Spine-related Pain in Sports Medicine
The spine is commonly involved in sports injuries. Although not the usual focus of a sports medicine practitioner, its importance should not be overlooked. Spinal conditions can have substantial effects on athlete’s performance, as well as important implications of the propensity for neurological injuries. Athletic performance is dependent upon a stable spine with well-coordinated neuromuscular patterns of movements.1-3 Bergmark studied the lumbar spine using a mechanical modeling approach and divided the musculature of the trunk into local and global systems.4 He believed that the global system, which included muscles such as the rectus abdominis and erector spinae, transferred force between the thoracic spine and pelvis. The local system, which consists of muscles that act directly on the lumbar vertebrae, such as the mutifidi, maintains force control within the lumbar spine. Panjabi described a model addressing spinal instability in which he proposed the existence of three separate but interrelated subsystems that act to control intersegmental stability.1,4 This model suggests that an injury affecting the passive subsystem could theoretically be at least partially compensated for through the enhancement of the function of the other subsystems.
The stable spine is maintained by three subsystems:
- passive subsystem (spinal column, eg., ligaments, vertebrae, disks) includes intrinsic spinal anatomy comprising vertebrae, intervertebral discs, facet articulations, joint capsules, and extensive ligamentous attachments
- active subsystem (spinal musculature) includes the muscles and tendons acting on the intrinsic elements
- neural control subsystem (eg., sensory receptors, cortical and subcortical controls) comprises afferent sensory receptors distributed throughout all tissues, an efferent arm, which executes motor actions, and a control center, which integrates sensorimotor function
Coordination of these subsystems is critical to the generation of movement.
The functional model for the physiatric approach to the spine in sports is outlined in the 1997 World Health Organization definitions of impairment, activity, and participation.4 These core principles include understanding spine biomechanics, flexibility, strength, conditioning, core strengthening, stabilization, and cross training. These core principles provide the building blocks for enhancing athletic performance. This applies to all levels of sports participation, from the weekend warrior to the elite athlete. Training to prevent injury and enhance performance defines rehabilitation treatment. Many athletes develop inefficient movement patterns due to asymmetries of flexibility and strength. By identifying and correcting these inefficiencies, the practitioner may help the athlete prevent injury, disability, and improve performance.
As society’s emphasis on continued physical activity and athletics throughout the lifespan has increased, so have the knowledge and skill required by the community of health care providers involved in managing the related injuries. It is essential for all sports medicine providers to realize that a team approach (physicians, physical therapists, athletic trainers, coaches, etc.)—which takes advantage of the collective knowledge, talent, and expertise of all these specialists in a collaborative effort—affords the athlete the optimal conditions for successful return to sport.1-22
It is important to note that with most athletes up to 60% of the “overuse” type injuries are related to training errors. Interaction with the coach/trainer is critical in solving this problem. Pain will get the athlete into the clinic, but the tricky part can be figuring out exactly what is causing the pain. The old acronym RICE (Rest, Ice, Compression, & Elevation) along with NSAIDS can do a very nice job of decreasing/eliminating the chemical pain associated with the inflammatory response. However, the real challenge is to identify the underlying dysfunction.
A thorough physical exam, biomechanical assessment, and functional movement analysis can provide great insight into how the body moves and reveal any joint dysfunction and/or muscle imbalances. The muscle imbalance leads to changes in the length-tension relationships of involved muscles. This change in force coupling decreases neuromuscular efficiency and leads to more rapid fatigue. As the muscles fatigue there is often a biomechanical compensation which may overload tissues not used to that new stress. Eventually breakdown must occur and the athlete enters the cumulative injury cycle of pain.
With the heightened interest in personal fitness and athletic participation, the physician is expected to see a variety of sports-related injuries and must be able to recognize these conditions in order to institute prompt and proper management. A thorough history, physical examination, radiographic studies, laboratory studies and, occasionally, further imaging studies are essential to establish and confirm the appropriate diagnosis and institute correct and adequate treatment for the injured athlete. The mechanism of injury must be established in order to proceed on the correct path. Symptoms must be evaluated in detail and categorized for initial stimulus, location, intensity, and characterization of the pain pattern (the major symptom in overuse injuries). The primary purpose of the physical examination is to define precisely the anatomical structures involved in the overuse injury. With musculoskeletal injuries, the easiest way to localize the maximally painful area is to have the athlete assume the position of maximal discomfort and then to point out the most painful location, which usually involves stretching the involved muscle. Radiographic and other diagnostic testing are occasionally used to evaluate and often exclude other sources of more serious pathology. Diagnostic testing should never be used initially to make a diagnosis, but instead used as a supplement to the thorough history and physical examination.1-22
Epidemiology of Spinal-related Pain in Athletes
The spine links the torso to the extremities. This link ensures a coordinated transfer of power from the ground through the body, producing movement and performance. Due to anatomic relationships, spinal elements are subject to tremendous stresses during athletic activity. In particular, the lumbar segments accept the greatest stress in the form of ground reaction forces, which are high due to gravitational effects and body weight. Pain episodes are typically related to one or two mechanisms: acute trauma or, more commonly, repetitive stress fatigue injury.
In the general population, back pain is one of the most common complaints prompting physician visits. The lifetime prevalence of spinal-related pain in most population studies ranges 60-80%. Recovery from episodic acute back pain occurs in 70% of cases within 3 weeks, 90% within 3 months, and 95% within 6 months.1-4 Chronic low back pain occurs in 4-5% of the general population. Up to 70% of patients have recurrent episodic back pain. Treatment costs and secondary disability-related costs create an enormous societal financial burden.