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Lumbar Disk Problems in the Athlete Clinical Presentation

  • Author: Luis E Palacio, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Nov 10, 2014
 

History

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 Medscape Reference articles Cauda Equina and Conus Medullaris Syndromes [in the Emergency Medicine section] and Cauda Equina and Conus Medullaris Syndromes [in the Orthopedic Surgery section].)

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Physical

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:

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 Medscape Reference 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

In 2014, the North American Spine Society (NASS) released evidence-based guidelines for lumbar disk herniation with radiculopathy. Recommended tests for diagnosis and imaging included:[10]

  • Manual muscle testing, sensory testing, supine straight leg raise, Lasegue sign, and crossed Lasegue sign.
  • Supine straight leg raise, compared with the seated straight leg raise is suggested
  • MRI
  • CT scan, myelography, and/or CT myelography
  • Cross-sectional imaging considered the diagnostic test of choice; electrodiagnostic studies only to confirm comorbid conditions.

The non-surgical and surgical treatments recommended included:[10]

  • A limited course of structured exercise for patients with mild-to-moderate symptoms
  • Spinal manipulation for symptomatic relief
  • Contrast-enhanced fluoroscopy to guide epidural steroid injections (ESIs) and improve the accuracy of medication delivery
  • Transforaminal ESI for short-term (2–4 weeks) pain relief
  • Interlaminar ESIs may be considered
  • Insufficient evidence to make a recommendation for or against the effectiveness of one injection approach over another
  • Endoscopic percutaneous discectomy for carefully selected patients to reduce early postoperative disability and reduce opioid use compared with open discectomy
  • Automated percutaneous discectomy may be considered
  • There is an insufficient evidence to make a recommendation for or against the use of automated percutaneous discectomy compared with open discectomy
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Causes

See the list below:

  • 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.
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Contributor Information and Disclosures
Author

Luis E Palacio, MD Director of Primary Care Sports Medicine, Northern Nevada Medical Group

Luis E Palacio, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Annie Collier, MD Staff Physician, Department of Emergency Medicine, Lincoln Medical Center, Cornell University School of Medicine

Annie Collier, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Jeffrey W R Dassel, MD Associate Director, Sports Medicine and Faculty, Department of Family and Community Medicine, Christiana Care Health System

Jeffrey W R Dassel, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Medical Society for Sports Medicine, Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

John Munyak, MD Associate Program Director, Director of Sports Medicine Education, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Disclosure: Nothing to disclose.

References
  1. McCormack RG, McLean N, Dasilva J, Fisher CG, Dvorak MF. Thoraco-lumbar flexion-distraction injury in a competitive gymnast: a case report. Clin J Sport Med. 2006 Jul. 16(4):369-71. [Medline].

  2. 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 Jun. 37(3):263-6. [Medline].

  3. Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007 Apr 15. 75(8):1181-8. [Medline]. [Full Text].

  4. Smeal WL, Tyburski M, Alleva J, Prather H, Hunt D. Conservative management of low back pain, part I. Discogenic/radicular pain. Dis Mon. 2004 Dec. 50(12):636-69. [Medline].

  5. Baker RJ, Patel D. Lower back pain in the athlete: common conditions and treatment. Prim Care. 2005 Mar. 32(1):201-29. [Medline].

  6. Peng B, Zhang Y, Hou S, Wu W, Fu X. Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain. Eur Spine J. 2007 Jan. 16(1):33-8. Epub 2006 Feb 22. [Medline].

  7. Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin North Am. 2002 Jun. 49(3):643-53. [Medline].

  8. Harwood MI, Smith BJ. Low back pain: a primary care approach. Clin Fam Pract. 2005. 7(2):279-303.

  9. Baker RJ, Patel D. Lower back pain in the athlete: common conditions and treatment. Prim Care. 2005 Mar. 32(1):201-29. [Medline]. [Full Text].

  10. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan. 14(1):180-91. [Medline].

  11. Eck JC, Riley LH 3rd. Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004 Jul. 23(3):367-79, viii. [Medline].

  12. Krych AJ, Richman D, Drakos M, et al. Epidural steroid injection for lumbar disc herniation in NFL athletes. Med Sci Sports Exerc. 2012 Feb. 44(2):193-8. [Medline].

  13. Cooke PM, Lutz GE. Internal disc disruption and axial back pain in the athlete. Phys Med Rehabil Clin N Am. 2000 Nov. 11(4):837-65. [Medline].

  14. Schroeder GD, McCarthy KJ, Micev AJ, Terry MA, Hsu WK. Performance-based outcomes after nonoperative treatment, discectomy, and/or fusion for a lumbar disc herniation in National Hockey League athletes. Am J Sports Med. 2013 Nov. 41(11):2604-8. [Medline].

  15. Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005 Nov 1. 30(21):2369-77; discussion 2378. [Medline].

  16. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998 Oct 8. 339(15):1021-9. [Medline].

  17. Day AL, Friedman WA, Indelicato PA. Observations on the treatment of lumbar disk disease in college football players. Am J Sports Med. 1987 Jan-Feb. 15(1):72-5. [Medline].

  18. Deyo RA, Loeser JD, Bigos SJ. Herniated lumbar intervertebral disk. Ann Intern Med. 1990 Apr 15. 112(8):598-603. [Medline].

  19. Dreisinger TE, Nelson B. Management of back pain in athletes. Sports Med. 1996 Apr. 21(4):313-20. [Medline].

  20. Earhart JS, Roberts D, Roc G, Gryzlo S, Hsu W. Effects of lumbar disk herniation on the careers of professional baseball players. Orthopedics. January 2012. 35(1):43-9. [Medline].

  21. Faas A. Exercises: which ones are worth trying, for which patients, and when? Presented at: The International Forum for Primary Care Research on Low Back Pain; October 12-14, 1995; Seattle, Wash.

  22. Franklin BA. Low back exercises. Roitman JL, Kelsey M, eds. American College of Sports Medicine's (ACSM's) Guidelines for Exercise Testing and Prescription. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1998. 116-25.

  23. Gerbino PG 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med. 1995 Jul. 14(3):571-90. [Medline].

  24. Kahanovitz N. Surgical disc excision. Clin Sports Med. 1993 Jul. 12(3):579-85. [Medline].

  25. Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin North Am. 2002 Jun. 49(3):643-53. [Medline].

  26. Montgomery S, Haak M. Management of lumbar injuries in athletes. Sports Med. 1999 Feb. 27(2):135-41. [Medline].

  27. Regan JJ. Clinical results of charité lumbar total disc replacement. Orthop Clin North Am. 2005 Jul. 36(3):323-40. [Medline].

  28. Schenck RC Jr, ed. Athletic Training and Sports Medicine. 3rd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999. 389-90.

  29. Singh V. Percutaneous disc decompression for the treatment of chronic atypical cervical discogenic pain. Pain Physician. 2004 Jan. 7(1):115-8. [Medline]. [Full Text].

  30. Stinson JT. Spine problems in the athlete. Md Med J. 1996 Aug. 45(8):655-8. [Medline].

  31. Tall RL, DeVault W. Spinal injury in sport: epidemiologic considerations. Clin Sports Med. 1993 Jul. 12(3):441-8. [Medline].

  32. Wang JC, Shapiro MS, Hatch JD, et al. The outcome of lumbar discectomy in elite athletes. Spine. 1999 Mar 15. 24(6):570-3. [Medline].

  33. Watkins RG. Lumbar disc injury in the athlete. Clin Sports Med. 2002 Jan. 21(1):147-65, viii. [Medline].

  34. Windsor RE. Lumbosacral discogenic pain syndrome. Medscape Reference. [Full Text].

  35. Young JL, Press JM, Herring SA. The disc at risk in athletes: perspectives on operative and nonoperative care. Med Sci Sports Exerc. 1997 Jul. 29(7 suppl):S222-32. [Medline].

 
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Radiograph of the lumbar spine. This image demonstrates L5-S1 disk space narrowing (the most common location).
Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
 
 
 
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