eMedicine Specialties > Sports Medicine > Spine

Lumbar Disk Problems in the Athlete

Luis E Palacio, MD, Director of Primary Care Sports Medicine, Department of Family and Community Medicine, Tufts University School of Medicine; Residency Faculty, Tufts University Family Medicine Residency/Cambridge Health Alliance
Jeffrey W R Dassel, MD, Sports Medicine Coordinator and Family Medicine Practitioner, Westside Health Center; Annie Collier, MD, Staff Physician, Department of Emergency Medicine, Our Lady of Mercy Medical Center; John Munyak, MD, Associate Program Director, Director of Sports Medicine Education, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Updated: Oct 12, 2007

Introduction

Background

Low back pain (LBP) is one of the most common reasons for missed playing time in professional athletics, as well as a leading reason for healthcare provider visits. When evaluating patients with LBP, lumbar disc problems should be considered.

Frequency

United States

At-risk sports for lumbar disc problems include activities that require frequent flexion, extension, and rotation of the spine. An example is gymnastics, in which disc degeneration is seen in up to 75% of participants that present with back pain.¹ Disc degeneration is significantly more common in elite athletes (75%) compared with nonathletes (31%).²
 
Lumbar disc herniation accounts for only 4% of back pain cases³ ; symptomatic disc herniations are more common in adults (48%) than adolescent athletes (11%). Acute disc herniations commonly occur in individuals between the ages 30 and 55 years⁴ ; however, athletes between ages 20 and 35 years are at the greatest risk for disc injury,⁵ and the L4-L5 and L5-S1 levels are most commonly affected.

Functional Anatomy

The vertebrae are separated by vertebral discs that are composed of a gel substance (nucleus pulposus) surrounded by outer collagen fibers, which are arranged in a crossed manner (annulus fibrosis). These discs are further supported by the anterior and posterior longitudinal ligaments. Together, the vertebral disc complex resists spinal compression. 

During axial rotation of the spine, the annular fibers are placed at a mechanical disadvantage. Furthermore, in forward flexion, the anterior vertebral endplates approximate, increasing the pressure of the disc posteriorly. The most common disc herniation is directed posteriorly toward the foraminal window, where the nerve roots exit the spinal canal. As such, a common mechanism of herniation in athletes is combined flexion, rotation, and compression of the spine. Football, wrestling, hockey, gymnastics, tennis, and golf are some sports in which this injury mechanism commonly occurs.

In the presence of a disc herniation, forward flexion worsens the herniation. In extension, the opposite occurs. The posterior vertebral endplates approximate, forcing the disc anteriorly, to reduce the herniation.

The anatomic structures that have been implicated as pain generators include the vertebral discs, nerve roots, ligaments, zygapophysial joints (z-joints), sacroiliac joints, and the musculature. Some studies suggest that discogenic pain secondary to annular disruption is the most common cause of LBP⁶ ; vascularized granulation tissue with innervation along a torn annulus fibrosis is thought to be the cause. Inflammatory factors caused by the leakage of nuclear material from annular tears can delay intradiscal tissue healing. These factors include matrix metalloproteinases (MMPs), phospholipase A₂ (PLA2), cyclooxygenase (COX), prostaglandins, nitric oxide (NO), cytokines, interleukins, and macrophages.
 
Classifications of disc herniations

• Disc protrusion describes a bulged annulus that has not ruptured. In this scenario, there is no contact between the nucleus and the extradiscal space.
• Disc extrusion describes a ruptured annulus with some expelled nucleus that remains attached to the disc.
• Sequestered disc or complete prolapse describes a nucleus that is expelled from the disc and is no longer attached.

Sport-Specific Biomechanics

In cycling, an incorrect seat position may predispose an individual to disc herniation. Running can cause wear and tear to the vertebral discs secondary to the repetitive trauma that is involved. Well-cushioned shoes and more forgiving training surfaces are thought to protect against disc injury.
 
Former elite weight lifters and soccer players have been noted to have a higher incidence of degenerative disc disease (DDD) — as noted on magnetic resonance imaging (MRI) studies — but these findings have not been correlated with increased pain in the affected athletes.⁵

(See also the eMedicine articles Lumbar Degenerative Disk Disease [in the Physical Medicine and Rehabilitation section], Degenerative Disk Disease [in the Orthopedic Surgery section], and Degenerative Lumbar Disc Disease in the Mature Athlete [in the Sports Medicine section].)

Clinical

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

• 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

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:

• 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 Claudicati on, 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

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) 

• 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.

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

• 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

Causes

• 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.

Differential Diagnoses

Other Problems to Be Considered

Abdominal aneurysm
Degenerative disorders
Developmental abnormalities
Discitis in children
Infections
Inflammation
Lumbar strain
Metabolic disorders
Neoplasm (cancer)
Neurologic disorders
Pars fracture
Psychiatric disorders
Referred pain
Renal stones
Sacroiliac joint sprain
Spinal stenosis

Workup

Laboratory Studies

• A complete blood cell (CBC) count may demonstrate evidence of infection or malignancy.
• The erythrocyte sedimentation rate (ESR) level is elevated in the presence of infection. 
• Alkaline phosphatase is a marker of bone destruction (among other diseases) and may be elevated in cases in which there are tumors or infection. 

Imaging Studies

Imaging studies should be interpreted with caution and correlated with the patient’s symptoms because abnormalities are commonly noted in asymptomatic populations. Imaging modalities for the evaluation of LBP include radiographs, MRI, computed tomography (CT) scanning, nuclear bone scanning, and discography.
 
Radiographs

• Anteroposterior (AP), lateral, and oblique views are commonly obtained.
• Radiographs are limited for the evaluation of disc herniations, but they may demonstrate disc space narrowing.
• Radiographs are best utilized to view:
  • Fractures
  • Osseous lesions
  • Sacroiliitis
  • Infection
  • Overall bony architecture
• Radiographs are not routinely needed in the first 4-6 weeks of symptoms, but radiography should be performed in the presence of trauma or any red flags (see History).

• MRI is the gold standard for visualization of herniated discs and should be performed in patients who have neurologic symptoms such as bowel/bladder incontinence and sexual dysfunction, as well as in those who have a history of lumbar spinal stenosis with neurologic deficit.
• MRI is a good method to evaluate vertebral discs, nerve root compression, and spinal cord impingement.
• Evidence of disc degeneration is present in 35% of patients aged 20-39 years, and in nearly 100% of subjects aged 60-80 years.¹⁰ Therefore, patient symptoms should be well corroborated with MRI findings. Note: Radicular symptoms alone are not an indication for an MRI scan, and the study should not be ordered unless the results are likely to change the patient’s management.

• Disadvantages of this modality include its high level of ionizing radiation exposure, its invasive nature, and its limited ability to evaluate the neuroforaminal and extraforaminal areas. 
• Some advantages include CT myelography's ability to evaluate abnormalities at the nerve root sleeve and to detect abnormalities not seen on MRI.

Nuclear bone scanning is useful for ruling out cancer, stress fractures, and osteomyelitis. (See also the eMedicine article Osteomyelitis.) 
 
The use of provocative discography remains controversial. This study is performed based on the principle that normal discs are not painful when injected at low pressures (with dye or saline). The goal of discography is to reproduce the patient’s clinical symptoms or to demonstrate leakage by injecting fluid into the disc. Some spine surgeons routinely order provocative discography before surgery.

Indications for discography include the following:

• Several months of LBP of unclear etiology despite thorough evaluation
• Equivocal findings on MRI or CT scans
• No clinical improvement with nonoperative measures

Other Tests

Electromyography (EMG) and nerve conduction studies (NCSs) evaluate nerve root function, help in the presence of inconclusive imaging studies, and aid in the assessment of nonstructural causes of radicular symptoms (infection and infiltration). These studies locate the level of the lesion, determine acuity, and are used for preoperative planning.

Procedures

Epidural steroid injections are performed under fluoroscopic guidance and are used for diagnostic or therapeutic purposes with varying results. Successful outcomes for steroid injections have been seen in up to 84% of nonathletes⁴ ; however, their use in athletic populations has not been studied. 
 
Epidural steroid injections are indicated when other nonoperative measures have failed, and they are commonly administered before surgical intervention.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Patients should avoid prolonged bed rest to prevent joint stiffness, muscle wasting, bone mineral loss, pressure sores, and deep venous thrombosis. Two days or less of relative rest may be prescribed initially.

Cooke and Lutz described a staged approach to LBP as the following¹¹ : 

• Stage I involves early, protected mobilization with brief rest (48-72 h). Medications and therapeutic modalities including heat, ice, nonsteroidal anti-inflammatory drugs [NSAIDs], soft-tissue mobilization, and epidural injection are considered.
• Stage II involves dynamic spinal stabilization exercises with co-contraction of the abdominal and lumbar extensors to stabilize the injured segment. Isometric exercises (muscle contraction without changing its length) retrain muscles to maintain a neutral postural position.
• Stage III involves exercises to strengthen lumbar musculature beginning with extension exercises and progressing to flexion exercises. Flexion exercises are delayed due to their increased load on the disc.
• Stage IV involves sports-specific exercises and plyometrics such as eccentric strengthening (resisted stretching of the muscle), followed by an explosive concentric contraction.
• Stage V involves maintenance exercises (home program) to prevent recurrence.

Surgical Intervention

Types of Surgical Intervention
 
Discectomy has been recommended for athletes with LBP because there is less anatomic disruption during the procedure, although some investigators argue that athletes have worse outcomes than the general population.¹⁰  These less-favorable outcomes are believed to be secondary to return to play before complete recovery has occurred. In one large case series, pediatric patients made up 0.4% of patients that underwent discectomy.⁵
 
Percutaneous lumbar disc decompression is indicated in patients with LBP that is associated with radicular symptoms down a lower extremity. Patients should undergo provocative discography examination before surgery.

Criteria for spinal fusion include multiple recurrences of lumbar disc problems or vertebral instability, and at least 4-6 months of symptoms with failed nonoperative therapy. The patient's pain should correlate with imaging studies (MRI). Midline spinal tenderness should correspond to the level of disease.
 
Randomized, controlled clinical trials have not shown significant long-term benefit with spinal fusion relative to aggressive physical and cognitive rehabilitation protocols.⁴ A disadvantage of spinal fusion includes loss of motion at the fused segment that leads to increased stress to the adjacent disc levels, which places the adjacent discs at risk of injury and degenerative changes.

Lumbar total disc replacement has been used in patients with purely discogenic symptoms secondary to DDD. There are, however, many contraindications and possible complications limiting the use of total disc replacement.

Consultations

Consultations with specialists in primary care sports medicine, orthopedic surgery, neurosurgery, neurology, or physiatry should be sought as indicated.

Recovery Phase

Rehabilitation Program

Physical Therapy

• Goals for physical therapy include pain reduction, reinforcement of a comfortable body position, core strengthening, and stabilization of the spine.
• Tight musculature, including the hamstrings, hip flexors/rotators/extensors, and abdominals, should be stretched.
• A home program should be tailored for performance on a lifelong basis.

Lifestyle modifications

• Exercise is not beneficial for the acute symptoms of LBP, but it is beneficial for chronic LBP sufferers. Increased activity reduces pain as well as improves functional status.
• Tobacco cessation improves outcomes for LBP.
• Weight loss in overweight patients

Medical Issues/Complications

If a patient continues to have pain in the back, buttock(s), and back of the thigh(s) without pain below the knee (true sciatica causes pain below the knee), then the diagnosis can be confusing in cases in which a disc herniation is present on MRI. A large percentage of patients have disk abnormalities on MRI without symptoms.

Surgical Intervention

Considerations for surgical referral include the following :

• Leg pain greater than back pain
• Cauda equina syndrome
• Progressive or profound neurologic deficit
• Severe and disabling pain that is refractory to nonoperative treatment
• Herniated disc (at least 4-6 wk)
• Spinal stenosis (at least 8-12 wk)
• Confirmation of the lesion on imaging studies

Surgical complications include the following :

• Infection
• Bleeding
• Nerve damage
• Worsened pain
• Recurrence of herniation
• Paralysis
• Idiosyncratic reaction
• Anaphylaxis
• Death

Consultations

Surgical consultation is indicated in the presence of any red flags (see History).

Referral for epidural spine injection or EMG should also be considered, if indicated.

Primary care sports medicine, neurosurgery, orthopedic surgery, neurology, and physiatry are specialties that have expert clinicians who often treat lumbar disc problems.

Other Treatment (Injection, manipulation, etc.)

Steroids may be injected into the epidural space of the spinal canal if the patient's sciatica persists even with bracing. Bracing may take as long as 4 months to be successful.

Maintenance Phase

Rehabilitation Program

Physical Therapy

During the maintenance phase, the performance of exercise stimulates tissue growth, slows or possibly reverses degenerative conditions, and enhances nutrition to the disc. Increasing the strength and endurance in the major muscle groups (eg, quadriceps, hamstrings, hip, and abdominal muscles) is important. Spine flexibility has not been shown to reduce the risk of future injury. Hip flexibility and abdominal strength exercises, however, has been demonstrated to be important, as well as hip ROM stretching and strengthening activities and hamstring and quadriceps stretching and strengthening activities.

Muscle contraction with the spine in neutral position is the most successful exercise program. Sport-specific exercises may now be integrated, and lifelong activity and lifestyle modification should be maintained.

Other Treatment

• Intradiscal electrothermal therapy (IDET) – There have been anecdotal reports of high failure rates with IDET in athletes.⁵  A randomized, double-blind control trial reported that IDET is a relatively safe procedure, but patients rarely experienced improvement and did not experience better results when compared to sham treatment.¹²
• Transcutaneous electrical nerve stimulation (TENS) is not effective for chronic LBP.⁵  Limited evidence supports the use of TENS, but this is a safe modality and could be utilized in the acute phase of LBP. 
• Acupuncture lacks controlled randomized studies to prove its efficacy. This therapy is generally safe, but it is not routinely recommended. 
• Conflicting evidence exists regarding spinal manipulation,⁵  which is not routinely recommended, but it is generally a safe modality. 
• Prolotherapy attempts to treat pain through injection of irritant solutions. This therapy is not recommended for the treatment of disc herniation, and there are limited long-term safety data.⁸  
• Back school has been used for patients with chronic LBP and marked functional impairment. There is a question of whether or not back school is a cost-effective option.
• Intradiscal methylene blue injection has been studied and reported to be effective in a prospective clinical trial by Peng et al.⁶ Methylene blue has a neurotropic effect that results in blocking nerve conduction and destruction of nerve endings. These neurologic changes result in pain relief when the patient's pain is discogenic in nature.

Medication

• NSAIDs are used to for LBP.
• Muscle relaxants (eg, cyclobenzaprine) show some benefit in controlling LBP, but the use of these agents should be limited to the acute phase (ie, the first 4-7 d). Side effects such as drowsiness limit the use of muscle relaxants, but they may be helpful for patients with night symptoms.
• Tramadol is effective for pain control in chronic LBP and can be safely used in combination with NSAIDs.
• Acetaminophen is effective for pain control in chronic LBP, although NSAIDs may be superior. Acetaminophen may also be used as an adjunct to the analgesic properties of NSAIDs (not to exceed 4 g/d).
• Narcotic medications may be helpful in severe cases that involve functional limitations, but long-term use should be avoided.
• Selective serotonin reuptake inhibitors (SSRIs) may have a role in managing chronic radicular symptoms.
• Tricyclic and tetracyclic antidepressants (TCAs) have shown moderate symptom reduction that is independent of the patient's depression status in chronic pain cases.
• Oral steroids help reduce acute pain and swelling; however, no study has shown benefit over the potential harmful side effects of steroid use.

Analgesics

Because pain is usually the most debilitating symptom of lumbar disc disease, pharmacologic therapy is directed at alleviating the patient's pain.

Acetaminophen (Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or who are taking oral anticoagulants.

Dosing

Adult

500-1000 mg PO q4h prn; not to exceed 4 g/d

Pediatric

15 mg/kg PO q4h prn; not to exceed 500-1000 mg/d

Interactions

Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity is possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed recommended maximum dose.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

This class of medications provides analgesia to the low back and reduces inflammation surrounding a herniated nucleus pulposus.

Ibuprofen (Motrin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

400-800 mg PO q6h prn

Pediatric

10 mg/kg PO q6h prn; not to exceed 400-800 mg

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently.

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy

Muscle relaxants

These agents are indicated for severe muscle spasms that are associated with LBP; little evidence exists to support universal use in lumbar disc disease.

Cyclobenzaprine HCl (Flexeril)

Skeletal muscle relaxant that acts centrally and reduces the motor activity of tonic somatic origins that influence both alpha and gamma motor neurons.

Structurally related to tricyclic antidepressants and, thus, carries some of the same liabilities.

One of the least expensive and least addictive options in this class.

Dosing

Adult

10 mg PO tid; not to exceed 60 mg/d; do not use for more than 3 wk

Pediatric

Not recommended

Interactions

Coadministration with MAO inhibitors and tricyclic antidepressants may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine

Contraindications

Documented hypersensitivity; patient has taken MAO inhibitors within the last 14 d

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in the presence of angle-closure glaucoma and urinary hesitance

Antidepressant, Tricyclic

These agents are used in the treatment of depression.

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain. Blocks reuptake of norepinephrine and serotonin, which increases concentrations in the CNS. Decreases pain by inhibiting spinal neurons that are involved in pain perception. Highly anticholinergic. Often discontinued because of somnolence and dry mouth.

Cardiac arrhythmia, especially in overdose, has been described; monitoring the QTc interval after reaching the target level is advised. Up to 1 mo may be needed to obtain clinical effects.

Dosing

Adult

10-100 mg PO qhs

Pediatric

Not established

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine and quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; use of MAO inhibitors within 14 d of initiating therapy; patients with history of seizures, cardiac arrhythmias, glaucoma, or urinary retention

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in the presence of cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in the elderly

Follow-up

Return to Play

Percutaneous discectomy requires at least 2-3 months of postoperative rest.
 
Microdiscectomy requires 6-8 weeks of rest for noncontact sports, and at least 3 months of rest (typically 4-6 months) for contact sports. Athletes are less likely to return to play when multiple disc levels are affected. Return to play for single-level microdiscectomy has been reported to be 90%.¹⁰
 
Return to play after spinal fusion is controversial. Some authors suggest no return to play at the professional or collegiate level for contact sports after spinal fusion. Others utilize criteria for return to contact sports to include the following¹⁰ :

• At least 1 year following surgery
• Evidence of solid fusion
• Resolution of pain
• Full strength
• Pain-free ROM
• Full endurance

Complications

Complications of lumbar disc problems include prolonged or permanent nerve symptoms, chronic pain, and inability to return to sports.

Prevention

Avoidance of injury can be achieved through proper education, use of proper body mechanics, and appropriate stretching and strengthening exercises. Smoking cessation, weight control, and maintaining an active lifestyle can also be helpful.

Prognosis

95% of athletes have symptom resolution within 4 weeks, and 95% of those with lumbar disc problems return to play fully recovered.

A history of LBP is the greatest predictor for future episodes by up to a 3-fold increased risk; active LBP increases the risk of recurrence by 6 fold.

Education

Coaches, trainers, gym classes, pamphlets, and team and/or primary care physicians should provide education on how to avoid lumbar disk injuries.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Bone Health Center. Also, see eMedicine's patient education articles Slipped Disk and Back Pain.

Miscellaneous

Medicolegal Pitfalls

Failure to diagnose patients who present with red flags can result in severe neurologic deficits, paralysis, or death (see History).

Special Concerns

Patients younger than age 20 years or older than age 50 years are more likely to present with a serious cause of lumbar disc problems, such as a tumor or infection; therefore, more a extensive workup is usually indicated in these populations.

Pediatric patients have a higher incidence of congenital, developmental, and bony abnormalities. Geriatric patients have a higher likelihood of life-threatening causes, including a rupturing intra-abdominal aortic aneurism, vertebral fracture, metastatic cancer, pancreatitis, and other intra-abdominal pathology.

Multimedia

Media file 1: Radiograph of the lumbar spine. This image demonstrates L5-S1 disk space narrowing (the most common location).

Media file 2: Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.

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Keywords

athletes and back pain, low back pain and sports, strained back, back is out, herniated disc, slipped disc, herniated nucleus pulposus, HNP, ruptured disc, degenerative disc disease, DDD, lumbago, mechanical low back pain, LBP, lumbar disc problems

Contributor Information and Disclosures

Author

Luis E Palacio, MD, Director of Primary Care Sports Medicine, Department of Family and Community Medicine, Tufts University School of Medicine; Residency Faculty, Tufts University Family Medicine Residency/Cambridge Health Alliance
Luis E Palacio, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey W R Dassel, MD, Sports Medicine Coordinator and Family Medicine Practitioner, Westside Health Center
Jeffrey W R Dassel, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Medical Association, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Annie Collier, MD, Staff Physician, Department of Emergency Medicine, Our Lady of Mercy Medical Center
Annie Collier, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

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.

Medical Editor

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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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