of nonsurgical treatment. Even in these athletes, surgical treatment has very limited results in terms of getting athletes back to sports activities. The usual surgical treatment of degenerative disc disease involves a lumbar fusion procedure. There are some surgeons performing disc replacement, although the use of disc replacement has very mixed results. In addition, this surgical procedure has not been specifically investigated in athletes.

Spondylolysis

Spondylolysis is a repetitive use injury to the bone of the vertebrae of the lumbar spine. This condition occurs as a result of repetitive microtrauma and causes a stress fracture of part of the vertebrae called the pars interarticularis. If the spondylolysis occurs on both the right and the left side of the spinal column, a condition that leads to instability of the vertebrae, called spondylolisthesis, can occur.

Spondylolysis is most common in specific sports, including gymnastics, diving, wrestling, and weight lifting. While it can occur in young athletes in other sports, it is much more common in the aforementioned activities. Most often, this stress fracture of the pars interarticularis occurs in adolescence and then becomes symptomatic later.  Often, when activity levels are increased in high school or collegiate athletics, or even thereafter, the spondylolysis becomes more symptomatic. It may have been present for a decade or longer, but only becomes problematic when activity levels increase in an athlete's late teens or twenties.

The most common symptom of spondylolysis is activity-related pain. When the condition called spondylolisthesis occurs, it is more common to have nerve symptoms causing pain, numbness, and weakness going down the leg. Diagnosis can sometimes be made with an X-ray, but sometimes a stress fracture may only be seen on a CT scan or MRI. CT scans are also helpful when assessing the healing of a stress fracture in the spine.

Treatment most often begins with activity modifications and physical therapy. If it is determined that the injury just recently occurred, and is not a flareup of an old injury, some physicians will elect to brace an athlete to try to allow for healing of the bone. If the injury is chronic, the likelihood of spontaneous healing is low, even when a brace is worn.

As mentioned, the vast majority of athletes can improve with nonsurgical intervention. Only after a prolonged, minimum 6 month trial of nonsurgical treatment should any type of surgical intervention be considered. Surgical treatment options vary depending on the appearance of the bone injury. If the bone is lined up well, then a repair of the stress fracture can be considered. If the stress fracture has led to shifting of the spinal alignment (spondylolisthesis), then a lumbar fusion surgery would be the usual treatment.

Muscular Back Pain

Muscle strains and ligament strains are by far the most common source of back pain, including in athletic individuals. While these injuries do not cause structural problems with the lumbar spine, they can cause significant disability and difficulty with athletic endeavors.

Making the diagnosis of muscular back pain is typically accomplished by examining the patient. Typical muscular low back pain is not accompanied by the same symptoms as some of the aforementioned problems. Athletes often complain of symptoms including muscle spasm, aching sensations, weakness, and discomfort that is hard to alleviate.

Seldom are imaging studies such as X-rays or MRIs helpful, and, in many cases, obtaining these studies can only serve to complicate the situation. "Abnormal" findings are typical on MRIs, yet they may have nothing to do with the source of discomfort, and obtaining studies sometimes confuses the situation and leads to a delay in the most appropriate treatments while a diagnostic workup is taking place.

The treatment of muscular low back pain is best accomplished with early mobilization, gentle movements of the lumbar spine, and efforts to increase core strength and lumbar biomechanics. Physical therapists can be helpful, as can athletic trainers, strength coaches, and sports coaches. Many athletes, particularly younger athletes, don't know to discuss these conditions with their coaches and trainers. However, good communication can ensure that athletes with a back problem can be helped with some simple modifications.