Lumbar Spine Injuries in Athletes of All Ages Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Clinical Professor of Orthopaedics and Family and Community Medicine 11/19/17
Objectives § Understand how an effective history and physical exam can lead you to a focused differential diagnosis for low back pain § Develop treatment plans for the most common causes of low back pain in your athlete population 2 11/19/17
Important Points ■ With a good history …you should arrive at the correct diagnosis 90% of the time u Or at least a confident top 3 differential! ■ With a good history, and comfortable knowledge of basic anatomy …it will make your exam focused, quick and efficient ◆ And give you more time to chart… ■ With a good history, and comfortable knowledge of basic anatomy, you will not need to palpate until the END of the exam… ◆ Or you risk your patient not letting you finish the exam! 3 11/19/17
Exam Room Tips § Stock gowns/sheets and paper shorts in the room § Be able to get to both sides of the exam table § Have a step stool handy 4 11/19/17
Low Back Pain – History (OPQRST) • Age, sport, occupation, etc. • Date of injury/symptom Onset • Injury Mechanism: • Acute: pop, ability to continue activity? • Chronic/Overuse: precipitating activity • Symptoms: Mechanical/Other • Locking, tightness, weakness, swelling, change in bowel/ bladder 5 11/19/17
Low Back Pain – History (OPQRST) • Symptoms: Pain/Numbness/Tingling § Location - Point to where the pain is • Quality - burning, sharp, dull, achy • Radiation - come from or go anywhere else • Severity – grade pain • Timing - constant, at night, w/ activity or position • Modifying/Other Factors • Provoke/Palliate , previous injury/surgery, other red flags 6 11/19/17
Low Back Pain – History (OLDCARTS vs OPQRST) ‒ O nset (O) ‒ L ocation ‒ D uration ‒ C haracter (Q) ‒ A ggravating/ A lleviating (P) ‒ R adiation (R) ‒ T iming (T) ‒ S everity (S) 7 11/19/17
Red Flags § History of cancer § Bilateral leg weakness § Progressive motor or sensory deficit § Fever and chills § Prolonged steroid use, IV drug use § Unrelenting severe pain with rest or at night § Major trauma § Loss of bowel or bladder function § Numbness in groin/saddle Henschke N et al. Cochrane Database Syst Rev 2013 8 11/19/17
LS Spine – Bones, Joints, and Discs 9 11/19/17
LS Spine – Pediatric Bones, Joints, and Discs § Increased ligamentous laxity/greater mobility of spine • spinal columns more elastic than spinal cord § Immature joints and ossification centers • Facet joints more shallow and horizontal • Vertebral bodies wedge-shaped • Less developed spinous process Basu S. Neurol 2012 10 11/19/17
LS Spine - Nerves § 31 prs of nerves § C7 nerve exits b/w 6 th and 7 th cervical vertebrae § L4 nerve exits b/w 4 th and 5 th lumbar vertebrae
LS Spine - Nerves § Dermatomes § Myotomes • L1/L2 – Hip flexion • L3/L4 – Knee extension • L4 – Ankle dorsiflexion • L5 – Great toe extension • S1 – Ankle plantarflexion
LS Spine - Nerves § Dermatomes Lee MWL et al, Clin Anat 2008
LS Spine - Muscles § Superficial § Deep • Thoracic group • Transversospinal group • Abdominal group ‒ Multifidus • Erector Spinae group ‒ Rotatores ‒ Spinalis ‒ Intertransversarius ‒ Longissimus ‒ Iliocostalis
LS Spine - Muscles
Lumbar Spine – A systematic exam § Observation: § Prone: • abrasions, bruising, comfort, • Tenderness LS spine, SI joints; motion femoral nerve stretch, passive extension hips/spine; Hamstring/ § Sitting: glut max strength, L5 reflex • slump test, L4 and S1 reflexes, § Standing: sensation, strength • ROM: flex, ext, sidebend, rot/ § Supine: exten; one legged extension, Gillet test (pelvic motion); feet, • SLR. Hip ROM /pain, Hamstring/ gait, heel/toe walk, functional Hip flexor tightness testing 16 11/19/17
Lumbar Spine – A systematic exam
Common Lumbar Spine Injuries in Athletes § Younger § Older • Mechanical low back pain • Lumbosacral strain • Spondylolysis • Herniated disc • Spondylolisthesis • Degenerative disc • Herniated disc Massel DH and Singh K. Instr Course Lect 2017 18
Case #1
Case #1- History 1. Age—22 professional soccer player 2. Date of injury/symptom onset--ACUTE 3. Injury Mechanism: • Acute: DIRECT BLOW; UNABLE TO CONTINUE PLAY 4. Symptoms: Mechanical/Other • TIGHTNESS, NO LOSS OF BOWEL/ BLADDER FXN. SWELLING AT SITE OF TRAUMA
Case #1- History 5. Symptoms: Pain/Numbness/Tingling • Location – MID-LEFT LUMBAR SPINE • Quality - SHARP • Radiation – TO LEFT BUTTOCKS • Severity - 13/10 PAIN • Timing – CONSTANT, WITH ANY CHANGE IN POSITION 6. Modifying/Other Factors • NO PREVIOUS INJURY/SURG; BEST WHEN LYING STILL
Case #1 - Exam § Observation: DISCOMFORT, IN PAIN § Sitting: LOCAL PAIN WITH SLUMP TEST, NO RADIATION. NL REFLEXES, STRENGTH, SENSATION § Supine: • (-)SLR, FROM HIP NO PAIN § Prone: • + TENDER LEFT LUMBAR SPINE L3 AND L4 LEVELS § Standing: • ROM: + PAIN IN ALL RANGES, PAIN WITH WALKING
Case #1 - Exam
Case #1 - Imaging
Case #1 Dx: Left L3 Transverse Process Fracture
Transverse Process Fracture § Sudden extreme twisting or side-bending movement, or direct impact
Transverse Process Fracture § Majority treated conservatively, no surgery needed § Stabilization not needed § Gradual introduction of movement and PT/rehab § Full return to activity expected Nagasawa DT et al. World Neurosurg 2017
Case #2- History 1. 50 YO OVERWT FEMALE CARPENTER 2. Date of injury/symptom onset: 2 DAYS AGO 3. Injury Mechanism: • Acute: PLAYING VB AT FAMILY REUNION AND TWISTED FOR A BALL 4. Symptoms: • STIFFNESS, NO WEAKNESS, BOWEL/ BLADDER OK
Case #2- History 5. Symptoms: Pain/Numbness/Tingling • Location – ENTIRE LOW BACK • Quality – BURNING • Radiation – NO • Severoty – 4/10 • Timing –NO NIGHT PAIN, WORSE W/ MOTION 6. Modifying/Other Factors • BETTER WITH ICE, IBUPROFEN, KNEES TO CHEST, NO RED FLAGS
Case #2 - Exam § Observation: STIFFNESS. DISCOMFOFT WITH MOVEMENT § Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH § Supine: NEG SLR, HIP FROM W/O PAIN § Prone: • NO BONY PAIN; TENDER BILAT PARASPINAL MM ON PALP • NEG FEMORAL NERVE STRETCH, HAM/GLUT MAX STRENGTH 5/5 § Standing: • ROM: STIFF/PAIN ESP FF W/ SPASM, PAIN WHEN RETURNING TO ERECT POSITION; SLOW GAIT, HEEL/TOE WALK OK
Case #2 - Exam
Case #2 Diagnosis – Muscle strain § Acute sudden • Proper movement movement or action patterns § Overuse from poor • Physical Therapy if posture, mm strength, no resolution endurance • Active daily exercise, § Common and self- e.g. walking in proper limiting shoewear § Treatment: • Weight management • Ice/Heat • NSAIDS • Proper posture • Muscle relaxers Traeger A et al. CMAJ 2017
Case #3- History 1. Age, occupation, etc.: 51 YO LESS OVERWT CARPENTER 2. Date of injury/symptom onset: 2 MONTHS AGO 3. Injury Mechanism: • 3 MONTHS AGO BEGAN MED BALL AB WORKOUT, INCREASING RUNNING MILEAGE ON TREADMILL 4. Symptoms: STIFF, WEAK, BOWEL/BLADDER OK
Case #3- History 5. Symptoms: Pain/Numbness/Tingling • Location – LOW BACK, L BUTTOCKS • Quality – ACHY PAIN AT NIGHT, SHARP/BURNING DURING DAY • Radiation – L OUTER LEG TO TOES • Severity – WORSENING 8/10 • Timing – AS ABOVE 6. Modifying/Other Factors • ICE/HEAT/NSAIDS TEMPORARY HELP, ê APPETITE, HURTS WITH COUGH/SNEEZE
Case #3 - Exam § Observation: STANDING WHEN YOU ENTER ROOM § Sitting: • + SLUMP, ABSENT S1 REFLEX, ê SENSATION FIRST WEBSPACE, LAT FOOT; ê STRENGTH 4/5 L GREAT TOE EXTENSION, L ANKLE DF; 5-/5 L ANKLE PF § Supine: • + L SLR AT 45 DEG, L HIP FROM BUT PAIN W/ ER
Case #3 - Exam § Prone: • + TENDER L4-5 > L5-S1, L SI JOINT • NEG FEMORAL N STRETCH TEST • L HAM/GLUT MAX 4+/5, ABSENT L L5 REFLEX § Standing: • ROM: PAINFUL FF TO 45 DEG; R SIDEBEND • ABLE TO TOE WALK; HARDER L HEEL WALK; 22 HEEL RAISES ON R, 16 ON L; NO ATROPHY
Testing L5 Reflex
Disc and nerve root relationship
Disc and nerve root relationship
Case #3: Imaging
Case #3: Imaging
Case #3 Dx – L4-5 disc herniation
Case #3 Dx – L4-5 disc herniation § Subspecialty referral for any weakness, loss of reflexes • Emergent care if loss of bowel/bladder, saddle anesthesia, increasing pain unresponsive to meds § Physical therapy; Posture/positions of comfort; Weight loss § NSAID alternating with acetaminophen every 3 hrs • E.g., 600 mg ibuprofen @ 0800, 1000 mg acetaminophen @ 1100, 600 ibu @ 1400, etc. § Other meds individualized • E.g., prednisone, TCA, narcotics, gabapentin Traeger A et al. CMAJ 2017
Case #4 - History 1. Age: 30 YO MALE PROGRAMMER TRAINING FOR SF MARATHON 2. Date of injury/symptom onset: OFF AND ON X 2 MONTHS 3. Injury Mechanism: • Chronic/Overuse: ? CAUSED BY INTERVALS 4. Symptoms: Mechanical/Other • TIGHTNESS IN L HAM, L LOW BACK
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