Lumbar Disk Problems in the Athlete Clinical Presentation

The following symptoms should be noted with regard to the patient's pain:

• Intensity (The severity of pain does not always correlate with the extent of the herniation.)
• Character or quality (eg, sharp, dull, achy, or burning)
• Location (Before irritation of the nerve root occurs, pain may be limited to the lower back without radicular symptoms.)
• Percentage of back to leg pain
• Onset (ie, sudden or insidious)
• Duration
• Exacerbating and relieving factors (eg, sitting, standing, lying, ambulating, or during Valsalva maneuver)
• Radiation (eg, dermatomal pattern)
• Morning stiffness (This is usually limited to 20-30 min with discogenic pain vs 2-3 h with arthritis.^[4] )
• Constitutional symptoms (eg, weight loss, fever, or nausea)
• Remote or recent trauma
• Recent change in training routine

It is imperative to ask the patient about any “red flags,” which are grounds for prompt specialist referral. These red flags include:

• Younger  or older patients (younger than age 20 y or older than 50 y)
• History of previous malignancy
• Fever/chills
• Weight loss
• Night symptoms
• History of intravenous/injection (IV) drug use
• Immunosuppressed patients
• Saddle anesthesia (eg, possible cauda equina syndrome)
• Recent bowel  or bladder dysfunction, particularly urinary retention
• Severe progressive neurologic deficit

Pediatric patients with vertebral disc pathology usually present with localized back pain as opposed to the radicular patterns more often seen in adults.^[7] These young patients may describe back stiffness, paraspinal muscle spasm, and buttock or hip pain. They may also present with a history that resembles a chronic hamstring strain in the absence of an acute hamstring injury.

Typical symptoms of nerve root compression are pain and paresthesias that follow a dermatomal pattern, and findings may include lower-extremity muscle weakness.

Cauda equina syndrome can occur in the presence of significant central disc herniation. This is considered a surgical emergency, and patients should be referred for evaluation without delay.

(See also the eMedicine articles Cauda Equina Syndrome [in the Emergency Medicine section] and Cauda Equina Syndrome [in the Orthopedic Surgery section].)

It is important to observe the patient's ambulation, posture, affect, gait, and need of assistive devices. Asymmetries in the patient's neck, shoulders, back, hips, and legs can also be helpful in the evaluation of LBP. Lumbar shift (ie, list) is commonly seen with disc herniation, and the list is usually away from the side of the pain.^[4]

The spinous process and interspinous ligaments should be palpated, and any step-off deformity should be noted.

Range-of-motion assessment should include the following:

• Flexion – This motion tends to produce pain with disc herniation and ligamentous injury.
• Extension – This motion tends to produce pain with facet disease, spinal stenosis, spondylolysis, and DDD. (See also the eMedicine articles Lumbar Facet Arthropathy, Spinal Stenosis and Neurogenic Claudication, Lumbar Spondylolysis and Spondylolisthesis [in the Physical Medicine and Rehabilitation section]; Lumbosacral Facet Syndrome [in the Sports Medicine section]; and Spondylolisthesis, Spondylolysis, and Spondylosis [in the Orthopedic Surgery section].)
• Axial Rotation and lateral bending

The neurologic examination should include sensory, motor, and reflex assessments.

Through light touch  and pinprick testing of the medial (L4), dorsal (L5), and lateral or plantar (S1) aspect of the foot, the most likely affected nerve roots are tested. Most herniations occur medial to the dorsal root ganglion (DRG), which is a bipolar neuron. Therefore, it is possible for distal sensory testing to remain normal despite abnormal motor testing.

Motor testing includes having the patient squat, as well as walk on the heels and toes. Manual muscle testing is commonly measured according to the Oxford scale, as follows:

• 0 – No movement
• 1 – Trace contraction without joint movement
• 2 – Joint motion with gravity eliminated
• 3 – Joint movement against gravity
• 4 – Movement against gravity and some resistance
• 5 – Normal strength

Repeat testing can fatigue the muscles and may allow the clinician to distinguish subtle weakness(es) on examination. The muscles to be tested include the following:

• Iliopsoas (L2-L3)
• Quadriceps (L3-L4)
• Hamstring (L5-S1)
• Tibialis anterior(L4-L5)
• Extensor hallucis longus (L5)
• Posterior tibialis (S1-S2)

The following reflexes should be tested and compared with the contralateral side:

• Patellar (L3-L4)
• Medial hamstring (L5) – Perform with the patient prone.
• Achilles (S1) – This reflex may be difficult to elicit. The calf must be relaxed and the foot slightly dorsiflexed. A diminished Achilles reflex is a common finding of radiculopathy.
• Upper motor neuron testing is performed through Babinski and clonus testing.

Neural tension testing

The straight-leg raise  (SLR) is performed with the patient supine as the examiner elevates the lower extremity. This test is considered to be positive if the patient's symptoms are reproduced between 30-70º of elevation. Pain at 60º is 95% sensitive for an L5-S1 radiculopathy.^[4] Pain at greater than 70º of elevation is more consistent with lumbar facet or sacroiliac pain.^[4] Performing a seated SLR gives fewer false-positive results,^[8] and the test is more commonly positive in adults relative to children. (See also the eMedicine article Sacroiliac Joint Injury.)

The distribution of pain with SLR testing can predict anatomic location of a lesion 88.5% of the time.^[9] The majority of lesions (95%) occur at the L4-L5 or L5-S1 disc space, affecting primarily the L5 and S1 nerve roots. S1 typically produces more leg pain than back pain and travels down the buttock region, posterior thigh, along posterolateral calf and heel, and into the lateral foot, and fourth and fifth toes. L5 typically affects the lateral aspect of the leg, the medial dorsal aspect of the foot, and the plantar aspect of the great toe.

The crossed straight-leg raise  (CSLR) test is an SLR test performed on the asymptomatic limb. The CSLR is considered positive if it reproduces pain that radiates down the symptomatic extremity. This test is less sensitive (25%) than the SLR, but it is more specific (90% vs 40%). A positive CSLR is suggestive of a large herniation and predicts minimal improvement with nonoperative treatment.^[4]

The slump test is performed with the patient seated at the edge of the examination table. The cervical, thoracic, and lumbar spine is flexed as the examiner passively extends the patient's leg. If pain occurs, the patient is asked to extend the neck. Relief of pain with cervical extension suggests neural tension radiculopathy; if the pain is not relieved, it suggests the cause of the pain is from stretching muscle fibers.

The femoral nerve tension sign  (femoral stretch test) evaluates higher lumbar disc radiculopathy (L2-L3). The test is performed with the patient in the prone position; the physician flexes the patient's knee to 90º, as well as extends the hip while keeping the patient's pelvis on the examination table. Although the validity of this test has not been well documented,^[4] it is thought that tension on the femoral nerve can reproduce anterior thigh radicular symptoms.

A hip examination is necessary because disc herniation may present with radicular symptoms to the anterior thigh and groin. These pain findings may be falsely attributed to L1-L3 nerve impingement. Hip range of motion should be evaluated, particularly internal rotation testing, which commonly elicits pain in cases in which there is intra-articular hip pathology.

The Waddell test maneuvers are a series of maneuvers (total flexion, extension, lateral flexion, palpation, supine SLR test, bilateral active SLR, active sit-up) that help the to clinician differentiate between those patients with LBP who have significant structural deformities (including fractures, surgical scars) or permanent neurologic deficits and those who do not.

The Waddell tests should be employed when nonorganic causes of pain are suspected in cases that include the following:

• Tenderness that is out of proportion to the examination
• Contradictory findings between the seated and supine SLR tests
• Pain with maneuvers that normally do not cause pain, such as light axial pressure to the cervical spine or gentle axial rotation
• Reduced pain response with distraction
• Disturbance that is not correlated with dermatomal distribution
• Overreaction during the examination

• Poor training technique and overtraining are frequent causes of disc herniation.
• Activities that involve chronic combined flexion and rotation with compression can lead to radial tears of the annulus fibrosis and gradual posterior disc bulging.
• Chronic changes such as calcification and osteophyte formation of the vertebrae can also lead to disc problems.