Advertisement

Evaluation of Athletes with Back or Leg Pain

  • Robert L. Brochin
  • Zoe B. Cheung
  • Andrew C. HechtEmail author
Chapter

Abstract

Low back pain (LBP) with or without leg pain in athletes is a significant cause of lost playing time. While the differential diagnosis of LBP in athletes is broad, a thorough history and physical examination are necessary to narrow the differential diagnosis and guide a clinician toward the correct diagnosis. Routine imaging is indicated in the setting of persistent LBP despite conservative treatment, with lumbar spine radiographs being the first line of imaging. The need for further advanced imaging to identify the correct diagnosis – such as MRI and/or CT scan– is determined as clinically warranted. The initial differential diagnosis for LBP in athletes includes orthopedic as well as non-orthopedic etiologies that must all be considered. Orthopedic pathologies discussed in this chapter include musculo-ligamentous injuries, degenerative disc disease, lumbar disc herniation, spondylolysis and spondylolisthesis, and sacral stress fracture.

Keywords

Back pain Leg pain Radiculopathy Athlete Sport Evaluation Physical examination Imaging Differential diagnosis 

References

  1. 1.
    Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028–37.PubMedCrossRefGoogle Scholar
  2. 2.
    Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13(3):205–17.PubMedCrossRefGoogle Scholar
  3. 3.
    Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008;8(1):8–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31(23):2724–7.CrossRefGoogle Scholar
  5. 5.
    Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769–81.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of the New Millennium. The burden of musculoskeletal conditions at the start of the new millennium. World Health Organ Tech Rep Ser. 2003;919:i–x, 1–218, back cover.Google Scholar
  7. 7.
    Heneweer H, Staes F, Aufdemkampe G, van Rijn M, Vanhees L. Physical activity and low back pain: a systematic review of recent literature. Eur Spine J. 2011;20(6):826–45.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Vuori IM. Dose-response of physical activity and low back pain, osteoarthritis, and osteoporosis. Med Sci Sports Exerc. 2001;33(6 Suppl):S551–86.PubMedCrossRefGoogle Scholar
  9. 9.
    Hoogendoom WE, Bongers PM, de Vet HC, Douwes M, Koes BW, Miedema MC, et al. Flexion and rotation of the trunk and lifting at work are risk factors for low back pain: results of a prospective cohort study. Spine (Phila Pa 1976). 2000;25(23):3087–92.CrossRefGoogle Scholar
  10. 10.
    Keene JS, Albert MJ, Springer SL, Drummond DS, Clancy WG Jr. Back injuries in college athletes. J Spinal Disord. 1989;2(3):190–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Granhed H, Morelli B. Low back pain among retired wrestlers and heavyweight lifters. Am J Sports Med. 1988;16(5):530–3.PubMedCrossRefGoogle Scholar
  12. 12.
    Curtis C, d’Hemecourt P. Diagnosis and management of back pain in adolescents. Adolesc Med State Art Rev. 2007;18(1):140–64.PubMedGoogle Scholar
  13. 13.
    Rossi F. Spondylolysis, spondylolisthesis and sports. J Sports Med Phys Fitness. 1978;18(4):317–40.PubMedGoogle Scholar
  14. 14.
    Tall RL, DeVault W. Spinal injury in sport: epidemiologic considerations. Clin Sports Med. 1993;12(3):441–8.PubMedGoogle Scholar
  15. 15.
    Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976). 2008;33(22):2464–72.CrossRefGoogle Scholar
  16. 16.
    Kamath SU, Kamath SS. Lasegue’s sign. J Clin Diagn Res. 2017;11(5):RG01–2.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Truumees E, Prather H. Orthopaedic knowledge update: spine 5. Rosemont: American Academy of Orthopaedic Surgeons; 2017. Print.Google Scholar
  18. 18.
    Sierra RJ, Trousdale RT, Ganz R, Leunig M. Hip disease in the young, active patient: evaluation and nonarthroplasty surgical options. J Am Acad Orthop Surg. 2008;16(12):689–703.PubMedCrossRefGoogle Scholar
  19. 19.
    Agency for Health Care Policy and Research. Acute low back problems in adults: assessment and treatment. Clin Pract Guidel Quick Ref Guide Clin. 1994;(14):iii–v, 1–25.Google Scholar
  20. 20.
    Beck NA, Miller R, Baldwin K, Zhu X, Spiegel D, Drummond D, Sankar WN, Flynn JM. Do oblique views add value in the diagnosis of spondylolysis in adolescents? J Bone Joint Surg Am. 2013;95(10):e65.PubMedCrossRefGoogle Scholar
  21. 21.
    Ledonio CG, Burton DC, Crawford CH 3rd, Bess RS, Buchowski JM, Hu SS, et al. Current evidence regarding diagnostic imaging methods for pediatric lumbar spondylolysis: a report from the Scoliosis Research Society Evidence-Based Medicine Committee. Spine Deform. 2017;5(2):97–101.PubMedCrossRefGoogle Scholar
  22. 22.
    Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology. 1991;180(2):509–12.PubMedCrossRefGoogle Scholar
  23. 23.
    Trout AT, Sharp SE, Anton CG, Gelfand MJ, Mehlman CT. Spondylolysis and beyond: value of SPECT/CT in evaluation of low back pain in children and young adults. Radiographics. 2015;35(3):819–34.PubMedCrossRefGoogle Scholar
  24. 24.
    Videman T, Sarna S, Battie MC, Koskinen S, Gill K, Paananen H, Gibbons L. The long-term effects of physical loading and exercise lifestyles on back-related symptoms, disability, and spinal pathology among men. Spine (Phila Pa 1976). 1995;20(6):699–709.CrossRefGoogle Scholar
  25. 25.
    Lundin O, Hellstrom M, Nilsson I, Sward L. Back pain and radiological changes in the thoraco-lumbar spine of athletes. A long-term follow-up. Scand J Med Sci Sports. 2001;11(2):103–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Baranto A, Hellstrom M, Cederlund CG, Nyman R, Sward L. Back pain and MRI changes in the thoraco-lumbar spine of top athletes in four different sports: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2009;17(9):1125–34.CrossRefGoogle Scholar
  27. 27.
    Witwit WA, Kovac P, Sward A, Agnvall C, Todd C, Thoreson O, et al. Disc degeneration on MRI is more prevalent in young elite skiers compared to controls. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):325–32.PubMedCrossRefGoogle Scholar
  28. 28.
    Bono CM. Low back pain in athletes. J Bone Joint Surg Am. 2004;86-A(2):382–96.CrossRefGoogle Scholar
  29. 29.
    Nwosu K, Bono CM. Incidence of low back pain in athletes and differential diagnosis and evaluation of athletes with back or leg pain. In: Hecht AC, editor. Spine injuries in athletes. Philadelphia: Wolters Kluwer; 2017. p. 146–53.Google Scholar
  30. 30.
    Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, Reilly J. Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine (Phila Pa 1976). 1978;3(4):319–28.CrossRefGoogle Scholar
  31. 31.
    Lawrence JP, Greene HS, Grauer JN. Back pain in athletes. J Am Acad Orthop Surg. 2006;14(13):726–35.CrossRefGoogle Scholar
  32. 32.
    Battié MC, Videman T, Kaprio J, Gibbons LE, Gil K, Manninen H, et al. The twin spine study: contributions to a changing view of disc degeneration. Spine J. 2009;9(1):47–59.PubMedCrossRefGoogle Scholar
  33. 33.
    Patel AA, Spiker WR, Daubs M, Brodke D, Cannon-Albright LA. Evidence for an inherited predisposition to lumbar disc disease. J Bone Joint Surg Am. 2011;93(3):225–9.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Hangai M, Kaneoka K, Hinotsu S, Shimizu K, Okubo Y, Miyakawa S, et al. Lumbar intervertebral disk degeneration in athletes. Am J Sports Med. 2009;37(1):149–55.CrossRefGoogle Scholar
  35. 35.
    Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med. 2003;37:263–6.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Hsu WK, Jenkins TJ. Management of lumbar conditions in the elite athlete. J Am Acad Orthop Surg. 2017;25(7):489–98.PubMedCrossRefGoogle Scholar
  37. 37.
    Stuber KJ, Bruno P, Sajko S, Hayden JA. Core stability exercises for low back pain in athletes: a systematic review of the literature. Clin J Sport Med. 2014;24(6):448–56.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hillibrand A, Albert T, Fischgrund J. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008;33(25):2789–800.CrossRefGoogle Scholar
  39. 39.
    Nair R, Kahlenberg CA, Hsu WK. Outcomes of lumbar discectomy in elite athletes: the need for high-level evidence. Clin Orthop Relat Res. 2015;473(6):1971–7.CrossRefGoogle Scholar
  40. 40.
    Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patient suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999;21(suppl):19S–38S.Google Scholar
  41. 41.
    Hsu WK, McCarthy KJ, Savage JW, Roberts DW, Roc GC, Micev AJ, et al. The professional athlete spine initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Spine J. 2011;11(3):180–6.CrossRefGoogle Scholar
  42. 42.
    Watkins RG. Lumbar disc injury in the athlete. Clin Sports Med. 2002;21:751–9.CrossRefGoogle Scholar
  43. 43.
    Standaert CJ, Herring SA. Spondylolysis: a critical review. Br J Sports Med. 2000;34:415–22.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Brooks BK, Southam SL, Mlady GW, Logan J, Rosett M. Lumbar spine spondylolysis in the adult population: using computed tomography to evaluate the possibility of adult onset lumbar spondylosis as a cause of back pain. Skelet Radiol. 2010;39(7):669–73.CrossRefGoogle Scholar
  45. 45.
    Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. 2000;28(1):57–62.PubMedCrossRefGoogle Scholar
  46. 46.
    Yamaguchi KT, Skaggs DL, Acevedo DC, Myung KS, Choi P, Andras L. Spondylolysis is frequently missed by MRI in adolescents with back pain. J Child Orthop. 2012;6(3):237–40.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop. 2009;29(2):146–56.CrossRefGoogle Scholar
  48. 48.
    Johnson AW, Weiss CB Jr, Stento K, Wheeler DL. Stress fractures of the sacrum. An atypical cause of low back pain in the female athletes. Am J Sports Med. 2001;29(4):498–508.PubMedCrossRefGoogle Scholar
  49. 49.
    Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(6):376–88.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Robert L. Brochin
    • 1
  • Zoe B. Cheung
    • 1
  • Andrew C. Hecht
    • 1
    Email author
  1. 1.Department of Orthopaedic SurgeryMount Sinai Medical CenterNew YorkUSA

Personalised recommendations