eMedicine Specialties > Sports Medicine > Spine
Lumbar Disk Problems in the Athlete: Treatment & Medication
Updated: Feb 28, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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.
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
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity
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.
Adult
400-800 mg PO q6h prn
Pediatric
10 mg/kg PO q6h prn; not to exceed 400-800 mg
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.
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
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.
Adult
10 mg PO tid; not to exceed 60 mg/d; do not use for more than 3 wk
Pediatric
Not recommended
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
Documented hypersensitivity; patient has taken MAO inhibitors within the last 14 d
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.
Adult
10-100 mg PO qhs
Pediatric
Not established
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
Documented hypersensitivity; use of MAO inhibitors within 14 d of initiating therapy; patients with history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
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
More on Lumbar Disk Problems in the Athlete |
| Overview: Lumbar Disk Problems in the Athlete |
| Differential Diagnoses & Workup: Lumbar Disk Problems in the Athlete |
 Treatment & Medication: Lumbar Disk Problems in the Athlete |
| Follow-up: Lumbar Disk Problems in the Athlete |
| Multimedia: Lumbar Disk Problems in the Athlete |
| References |
| « Previous Page | Next Page » |
References
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. Jul 2006;16(4):369-71. [Medline].
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. Jun 2003;37(3):263-6. [Medline].
Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. Apr 15 2007;75(8):1181-8. [Medline]. [Full Text].
Smeal WL, Tyburski M, Alleva J, Prather H, Hunt D. Conservative management of low back pain, part I. Discogenic/radicular pain. Dis Mon. Dec 2004;50(12):636-69. [Medline].
Baker RJ, Patel D. Lower back pain in the athlete: common conditions and treatment. Prim Care. Mar 2005;32(1):201-29. [Medline].
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. Jan 2007;16(1):33-8. Epub 2006 Feb 22. [Medline].
Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin North Am. Jun 2002;49(3):643-53. [Medline].
Harwood MI, Smith BJ. Low back pain: a primary care approach. Fam Pract Clin. 2005;7(2):279-303.
Xin SQ, Zhang QZ, Fan DH. Significance of the straight-leg-raising test in the diagnosis and clinical evaluation of lower lumbar intervertebral-disc protrusion. J Bone Joint Surg Am. Apr 1987;69(4):517-22. [Medline]. [Full Text].
Eck JC, Riley LH 3rd. Return to play after lumbar spine conditions and surgeries. Clin Sports Med. Jul 2004;23(3):367-79, viii. [Medline].
Cooke PM, Lutz GE. Internal disc disruption and axial back pain in the athlete. Phys Med Rehabil Clin N Am. Nov 2000;11(4):837-65. [Medline].
[Best Evidence] 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. Nov 1 2005;30(21):2369-77; discussion 2378. [Medline].
Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. Feb 2004;86-A(2):382-96. [Medline]. [Full Text].
Cherkin DC, Deyo RA, Battié 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. Oct 8 1998;339(15):1021-9. [Medline].
Day AL, Friedman WA, Indelicato PA. Observations on the treatment of lumbar disk disease in college football players. Am J Sports Med. Jan-Feb 1987;15(1):72-5. [Medline].
Deyo RA, Loeser JD, Bigos SJ. Herniated lumbar intervertebral disk. Ann Intern Med. Apr 15 1990;112(8):598-603. [Medline].
Dreisinger TE, Nelson B. Management of back pain in athletes. Sports Med. Apr 1996;21(4):313-20. [Medline].
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.
Franklin BA. Low back exercises. In: 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.
Gerbino PG 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med. Jul 1995;14(3):571-90. [Medline].
Kahanovitz N. Surgical disc excision. Clin Sports Med. Jul 1993;12(3):579-85. [Medline].
Montgomery S, Haak M. Management of lumbar injuries in athletes. Sports Med. Feb 1999;27(2):135-41. [Medline].
Regan JJ. Clinical results of charité lumbar total disc replacement. Orthop Clin North Am. Jul 2005;36(3):323-40. [Medline].
Schenck RC Jr, ed. Athletic Training and Sports Medicine. 3rd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:389-90.
Singh V. Percutaneous disc decompression for the treatment of chronic atypical cervical discogenic pain. Pain Physician. Jan 2004;7(1):115-8. [Medline]. [Full Text].
Stinson JT. Spine problems in the athlete. Md Med J. Aug 1996;45(8):655-8. [Medline].
Tall RL, DeVault W. Spinal injury in sport: epidemiologic considerations. Clin Sports Med. Jul 1993;12(3):441-8. [Medline].
Wang JC, Shapiro MS, Hatch JD, et al. The outcome of lumbar discectomy in elite athletes. Spine. Mar 15 1999;24(6):570-3. [Medline].
Watkins RG. Lumbar disc injury in the athlete. Clin Sports Med. Jan 2002;21(1):147-65, viii. [Medline].
Windsor RE. Lumbosacral discogenic pain syndrome. eMedicine from WebMD. Updated June 5, 2006. Accessed October 10, 2007. Available at http://emedicine.medscape.com/article/94673-overview.
Young JL, Press JM, Herring SA. The disc at risk in athletes: perspectives on operative and nonoperative care. Med Sci Sports Exerc. Jul 1997;29(7 suppl):S222-32. [Medline].
Further Reading
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
