This is the second in a three-part series on anatomy, back pain and solutions. To see the first of three, click here. These blogs were written by Earth Fed Elite and PA-C Matt Shaw. It is not intended to diagnose or treat disease or injury, but to provide you with a solid foundation for health and fitness!
Now that we have a general knowledge of back anatomy, let’s look at a few of the most common causes of low back pain seen in athletes:
- Degenerative Disc Disease (DDD)
DDD is a result of wear and tear on the spine in which vertebral
discs lose their cushioning. As the disease progresses, boney growths (osteophytes) can form extending from the borders of the bone. In severe cases, nerves can be involved sending signals of numbness, tingling or pain down the legs. The cause is generally an accumulation of stress over time, but genetics can certainly predispose certain unlucky individuals.
- To confirm diagnosis, standard x-rays can be performed. When it comes to arthritis, one of the most important things a patient can do is maintain motion. Exercise, particularly core strengthening, healthy weight management and proper nutrition are all critical elements to managing this condition. Acute flare ups can be treated with ice/heat modalities and non-steroidal anti-inflammatories (NSAIDs), but they typically only lead to temporary relief. End of the road treatment involves surgery to decompress and stabilize the affected area.
- Bulging/Herniated Disc (with/without sciatica)
Imagine a jelly filled donut. If enough pressure is applied,
eventually the jelly will ooze out of the outer layer. While clearly a vertebral disc is far more resilient, it is a similar concept. When uneven force is distributed, the inner gel (nucleus pulposis) can cause a bulge or even break through/herniate the protective wall. Generally a herniated disc is considered more severe and has a higher likelihood of irritating a nerve. In certain situations, the sciatic nerve can be involved causing pain and numbness traveling down the back of the thigh and even into the big toe. A common cause of disc injury is movement of the spine while under tension (ex. A slight twist or arched back when performing a deadlift or pulling motion). Pain will typically worsen with forward flexion movements once the injury has occurred. The discs most commonly involved include L4-L5 and L5-S1.
Initial treatment involves activity modification, rest and pain
control with ice/heat modalities and NSAIDs. Most cases are treated non-operatively with physical therapy to address weakness, poor posture, improper lifting techniques, etc. Your medical provider may discuss a cortisone injection or regenerative therapies with you to alleviate symptoms. While this may lead to quick improvements, without addressing the cause, it is likely to return in the future. Persistent symptoms may warrant an MRI to understand the true severity of the injury. Surgery may be considered when all else fails.
A stress fracture through the pars interarticularis of the lumbar
vertebrae. L5 vertebra is most commonly involved. It is most often seen in children or athletes exposed to repetitive low back stress (ex. gymnastics, football, lifting). Symptoms can range from asymptomatic to severe localized tenderness. It is generally worse with extension movements.
First line treatment involves rest, NSAIDs, physical therapy and in some cases a back brace. It is very important to diagnose and treat this condition before it progresses to a condition called
spondylolisthesis, which results in instability and forward shift of
the vertebra. In severe cases or failed conservative treatments,
surgery may be required to fuse the involved vertebrae. The majority of patients, both operative and non-operative, are able to return to full activity.
- Facet Synovitis/Arthropathy
- An inflammatory condition at a facet joint caused by degenerative changes or acute injury. The cartilage that coats the end of the bone breaks down or gets inflamed and causes irritation to nearby nerves. Due to their critical role in sensing movements and position, these joints are quite sensitive. Symptoms are typically worsened with extension and twisting motions. The pain is usually localized just off of the midline and is described as deep and aching pain.
- Important first steps include focusing on proper posture, NSAIDs, ice and weight loss. Home exercises or formal physical therapy, such as the McKenzie Protocol, can also be very helpful for irritated facet joints. In some cases, your medical provider may recommend a steroid injection. While relief from the injection may be temporary, it can alleviate symptoms and allow you to get more out of physical therapy and home exercises to truly address the underlying cause of pain. When all else fails, spine fusion surgery can be considered.
- Sacroiliac Dysfunction
- Sacroiliac pain is located at the joint where the spine meets the hip. It is the result of improper movement that generates an inflammatory response leading to pain and discomfort. Pain is elicited with transitional movements such as rising from seated to standing position, getting in and out of the car, etc.
- Treatment begins with appropriate pain control including brief period of rest, ice/heat modalities and NSAIDs. The next step is addressing the weakness or muscular imbalance leading to improper movement in the joint. In cases of instability or muscle imbalance, stretching alone can actually cause worsening symptoms. Cortisone and regenerative injections are a treatment option if conservative management fails.
- Musculoligamentous Strain
- While many healthcare providers are quick to label low back pain as a muscle or tendon strain, it is very common for inflammation from the underlying pathology to cause muscle spasm or irritation to overlying muscle group. The surrounding muscles go into tension in order to protect the spine itself. Yes, there are symptoms present at the muscle/tendon, but until the underlying cause is treated, the symptoms are likely to persist. A true muscle or tendon strain can be a result of over stretching, poor lifting technique or improper warm up prior to activity.
- In a true musculoligamentous strain, treatment is centered around reduction in pain and improvement in function to prevent return of symptoms. A brief period of rest (48-72 hrs) may be appropriate to allow symptoms to settle down. Next steps include gentle exercises and stretches, ice/heat modalities, massages, trigger points, NSAIDs and in some cases muscle relaxants. One of the most common mistakes is prolonged inactivity. Unfortunately doing nothing for a week does not magically fix the problem and will likely result in recurrence of pain with return to activity. Localized trigger point injections with a health care provider can help alleviate symptoms of muscular pain and spasms.