Download spinal conditions in athletes - South Australian Sports Medicine

22/04/2015
SPINAL CONDITIONS
IN
SPORT
BACK PAIN
GENERAL POPULATION
Common & self-limiting
60 – 80 % at some time
70 % return to work within 2 weeks
90 % within 3 months regardless of
treatment
Athletes no different
DR. ANDREW POTTER
SPORT & EXERCISE MEDICINE
PHYSICIAN
HEALTHY SPINE
Able to withstand large stresses
muscles, discs
Good muscle function – strength,
length, balance
Sound posture
Reasonable body weight
Gradual adaptation to new tasks
Genetic factors predispose some
to pathology (disc)
SPINAL INJURIES
INJURY MECHANISMS
Type of activity dictates structural stress
Collision – muscle contusion, bony processes
Compression – vertebral end plate, pars
Torsion – annular disc tears
Acute sprain – ligaments, musculotendonous
Flexion-lateral bending-axial compression – disc herniation
Acute or Chronic
MANAGEMENT PRINCIPLES
Soft tissue & self-limiting responding to conservative care
ACUTE
non-specific, diagnosis difficult
muscle, ligament, disc, facet joint
neural involvement
generic management – reduce pain & muscle
irritability
Athlete specific rehabilitation
graded return to full activity
sport specific preventative measures
Non-specific diagnosis means empiric rehab
CHRONIC
degenerative conditions
investigations, specific diagnosis & treatment
Conservative treatment initially
prolonged rehab program with continuing preventative
measures
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ANATOMY
VERTEBRAE
Increase in size from cervical to lumbar
Vertebrae
Strength is higher in compression than tension
Facet joints
Cancellous bone is main load-carrying component
Intervertebral discs
Components – body
laminae
spinous process
transverse processes
Passive stability
Active stability
FACET JOINTS
IV DISCS
Posterior support for vertebral column
Locked in spinal extension
Resist compression load – up 20% upright
Resist anterior sheer force - > 50% in flexion
Function – shock absorption
resistance to compression
flexibility with bending, twisting
Load increased with disc degeneration
Nucleus pulposus - fine collagen fibrils
random arrangement
dense proteoglycans
90% water
highly viscous gel
dries with age
More prone to injury with age
flexion-rotation-hyperextension activities
(golf swing)
IV DISCS
Annulus – large dense collagen fibres in basket weave
outer fibres connect to bone
inner fibres insert into cartilage end plates
65% water
Vascular outer annulus, but most nutrition by diffusion
Nerve supply from posterior longitudinal ligament to outer
annulus, not nucleus
PASSIVE STABILITY
Anterior longitudinal ligament
Posterior longitudinal ligament
Interspinous ligaments
Smaller ligaments
Supporting ligaments thinner posterolaterally
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ACTIVE STABILITY
Abdominal – transversus abdominis
Deep erector spinae - multifidus
Diaphragm
Pelvic floor
Thoracolumbar fascia
Erector spinae - superficial spinalis
Gluteals
Hamstrings
Psoas
Quads
POSTURE
Lordosis – cervical & lumbar
Kyphosis – thoracic & sacral
Lumbar lordosis most at L-S junction
normal 120 – 130 degrees
excessive often 95 – 100 degrees
increased stress on posterior spinal elements
anterior longitudinal ligament
ASSESSMENT
MOVEMENTS
HISTORY
CERVICAL
relatively mobile
rotation at C1-2
flexion stress at C5-6, extension at C6-7
THORACIC
immobile
5 degrees in all directions
LUMBAR
flexion- extension most at L4-5
increased movement at hips
rotation stresses SIJ
MOST ROTATION AT C/T & T/L JUNCTIONS
Age – young: often soft tissue
acute, growth, repetitive
older: more degenerative, acute disc injury
Activity – mechanism
Pain – onset, site, referral, associations
Systemic upset
Sensation
Weakness
Bladder & bowel control
ASSESSMENT
EXAMINATION
ACUTE BACK PAIN
Posture – curves, leg length
Movement – active, passive
Neural irritation – SLR, Slump
Mostly soft tissue – sprains, strains, contusions
Sensation - dermatomes
Bone fractures – transverse, spinous process
muscle damage
Strength - myotomes
Specific diagnosis difficult
Reflexes
Proprioception
Examination difficult – local tenderness
severe muscle spasm
movement difficult
Palpation – tenderness, muscle tone
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ACUTE BACK PAIN
CHRONIC BACK PAIN
Local pain
Management in first 7 days heat / ice
NSAIDs, analgaesics
active rest
active pain-free movement
physiotherapy (modalities, support)
graded return to sport
Re-assess – investigate
ongoing muscle support programs
CHRONIC BACK PAIN
Stiffness –with prolonged activity, inactivity
Muscle spasm
Runners, cyclists, hockey
Associations – tight hamstrings, gluteals, hip flexor
uneven terrain
training techniques
shoes, biomechanics
overweight
leg length discrepancies
chronic spinal disorders
REHABILITATION
EXERCISES
MUSCLE BALANCE
Acute interventions
Avoid aggravating factors
Address – posture (sitting, standing)
training errors
biomechanical errors (pelvic tilt)
change to low impact routines
stretching
strengthening
graded return to normal activity
REHABILITATION
EXERCISES
Formal motor skill training
Progress to
light functional tasks
heavier loads and sport
specific skills
Other muscle dysfunctions
psoas
gluteals
ITB
hamstrings
quads
hip rotators
Maintenance programs
Improve time of onset, length of contraction
transversus abdominis
multifidus
Drawing in abdominal wall without moving spine
4 point kneeling position
Supine
Feedback – ultrasound
pressure biofeedback
CERVICAL SPINE
Postural – upper cervical lordosis
stiff thoracic kyphosis
rounded shoulders
tight anterior shoulder structures
adolescents, cyclists, hockey players
Wry neck – ? facet joint sprain
Referred pain to trapezius, rhomboids, rotator cuff
Nerve root pain – disc, osteophyte in foramen
neural tension tests
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THORACIC SPINE
Local or referred pain
Common cause of anterior, lateral chest wall pain
Associated – local tenderness
painful movement (rotation, lateral flexion)
local hypomobility
paravertebral muscle spasm
Investigations – x-ray for Scheuerman’s, tumours
CT/MRI for disc prolapse
THORACIC SPINE
DISC – repetitive twisting
tenderness, immobility
FACET JOINT – most common
local tenderness
restore mobility
anti-inflammatory (heat, NSAID)
COSTOVERTEBRAL JOINT – inflammatory, mechanical
systemic NSAID
local heat, mobilisation
corticosteroid injection
DISC INJURIES
1.
2.
3.
4.
5.
Annular tear (circumferential)
Annular tear (rim – separation from vertebral body)
Nucleus protruding into annulus (radial)
Nucleus prolapsed through annulus
Sequestrum
1 - 3 commonest in sport
3 & 4 irritate posterior longitudinal ligament
nerve root
5 sciatica or radiculopathy
LUMBAR
DISC INJURIES
Injuries to annulus due to changes in pressure
Attempt to repair with ingrowth of vessels & nerves
All types of disc injuries
Healing never fully successful
- at 50 years, 50% of lumbar discs innervated
Injured disc is dysfunctional
- advancement of facet joint arthritis
- development of osteophytes
Difficult to diagnose in acute phase if no neurological signs
LUMBAR
DISC PROTRUSIONS
Posterior, posterolateral
Acute onset – event, tearing, pain
DISC PROTRUSIONS
PAIN
Nagging
Back, buttock, groin, leg, calf, foot
Flexion limiting
Local pain
Reverse flexion
Nerve root pain – dermatome
Radicular symptoms – paraesthesia, weakness, tendon reflex
Segmental picture often unclear
Dressing
Prolonged sitting, standing
Inactivity - lying
L4-5 > L5-S1 > L3-4
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DISC INJURY
MANAGEMENT
Urgent decompression of cauda equina
Analgaesia, NSAIDs
Heat / ice
Active rest – change position frequently
Review for worsening signs
Maintain pain free movement
Physiotherapy for movement and muscle spasm
Manipulation ?
DISC INJURIES
Prolonged or worsening symptoms, signs
Re-evaluate clinical picture
Investigate
plain x-ray
CT scan - bony compression
disc protrusion
MRI scan – soft tissues
Most resolve in 6 weeks to 6 months
PROLONGED TOTAL REST CONTRA-INDICATED
DISC HERNIATION
DISCECTOMY
TREATMENT
INDICATIONS
EPIDURAL
Anaesthetic & corticosteroid
Acute nerve root pain
Accelerates natural progression
Effective in up to 50%
Hospitalisation
FORAMINAL INJECTION
Lateral compression of nerve root
CT guided
Anaesthetic & corticosteroid
DISC INJURIES
Sequestrated disc
Failure of conservative management
Persistent or worsening radiculopathy
Pre-operative MRI or CT myelography
Neurosurgeon or orthopaedic surgeon
SPONDYLOPATHIES
ALL REQUIRE ACTIVE REHABILITATION
Common cause of back & leg pain
Strengthening of active supports
Care with activity – frequent postural changes
avoid aggravating factors
Graded increase in aerobic activity
Graded return to sport
Spondylolysis – pars interarticularis defect
Spondylolisthesis – accompanying anterior slip
Associations – spina bifida
sacralisation of Lx spine
increased Lx lordosis
disc, facet joint degeneration
Ideal body weight
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SPONDYLOPATHIES
SPONDYLOLYSIS
Developmental – 5% generally, 5-10 years
Traumatic – non-union, fibrous pseudoarthrosis
stress fracture
Unilateral or bilateral
Associated with hyperextension activities
L5 > L4
Back pain in young athletes
Acute fracture
Acute inflammation of pars defect
Acute slip anteriorly – most before 15 years
Associated disc & facet joint dysfunction
Gymnasts, weight lifters, cricket fast bowlers
SPONDYLOPATHIES
Pain – local, referred
related to activity (extension)
nerve root irritation
lumbar extension-rotation
single leg hyperextension test
SPONDYLOPATHIES
INVESTIGATIONS
Back pain and pars defect may not be related
Plain x-ray with oblique views
Tenderness – over affected segment
Nuclear bone scan with Single Photon Emission CT
Palpable step – if spondylolisthesis
Muscle spasm – local
hamstrings
CT scan at active level - reverse angle gantry
multislice
MRI
Increased Lx lordosis
SPONDYLOPATHY
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SPONDYLOPATHIES
SPONDYLOPATHIES
MANAGEMENT
Relative rest – avoid aggravation (extension)
running
Rehab program
correct posture (bracing), technique
core stability – stretch, strengthen
hamstrings, gluteals
abdominals, back extensors
Corticosteroid injection – CT guided to lesion, adjacent facet joints
Graded regime of aerobic exercise
walk, swim, cycle, water running
jog, run, sprint
sport specific activities
Risk factors for progression
- adolescence
- persistent symptoms
- generalised ligament laxity
Surgery
- progressive slip
- >50% slip in immature individual
- neurological defect
Return to sport in 6 weeks to 6 months
(5 months)
OSTEOCHONDRITIS
Ring apophysis of vertebral end plates
Back pain in adolescents – M:F = 1:2
SCHEUERMAN’S DISEASE
RADIOLOGY
Irregular vertebral end plates
(anteriorly)
Thoracic, thoracolumbar areas
Periods of growth acceleration
Poor posture – round shoulders
tight anterior shoulder muscles
protracted scapulae
lumbar lordosis
tight hamstrings
Schmorl’s nodes – disc
herniation through end plate
Apparent disc narrowing
Kyphosis > 35 degrees
3 or more adjacent vertebrae
> 5 degrees anterior wedging
Activity – repetitive flexion/ flexion-extension
POSTERIOR THIGH PAIN
OSTEOCHONDRITIS
HAMSTRING OR REFERRED ?
MANAGEMENT
HAMSTRING
REFERRED
Sudden onset
Slow onset / cramping
Correct posture with muscle balance programs
Local tenderness
muscle spasm
Hamstring spasm, shortening,
tenderness
Hyperextension exercises
Pain on stretch
Dural / neural irritation
slump test positive
Anti-inflammatory – systemic medication
local therapy
Modify activity to avoid aggravating factors
Painful contraction
knee flexion
hip extension
mid & outer range
supine, prone
Inner range
Signs at other sites
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SACROILIAC JOINT
Mechanical or inflammatory
Pain – local or referred
Local tenderness
Pain on stress – compression, FABER, bilateral SLR
Associated with ankylosing spondylitis
ANKYLOSING SPONDYLITIS
Inflammatory – seronegative arthropathy
Familial, M>F, 20’s
Investigations – x-ray, bone scan, CT scan
serology for inflammatory arthropathy
Lumbar spine
Thoracic spine, C-V joints
SIJs
Management – systemic therapy (analgaesics, NSAIDs)
local therapy
mobilisation
local injection (corticosteroid)
correct causes – muscle balance rehab
Associations
Enthesopathies – Achilles tendon, plantar fascia
Lower limb arthritis – asymmetrical, large joints
Conjunctivitis, uveitis
Aortic Incompetence
SPINAL INJURIES
ANKYLOSING SPONDYLITIS
PREVENTION
Insidious onset of backache
a.m. stiffness, activity
related
Systemic non-specific symptoms
Flexibility
Reduced spinal, chest wall
movement
Muscle balance – abdominals, pelvic, thigh
core stability
Investigations – x-ray, bone scan
ESR, CRP, HLA B27
Posture – rest, activity
Management – analgaesia
anti-inflammatory
activity modification
maintain mobility
Muscle strength, endurance – graded increase in training
Technique – sport specific
Aerobic fitness – low impact activities
Maintain ideal weight
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