Low-back pain in athletes

Correlation of Radiographic Healing on Advanced Imaging in Young Adults and Adolescents With Symptomatic Spondylolysis Before and After Treatment: A Retrospective Study

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To determine the effect of conservative measures on radiographic outcomes in those with isolated spondylolysis.

SUMMARY OF BACKGROUND DATA

Spondylolysis is a common cause of low back pain in pediatric patients, affecting between 4.4% and 4.7% of all pediatric patients. This rate is even higher in high-level athletes, with recent studies suggesting a rate of 47% in this population. Conservative measures are recommended for treating symptomatic spondylolysis and are effective in controlling symptoms, but there is little evidence regarding their effect on radiographic outcomes.

METHODS

A retrospective review was conducted of patients diagnosed with spondylolysis who were treated at a single academic institution between January 1, 2012, and January 1, 2022. Data collected included demographics, presentation characteristics, pretreatment and post-treatment radiologic findings, types of treatments employed, and final symptomatic status at follow-up. The Student t test and the Wilcoxon rank sum test were used to compare continuous variables. The χ 2 test was used to compare categorical variables.

RESULTS

A total of 119 patients were included in the study. There was an 81.5% rate of healing on advanced imaging for those treated with conservative measures. When comparing those with healing on advanced imaging to those without, those with healing were more likely to have an acute fracture ( P= 0.04), have symptomatic improvement ( P <0.01), and return-to-play ( P= 0.02) compared with those without. Those with healing also had an odds ratio of 6.9 ( P <0.01) and 4.5 ( P =0.02) to achieve symptomatic improvement and return to their sport, respectively, compared with those who did not.

CONCLUSION

Our study found those with isolated spondylolysis who were treated with conservative measures had a high healing rate on advanced imaging and those with healing had significantly higher odds of having symptomatic improvement and returning to play compared with those without.

LEVEL OF EVIDENCE

4.

The Burden of Back and Neck Strains and Sprains in Professional Baseball Players

STUDY DESIGN

A retrospective case series study.

OBJECTIVE

To analyze the epidemiology of diagnoses of back and neck strains and sprains among Major League (MLB) and Minor League (MiLB) Baseball players.

BACKGROUND

Baseball players perform unique sets of repetitive movements that may predispose to neck and back strains and sprains. Data are lacking concerning the epidemiology of these diagnoses in this population.

MATERIALS AND METHODS

De-identified data on neck/back strains and sprains were collected from all MLB and MiLB teams from 2011 to 2016 using the MLB-commissioned Health and Injury Tracking System database. Diagnosis rates of conditions related to cervical, thoracic, and lumbar musculature and their impact on days missed due to injury, player participation, and season or career-ending status were assessed. Injury rates were reported as injuries per 1000 athlete exposures (AEs).

RESULTS

There were 3447 cases of neck/back strains and sprains in professional baseball players from 2011 to 2016. Seven hundred twenty-one of these occurred in MLB versus 2726 in MiLB. Of injuries 136 were season-ending (26 in MLB, 110 in MiLB); 22 were career-ending (2 in MLB, 20 in MiLB). The total days missed were 39,118 (8838 from MLB and 30,280 from MiLB). Excluding season or career-ending injuries, the mean days missed were 11.8 (12.7 and 11.6 in MLB and MiLB, respectively). The median days missed were 4 (3 and 5 in MLB and MiLB, respectively). Combining MLB and MiLB, the pitcher injury rate was 1.893 per 1000 AEs versus 0.743 per 1000 Aes for other position players ( P < 0.0001).

CONCLUSION

There was a high incidence of neck/back strains and sprains in MLB and MiLB players, with nearly 40,000 aggregate days missed in our 6-year study period. The median days missed were lower than the mean days missed, indicating rightward outliers. Pitchers had over double the rates of injuries compared with other position players.

LEVEL OF EVIDENCE

Level III.

Clinical Features and Therapeutic Process of Sacral Fatigue Fractures in Adolescents

BACKGROUND

Sacral fatigue fractures are a rare injury but should be considered as a differential diagnosis for low back and buttock pain in young adults. Collective reports are limited, most of which have focused on long-distance runners.

PURPOSE

To investigate the characteristics of sacral fatigue fractures in adolescents.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We analyzed patient background characteristics, physical examination and imaging findings, and treatment courses of those diagnosed with sacral fatigue fractures using magnetic resonance imaging.

RESULTS

Among 34 patients with sacral fatigue fractures, 15 and 19 were male and female patients, respectively, with an age range of 11 to 19 years (mean age, 15.0 years). Almost all patients were athletes, and 29 patients performed their sport ≥5 times a week. Long-distance runners were the most commonly affected, comprising 7 patients, and participants in other common sports such as baseball (6 patients), basketball (4 patients), and soccer (3 patients) were also affected. Physical examination revealed tension sign (Lasègue test) on the affected side in 6 patients and tight hamstrings in 24 patients. Imaging findings included 18 patients with right-side involvement, 12 with left-side involvement, and 4 with involvement on both sides. In 11 patients, spina bifida occulta was observed at S1 and 8 patients had a history of lumbar spondylolysis with 4 patients having concurrent sacral fatigue fractures. Physical therapy was performed concurrently with the cessation of exercise, and return to exercise was permitted if the pain had been relieved after 1 month. All patients returned to sports at a median of 48 days (range, 20-226 days) after symptom onset. However, 2 patients experienced recurrence (1 patient on the ipsilateral side and 1 patient on the contralateral side).

CONCLUSION

Sacral stress fractures are not limited to long-distance runners in this population and can manifest as lower back pain or buttock pain in athletes participating in a variety of sports. Although the course of treatment was generally good, the possibility of recurrence must always be considered.

Effects of the Three-Direction Movement Control Focus Complex Pain Program and Neurodynamic Focus Complex Pain Program on Pain, Mechanosensitivity, and Body Function in Taekwondo Athletes with Non-Specific Low Back Pain: A Preliminary Study

We aimed to determine the effects of three-direction movement control focus complex pain program (3D-MCE) and neurodynamic focus complex pain program (NDT) on pain, mechanosensitivity, and body function in Taekwondo athletes with non-specific low back pain. This study used a two-group pretest-posttest design and was conducted at a university physiotherapy lab and training center. It included 21 Taekwondo athletes with non-specific low back pain from a Taekwondo studio and a University in Busan. Participants were divided into a 3D-MCE group (n = 10) and an NDT group (n = 10). The numerical rating pain scale (NRPS), pain pressure threshold (PPT), movement analysis, and Oswestry Disability Index (ODI) were measured before and after the intervention. The intervention was performed for 45 min twice a week for 4 weeks. Each group performed movement control exercises and neurodynamic techniques. The NRPS, motion analysis, and ODI were significantly changed after the intervention in the 3-DMCE group. The NRPS, PPT, and ODI changed significantly after the intervention in the NDT group. Moreover, the PPT and motion analysis showed significant differences between the two groups. For Taekwondo athletes with non-specific low back pain, 3D-MCE improved the stability control ability of the lumbar spine. It was confirmed that neurodynamic techniques reduce muscle and nerve mechanosensitivity.

Effects of Complex Pain Control Programs on Taekwondo Athletes with Recurrent Low Back Pain: A Case Study

Background and Objectives: Practitioners of martial arts such as Taekwondo are likelier to experience back pain during training or competition. As the back pain of taekwondo athletes shows various symptoms depending on the athlete's characteristics, such as technique and movement, a case study was conducted to verify the intervention effect suitable for individual traits. We examined the effects of a complex pain control program on pain, mechanosensitivity, and physical function in a Taekwondo athlete with recurrent low back pain (LBP). Materials and Methods: A Taekwondo athlete with LBP was recruited from D University, Busan. The intervention program was performed for 45 min twice a week for 3 weeks, and the patient was followed up with after 2 weeks. The numerical rating pain scale (NRPS), pain pressure threshold, mechanosensitivity, and Oswestry Disability Index (ODI) scores were measured before and after the intervention. Therapeutic massage and nerve stimulation therapy were performed. Lumbar flexion, extension, and rotation were performed in the movement control exercise group, whereas the sliding technique, a neurodynamic technique of the tibial nerve, was applied in the neurodynamic technique group. This effect was verified by comparing the average measured values before and after the intervention. Results: Pain (NRPS) and mechanosensitivity reduced, range of motion and tactile discrimination abilities improved, and physical function (ODI) improved. The effect of the improved intervention lasted 2 weeks. Conclusions: These results indicate that application of complex pain control programs considering the four aspects of pain mechanisms for 3 weeks can be an effective intervention in Taekwondo athletes with recurrent LBP.

Age-Related Differences in the Limited Range of Motion of the Lower Extremity and Their Relation to Low Back Pain in Young Baseball Players: A Cross-Sectional Study of 1215 Players

BACKGROUND

Age-related differences in the limited range of motion of the lower extremities and their relationship with low back pain in juvenile athletes have not been well assessed. This study investigated the relationship between low back pain and limited range of motion of the hip and knee in young baseball players during the baseball season.

RESULTS

Participants comprised 1215 baseball players (216 pitchers, 999 fielders) aged 6-16 years who underwent medical checkups (self-completed questionnaire and physical examination). Of the 1215 players, 255 (21.0%) experienced seasonal low back pain requiring rest during the previous year. The prevalence of low back pain and a positive Thomas test, straight-leg-raising test, and heel-to-buttock test increased with age. Univariate analysis revealed that a positive heel-to-buttock test in both the throwing and non-throwing arm sides in the 11-12 age group and a positive Thomas test in the throwing arm side in the 13-14 age group were associated with seasonal low back pain (P = 0.0051, P = 0.021, and P = 0.048, respectively). Multivariate analysis, adjusted for factors associated with low back pain, showed significant associations between the positive heel-to-buttock test (odds ratio 1.75, 95% confidence interval 1.11-2.79; P = 0.016) and low back pain in players aged 11-14 years.

CONCLUSIONS

A positive heel-to-buttock test is potentially associated with low back pain among juvenile baseball players. Particular attention should be paid to the limited range of motion of the knee joint and tightness of the quadriceps femoris muscle among baseball players with low back pain aged 11-14 years.

Epidemiology of Lumbar Spine Conditions in Professional Baseball Players

STUDY DESIGN

A retrospective case series study.

OBJECTIVE

To analyze the epidemiology and burden of diagnoses of lumbar spinal conditions affecting Major League Baseball (MLB) and Minor League Baseball players.

SUMMARY OF BACKGROUND DATA

Lumbar spinal conditions are a common cause of low back pain in the general population and can be caused by participation in sports and athletics. Data concerning the epidemiology of these injuries in professional baseball players are limited.

METHODS

We collected deidentified MLB and Minor League Baseball data concerning lumbar spine conditions (lumbar disk herniations, lumbar degenerative disease, or pars conditions) from 2011 to 2017 using the MLB-commissioned Health and Injury Tracking System database. Data concerning days missed because of injury, need for surgery, and player participation and career-ending status were assessed. Injury rates were reported as injuries per 1000 athlete exposures in concordance with prior studies.

RESULTS

Over 2011-2017, 5948 days of play were missed because of 206 lumbar spine-related injuries, of which 60 (29.1%) were season ending. Twenty-seven (13.1%) of these injuries required surgery. The most common injury among both pitchers and position players were lumbar disk herniations (45, 44.1% and 41, 39.4%, respectively). More surgeries were performed for lumbar disk herniations and degenerative disk disease compared with pars conditions (74% and 18.5% vs. 3.7%). Injury rates for pitchers was significantly higher than those of other position players 0.111 per 1000 AEs versus 0.040 per 1000 AEs (P<0.0001). Injuries requiring surgery did not vary significantly by league, age group, or player position.

CONCLUSIONS

Lumbar spine-related injuries incurred substantial disability and days missed from play in professional baseball players. Lumbar disk herniations were the most common injury, and together with pars conditions led to higher rates of surgery compared with degenerative conditions.

LEVEL OF EVIDENCE

III.

Entry phase in men's backward dive pike: association between the shoulder joint and trunk angles

BACKGROUND

A high prevalence of lower back pain has been observed in competitive divers. Hyperextension of the lumbar vertebrae during water entry is considered the main mechanism behind the incidence of lower back pain in divers. Therefore, this study aimed to investigate the influence of the shoulder angle on the entry alignment.

METHODS

Posture angles of 13 male drivers (age: 16.8±2.9 years) who were invited to the national training camp in 2012 by Japan Swimming were recorded at the time of water entry via 201B using a high-speed camera.

RESULTS

A negative correlation was observed between shoulder joint flexion and trunk extension angles on water entry. In addition, the trunk angle was significantly different between groups. For the lower back pain group, 210.4±5.7°, and in the non-lower back pain group, 199.9±9.0°, angles were observed with a larger extension of the trunk on water entry in the lower back pain group.

CONCLUSIONS

The alignment on water entry was associated with the occurrence of lower back pain. Which suggested that enough shoulder flexibility can prevent the incidence of lower back pain.

Multifidus muscle cross-sectional area adaptations over two volleyball seasons and one off-season in athletes with and without low back pain

BACKGROUND

The multifidus muscle is important in spine stabilization. Atrophy of the multifidus muscle has been associated with low back pain.

OBJECTIVE

To examine multifidus muscle cross-sectional area (CSA) adaptations over two volleyball seasons and one off-season in volleyball athletes experiencing low back pain or no low back pain.

METHODS

Twelve female NCAA division 1 volleyball athletes participated. Athletes were placed into a low back pain or no low back pain group. Athlete's multifidus was imaged and measured using ultrasound at four time points across seasons. Imaging time points were before season one, following season one, following off-season, and following season two. A single level mixed-model analysis of variance was used for all analyses. A Tukey HSD post hoc test was used to determine differences between and within the low back pain and the no low back pain groups.

RESULTS

Following off-season training the pain group had clinically significant smaller multifidus CSA at the L4 (-2.36 cm2 difference or 17.5%) and L5 (-2.40 cm2 or 12.5%) levels. Non-significant (p> 0.05) decreases in multifidus CSA were seen in both groups following season one and two. Athletes with pain had decreased multifidus CSA at the L4 and L5 vertebral levels at all time points which was non-significant (p> 0.05).

CONCLUSIONS

Clinically significant decreases in multifidus CSA occurred in female volleyball athletes with low back pain at the L4 and L5 level following off-season training. Volleyball athletes with pain had smaller multifidus CSA averages at all time points measured of the two year period.

No Significant Change in MRI Abnormalities or Back Pain Prevalence in the Thoraco-Lumbar Spine of Young Elite Skiers Over a 2-Year Follow-Up

Background

Young athletes are at increasing risk for spinal column injuries due to overloading the spine with excessive sports activities, with potential development of complications later in life.

Purpose

The purpose of this 2-year follow-up study of young elite skiers and non-athletes was to investigate any potential change in the thoraco-lumbar findings on MRI and to outline any change in back pain prevalence with continuing sporting activity and age.

Study Design

Longitudinal cross-sectional study.

Methods

MRI of the thoraco-lumbar spine was performed on 30 skiers (mean age 20 years, female 43%) and 16 non-athletes (mean age 19, female 75%), available for the 2-year follow-up. The intervertebral discs were evaluated for signal, height, bulge/herniation, and additionally according to Pfirrmann classification, and the endplates were graded according to endplate defect score. Any of the following disc findings was defined as disc degenerative change: reduced signal, reduced height, bulge, or herniation. All participants answered a specific back pain questionnaire.

Results

No significant difference in spinal column abnormalities, nor back pain, was found between baseline and 2-year follow-up in neither skiers nor controls. There was significantly higher prevalence of disc degenerative changes in skiers (73%) than in non-athletes (44%, p=0.05). Skiers (63%) had significantly more Pfirrmann grade ≥3 discs compared to non-athletes (25%) (p=0.03). There was no significant difference in number of endplates with score ≥4 between skiers and non-athletes (50% vs 38%, p=0.40) nor in lifetime prevalence of back pain between skiers (46%) and non-athletes (40%).

Conclusion

There was no significant change over time of the spinal column MRI abnormalities, nor back pain prevalence, during a 2-year follow-up of skiers and non-athletes. Young skiers had significantly higher prevalence of spine abnormalities compared with non-athletes. There was no significant difference of the back pain lifetime prevalence in skiers compared with non-athletes.

Prevalence and risk factors of chronic low back pain in university athletes: a cross-sectional study

AIM

This study aimed to establish the prevalence of chronic low back pain (CLBP) in university-level athletes and to examine the influence of age, sex, body mass index (BMI), sports discipline, sleep, anxiety, and depression on CLBP. The secondary purpose was to check the association of certain variables in athletes having CLBP with the sports discipline and chronicity of LBP.

METHODS

A total of 340 players (100% response rate) from different sports, aged 18-30 years with at least 1 year of participation in sports at the university level were screened for the present study. The subjects completed a detailed, semi-structured questionnaire that gathered data regarding their demographic variables, personal and pain-related factors. The study was registered on the clinical trials registry, India (CTRI/2021/09/036675).

RESULTS

The results revealed the sport-wise point prevalence as follows: cricket (18.5%), basketball (15.6%), volleyball (20.0%), football (11.4%), badminton (7.7%) and tennis (7.7%). A higher number of years at university-level participation (>4 years), smoking, anxiety and BMI (>25 kg/m²) are risk factors for CLBP. The type of LBP, the intensity of the pain (current and last week), variation of the pain intensity, disability, intake of oral medications, physiotherapy for CLBP, number of missed days of training and number of missed matches are not significantly related to the chronicity of LBP or the sports discipline. Only the number of missed days of training had a significant association with the chronicity of LBP.

CONCLUSIONS

CLBP is a common complaint in Indian university athletes, and our findings indicate the necessity for a specific prevention program.

The Specifics of Non-specific Low Back Pain: Re-evaluating the Current Paradigm to Improve Patient Outcomes

Low back pain (LBP) is the leading cause of pain and debility worldwide and the most frequent reason for work-related disability. Global expenditures related to LBP are staggering and amount to billions of dollars each year in the United States alone. Yet, despite the considerable healthcare resources consumed, the care provided to patients with LBP has regularly been cited as both ineffective and exorbitant. Among the myriad reasons for this suboptimal care, the current approach to evaluation and management of patients with LBP is a likely contributor and is hitherto un-investigated. Following the current methodology, over 90% of patients with LBP are provided with no specific diagnosis, are managed inconsistently, and receive no express preventative care. We believed that this approach added costs and promoted chronic unresolved pain and disability. This narrative review highlights problems with the current methodology, proposes a novel concept for categorizing patients with LBP, and recommends strategies for improvement. Stratifying patients according to the etiology, in lieu of the prospects for morbidity, the strategy proposed in this article may help ascertain the cause of patient's LBP early, consolidate treatments, permit timely preventative measures, and, as a result, may improve patient outcomes.

Chromobox homolog 4 overexpression inhibits TNF-α-induced matrix catabolism and senescence by suppressing activation of the NF-κB signaling pathway in nucleus pulposus cells

Intervertebral disc degeneration (IDD) is featured as enhanced catabolism of extracellular matrix (ECM) in the nucleus pulposus (NP), in which tumor necrosis factor-alpha (TNF-α)-related cell senescence is involved. Chromobox homolog protein 4 (CBX4) exhibits anti-inflammatory effects and shows promising therapeutic potential. Thus, in the present study, we explore the role of CBX4 in IDD. Immunohistochemistry staining reveals that CBX4 expression is decreased in severe degenerative NP tissues compared to mild degenerative tissues, and real-time PCR and western blot analysis results show that CBX4 expression is downregulated under TNF-α stimulation in NP cells. siRNA and adenoviruses are used to knockdown or overexpress CBX4, respectively. The results demonstrate that CBX4 knockdown augments the catabolism of ECM in human NP cells, while CBX4 overexpression in rat NP cells restores the ECM degradation induced by TNF-α, as illustrated by immunofluorescence and western blot analysis. In addition, transcriptome sequencing results reveal the regulatory effect of CBX4 on the cell cycle, and further western blot analysis and senescence-associated β-galactosidase staining assay indicate that CBX4 overexpression alleviates cell senescence in the presence of TNF-α. Moreover, the phosphorylation of p65, which indicates the activation of NF-κB signaling, is measured by western blot analysis and immunofluorescence assay, and the results reveal that CBX4 overexpression reduces the TNF-α-induced increase in the p-p65/p65 ratio. In addition, the effect of CBX4 overexpression in NP cells is suppressed by NF-κB agonist. In summary, our results indicate that CBX4 overexpression can suppress TNF-α-induced matrix catabolism and cell senescence in the NP by inhibiting NF-κB activation. This study may provide new approaches for preventing and treating IDD.

Return to sport after lumbar microdiscectomy in high school and college age athletes

BACKGROUND

Previous studies have reported return to play (RTP) rates for athletes after lumbar discectomy, but not specifically younger athletes. The purpose of this study was to evaluate RTP rate of young athletes after lumbar microdiscectomy.

METHODS

Medical records for a single spine surgeon were reviewed to identify lumbar microdiscectomy patients. Patients were included if they were 21 years old or younger at the time of surgery and were athletes. 38 patients (25 male, 13 female) were identified, with mean age at surgery of 19 years. Level of herniated nucleus pulposus, variant anatomy, degenerative change, gender, preoperative blocks, ring apophyseal fractures, and duration of symptoms from onset until surgery were recorded. Patients were contacted to determine when and if they RTP.

RESULTS

Most patients had degenerative changes at the time of surgery, with a mean Pfirrmann score of 2.2. The average time from onset of symptoms until surgery was 11 months. All patients were reached for follow-up at an average 51 months post-op. 71% returned to play at an average of 4.5 months. There were no statistical differences in Pfirrmann Grade and RTP rates between high school and collegiate athletes, between males and females, nor between patients with two-level and one-level discectomies. Pfirrmann Grade was not significantly different between patients who RTP and those who did not RTP.

CONCLUSIONS

The prognosis for returning to competitive sports after lumbar microdiscectomy in young athletes is good. RTP rate and Pfirrmann Grade were not related to gender, sport level, or discectomy level.

Throwing Injury Prevention Strategies with a Whole Kinetic Chain-Focused Approach

Purpose of Review

This review examines the relationship between the baseball pitching motion and the kinetic chain. The goal was to determine the underlying causes of a deficiency in throwing mechanics throughout a throwing motion, and to provide an evidence-based approach on how to prevent injuries caused by a lack of proper mechanics. In doing so, we sought to provide a warm-up strategy that can be added to every baseball player’s daily on-field routine that is tailored to each phase of the throwing motion.

Recent Findings

To help minimize the risk of injury to overhead throwing athletes, a thorough understanding of the throwing motion is critical. Throwing a ball places extreme stress on the body, notably the shoulder and elbow joints. With a clear understanding of the biomechanics of throwing, we can develop an injury prevention routine to minimize unnecessary stresses throughout the kinetic chain.

Summary

The throwing cycle is a complex motion that places various stresses throughout the thrower’s body, from the ankle to the core, and from the back to the shoulder and elbow. A thorough understanding of the mechanics of this motion, along with specific exercises to target the specific actions of each phase, may allow for throwers, regardless of their age and experience, to minimize injury risk.

Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery

STUDY DESIGN

Narrative review.

OBJECTIVE

To address the gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing.

METHODS

This review did not involve patient care or any clinical prospective or retrospective review of patient information and thus did not warrant institutional review board approval. The available literature of PubMed, Medline, and OVID was utilized to review the existing literature.

RESULTS

Studies have shown that the forces through the lumbar spine in the modern-era golf swing are like other contact sports. Methods of protecting the lumbar spine include proper swing mechanics, abdominal and paraspinal musculature strengthening and flexibility as well as physical fitness. There are a variety of treatment options available to treat lumbar spine pathology each with a different return to play recommendations from doctors in the field.

CONCLUSIONS

With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature

Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.

Lumbar Spine and Lower Extremity Overuse Injuries

Both lower extremities and lower back are common sources of injury for cyclists. For providers to optimize care within this area of sports medicine, they need to understand the most common sources of injury in this population. Cycling presents a unique challenge: treating both the athlete and the complex relationship between rider and bicycle. Physicians should not replace the role of a professional bike fitter and should view these individuals as integral members of the team to alleviate current and prevent future injury. This article explores common lower extremity and lumbar back overuse injuries in cyclists and their medical management.

The Management of Acute Lumbar Stress Reactions of the Pedicle and Pars in Professional Athletes Playing Collision Sports

Acute stress reactions in the lumbar spine most commonly occur in athletes at the pars interarticularis followed by the pedicle. These reactions occur as a result of repetitive microtrauma from supraphysiological loads applied to the lumbar spine. Characteristic motions such as trunk extension and twisting are also thought to play a role and may be sport-specific. Other risk factors include increased lumbar lordosis, hamstring and thoracolumbar fascia tightness, and abdominal weakness. On physical examination, pain is typically reproduced with lumbar hyperextension. Currently, magnetic resonance imaging or nuclear imaging remain the most sensitive imaging modalities for identifying acute lesions. In the elite athlete, management of these conditions can be challenging, particularly in those playing collision sports such as American football, hockey, or rugby. Nonoperative treatment is the treatment of choice with rehabilitation programs focused on pain-free positioning and progressive strengthening. Operative treatment is rare, but may be warranted for patients symptomatic for >12 months. Specialized diagnosis protocols as well as treatment and return to play guidelines from 4 physicians treating elite athletes playing collision sports are presented and reviewed.

An analysis of pre-season risk factors for low back injury in high-school baseball pitchers: a prospective study

Pitching motion requires whole-body coordination; therefore, poor control of the lower extremities, pelvis and trunk may cause shoulder and elbow injuries. However, few studies have described the relationship between the shoulder joint function and low back injury in high-school baseball pitchers. A total of 128 healthy high school pitchers underwent pre-season medical checkups, where their shoulder range of motion and shoulder strength were measured. The participants completed a self-recorded daily questionnaire regarding the presence of low back pain. Pitchers were divided into injured and non-injured groups. Low back injury was observed in 13 participants (13.4%). In the injured group, horizontal adduction on the dominant shoulder was significantly less than in the non-injured group. A logistic regression analysis showed that horizontal adduction on the dominant side was a significant independent risk factor for low back injury during the season. It is important to recognize that restriction of the shoulder function not only causes shoulder and elbow injuries but can also risk low back injury.

Axial Low Back Pain in Elite Athletes

Back pain in sport is a common complaint and seen by athletes, trainers, and treating physicians. Although there are a multitude of pain generators, mechanical sources are most common. Certain sports can lead to increased mechanical and axial loading, such as competitive weightlifting and football. Common mechanical causes of pain include disk herniation and spondylolysis. Patients typically respond to early identification and conservative treatment. In others, surgical intervention is required to provide stability and prevent long-term sequelae.

Different disc characteristics between young elite skiers with diverse training histories revealed with a novel quantitative magnetic resonance imaging method

PURPOSE

To evaluate if there are differences in thoraco-lumbar disc characteristics between elite skiers and non-athletic controls as well as between different types of elite skiers, with diverse training histories, using a novel quantitative MRI method.

METHODS

The thoraco-lumbar spine of 58 elite skiers (age = 18.2 ± 1.1 years, 30 males) and 26 normally active controls (age = 16.4 ± 0.6 years, 9 males) was examined using T2w-MRI. Disc characteristics were compared quantitatively between groups using histogram and regional image analyses to determine delta peak and T2-values in five sub-regions.

RESULTS

A statistical difference in the delta peak value was found between skiers and controls (p <0.001), reflecting higher degree of disc degeneration. The histogram analysis also revealed that the type of training determines where and to what extent the changes occur. Alpine skiers displayed lumbar changes, while mogul skiers displayed changes also in the thoracic spine. Alpine skiers with diverse training dose differed in delta peak value (p = 0.005), where skiers with highest training dose displayed less changes. Regional T2-value differences were found in skiers with divergent training histories (p <0.05), reflecting differences in disc degeneration patterns, foremost within the dorsal annulus.

CONCLUSION

Differences in quantitative disc characteristics were found not only between elite skiers and non-athletic controls but also between subgroups of elite skiers with diverse training histories. The differences in the disc measures, reflecting tissue degradation, are likely related to type and intensity of the physical training. Future studies are encouraged to explore the relation between disc functionality, training history and pain to establish adequate prevention and rehabilitation programs.

Water Ski Injuries and Chronic Pain in Collegiate Athletes

This study examined the rate of injuries and chronic pain in collegiate water-ski athletes as a preliminary study. We also compared the mechanics and cause of injuries by the level of water-skiing experiences. A total number of 96 collegiate water-ski athletes, aged 21.4 ± 2.23 years, participated in the study. An off-line questionnaire was distributed at the collegiate tournaments in the United States. The questionnaire consisted of 20 questions, including demographic information, body region and type of injuries, mechanics and cause of injuries, chronic pain and pain management. A Chi-squared test was used to examine the differences in injury rates by sex and the level of experiences (beginner: <5 years, intermediate: 5–10 years, advanced: <10 years). The significance level was set at ≤0.05. A total of 336 water skiing-related injuries were observed from 96 participants. The ankle/feet, knee, and head/neck regions were the most common body regions injured, representing 26.5, 16.7, and 15.8%, respectively. Female athletes were more likely to have nerve injuries than male athletes (p = 0.039). The intermediate athletes were more likely to have trunk (p = 0.047) and upper extremity (p = 0.042) injuries than beginner athletes, and the beginner athletes had less joint/ligament (p = 0.001) and bone injury (p = 0.010) compared to the advanced athletes. Torsion/twisting (32.8%) and deceleration (26.9%) were the most common mechanism of injury. Beginner athletes experienced injuries more due to insufficient skill (p = 0.03), while the advanced athletes were likely to have more injuries by the loss of control (p = 0.01). Collegiate athletes had higher rates of chronic pain in the trunk (42.7%) and skeletal muscle (43.8%), and they participated in stretching/exercise (40.8%) and massage/form rolling (29.6%) to manage their chronic pain. The present study revealed that injury rates in males and females were 49.7% and 50.2%, respectively. Female athletes were more likely to have a nerve injury than male athletes. The mechanics and cause of injuries were different by the level of experiences where different training approaches may be required to minimize the injuries. Additionally, the strength and conditioning program that is systematically designed for core strength is needed to eliminate chronic trunk pain in collegiate water-skiing athletes.

Effects of combining diaphragm training with electrical stimulation on pain, function, and balance in athletes with chronic low back pain: a randomized clinical trial

BACKGROUND

It is unknown how diaphragm training combined with electrical stimulation affects pain, function, static stability, and balance in athletes with chronic low back pain (CLBP). This study aimed to explore the effects of combining diaphragm training with electrical stimulation on pain, function, static stability, and dynamic balance in athletes with nonspecific CLBP.

METHODS

The design was a randomized clinical trial. A total of 24 amateur athletes (12 women, 12 men, mean age: 35.2 ± 9.8) with nonspecific CLBP were randomly allocated into two groups. The experimental group (n = 12) received diaphragm training plus Transcutaneous Electrical Nerve Stimulation (TENS), while the control group (n = 12) received TENS alone. Both groups underwent 12 sessions over a four-week period. Static stability, dynamic balance, pain, and function were measured pre- and post-intervention.

RESULTS

Analysis of variance 2 × 2 revealed greater improvements in pain (p < 0.001), static stability (p < 0.001), and dynamic balance (p < 0.01) in the experimental group compared to the control group. Function was improved in both groups following the interventions (p < 0.001), and there was a trend of a larger improvement in the experimental group than the control group (p = 0.09). Fisher's exact test showed that the experimental group reported ≥50% improvement only in the pain score, not function, compared to the group that received TENS alone (p = 0.005).

CONCLUSIONS

Pain, function, static stability, and dynamic balance were improved in both groups following 12 intervention sessions. However, pain, static stability, and dynamic balance were improved to a greater extent in diaphragm training plus TENS than TENS alone in amateur athletes with CLBP. Therefore, it seems beneficial to add diaphragm training to the rehabilitation program for athletes with nonspecific CLBP.

TRIAL REGISTRATION

The trial was retrospectively registered in the Iranian Registry of Clinical Trials ( www.irct.ir ) on September 10, 2020 as IRCT20090228001719N8 .

Incidence and Risk Factors of Low Back Pain in Marathon Runners

Purpose

The occurrence of low back pain (LBP) in marathon runners has been poorly understood. This study aimed to describe the risk factors and identify whether these factors can cause LBP in these athletes.

Methods

A self-developed questionnaire was randomly distributed to 850 runners of running a half or a full marathon. Participants responded with the questionnaire focusing on previous training and running conditions after their competitions.

Results

On the basis of the remaining 800 valid questionnaires, the incidence of LBP was 4.50% (n = 36). A total of 572 (71.5%) males and 228 (28.5%) females, with an average age range of 33.9 ± 9.0 years, came from different occupations with different physical activity characteristics. However, no significant associations between occupation and runners with LBP (p > 0.05) were found. In the final models, risk factors, including warm-up activities (p=0.012, OR = 2.617), fatigue (p = 0.008, OR = 2.680), running gait posture (p=0.041, OR = 2.273), and environmental temperature (p=0.020, OR = 6.584), were significantly associated with LBP in marathoners.

Conclusion

Although LBP was uncommon in marathoners, it was linked to the factors such as insufficient warm-up activities, fatigue, poor running gait posture, and uncomfortable environmental temperature. Future studies need to validate these results. Nevertheless, these findings could still be useful for protecting the lower back area of runners clinically.

Orthopaedic medical examination for young amateur athletes: a repeated cross-sectional study from 2014 to 2018

OBJECTIVES

Medical examinations for adult elite athletes are performed all over the world, however, no studies in the relevant English literature have reported on orthopaedic medical examinations for young amateur athletes. The purpose of this study was to report the results of orthopaedic medical examinations of the spine and lower extremities in young amateur athletes.

METHODS

This repeated cross-sectional study from 2014 to 2018 included a total of 323 young amateur athletes (age, 12-18 years) who were active in one of the following four sports: boxing, canoeing, weightlifting and track and field. The orthopaedic medical examination consisted of six assessments (physical examinations, the generalised joint laxity, muscle and joint tightness, static alignment and muscle volume of the lower extremities and the medial longitudinal arch of the foot). Questions regarding pain in the spine and lower extremities were also performed.

RESULTS

Among 323 young amateur athletes, 17 (5.3%) had received orthopaedic treatment at the time of the medical examination, with spondylolysis being the most common cause (29.4%, 5/17). Among 306 young athletes who had not received orthopaedic treatment, 61 (19.9%) had at least one positive finding in physical examinations or had pain in the spine or lower extremities. Anterior drawer test of the ankle and Kemp test for the spine accounted for 34% and 28% of positive findings, respectively. Low back pain and knee pain accounted for 58% and 16% of pain, respectively.

CONCLUSIONS

The present study showed that approximately one-fifth of young amateur athletes who had not received orthopaedic treatment had pain in the spine and lower extremities and positive findings in physical examinations that may require orthopaedic treatments. In addition to the early detection of injuries, orthopaedic medical examinations for young amateur athletes provide an opportunity to educate such athletes.

Low back pain in children and adolescents: Real life experience of 106 patients

OBJECTIVE:

To analyze the demographic data, etiologies and risk factors of 106 children and adolescents with low back pain (LBP) who applied to our clinic.

METHODS:

The medical records of patients with low back pain under 18 presenting to our clinic in 2014–2018 were examined retrospectively. Patients’ demographic data, physical examination findings, laboratory and imaging results, and risk factors for low back pain were evaluated; diagnosis and treatment modalities were recorded.

RESULTS:

In this study, 106 children and adolescents 8–17 (mean 14.24±2.33) years, 55 girls (51.8%) and 51 boys (48.1%) were included. Sixty-two patients (58.4%) were diagnosed with non-specific low back pain, 24 (22.6%) with lumbar disc herniation, six (5.6%) with inflammatory low back pain, five (4.7%) with spondylolysis (with accompanying listhesis in two), five (4.7%) with scoliosis, and four (3.7%) with Scheuermann Disease. Three patients were operated and another patient underwent an algological intervention for persistent pain. Six patients diagnosed as spondyloarthropathy were referred to the pediatric rheumatology department. Pain in the remaining cases was brought under control using conservative methods in a combination of medical treatment, rest and physiotherapy.

CONCLUSION:

Low back pain is a frequent complaint in the child-adolescent age group. The causes of low back pain are as diverse as adults in this age group. The contrary common belief that severe problems, such as malignancy are common, mechanical reasons as the most common cause of low back pain.

Back injuries in Major League Baseball

BACKGROUND

There is a scarcity of epidemiological studies on back injuries in Major League Baseball (MLB). In our study, we explore all back related injuries in the MLB from 2010 to 2016 (inclusive) in an aim to help better understand these injuries, assess their risks, and improve their prevention policies.

METHODS

The transaction lists from the MLB website were screened for back injuries from 2010 THROUGH 2016. Only players who were placed on the disabled list (DL) for one or more days due to back-related injury were included in our study. Our database included the player's position, team, injury location, injury type, days spent on the DL and month of injury occurrence.

RESULTS

254 back injuries, an equivalent of 7% of all injuries, were recorded between 2010 and 2016 (inclusive). These injuries increased from 2010 to 2016. Back related injuries were found to place players on the disabled list for around 54 days. Injuries were recorded mostly during April, and strain was significantly greater than any other type of injury (P value <0.001).

CONCLUSIONS

Back injuries are prevalent in the MLB. Better understanding of the trends and patterns of these injuries will help in establishing better prevention policies.

The one-year prevalence of nonspecific back pain in public primary health care establishments among 1.7 million people in western Sweden

Aim:

The one-year prevalence of diagnosed nonspecific back pain in Sweden is not known. Thus, this observational register-based study aimed to evaluate this prevalence by using data from the Region Västra Götaland, inhabiting 1.7 million people.

Methods:

Data from 2014 to 2018 were extracted from the VEGA database register. This register holds all health data from the publicly funded health care establishments in Region Västra Götaland. Aggregated data are presented as the one-year prevalence of unique individuals diagnosed with nonspecific back pain (i.e., the ICD-10 code M54). Stratification by health care level, gender, age, and M54 sub-diagnoses were made.

Findings:

Between 2014 and 2018, the annual prevalence of diagnosed nonspecific back pain in public primary health care increased from 4.8% to 6.0% (26% increase, P < 0.001, CI 25–27%). In 2018, the one-year prevalence was 7.2% among women and 4.8% among men (50% difference, P = 0.001, CI 49–52%). The one-year prevalence increased by age, and the highest figure (11%) was seen in the age group of 80–84. Low back pain, M54.5, was the most common sub-diagnosis. The one-year prevalence was significantly higher (P < 0.001) among women in all the M54 sub-diagnoses.

Conclusion:

The one-year prevalence of diagnosed nonspecific back pain was 6% in public primary health care in 2018 and has increased since 2014. Women were diagnosed considerably more frequently than men. Publicly funded rehabilitation efforts, as well as actions focusing on the prevention of back pain, is probably money well spent.

Inspiratory Muscle Training in Rehabilitation of Low Back Pain: A Randomized Controlled Trial

CONTEXT

People with chronic low back pain (CLBP) suffer from weaknesses in their core muscle activity and dysfunctional breathing. Inspiratory muscle training (IMT) was recently developed to treat this condition.

OBJECTIVES

The present study was conducted to investigate the effect of IMT on core muscle activity, pulmonary parameters, and pain intensity in athletes with CLBP.

DESIGN

This study was designed as a single-blind, randomized, controlled trial.

SETTING

Clinical rehabilitation laboratory.

PARTICIPANTS

A total of 23 male and 24 female athletes with CLBP were randomly divided into the experimental and control groups.

MAIN OUTCOME MEASURES

The experimental group performed IMT for 8 weeks, 7 days per week and twice daily, using POWERbreathe KH1, beginning at 50% of maximum inspiratory pressure with a progressively increasing training load. The surface electromyography muscle activity of the erector spinae, multifidus, transverse abdominis and rectus abdominis, respiratory function and Visual Analogue Scale score were also measured before and after the intervention in both groups. The repeated-measures analysis of variance and 1-way analysis of covariance were further used to compare the intragroup and intergroup results following the intervention.

RESULTS

The findings of the study revealed that multifidus and transverse abdominis activity, as well as respiratory function, increased significantly in the IMT group (P < .05). Moreover, a descending trend was observed in the Visual Analogue Scale score in the experimental group (P < .05).

CONCLUSION

The results showed that IMT can improve respiratory function, increase core muscle activity, and, consequently, reduce pain intensity in athletes with CLBP.

Full-endoscopic Decompression of Foraminal Stenosis Caused by Facet Hypertrophy Contralateral to the Dominant Hand in a Baseball Pitcher: A Case Report

Back pain and lower extremity pain have various causes and occasionally occur simultaneously, creating diagnostic difficulties. In addition, athletes require special consideration in terms of treatment. Here, we report a case of foraminal stenosis as a result of lumbar disc prolapse combined with facet hypertrophy contralateral to the dominant hand in a baseball pitcher that was successfully treated by minimally invasive full-endoscopic surgery. A 31-year-old left-handed male baseball pitcher presented with complaints of low back pain and right buttock pain while pitching. A diagnosis of foraminal stenosis caused by a disc bulge combined with facet hypertrophy contralateral to the dominant hand was made on the basis of physical and radiological findings. His symptoms improved immediately after transforaminal full-endoscopic lumbar discectomy and foraminoplasty under local anesthesia. He returned to play 3 months after surgery. Foraminal stenosis due to facet hypertrophy may occur in the side contralateral to the throwing arm in pitchers. Minimally invasive decompression using a full-endoscopic procedure is required for high-level athletes at this position.

Sports Imaging of Team Handball Injuries

Team handball is a fast high-scoring indoor contact sport with > 20 million registered players who are organized in > 150 federations worldwide. The combination of complex and unique biomechanics of handball throwing, permitted body tackles and blocks, and illegal fouls contribute to team handball ranging among the four athletic sports that carry the highest risks of injury. The categories include a broad range of acute and overuse injuries that most commonly occur in the shoulder, knee, and ankle. In concert with sports medicine, physicians, surgeons, physical therapists, and radiologists consult in the care of handball players through the appropriate use and expert interpretations of radiography, ultrasonography, CT, and MRI studies to facilitate diagnosis, characterization, and healing of a broad spectrum of acute, complex, concomitant, chronic, and overuse injuries. This article is based on published data and the author team's cumulative experience in playing and caring for handball players in Denmark, Sweden, Norway, Germany, Switzerland, and Spain. The article reviews and illustrates the spectrum of common handball injuries and highlights the contributions of sports imaging for diagnosis and management.

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.

Repetitive Traumatic Discopathy in the Modern-Era Tennis Player

Degenerative disc disease is more prevalent among athletes than the general population. Repetitive traumatic discopathy is a pattern of injury that has been described in athletes participating in sports that impart repetitive mechanical forces on the lumbar spine. Hence, tennis players may be particularly susceptible to repetitive traumatic discopathy due to the fast-paced nature of the modern tennis match. Recent biomechanical studies have identified the lumbar spine as the focal point of motion during tennis strokes, and the lumbar spine is notably the most frequent location of injury observed in tennis players. In this comprehensive review, we examine current evidence and discuss the epidemiology, pathophysiology, biomechanics, diagnosis, and treatment of repetitive traumatic discopathy in tennis players. Additionally, we outline considerations for rehabilitation and return to the tennis court after operative management.

Effects of core stability exercise combined with virtual reality in collegiate athletes with nonspecific low back pain: a randomized clinical trial

Background

Nonspecific low back pain (LBP) in collegiate athletes is shown to be accompanied by poor core endurance. Consequently, trunk muscle stabilization exercises for lumbar instability are widely used. Virtual reality (VR) training can activate the cerebral cortex and enhance the cortex to control balance and improve motion function. The purpose of the study was to assess the effect of combined core stability exercises (CSE) and VR training in improving body balance and function in collegiate male athletes with nonspecific low back pain (LBP).

Results

The post-values of the experimental group were significantly higher than that of the control group for the dynamic balance in anterior (p = 0.031), posterolateral (p = 0.034), and posteromedial (p = 0.037) directions. Moreover, there was a significant difference in the post-values of both groups regarding reducing the Micheli Functional Scale in favor of the experimental group (p = 0.012).

Conclusions

CSE training plus virtual reality is more effective than CSE training alone in improving total body balance and dysfunction level in collegiate male athletes with nonspecific LBP. It is recommended that clinicians consider CSE combined with VR to maximize the improvement in overall body balance when developing rehabilitation programs for collegiate athletes with nonspecific low back pain.

Trial registration

Pan African Clinical Trial Registry, PACTR201907749053096. Retrospectively registered on 15 April 2019. https://pactr.samrc.ac.za/Researcher/ManageTrials.aspx

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.

Rowing Injuries in Elite Athletes: A Review of Incidence with Risk Factors and the Role of Biomechanics in Its Management

BACKGROUND

Rowing is an Olympic sport gaining popularity in India and injuries are common in these athletes. Determinants of performance, injury risk and training are all interrelated in rowing. Injuries result from various risk factors including fitness issues and improper techniques. Rowers should have adequate leg extension strength and lumbo-pelvic coordination to produce and transmit power from the legs to the oar handle. Biomechanical analysis of the rowing stroke can help in preventing injuries and optimise technique for best performance. It involves a detailed and systematic observation of movement patterns to establish the quality of the movement and provide feedback to the rower about the key variables affecting performance and injury risk. Kinetics such as foot forces and kinematics such as key joint angles can be accurately measured by instrumented foot stretcher and three-dimensional motion capture.

AIM

To do a detailed review of literature regarding the incidence and risk factors for rowing injuries and to get an insight on the role of biomechanics in its management.

MATERIALS AND METHODS

Literature review was carried out with standard academic search engines and databases including Science Direct, PubMed and Google Scholar using keywords of relevance. A total number of 38 articles were analysed and results were collated to compile this review report.

RESULTS

Lumbar spine is most commonly injured (up to 53%), followed by rib cage (9-10%) and shoulder and other anatomical areas. Rowers with a trunk-driven rowing action will have a lower hip:trunk score and carry a high injury risk. A player with lumbar injury will take a minimum of 3-4 months to recover.

CONCLUSION

Rowing injuries are common. Regular screening of the rowing athletes by comprehensive fitness and biomechanics assessment will help in prevention of injuries. Rowers need to be tested for pain, strength, flexibility, reproducibility of rowing action with modified mechanics, coordination, fatigue level, explosive power, aerobic and anaerobic endurance. Early recognition of risk factors and timely intervention is the key aspect of a successful return to play.

Total Disc Replacement Surgery in a Professional Australian Rugby League Player: A Case Report

Chronic persistent lower back pain due to degenerative disc disease (DDD) of the lumbar spine is a common condition in the athletic population, which does not always improve with nonoperative treatment. We present a case report of a professional Australian rugby league player with DDD of the lumbar spine presenting with persistent lower back pain, which was not responding to conventional nonsurgical treatment. He then underwent a surgical total disc replacement of the lumbar spine and was subsequently able to return to playing professional rugby league at his previous level of competition. This is the only known documented case of a professional athlete in any form of contact sport successfully returning to his previous level of function and competition after undergoing a total disc replacement of the lumbar spine.

Trunk peak torque, muscle activation pattern and sudden loading compensation in adolescent athletes with back pain

OBJECTIVE

To evaluate trunk peak torque and muscle activation pattern during isokinetic and sudden trunk loading (STL) between adolescent athletes with/without back pain.

METHODS

Nine adolescent athletes with back pain (BP) (m/f 2/7; 15.6 ± 1.2 y; 177 ± 9 cm; 67 ± 13 kg; 22.5 ± 9.8 h/week) and nine matched controls (m/f 2/7; 15.7 ± 1.4 y; 177 ± 12 cm; 65 ± 9 kg; 16.5 ± 8.0 h/week training) were included. Trunk strength in rotation and flexion/extension was assessed. Sudden trunk loading was measured during eccentric extension and rotation (30∘/s) with additional perturbation. Trunk muscle activity was measured using a 12 lead-EMG (electromyography). Main outcome measures were peak torque [Nm] and MVC normalized EMG-amplitudes (RMS [%]) for each muscle. Additionally, the mean EMG-RMS for four areas of the trunk was calculated (right/left ventral, right/left dorsal).

RESULTS

Back pain showed lower trunk peak torque for all conditions in extension/flexion, but not for rotation. EMG amplitudes were increased for BP athletes with statistical significant differences for dorsal muscles in rotation and extension (p< 0.0042), not for ventral muscles in flexion.

CONCLUSIONS

The evaluation of strength and muscle activity in isokinetic and sudden trunk loading presents altered trunk function in adolescent back pain athletes. Training interventions focusing on trunk strength and muscular activation pattern appears reasonable.

Prevalence of back pain in a group of elite athletes exposed to repetitive overhead activity

Background

The prevalence of back pain in athletes has been investigated in several studies, but there are still under- or uninvestigated sports discipline like sports exposed to repetitive overhead activity. Elite athletes spend much time in training and competition and, because of the nature of their disciplines, subject their bodies to a great deal of mechanical strain, which puts a high level of stress on their musculoskeletal systems. From this it is hypothesized that elite athletes who engage in repetitive overhead motions experience a higher strain on their spine and thus possibly a higher prevalence of back pain compared with an active control group.

Objectives

To examine the prevalence of back pain and the exact location of pain in a cohort of elite athletes with repetitive overhead activity and in a control group of physically active sport students. Additionally, to examine different characteristics of pain, and to evaluate the influence of confounders on back pain.

Methods

A standardized and validated online back pain questionnaire was sent by the German Olympic Sports Confederation to German national and international elite athletes, and a control group of physically active but non-elite sports students.

Results

The final sample comprised 181 elite athletes of the sports disciplines badminton, beach volleyball, handball, tennis and volleyball and 166 physically active controls. In elite athletes, lifetime prevalence of back pain was 85%, 12-month prevalence was 75%, 3-month prevalence was 58% and point prevalence was 38%; for the physically active control group, these prevalences were 81%, 70%, 59% and 43%, respectively. There was no significant group difference in prevalence over all time periods. The lower back was the main location of back pain in elite athletes across all disciplines and in controls; additionally a distinct problem of upper back pain was found among volleyball players.

Conclusion

Despite the high mechanical load inherent in the sport disciplines included in this study, the elite athletes who engaged in repetitive overhead activities did not suffer more from back pain than the physically active controls. This suggests that other mechanisms may be influencing back pain prevalences in a positive way in these athletes. Furthermore, these disciplines may practice preventive factors for back pain that outweigh their detrimental factors. Therefore, we posit that extensive prevention work is already being implemented in these sports and that there are additional individual protection factors in play. More research is required to explore these suppositions, and should include investigations into which preventive training programs are being used. Nevertheless, in volleyball particularly, a focus on stabilization/preventive training should be applied to the upper back and neck.

Epidemiological profile of soccer-related injuries in a state Brazilian championship: An observational study of 2014-15 season

BACKGROUND

Soccer related injuries are often reported in studies, but epidemiological research on this theme is rare in Brazil, Furthermore, the conditions in which athletes have returned to sports practice, namely, either symptomatic or asymptomatic, have been neglected in research.

OBJECTIVES

The aim of this study was to describe the epidemiological features of injuries among professional Brazilian soccer players in relation to location, type, mechanism, severity, recurrence, treatment and, lastly, symptoms in return to sport.

STUDY DESIGN

Descriptive and cross-sectional, observational study.

STUDY CENTER

School of Physical Therapy of the University of Mato Grosso do Sul, Brazil.

METHODS

116 male professional athletes of teams from a Brazilian state championship were interviewed and information about injuries was recorded using a retrospective reported morbidity questionnaire. Data were analyzed in mean ± SD for physical characteristics and sports practice history in absolute and relative frequencies (chi-square test with Bonferroni's correction) for characterization of soccer injuries in terms of type, location, severity, recurrence and symptoms in return to sport.

RESULTS

The numbers of injuries per athlete and per injured athlete were 0.92 and 1.43 respectively. The injuries of muscle-tendon unit and the joint types localized on lower limbs constituted the most important clinical occurrences with significant difference both in relation to other types (p < 0.05). Moderate and severe injuries were the most frequent occurrences. In relation to mechanisms for each type of injury, body contact was at least three times more responsible for injury cases. This type of mechanism was associated with a significantly greater impairment of joint structures. Concerning occurrence and recurrence of cases, the number of recurrent injuries of the muscle-tendon unit reached about 7.5% of the first-time injuries, while the number of joint recurrent injuries integrated almost 40% of the first-time cases. Significant differences between first-time injuries and recurrent injuries were found only for muscle-tendon and joint structures (p < 0.05), while significant differences among the type of injuries within each type of occurrence (first-time or recurrent injuries) were also found between muscle-tendon and joint injuries (p < 0.05). In relation to athletes with symptoms, in return to sport, 77.6% of them were treated for their injuries but more than half of them returned with symptoms still present when compared to those who returned without any symptoms. Among athletes who did not receive treatment, a lower percentage (58.3%) returned to the sport with symptoms still present. Significant associations between treatment and symptomatology were not found.

Dose-response relationship of core-specific sensorimotor interventions in healthy, well-trained participants: study protocol for a (MiSpEx) randomized controlled trial

BACKGROUND

Core-specific sensorimotor exercises are proven to enhance neuromuscular activity of the trunk, improve athletic performance and prevent back pain. However, the dose-response relationship and, therefore, the dose required to improve trunk function is still under debate. The purpose of the present trial will be to compare four different intervention strategies of sensorimotor exercises that will result in improved trunk function.

METHODS/DESIGN

A single-blind, four-armed, randomized controlled trial with a 3-week (home-based) intervention phase and two measurement days pre and post intervention (M1/M2) is designed. Experimental procedures on both measurement days will include evaluation of maximum isokinetic and isometric trunk strength (extension/flexion, rotation) including perturbations, as well as neuromuscular trunk activity while performing strength testing. The primary outcome is trunk strength (peak torque). Neuromuscular activity (amplitude, latencies as a response to perturbation) serves as secondary outcome. The control group will perform a standardized exercise program of four sensorimotor exercises (three sets of 10 repetitions) in each of six training sessions (30 min duration) over 3 weeks. The intervention groups' programs differ in the number of exercises, sets per exercise and, therefore, overall training amount (group I: six sessions, three exercises, two sets; group II: six sessions, two exercises, two sets; group III: six sessions, one exercise, three sets). The intervention programs of groups I, II and III include additional perturbations for all exercises to increase both the difficulty and the efficacy of the exercises performed. Statistical analysis will be performed after examining the underlying assumptions for parametric and non-parametric testing.

DISCUSSION

The results of the study will be clinically relevant, not only for researchers but also for (sports) therapists, physicians, coaches, athletes and the general population who have the aim of improving trunk function.

TRIAL REGISTRATION

German Clinical Trials Register, ID: DRKS00012917 . Registered on 22 August 2017.

Outcomes of Various Treatment Modalities for Lumbar Spinal Ailments in Elite Athletes: A Literature Review

Lumbar spinal injuries are common in elite athletes, who can present with a spectrum of ailments ranging from lumbar strain to prolapsed intervertebral discs. Sequelae can include neurological impairment and lumbar instability among other possible outcomes. This group of patients is unique in terms of their clinicoradiological presentation and treatment modalities. The primary goals of treatment are a rapid return to play and prevention of recurrence, thus prolonging the athlete’s professional career. Treatment modalities can range from activity restriction to nerve root blocks and surgery. A successful treatment outcome is based on timely diagnosis, treatment suiting the demands of the particular sport, and early rehabilitation. A multidisciplinary team approach involving the coach, rehabilitation specialist, pain management specialist, and spine surgeon helps in planning appropriate treatment. In this article, we review special considerations in the elite athletic population with lumbar spinal ailments as well as the outcomes of various treatment modalities.

Muscle Strength and Neuromuscular Control in Low-Back Pain: Elite Athletes Versus General Population

The purpose of the study was to investigate the athletic-based specificity of muscle strength and neuromuscular control of spine stability in chronic non-specific low-back pain (LBP). Thirty elite athletes and 29 age-matched non-athletes with (15 athletes and 15 non-athletes) and without LBP (15 athletes and 14 non-athletes) participated in the study. Muscle strength was measured during maximal isometric trunk flexion and trunk extension contractions. The neuromuscular control of spine stability was analyzed by determining trunk stiffness, trunk damping, and onset times of the lumbar and thoracic erector spinae muscles after sudden perturbations (quick release experiments) as well as maximum Lyapunov exponents (local dynamic stability) using non-linear time series analysis of repetitive lifting movements. LBP was assessed using the visual analog scale. We found lower maximal trunk extension moments (p = 0.03), higher trunk damping (p = 0.018) and shorter onset times (p = 0.03) of the investigated trunk muscles in LBP patients in both athletes and non-athletes. Trunk stiffness and the local dynamic stability did not show any differences (p = 0.136 and p = 0.375, respectively) between LBP patients and healthy controls in both groups. It can be concluded that, despite the high-level of training in athletes, both athletes and non-athletes with LBP showed the same deconditioning of the lumbar extensor muscles and developed similar strategies to ensure spine stability after sudden perturbations to protect the spine from pain and damage. The findings highlight that specific training interventions for the trunk muscles are not only crucial for individuals of the general population, but also for well-trained athletes.

Factors Associated with the Symptoms of Young Adults with L5 Spondylolysis

Study Design

A retrospective cohort study.

Purpose

To investigate the factors affecting symptoms in young adults with L5 spondylolysis.

Overview of Literature

L5 spondylolysis is a common disease. However, not all patients diagnosed with L5 spondylolysis exhibit symptoms. This study examined the factors associated with the symptoms of young adults with L5 spondylolysis.

Methods

The medical records of 70 young adults (mean age, 31.1 years; range, 20–39 years) with L5 spondylolysis treated at the authors’ spine center between March 2008 and February 2015 were reviewed systematically. The symptomatic group (n=46) presented with symptoms, such as back pain and/or intermittent lower limb radiating pain, whereas the asymptomatic group (n=24) did not. Age, sex, body mass index (BMI), adjacent disc degeneration, facet degeneration, and measured spino-pelvic parameters (pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, sacral inclination, and sacral table angle) were investigated with respect to the presence of symptoms. Adjacent disc degeneration was evaluated using T2-weighted sagittal magnetic resonance imaging (MRI, Pfirrmann classification), whereas facet degeneration was evaluated using T2-weighted axial MRI (Grogan classification).

Results

Significant differences in the BMI (p =0.032), L4–5 disc degeneration (p =0.030), L5–S1 disc degeneration (p =0.046), L4–5 facet degeneration (p =0.041), and L5–S1 facet degeneration (p =0.027) were observed between the symptomatic and asymptomatic groups. However, multivariate logistic regression analysis revealed that L5–S1 disc degeneration (p =0.033) was the only significant factor.

Conclusions

BMI and adjacent disc and facet degeneration may be associated with the manifestation of disease symptoms in young adults with L5 spondylolysis, and the likelihood of the patient exhibiting symptoms increases with increasing severity of L5–S1 disc degeneration.

Stress and risk for depression in competitive athletes suffering from back pain - Do age and gender matter?

Back pain (BP), a prominent problem for competitive athletes, is a primary reason for limitations in athletic performance and daily life restrictions. As studies on the relationship between psychological variables and BP in athletes are scarce, the aim of this study was to investigate stress and depression in competitive athletes with BP. In a cross-sectional design, data of 154 competitive athletes (51% female; M_age= 18.81 years, SD_age= 5.05 years) were collected, assessing Performance stress, Socio-emotional stress, Risk for depression and Psychological well-being and the two BP parameters BP Intensity and Disability. Two multiple linear regressions were conducted to predict (1) BP Intensity and (2) Disability from Performance stress, Socio-emotional stress, Risk for depression and Psychological well-being. Multiple linear regressions demonstrated that Performance stress (β = .21, p = .01) was the only significant predictor of BP Intensity (F_1,142= 6.68, p = .01, R² = .05), whilst Risk for depression (β = .24, p = .01) was the only significant predictor of Disability (F_1,142= 8.46, p = .01, R² = .06). Neither gender nor age explained a significant amount of variance in the models. Study results showed that, as in the general population, the variables stress and depression are related to BP in competitive athletes. In particular, BP intensity was found to be associated with stress and BP-related disability was associated with depression, whereas age and gender showed no association with the BP parameters. A longitudinal investigation is warranted to determine the direction of the observed relationships.