Lumbar spine MRI in the elite-level female gymnast with low back pain

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

Incidence of lumbar spondylolysis in athletes with low back pain: A systematic evaluation and single-arm meta-analysis

BACKGROUND

Low back pain (LBP) is a common chief complaint from athletes. Lumbar spondylolysis (LS) is a common sport injury. Severe LS is likely to cause spinal instability, resulting in lumbar spondylolisthesis or lumbar disc herniation, and even damage to the spinal nerve roots. The incidence of LS is approximately 5% in the adult population, and nearly half of young athletes with LBP are diagnosed with LS. This meta-analysis analyzed the incidence of LS in athletes with LBP.

METHODS

PubMed, Embase, Cochrane (Cochrane Central Register of Controlled Trials), and Web of Science databases were systematically searched for published case report and retrospective analyses related to the topic from the date of database creation to January 1,2023. Relevant literature was screened and information extracted, and risk of bias was assessed for included studies using the methodological index for non-randomized-studies scale. Single-arm Meta-analysis was performed using R4.04 software. Heterogeneity was quantified by Cochran Q test and Higgins I2. Funnel plots were used to visualize publication bias, and Egger test and Begg test were used to statistical tests.

RESULTS

A total of 9 studies (835 patients) were included in this study. Meta-analysis revealed that the prevalence of LS in athletes with LBP was estimated at 41.7%, [95% CI = (0.28-0.55)], but this prevalence varied considerably with the gender and age of the athletes.

CONCLUSION

The estimated prevalence of LS in athletes with LBP is 41.7%, and future correlations between the prevalence of LS in adolescent athletes worldwide need to be assessed from different perspectives, including biomechanical, hormonal, anatomical, behavioral, and gender differences.

Low occurrence of MRI spinal changes in elite climbing athletes; a cross-sectional study

OBJECTIVES

To examine the occurrence of magnetic resonance imaging (MRI) changes in the thoracolumbar spine among elite climbing athletes.

METHODS

All climbers of the Swedish national sport climbing team (n = 8), and individuals having trained for selection to the national team (n = 11), were prospectively included. A control group, matched in age and sex, were recruited. All participants underwent a thoracolumbar MRI (1.5 T, T1- and T2-weighted imaging), evaluated according to Pfirrmann classification, modified Endplate defect score, Modic changes, apophyseal injuries and spondylolisthesis. Pfirrmann ≥ 3, Endplate defect score ≥ 2 and Modic ≥ 1 was defined as degenerative findings.

RESULTS

Fifteen individuals, 8 women, participated in both the climbing group (mean age 23.1, SD 3.2 years) and the control group respectively (mean age 24.3, SD 1.5 years). In the climbing group, 6.1% of the thoracic and 10.6% of the lumbar intervertebral discs showed signs of degeneration according to Pfirrmann. One disc with a grade above 3 was present. Modic changes in the thoracic/lumbar spine were prevalent in 1.7%/1.3% of the vertebrae. Degenerative endplate changes according to the Endplate defect score were found in 8.9% and 6.6% of the thoracic and lumbar spinal segments of the climbing group, respectively. Two apophyseal injuries were found, while no participants displayed signs of spondylolisthesis. There was no difference in point-prevalence of radiographic spinal changes between climbers and controls (0.07 < p < 1.0).

CONCLUSION

In this small cross-sectional study, only a low proportion of elite climbers displayed changes of the spinal endplates or intervertebral discs, as opposed to other sports with high spinal loads. Most observed abnormalities were low grade degenerative changes and did not differ statistically compared to controls.

Association of Lumbar Spondylolytic Spondylolisthesis With the Incidence and Prognosis of Anterior Ring Apophyseal Abnormalities of the Vertebrae in Young Gymnasts

Background

Although anterior apophyseal abnormalities of the vertebrae and spondylolytic spondylolisthesis (SS) are prevalent in gymnasts during growth spurts, no studies have examined the relationship between apophyseal abnormalities and SS.

Hypothesis

A significant relationship will exist between anterior apophyseal abnormalities and SS in young gymnasts.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 306 gymnasts (123 male, 183 female; age range, 6-28 years) with >2 weeks of back pain were enrolled in this study. Apophyseal abnormalities were evaluated using radiography. In the primary analysis, multiple logistic regression analysis was performed to assess the odds ratio (OR) for multivariate factors (age, body mass index, sex, skeletal maturity, competitive level, and presence of spondylolysis or SS) influencing the incidence of apophyseal abnormalities. In the secondary analysis, 90 of the 306 gymnasts were followed up radiographically for a minimum of 2 years, and factors contributing to the worsening of apophyseal abnormalities were identified.

Results

In the primary analysis, the chi-square test revealed a relationship between anterior ring apophyseal abnormalities and SS at the L5-S1 segment (OR, 7.6). Multiple logistic regression analysis demonstrated that the presence of SS at L5-S1 (OR, 9.5) and competitive level (international: OR, 6.7; national: OR, 4.5) correlated with the incidence of apophyseal abnormalities. The secondary analysis identified the presence of SS at L5-S1 (OR, 5.9) as a significant factor contributing to the worsening of apophyseal abnormalities.

Conclusion

The presence of SS was a factor affecting the incidence and prognosis of anterior apophyseal abnormalities.

Isthmic spondylolisthesis in adults… A review of the current literature

Isthmic spondylolisthesis can be defined as the anterior translation of a vertebral body relative to the one subjacent to it and secondary to an abnormality of the pars interarticularis. Isthmic spondylolisthesis is usually asymptomatic and discovered as an incidental radiographic finding. However, it can be symptomatic due to its biomechanical effects on the adjacent neural structures and patients may present with low back and/or radicular leg pain. Standing plain radiographs can be obtained to confirm the presence or assess the degree of isthmic spondylolisthesis. Computed tomography (CT) clearly shows the pars defect and provides a better assessment of the pathology. Magnetic resonance imaging (MRI) is indicated in patients with neurologic manifestations and can be used to assess the degree of foraminal or central stenosis. Conservative management including oral anti-inflammatory medication, physical therapy, and/or transforaminal epidural corticosteroid injections can be utilized initially. Surgery can be considered in the setting of persistent symptoms unrelieved with conservative management or significant neurologic compromise. Several surgical methods and techniques are available in the management of isthmic spondylolisthesis. There has been a significant national increase in the use of interbody fusion posteriorly for the management of isthmic spondylolisthesis. Reports have suggested that interbody fusion can be a cost-effective technique in selected patients with isthmic spondylolisthesis. Future studies are encouraged to further characterize the specific indications of various surgical modalities in patients with isthmic spondylolisthesis.

The influence of spinal position on imaging findings: an observational study of thoracolumbar spine upright MRI in elite gymnasts

PURPOSE

To investigate whether upright magnetic resonance imaging (MRI) has a role in defining thoracolumbar spine pathology in elite gymnastics.

METHODS

A prospective cross-sectional observational study of National Senior and Junior Artistic gymnasts in three MRI positions (standard supine, upright flexed and extended positions). Two specialist musculoskeletal radiologists independently analysed images with neutral as a baseline with the effects of flexion and extension reported in line with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.

RESULTS

Forty (18 males) gymnasts aged 13-24 years with a mean (SD) of 32 (5.3) training hours per week consented with 75% showing MRI abnormalities. Degenerative disc disease (DDD) was evident in 55% participants with vertebral end plate (VEP) changes in 42.5%. Spondylolysis was present in 40% with an additional 17% showing chronic bilateral complete L5 pars defects. 23% participants demonstrated different MRI findings in upright flexion compared to neutral.

CONCLUSION

Findings suggest a high levels of MRI abnormalities in elite gymnastics including altered disc morphology and posterior element abnormalities. High prevalence of T11/12 DDD and VEP changes reflects the thoracolumbar junction being a transition zone. Upright MRI and varying spine position offer promise for enhanced visualisation of posterior element abnormalities.

The Prevalence of Abnormalities in the Pediatric Spine on MRI: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to provide an overview of the prevalence of reported musculoskeletal abnormalities on magnetic resonance imaging (MRI) of the pediatric spine.

SUMMARY OF BACKGROUND DATA

Back pain is a common complaint and significant health issue, already in children. Several studies have investigated musculoskeletal abnormalities of the pediatric spine as possible cause of low back pain (LBP). However, it is not clear which abnormalities are the most prevalent among children.

METHODS

A systematic literature search on the prevalence of musculoskeletal spinal abnormalities on MRI in children was conducted in the Embase, Medline Ovid, and Cochrane CENTRAL databases. Risk of bias (RoB) was assessed using a checklist based on the Downs and Black checklist. General information on study and patient characteristics and the prevalence of spinal abnormalities were extracted from the studies. Prevalence data were presented in three subgroups: nonathletes without LBP, participants with LBP, and athletes. Prevalence data of the most reported abnormalities were pooled using random-effects proportion meta-analysis. The study protocol was prospectively registered in PROSPERO (CRD42017080543).

RESULTS

The search resulted in 16,783 articles, of which 31 articles (2373 participants) were included in this systematic review. Two-thirds of the studies had a low RoB. The pooled prevalence in nonathletes without LBP, participants with LBP, and athletes without LBP was respectively 22%, 44%, and 22% for disc degeneration, 1%, 38%, and 13% for herniated discs, 5%, 22%, and 11% for endplate changes, and 0%, 30%, and 6% for pars fractures.

CONCLUSION

Disc degeneration, herniated discs, endplate changes, and spondylolysis are the most reported spinal abnormalities on MRI in children in literature. Spinal abnormalities seen in adults are already prevalent in children with LBP, with the highest prevalence for disc degeneration and herniated discs.

LEVEL OF EVIDENCE

2.

Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis

BACKGROUND

Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players.

PURPOSE

To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance.

RESULTS

During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode.

CONCLUSION

Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

Perceptions of low back pain in elite gymnastics: A multi-disciplinary qualitative focus group study

OBJECTIVES

To explore the multidisciplinary team experience of Low Back Pain (LBP) in elite gymnastics.

DESIGN

A qualitative focus group.

SETTING

British Gymnastics.

PARTICIPANTS

Ten coaching, sports science and medicine multidisciplinary team members working with British gymnasts.

MAIN OUTCOME MEASURES

A topic guide informed by literature/expert opinion enabled discussion that was recorded/transcribed verbatim. Initial inductive analytic process developed theoretical insights. Manual coding using constant comparative methods categorised meaningful themes and sub-themes.

RESULTS

Two key aspects were identified. Emerging themes for LBP presentation included: early identification LBP and influence of multidisciplinary team members on outcomes; factors influencing LBP reporting e.g. coach-athlete relationship; frequent presentations of LBP and accepted norms; athlete history and physical examination e.g. training load. Emerging themes for causation of LBP included: intrinsic risk factors e.g. growth and maturation; extrinsic risk factors e.g. equipment.

CONCLUSIONS

Individual responses of a gymnast to experiencing LBP were important across all themes. Some LBP was perceived as normal. The coach-athlete relationship and support team are crucial decision-makers around training load and adaptation. Early detection will help minimise time loss from training/performance to expedite healing.

The Incidence of Pars Interarticularis Defects in Athletes

STUDY DESIGN

Literature review.

OBJECTIVE

To conduct a literature review of studies reporting the incidence of pars interarticularis defects in athletes of specific sports, in order to allow more targeted prevention and treatment strategies to be implemented for the groups at highest risk.

METHODS

Electronic searches were performed using PubMed, Ovid Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Database of Controlled Trials from their dates of inception to September 2017, with the following keywords: "spondylolysis," "sports," "low back pain," and "pars defects."

RESULTS

A total of 509 total articles were retrieved, of which 114 were used in the final review. The incidence of pars interarticularis defects was found to be highest in diving (35.38%), cricket (31.97%), baseball/softball (26.91%), rugby (22.22%), weightlifting (19.49%), sailing (17.18%), table tennis (15.63%), and wrestling (14.74%). Only 5 studies reported the management instituted for their participants, and these were all case reports. Of 74 players with spondylolysis in these studies, 70 (94.59%) underwent conservative treatment and 4 (5.41%) underwent surgical treatment. 61 (82.43%) returned to their previous level of play, 6 (8.11%) retired, and the disposition of the final 7 was not reported.

CONCLUSION

The current medical literature provides good evidence that the incidence of pars interarticularis defects is higher in the athletic population, with the highest incidence in diving. There remains no gold standard protocol for the management of pars interarticularis defects. Further research is required to compare conservative therapy to surgical therapy and to compare the various surgical techniques to each other.

Epidemiology of bone stress injuries in Australian high performance athletes: A retrospective cohort study

OBJECTIVES

To examine the epidemiology of bone stress injuries in an elite sports institute.

DESIGN

Retrospective cohort study at the Australian Institute of Sport.

METHODS

A retrospective analysis of the clinical records contained within the Australian Institute of Sport Athlete Management System electronic database was performed. Records with Orchard Sports Injury Classification System codes relating to bone stress injuries and stress fractures were reviewed and descriptive statistics relating to sport, site of injury, athlete age, sex and activity were analysed.

RESULTS

In the three-year period January 2014-2017, 11,942 injuries were recorded across 48 sports. 181 bone stress injuries (0.15% of all injuries) were recorded across 16 sports. BSIs in the foot and lumbar spine were the most common accounting for 30% and 23% of all the reported BSIs respectively. Gymnasts had a high frequency of lumbar spine stress injuries (n=24, 51%) and rowers had a high frequency of rib stress injuries (n=22, 88%). The most common location for stress injuries, equally distributed across a variety of sports, were in the foot (n=54, 30%). Female athletes recorded more BSIs than males.

CONCLUSION

Across a three-year period, 0.15% of injuries were related to bone stress injuries. Almost double the cases were recorded in female athletes. Sport specific injury sites were observed in the dataset.

A systematic review of injuries in gymnastics

OBJECTIVES

To identify all studies of gymnastics injuries and assess injury rates, types, locations, and causes.

METHODS

Seven electronic and two grey literature databases were searched. Two reviewers independently assessed titles/abstracts, abstracted data, and calculated average rates weighted by study size.

RESULTS

One study (n = 963) of three Olympic games (2008,2012,2016) provided injury rates for females of 86.4/1000gymnasts and males 79.9. For 29 databases one study of males (n = 64) provided a rate of 8.8 injuries/1000hours/AE (AE = athletic-exposure) and three of females varied rates (8.5, 9.4, and 91). Three studies for males (n = 153) provided a weighted average rate of 1.4 injuries/1000hours/training, and for females six studies (n = 476) 1.5 injuries. Four studies of males (n = 286) provided a weighted average of 678 injuries/1000gymnasts per year and eight studies of females (n = 1,764) a rate of 306. Of 19 surveys, eight provided rates for females (n = 1,463) of 596 injuries/gymnast per year and two for males (n = 40) a rate of 1,036. In the Olympics injuries were preponderately lower limb (63%) then trunk (23%) and upper limb (14%); injury type was sprains (35%) followed by tendinopathy/arthritis/impingements (17%), contusions (10%), and fractures (7%). Five database studies provided injury location data for 274 males: averages weighted by study size were upper extremity 42.8%, lower extremity 33.6%, torso/spine 11.8%, and head/neck 4.9% and 12 studies with 843 females provided average rates for lower extremity 51%, upper extremity 30.8%, torso/spine 13% and head/neck 0.8%. Official gymnastics organizations' websites provide no readily available data about injury rates or methods of prevention.

CONCLUSIONS

Studies need to collect comprehensive data for injury rates by training/competitions, gender, age, injury location/type/cause. Studies could assess whether trainers and physiotherapists monitoring gymnasts closely for injury risk would reduce injuries. Studies including randomized controlled trials (RCTs) of interventions in training, videotaping and performance feedback to reduce injury rates would be helpful.

Current Evidence Regarding the Diagnostic Methods for Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee

STUDY DESIGN

Structured literature review.

OBJECTIVES

The Scoliosis Research Society (SRS) requested an assessment of the current state of peer-reviewed evidence regarding pediatric lumbar spondylolisthesis with the goal of identifying what is known and what gaps remain in further understanding the diagnostic methods for pediatric spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Spondylolisthesis in the lumbar spine is common among children and adolescents and no formal synthesis of the published literature regarding diagnostic methods has been previously performed.

METHODS

A comprehensive literature search was performed. Abstracts were reviewed and data from included studies were analyzed by the committee. From 6600 initial citations with abstract, 663 articles underwent full-text review. The best available evidence for the clinical questions regarding diagnostic methods was provided by 26 included studies. Six of the studies were graded as Level III (retrospective comparative), and represent the current best available evidence whereas 20 of the studies were graded as Level IV (retrospective case series) evidence. No Level V (expert opinion) studies were included in the final list. None of the studies were graded as Level I or Level II.

RESULTS

Plain radiography is the workhorse imaging modality for diagnosing spondylolisthesis. No association between radiologic grade of spondylolisthesis and clinical presentation were noted; however, grade III and IV slips more often required surgery, and increasing slip angles were associated with worse baseline outcome scores. There is Level III evidence that the Meyerding grade appears to be more accurate for measuring slip percentage whereas the Lonstein Slip angle and Dubousset Lumbosacral Kyphosis angles are the best for measuring lumbosacral kyphosis in spondylolisthesis. In addition, higher sacral table index, pelvic incidence, sacral slope, and lower sacral table angle were associated with spondylolisthesis. True incidence could not be determined by the current literature available. However, studies in adolescent athletes demonstrated an incidence of 6% to 7% across studies.

CONCLUSIONS

The current "best available" evidence to guide the diagnosis and characterization of pediatric spondylolisthesis is presented. Future studies are needed to provide more high-quality evidence to answer these clinically relevant questions.

LEVEL OF EVIDENCE

Level III, review of Level III studies.

Stretching the Spines of Gymnasts: A Review

Gymnastics is noted for involving highly specialized strength, power, agility and flexibility. Flexibility is perhaps the single greatest discriminator of gymnastics from other sports. The extreme ranges of motion achieved by gymnasts require long periods of training, often occupying more than a decade. Gymnasts also start training at an early age (particularly female gymnasts), and the effect of gymnastics training on these young athletes is poorly understood. One of the concerns of many gymnastics professionals is the training of the spine in hyperextension-the ubiquitous 'arch' seen in many gymnastics positions and movements. Training in spine hyperextension usually begins in early childhood through performance of a skill known as a back-bend. Does practising a back-bend and other hyperextension exercises harm young gymnasts? Current information on spine stretching among gymnasts indicates that, within reason, spine stretching does not appear to be an unusual threat to gymnasts' health. However, the paucity of information demands that further study be undertaken.

MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Imaging features of spine degeneration are common in symptomatic and asymptomatic individuals. We compared the prevalence of MR imaging features of lumbar spine degeneration in adults 50 years of age and younger with and without self-reported low back pain.

MATERIALS AND METHODS

We performed a meta-analysis of studies reporting the prevalence of degenerative lumbar spine MR imaging findings in asymptomatic and symptomatic adults 50 years of age or younger. Symptomatic individuals had axial low back pain with or without radicular symptoms. Two reviewers evaluated each article for the following outcomes: disc bulge, disc degeneration, disc extrusion, disc protrusion, annular fissures, Modic 1 changes, any Modic changes, central canal stenosis, spondylolisthesis, and spondylolysis. The meta-analysis was performed by using a random-effects model.

RESULTS

An initial search yielded 280 unique studies. Fourteen (5.0%) met the inclusion criteria (3097 individuals; 1193, 38.6%, asymptomatic; 1904, 61.4%, symptomatic). Imaging findings with a higher prevalence in symptomatic individuals 50 years of age or younger included disc bulge (OR, 7.54; 95% CI, 1.28-44.56; P = .03), spondylolysis (OR, 5.06; 95% CI, 1.65-15.53; P < .01), disc extrusion (OR, 4.38; 95% CI, 1.98-9.68; P < .01), Modic 1 changes (OR, 4.01; 95% CI, 1.10-14.55; P = .04), disc protrusion (OR, 2.65; 95% CI, 1.52-4.62; P < .01), and disc degeneration (OR, 2.24; 95% CI, 1.21-4.15, P = .01). Imaging findings not associated with low back pain included any Modic change (OR, 1.62; 95% CI, 0.48-5.41, P = .43), central canal stenosis (OR, 20.58; 95% CI, 0.05-798.77; P = .32), high-intensity zone (OR = 2.10; 95% CI, 0.73-6.02; P = .17), annular fissures (OR = 1.79; 95% CI, 0.97-3.31; P = .06), and spondylolisthesis (OR = 1.59; 95% CI, 0.78-3.24; P = .20).

CONCLUSIONS

Meta-analysis demonstrates that MR imaging evidence of disc bulge, degeneration, extrusion, protrusion, Modic 1 changes, and spondylolysis are more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals.

Low back pain in female elite football and handball players compared with an active control group

PURPOSE

The purpose of this cross-sectional study was to compare the prevalence of low back pain (LBP) among female elite football and handball players to a matched non-professional active control group.

METHODS

The participants were requested to answer a questionnaire based on standardized Nordic questionnaires for musculoskeletal symptoms to assess the prevalence of LBP. Included participants were elite female football (n = 277) and handball players (n = 190), and a randomly selected control group from the Norwegian population (n = 167).

RESULTS

Fifty-seven percentage of the football players, 59 % of the handball players and 60 % of the control group had experienced LBP the previous year. There were no significant group differences in the prevalence of LBP ever (p = 0.62), the previous year (p = 0.85) or the previous 7 days (p = 0.63). For both sports, there was a significant increase in prevalence of LBP from the resting period to the competitive periods of the season (p ≤ 0.001). Seventy percent of the goalkeepers in both football and handball had experienced LBP the previous year.

CONCLUSION

There were no difference in LBP among female elite football and handball players compared with the control group. However, female elite athletes in football and handball reported a high prevalence of LBP compared to previous studies. The variations in LBP and playing positions indicate that specific field positions, in football and handball, is a risk factor for developing LBP.

Is the Zumba fitness responsible for low back pain?

PURPOSE

Zumba fitness requires aerobic repetition exercises, involving the whole body including the spine. Our study is aimed at verifying whether this sport may cause low back pain.

METHODS

Young healthy females were recruited. They were allocated to a "Zumba group" (n = 25) or an "inactivity control group" (n = 25). The Roland-Morris Disability, the Oswestry, the SF-36 and the Spinal Functional Sort Questionaries of all subjects were measured at the baseline (T0) and at 6 months (T1). During this 6-month study, the number of episodes of low back pain was recorded.

RESULTS

At T1, improvements were seen in the "Zumba group." The "inactivity control group" showed worsening in each test at T1. The differences between the two groups were statistically significant for the items Role limitations and physical problems, Physical functioning, Pain and Social activity of SF-36 (p < 0.05). There were no any statistically significant differences in either group of episodes of back pain (p > 0.05).

CONCLUSIONS

We verified that Zumba is not responsible for low back pain. Furthermore, we revealed that Zumba can increase the normal functional activity of the spine. On the basis of this data, we can recommend the practice of this sport on a regular basis for the healthy population, without worrying about the risk of overloading the spine. Further studies are necessary to check whether the patients with chronic spine disease may practice Zumba.

Low back pain in the adolescent athlete

Clinicians must have knowledge of the growth and development of the adolescent spine and the subsequent injury patterns and other spinal conditions common in the adolescent athlete. The management and treatment of spinal injuries in adolescent athletes require a coordinated effort between the clinician, patients, parents/guardians, coaches, therapists, and athletic trainers. Treatment should not only help alleviate the current symptoms but also address flexibility and muscle imbalances to prevent future injuries by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength.

MRI findings in the lumbar spines of asymptomatic elite junior tennis players

OBJECTIVE

To evaluate the MRI findings in the lumbar spines of asymptomatic elite junior tennis players.

MATERIALS AND METHODS

The lumbar spine MRI studies of 98 asymptomatic junior elite tennis players (51 male, 47 female) with a mean age of 18 years (age range 11.2-26.3 years; standard deviation 3.1) was reviewed by two consultant musculoskeletal radiologists using consensus opinion. Images were assessed using accepted classification systems.

RESULTS

Four players (4%) had no abnormality. Facet joint arthropathy occurred in 89.7% of the players, being mild in 84.5% of cases. There were 41 synovial cysts in 22.4% of the cohort all occurring in the presence of facet arthropathy. Disc degeneration was noted in 62.2 % of players, being mild in 76.2% of those affected. Disc herniation was noted in 30.6% of players, with 86.1% of these being broad based and 13.9% being focal. There was nerve root compression in 2%. There were 41 pars interarticularis abnormalities in 29.6% of patients, 63.4% of these being grades 1-3. There was grade 1 spondylolisthesis in 5.1% of players. The prevalence of facet joint arthropathy, disc degeneration, disc herniation and pars interarticularis fracture was lower in female players than in male and lower in the under 16-year-olds compared with the over 20-year-olds.

CONCLUSION

There is a significant amount of underlying pathology that would normally go undetected in this group of asymptomatic elite athletes. Whilst these findings cannot be detected clinically, their relevance is in facilitating appropriate prehabilitation to prevent loss of playing time and potentially career-ending injuries.

Anterior Limbus Vertebra and Intervertebral Disk Degeneration in Japanese Collegiate Gymnasts

Background:

Magnetic resonance imaging (MRI) studies have shown that gymnasts have a high prevalence of radiological abnormalities, such as intervertebral disk degeneration (IDD) and anterior limbus vertebra (ALV). These 2 abnormalities may coexist at the same spinal level. However, the relationship between IDD and ALV remains unclear.

Hypothesis:

A significant relationship exists between IDD and ALV in Japanese collegiate gymnasts.

Study Design:

Case-control study.

Methods:

A total of 104 Japanese collegiate gymnasts (70 men and 34 women; age, 19.7 ± 1.0 years) with 11.8 ± 3.6 years of sporting experience participated. T1- and T2-weighted MRIs were used to evaluate ALV and IDD.

Results:

The prevalence among the gymnasts of IDD and ALV was 40.4% (42/104) and 20.2% (21/104), respectively. The prevalence of IDD was significantly higher in gymnasts with ALV than those without ALV, as determined using the chi-square test. Logistic regression analysis demonstrated a significant association between IDD and ALV (adjusted odds ratio [OR], 6.60; 95% confidence interval [CI], 2.14-20.35). IDD was further grouped by whether it was present in the upper lumbar region (L1-2, L2-3, and L3-4 disks) or in the lower lumbar region (L4-5 and L5-S1 disks). Upper IDD had a greater association with ALV (adjusted OR, 33.17; 95% CI, 7.09-155.25) than did lower IDD (adjusted OR, 6.71; 95% CI, 1.57-28.73).

Conclusion:

In Japanese collegiate gymnasts, ALV is a predictor of IDD, especially in the upper lumbar region.

Clinical Relevance:

Information regarding ALV is important to prevent IDD in Japanese collegiate gymnasts.

Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment

Paralleling the growing popularity of organized sports among pediatric athletes, the stress and intensity of training regimens has escalated the frequency and severity of pediatric overuse injuries. It is essential that radiologists have a thorough knowledge of the pathogenesis of these injuries and of their characteristic patterns with different imaging techniques in order to appropriately diagnose overuse injuries in the pediatric skeleton. Knowledge of the classification, mechanism, clinical and imaging manifestations of acute and chronic overuse injuries of the lower extremities common among pediatric athletes can assist in imaging-based diagnosis and characterization of injury.

The prevalence of low back pain among former elite cross-country skiers, rowers, orienteerers, and nonathletes: a 10-year cohort study

BACKGROUND

Some cross-sectional studies have suggested that the prevalence of low back pain (LBP) may be high among endurance athletes with repetitive back loading, but there are no large, prospective cohort studies addressing this issue.

PURPOSE

To compare the prevalence of symptoms of low back pain (LBP) among former endurance athletes with different loading characteristics on the lumbar region: cross-country skiing (flexion loading), rowing (extension loading), and orienteering (no specific loading), as well as a nonathletic control group.

STUDY DESIGN

Cohort study; level of evidence, 2.

METHODS

Self-reported questionnaire on LBP adapted for sports based on standardized Nordic questionnaires for musculoskeletal symptoms. Responders were 173 rowers, 209 orienteerers, 242 cross-country skiers, and 116 control subjects (88% of the original cohort).

RESULTS

There were no group differences between the athletic groups and the control group with regard to the 2 main outcomes: reported LBP the previous 12 months (P = .66) and frequent LBP the past year (>30 days with LBP) (P = .14). More rowers than orienteerers reported frequent LBP the past year (adjusted OR = 2.32; CI, 1.02-5.28). Occupational changes due to LBP were reported more often by rowers (13%) than skiers (7%) and orienteerers (3%) (P = .002). More rowers and skiers reported having received outpatient medical assistance than orienteerers or controls. A training volume >550 h/y was a risk factor for reporting LBP during the previous 12 months compared with a training volume <200 h/y (adjusted OR = 2.51; CI, 1.26-5.02). A previous episode with LBP was associated with LBP later in life (adjusted OR = 3.02; CI, 2.22-4.10).

CONCLUSION

Low back pain was not more common among former endurance athletes with specific back loading compared with non-athletes. The results indicate that years of prolonged and repetitive flexion or extension loading in endurance sports does not lead to more LBP. However, a large training volume in the past year and previous episodes with LBP are risk factors for LBP. Comparing the sports of rowing, cross-country skiing, and orienteering, it appears that whereas orienteering is protective, rowing can provoke LBP.

Association of modic changes, Schmorl's nodes, spondylolytic defects, high-intensity zone lesions, disc herniations, and radial tears with low back symptom severity among young Finnish adults

STUDY DESIGN

A cross-sectional magnetic resonance imaging (MRI) study.

OBJECTIVE

We investigated the association among Modic changes, Schmorl's nodes, spondylolytic defects, high-intensity zone lesions, radial tears, herniations, and low back symptom severity.

SUMMARY OF BACKGROUND DATA

Disc degeneration is associated with low back pain in early adulthood, but the associations between other MRI findings and low back pain are not well known.

METHODS

Questionnaire data and MRI scans (1.5-T) were available for 554 subjects derived from a birth cohort at 21 years of age. Data on low back pain and back-related functional limitations at 18, 19, and 21 years of age were used for clustering of subjects, using latent class analysis. We used logistic regression with adjustment for the degree of disc degeneration to evaluate the associations between specific imaging findings and low back symptom severity.

RESULTS

The prevalence of herniations was 20%, Schmorl's nodes 17%, radial tears 9.9%, high-intensity zone lesions 3.2%, spondylolytic defects 5.8%, and Modic changes 0.7%. Latent class analysis produced 5 clusters: "Always Painful" (n = 65) meant painful at all time points and "Recent Onset Pain" (n = 56) meant increasing symptom severity, whereas subjects in the "Moderately Painful" (n = 73), "Minor Pain" (n = 193), and "No Pain" (n = 167) clusters had fewer symptoms. Compared with the "No Pain" cluster, Schmorl's nodes were more likely to occur in the "Always Painful" cluster (P = 0.017) and herniations in the 3 most painful clusters (P < 0.001). Herniations were associated with low back symptom severity (odds ratio, 2.5; 95% confidence interval, 1.4-4.4). Schmorl's nodes and radial tears were associated with symptoms in crude analyses only, whereas high-intensity zone lesions and spondylolytic defects occurred in similar frequencies in all clusters.

CONCLUSION

Herniations were most likely in the subjects with recent onset or persistent (3-yr period) low back symptoms, although they were also detected in subjects with no symptoms. The clinical relevance of herniations on MRI remains to be evaluated in the context of symptoms.

Sacral facet fractures in elite athletes

STUDY DESIGN

Case series of elite athletes with sacral facet fractures.

OBJECTIVE

To report a case series of elite athletes with sacral facet fractures that may be an underrecognized career-ending injury.

SUMMARY OF BACKGROUND DATA

Injury of the posterior elements including spondylolysis and spondylolisthesis are well-known causes of back pain in the young athlete, but there has been only 1 previous case report of a sacral facet fracture.

METHODS

This study is a retrospective chart review of 3 elite athletes with severe back pain and sacral facet fractures. An 18-year-old gymnast with a 2-year history of back pain, a 14-year-old gymnast with a 6-month history of back pain, and a 14-year-old tennis player with a 18-year history of back pain.

RESULTS

This series consists of 3 nationally competitive athletes with back pain severe enough to stop participation in sports. All patients had intra-articular sacral facet fractures proven by computed tomography, none of which were recognized on magnetic resonance imaging. Clinically, all had localized pain with back extension. Multiple tests and invasive procedures were performed without significant improvement prior to the correct diagnosis being made. Treatment with minimally invasive removal of the intra-articular fragments led to immediate pain relief and return to sport in 2 patients and transient though not long-lasting pain relief in the patient whose injury was undiagnosed for 2 years.

CONCLUSION

Intra-articular sacral facet fractures may be an underrecognized and misdiagnosed career-ending injury in elite athletes. In patients who have localized pain with back extension, a computed tomographic scan, and not a magnetic resonance image, diagnosed this injury. Although this series is small, it seems that early recognition and treatment of sacral facet fractures maximize chances of pain resolution and return to sport.

Intervertebral disc changes after 1 h of running: a study on athletes

The lumbar spines of 25 long-distance runners were examined using an upright magnetic resonance imaging scanner. All volunteer runners were scanned before and after running for 1 h. Scanning was performed with the runners seated upright (neutral), leaning forwards (flexion) and leaning backwards (extension). All measured discs showed a reduction in disc height after 1 h of running. A significant reduction in disc height was observed in all three body positions (neutral, flexion and extension) after 1 h of running. The results showed that, in flexion, extension and neutral positions, intervertebral discs undergo significant strain after 1 h of running. The lowest disc-height reduction was found at the L5 - S1 space in the neutral position; the same space had the highest percentage of disc degeneration.

[Radiological manifestations of Baastrup's disease in children]

Baastrup's disease is not usually considered among the possible causes of low back pain in children. Classically, Baastrup's disease is characterized by degenerative phenomena secondary to friction between adjacent spinous processes, with sclerosis of the margins and decrease in the interspinous space. Baastrup's disease becomes more prevalent with age and is usually accompanied by degenerative changes in the vertebral column, such as lumbar facet hypertrophy or disc disease. Certain activities like dance or gymnastics can make Baastrup's disease more likely to appear at an earlier age. In children, Baastrup's disease can manifest in a different way, with increased interspinous spaces and bone remodeling. In this article, we present the cases of two patients with low back pain who were diagnosed with Baastrup's disease.

Spondylolysis in the adolescent athlete

PURPOSE OF REVIEW

Spondylolysis is a common cause for back pain in the adolescent athlete. Increased awareness of the presentation of this subset of patients can aid in optimal outcomes. This paper aims to review the typical presentation of spondylolysis in the adolescent with specific focus on the adolescent athlete. We review current controversies in diagnosis and management and aim to provide a thorough review to aid the pediatrician in making clinical decisions for this subset of patients.

RECENT FINDINGS

The optimal algorithm for diagnostic imaging is controversial. Single positron emission computerized tomography can provide good sensitivity but poor specificity for spondylolysis. Computerized tomography can be useful as a follow-up exam to visualize the bony anatomy and osseous healing but has the concern of high radiation exposure. MRI may be a useful tool for diagnosis and follow-up examination, which may have significant advantages over traditional imaging techniques. Brace use is controversial and most likely functions as an adjunct for limiting motion to promote activity restrictions.

SUMMARY

Spondylolysis in the adolescent athlete is a common problem. MRI is a good study for diagnosis, although further studies need to be done in order to show its advantages over traditional diagnostic methods. Brace wear is encouraged as a method for promoting activity modification, although its efficacy in promoting healing and success in treating spondylolysis is controversial.

Injuries to the lower back in elite fast bowlers

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded.

In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.

Gymnastics injuries and imaging in children

Injuries of children participating in gymnastics are seen less often than in more popular sports. Patterns of injury are predictable based upon sex, age and level of intensity of training and competition. More injuries are seen in girls than in boys, and the great majority of early adolescents who compete have wrist pain. Some otherwise quiescent congenital spine anomalies may be uncovered by the stress of gymnastics maneuvers and present with low back pain. In addition to diagnosis of injuries, imaging can be used to guide analgesic and anti-inflammatory therapy in some injured athletes. Parents whose children wish to participate in gymnastics should understand that fewer injuries occur in the child enjoying recreational gymnastics than in competing gymnasts. More gymnastics injuries are found in very competitive athletes training at higher levels.

Magnetic resonance study of lumbar disks in female dancers

BACKGROUND

Previous imaging studies have shown that degenerative disk disease is more common in the competitive female gymnast than in asymptomatic nonathletic people of the same age training to any degree. However, results of exposure-discordant monozygotic and classic twin studies suggest that physical loading specific to occupation and sport has a relatively minor role in disk degeneration, beyond that of upright postures and routine activities of daily living.

HYPOTHESIS

Intensive, regular, and prolonged dancing causes strain on the lumbar spine and can trigger or accelerate the development of degenerative diskopathy.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Forty volunteer female dancers (20 ballet and 20 flamenco) aged between 18 and 31 years (mean = 24.2) underwent magnetic resonance imaging of the lumbar spine. They were compared against a control group of 20 women of the same age. A descriptive analysis was done, and the 2 groups were compared by contingency table analysis using the Pearson chi-square test complemented by an analysis of residuals. Results Nine of the 20 women (45%) in the control group had disk degeneration compared with 13 of the 40 (32.5%) women in the dancer group, with a chi-square of 0.897 (not significant). There were 12 degenerated disks of the 100 explored (12%) in the control group compared with 21 of the 200 explored (10.5%) in the dancer group (chi-square = 0.153; not significant).

CONCLUSION

Dancing cannot be considered a risk factor for lumbar disk degeneration in women.

CLINICAL RELEVANCE

The present study indicates that dancing has no negative effect on the development of degenerative diskopathy.

Sport injuries in the paediatric and adolescent patient: a growing problem

With an increasing number of paediatric and adolescent athletes presenting with injuries due to overuse, a greater demand is put on clinicians and radiologists to assess the specific type of injury. Repetitive forces applied to the immature skeleton cause a different type of injury than those seen in adults due to the differences in vulnerability of the musculoskeletal system, especially at the site of the growth cartilage. Intrinsic and extrinsic risk factors all play a role in the development of overuse injuries. MRI plays a key role in imaging overuse injuries due to its high potential for depicting cartilaginous and soft-tissue structures. Sport-specific biomechanics are described, since this knowledge is essential for adequate MRI assessment. An overview of several sport-related injuries is presented, based on anatomical location.

Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain

The prevalence of "vertebral endplate signal changes" (VESC) and its association with low back pain (LBP) varies greatly between studies. This wide range in reported prevalence rates and associations with LBP could be explained by differences in the definitions of VESC, LBP, or study sample. The objectives of this systematic critical review were to investigate the current literature in relation to the prevalence of VESC (including Modic changes) and the association with non-specific low back pain (LBP). The MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to November 2007. Included were the articles that reported the prevalence of VESC in non-LBP, general, working, and clinical populations. Included were also articles that investigated the association between VESC and LBP. Articles on specific LBP conditions were excluded. A checklist including items related to the research questions and overall quality of the articles was used for data collection and quality assessment. The reported prevalence rates were studied in relation to mean age, gender, study sample, year of publication, country of study, and quality score. To estimate the association between VESC and LBP, 2 x 2 tables were created to calculate the exact odds ratio (OR) with 95% confidence intervals. Eighty-two study samples from 77 original articles were identified and included in the analysis. The median of the reported prevalence rates for any type of VESC was 43% in patients with non-specific LBP and/or sciatica and 6% in non-clinical populations. The prevalence was positively associated with age and was negatively associated with the overall quality of the studies. A positive association between VESC and non-specific LBP was found in seven of ten studies from the general, working, and clinical populations with ORs from 2.0 to 19.9. This systematic review shows that VESC is a common MRI-finding in patients with non-specific LBP and is associated with pain. However, it should be noted that VESC may be present in individuals without LBP.

Low back pain in the adolescent athlete

Low back pain is a common problem among young athletes. These individuals are at risk for significant structural injuries or nonmechanical problems that can be associated with their symptoms. Any athlete who has severe, persisting, or activity-limiting symptoms must be evaluated thoroughly. Clinicians must have a working knowledge of the developmental issues, injury patterns, and particular conditions that may affect a given athlete and be able to work with patients in addition to families, coaches, trainers, and others involved in the care and training of the injured athlete.

Adolescent back pain

PURPOSE OF REVIEW

Adolescent back pain poses a distinct diagnostic challenge to the physician due to skeletal maturity and activity levels seen in adolescent patients. The purpose of this review is to focus on the musculoskeletal causes of adolescent back pain and to review the current literature on the etiology, diagnosis and treatment options.

RECENT FINDINGS

Etiologies of adolescent back pain include a vast differential diagnosis, including traumatic, morphologic, infectious and neoplastic etiologies. Recent literature has focused on spondylolysis, back pack-related pain, disc herniations and back pain in adolescent athletes. Recent anatomic studies have demonstrated a distinct morphology to spondylytic spines attributing the etiology of spondylolysis in part to morphologic predispositions.

SUMMARY

Increasing numbers of active adolescents will lead to increasing complaints of back pain seen by the primary care physician. Recent epidemiological studies have suggested a correlation between adolescent back pain and adult-onset back pain. A systematic approach to the adolescent with back pain is for arriving at a clear diagnosis and guiding appropriate treatments.

MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players

OBJECTIVE

To describe magnetic resonance imaging (MRI) findings in the lumbar spine in asymptomatic elite adolescent tennis players, to serve as the baseline for a future prospective longitudinal cohort study.

DESIGN

Observational study.

SETTING

Institutional, national tennis centre.

PARTICIPANTS

33 asymptomatic elite adolescent tennis players, mean (SD) age, 17.3 (1.7) years (18 male, 15 female).

METHODS

Sagittal T1, T2, STIR, and axial T2 weighted MRI images were reviewed for the presence of abnormalities by two radiologists in consensus. Abnormalities included disc degeneration, disc herniation, pars lesions (fracture or stress reaction), and facet joint arthropathy.

RESULTS

Five players (15.2%) had a normal MRI examination and 28 (84.8%) had an abnormal examination. Nine players showed pars lesions (10 lesions; one at two levels) predominately at the L5 level (9/10, L5; 1/10, L4). Three of the 10 lesions were complete fractures; two showed grade 1 and one grade 2 spondylolisthesis, both of which resulted in moderate narrowing of the L5 exit foramen. There were two acute and five chronic stress reactions of the pars. Twenty three patients showed signs of early facet arthropathy occurring at L5/S1 (15/29 joints) and L4/5 (12/29 joints). These were classified as mild degeneration (20/29) and moderate degeneration (9/29), with 20/29 showing sclerosis and 24/29 showing hypertrophy of the facet joint. Synovial cysts were identified in 14 of the 29 joints. Thirteen players showed disc desiccation and disc bulging (mild in 13; moderate in two) most often at L4/5 and L5/S1 levels (12 of 15 discs).

CONCLUSIONS

Abnormalities were frequent, predominately in the lower lumbar spine, almost exclusively at L4/5 and L5/S1 levels. Pars injuries and facet joint arthroses were relatively common.

Spinal injury in sport

Spinal injuries are very common among professional or amateur athletes. Spinal sport lesions can be classified in overuse and acute injuries. Overuse injuries can be found after years of repetitive spinal load during sport activity; however specific overuse injuries can also be found in adolescents. Acute traumas are common in contact sports. Most of the acute injuries are minor and self-healing, but severe and catastrophic events are possible. The aim of this article is to review the wide spectrum of spinal injuries related to sport activity, with special regard to imaging finding.