eMedicine Specialties > Sports Medicine > Spine

Degenerative Lumbar Disc Disease in the Mature Athlete

Author: Gerard A Malanga, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry at New Jersey, New Jersey Medical School; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Mountainside Hospital
Coauthor(s): Michal E Eisenberg, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Stephen G Andrus, MD, Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, UMDNJ
Contributor Information and Disclosures

Updated: Apr 6, 2006

Introduction

Background

Older individuals today are participating in athletic activities in greater and greater numbers, whether it is weekend sports enthusiasts or highly competitive senior athletes. Degeneration of the lumbar disc, associated degenerative facet arthritis, and spinal stenosis are the most common causes of low back and leg pain in the aging population, and the mature athlete is not immune from these processes.

Many mature athletes (typically aged 30 y or older) present with complaints of low back pain (LBP), radicular symptoms, neurogenic claudication, or a combination of all of these symptoms. These clinical syndromes in the mature athlete should be fully evaluated, accurately diagnosed, and appropriately treated to allow for return to athletic participation.

Frequency

United States

LBP has an incidence of 5% per year and a prevalence of 60-90% in the general population. Epidemiological studies have found that the frequency of LBP increases as age increases to 60 years; in those older than 60 years, the frequency declines with increasing age.

Certain groups of athletes, including weightlifters and soccer players, appear to have a higher incidence of disc space narrowing and spondylolisthesis, but this does not correlate to a greater incidence of back pain compared with the general population.

Functional Anatomy

The spine is composed of a series of spinal functional units, wherein each unit consists of 3 joints with an anterior and posterior segment. The anterior segment consists of 2 adjacent vertebral bodies and the intervertebral disc between them. The posterior segment consists of the laminae and their processes. One joint is formed between the 2 vertebral bodies, while the other 2 joints are formed by the articulation of the superior articular processes of 1 vertebra with the inferior articular processes of the vertebra above. The intervertebral disc consists of an inner core of gelatinous material called the nucleus pulposus. The nucleus pulposus is enclosed by a ring called the annulus fibrosus.

The individual lumbar nerve roots exit laterally through the intervertebral foramen located on each side of the spinal functional unit. Each intervertebral foramen is bound anteriorly by the vertebral column and intervertebral disc. The intervertebral foramen is bound superiorly and inferiorly by a pedicle, while posteriorly it is bound by the vertebral lamina and zygapophyseal joint. The outer one third of the intervertebral disc is an innervated structure, while the remainder of the disc, including the nucleus pulposus, lacks any innervation.

The sinuvertebral nerves are recurrent branches of the ventral rami that reenter the intervertebral foramina to be distributed within the vertebral canal. These nerves are mixed nerves, formed by a somatic root from a ventral ramus and an autonomic root from a gray ramus communicans. The sinuvertebral nerve supplies the posterior margin of the annulus fibrosus, anterior dura mater, dural sleeve, posterior vertebral periosteum, and the posterior longitudinal ligament. The anterior longitudinal ligament and the lateral aspect of the annulus fibrosus are both innervated by ventral rami and gray ramus communicans. The posterior rami of the spinal nerves supply zygapophyseal joints above and below the nerve, as well as the paraspinous muscles at multiple levels.

The spinal motions that frequently are encountered in many sports and other activities include flexion and extension, torsion (rotational forces), and lateral bending. Additionally, certain sports can subject the spine to shear forces in the anterior and posterior position, as well as to compressive forces in the craniocaudal direction. Protection of the functional units of the spine requires unrestricted and efficient motions between adjacent vertebral segments. Simple flexion/extension movements and even moderate axial compression forces are relatively well tolerated by the disc and the associated joint complexes of the spine.

Rotational forces and combined motions, such as forward flexion with rotation, have been shown to be the most injurious to the disc. Therefore, it is crucial that the supporting stabilizers of the spine, both static and dynamic, are sufficiently strong to offset some of these potentially injurious forces.

The static stabilizers of the lumbar spine include the longitudinal ligaments, the intervertebral discs between the vertebral bodies, and the zygapophyseal joint capsules connecting the posterior elements of the spine. The dynamic stabilizers are comprised not only of the musculature surrounding the lumbar spine, but also include the abdominal and hip muscles, including the hip flexors, extensors, and abductors.

The relationship of the pelvis to the spine is an important consideration when assessing problems in the lumbar spine. Increased lumbar lordosis may result from anterior pelvic tilt, resulting from weak abdominals and/or tight hip flexors. Decreased lumbar lordosis may result from posterior pelvic tilt, resulting from weak paraspinal extensor muscles and/or tight hamstring muscles. The dynamic stabilizers of the spine, when acting synergistically, can directly or indirectly reduce the shear forces to the intervertebral disc and to the zygapophyseal joints of the spine. Of note, athletes overall do not necessarily seem to have stronger back muscles when compared to nonathletes, at least in studies of certain collegiate level athletes.

Sport Specific Biomechanics

Sports injuries often involve a twisting or torsion movement, whereas falls are rarely a precipitating cause.

The most common area of complaint among male golfers of the Professional Golfer's Association is the lower back, with an estimated 10-33% of touring professionals reportedly playing with back complaints of some degree. Amateur golfers also identified LBP as their most common golf-related injury. The golf swing frequently has been implicated as a major source of injury to the spine in both professional and amateur golfers. Discogenic LBP most likely develops because of the axial rotation of the lumbar spine at the top of the backswing, with the subsequent uncoiling and hyperextension through the downswing and follow-through.

Several forces act on the lumbar spine during the golf swing. Rotational forces are developed as a result of twisting of the vertebral segments about the spine. Additionally, the spine is subjected to shear forces in the anteroposterior direction, axial compressive forces, and lateral bending forces.

Hosea and Gatt analyzed the various forces on the spine in the swings of amateur and professional golfers. They determined that these forces were actually greater in amateur players compared to professional players. The amateur golfers generated greater lateral bending, anteroposterior shear, and rotational forces, with equal axial compression noted in the 2 groups. They determined that the loads required to cause disc disruption in cadaveric studies were similar to the loads that occur in the golf swing. The importance of trying to minimize forces on the spine through proper swing mechanics becomes clear. Additionally, strengthening the dynamic stabilizers of the spine to counteract the significant forces exerted on the spine during the golf swing is important in both the prevention and treatment of golf-related low back injuries.

Clinical

History

Establishing a diagnosis in the mature athlete with lower back or leg complaints begins with obtaining a detailed history and performing a physical examination.

• The basic history should include a temporal account of the patient's symptoms and a complete description of complaints. Ask the patient whether their symptoms are associated with participation in a specific sport or activity. If the chief complaint is pain, the primary site, intensity, character, frequency, and radiation of the pain should be determined.
• Identify red flags by asking the patients questions regarding the following:
• • Trauma, unexplained weight loss, fever, and chills: Answers to these questions may indicate a more serious medical condition that requires further workup.
  • Prior episodes of similar symptoms: A history consisting of previous episodes may provide clues to the patient's present condition.
  • Previous treatment: The examiner should ask what previous treatments have been tried (eg, use of ice or heat, use of any medications such as acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs [NSAIDs]). If lumbar injections of any type were a part of the patient's treatment, it is important to know which approach was used and whether fluoroscopic guidance was used because nonfluoroscopic injections have been noted to miss the epidural space in as many as 40% of patients.
  • Previous physical therapy: Ask questions about previous participation in a physical therapy program, and attempt to understand the therapeutic exercises used. If, according to the patient, previous physical therapy failed, the physician should ask about the specific therapy approach used, modalities employed, and inclusion of and compliance with a home exercise program. Knowing this information is beneficial for the physician to appreciate the extent and comprehensiveness of previous treatment strategies.
• The clinical presentation that results from the underlying degenerative processes in the intervertebral discs of the mature athlete can take several different forms.
• • As the intervertebral discs deteriorate, small tears can appear in the annulus, and these tears can coalesce to weaken the annulus. At this stage in degenerative disc disease (DDD), back pain is the most common symptom. Discogenic pain usually is worse with prolonged sitting and with flexion of the spine, and it is relieved with extension and moderation of activity.
  • Increased pain with coughing, sneezing, or straining also may be consistent with a discogenic cause of back pain.
  • If there is progression to frank herniation of the nucleus pulposus, then leg pain, with or without back pain, usually will be the predominant symptom. The distribution of the radiating pain in the extremities depends on which nerve root is compressed or inflamed. Associated motor and sensory deficits may occur, depending on the degree of nerve root involvement.
  • This clinical picture usually is seen in persons aged 30-50 years, in whom degenerative changes are present in the disc but in whom the spine is still relatively mobile.
• As the spine ages, loss of disc height can lead to segmental instability and secondary spinal stenosis (ie, narrowing of the vertebral foramen).
• • Symptoms of spinal stenosis are determined by the location of the compression on the neural elements. Typically, compression from central stenosis results in neurogenic claudication with unilateral or bilateral discomfort in the buttocks, thighs, or legs.
  • Symptoms are produced by standing or walking, and they are relieved by adopting a lumbar flexed posture.
  • Symptoms can include pain, numbness or paresthesias, weakness, or a combination of these symptoms.
  • When the neural foramen is the site of stenosis, the clinical features are different from those of central canal stenosis. Patients can present with unilateral sciatic pain (usually L5 or S1 nerve root irritation) that is provoked by standing or walking and relieved by sitting or flexing the lumbar spine.

Physical

A comprehensive physical examination of the mature athlete with LBP should include an in-depth evaluation of the neurologic and musculoskeletal systems. Combining the findings of the history and physical examination increases the overall predictive value of the evaluation process.

• Inspection
• • The examination begins with observation of the patient during the history portion of the evaluation. Note any paraspinal spasms, scoliosis, an increase or decrease in lordosis, muscle atrophies, or asymmetries.
  • Observe the iliac crests for any difference in height that may indicate a functional leg length discrepancy.
  • When acute disc herniation is present with nerve root involvement, the patient often will list to one side. With a disc herniation lateral to the nerve roots, the patient will list away from the side of the irritated nerve root in an attempt to draw the nerve root away from the disc. Likewise, when the herniation is medial to the nerve root, the patient will list toward the side of the lesion.
• Palpation
• • Determine whether any tender or trigger points can be appreciated in the lumbar paraspinal musculature and whether muscle spasm is present. Tenderness also may be present along muscles in which symptoms are referred, such as in the gluteal region and in the lower extremity.
  • Palpation of the lumbar spine in the midline sometimes can elicit pain at the level of a symptomatic intervertebral disc.
• Range of motion
• • Determine range of motion (ROM) for flexion, extension, lateral bending, and rotation.
  • On forward flexion, the lumbar spine should move from its normal lordotic curvature to a straight or slightly flexed posture. The Modified Schober test may be used to measure the amount of flexion occurring in the lumbar spine. A point is marked midway between the 2 posterior sacroiliac spines; then, points 5 cm below and 10 cm above that point are marked. The distance between the 3 points is measured. The patient then is asked to flex forward, and the distance is measured again. The distance between the 2 measurements is an indication of the amount of flexion occurring in the lumbar spine. Less than a 4-cm change between the 2 measurements suggests a loss of normal segmental motion in the lumbar spine.
  • In addition to ROM of the spine, assess the other lower extremity joints because pain referral patterns may be confused with focal peripheral involvement. For example, a patient with anterior thigh pain and knee pain may actually have a degenerative hip condition, not an upper lumbar radiculopathy. Reproduction of the patient's pain with hip internal rotation, external rotation, or other provocative hip maneuvers may further distinguish hip pathology from spine involvement.
• Muscle strength
• • Manual muscle testing is important to determine whether weakness is present and whether the distribution of weakness corresponds to a single root, to multiple roots, or to a peripheral nerve or plexus.
  • Additionally, evaluate the dynamic stabilizers of the lumbar spine, including the abdominals and the muscles about the hip, to include the hip flexors, extensors, and abductors.
• Flexibility
  
  
  • Inflexibility of the musculature about the pelvis has a direct result on the mechanics of the lumbosacral spine.
  • Increased tightness of the hamstrings or gluteus maximus muscles can cause a posterior tilt to the pelvis, reducing the lumbar lordosis. Tightness of the rectus femoris and iliopsoas muscles anteriorly can cause an anterior tilt to the pelvis, increasing the lumbar lordosis. Both of these effects can cause increased force to be distributed to the lumbar spine and can predispose individuals to LBP.
     
• Sensory examination
  
  
  • On sensory examination, a dermatomal decrease or loss of sensation should be found in patients with clear-cut radiculopathy, whether caused by disc herniation or foraminal stenosis.
  • Patients with radiculopathy also may have hyperesthesia to light touch and pinprick examination. However, the sensory examination can be quite subjective, since it requires patient response.
     
• Muscle stretch reflexes
  
  
  • Muscle stretch reflexes are helpful in the evaluation of patients presenting with limb symptoms suggestive of a radiculopathy.
  • Neither a decrease nor an increase of these reflexes can be interpreted as definitely abnormal. The asymmetry of reflexes is most significant; therefore, a patient's reflexes must be compared with the contralateral side.
     
• Straight leg raising test
  
  
  • Provocative maneuvers, such as straight leg raising, may provide evidence of increased dural tension, indicating underlying nerve root pathology.
  • Unilateral straight leg raising primarily tests the L5, S1, and S2 nerve roots, with symptoms further provoked by ankle dorsiflexion. Straight leg raising test is only considered positive if pain occurs when the leg is elevated 30-70° and when pain travels down below the knee. Minimal nerve root tension occurs below 30° of elevation, and pain elicited above 70° is most likely related to tightness within the hamstrings or gluteal muscles.
  • Elevation of the asymptomatic lower extremity causing pain in the symptomatic side (crossed straight leg raising sign) is suggestive of a herniated disc.
     
• Peripheral vascular examination
  
  
  • Examination of the peripheral circulation is important, especially when attempting to differentiate between the neurogenic claudication seen in spinal stenosis and the vascular claudication seen in peripheral vascular disease.
  • Examination of the posterior tibial and dorsalis pedis arteries should be performed, as well as examination of the skin temperature and inspection for the presence of trophic changes seen with ischemic disease.
     
• Pain centralization maneuvers: Attempts at pain centralization through postural changes, such as lumbar extension, may suggest a discogenic cause for the back pain and may help in determining the success of future treatment strategies.
• The clinical features in many cases of radiculopathy are inadequately explained by anatomic abnormalities alone. High levels of an inflammatory enzyme, phospholipase A2, have been identified in lumbar herniated and degenerative discs. Saal et al and other authors support the concept that the clinical features of many patients with lumbar disc disease may be explained by inflammation caused by biochemical factors working alone or in combination with the mechanical deformations described above.

Causes

Deterioration of the spinal structures is a universal phenomenon with progression of age, occurring in both athletic and nonathletic populations. The intervertebral disc is part of a 3-joint complex; therefore, damage at the level of either the zygapophyseal joints or the disc affects the function of the entire unit.

• The deteriorative process most likely begins with the intervertebral disc. Tiny blood vessels enter and exit the disc in the early decades of life, but these vessels become obliterated, leaving the intervertebral disc an avascular structure. Thereafter, nutrition of the disc is supported only through extracellular fluid osmosis. Water is drawn into the disc, and, with motion, the water is partially expelled. This constant movement of water into and out of the disc is thought to allow the disc to remain healthy by bringing in needed nutrients. With the aging process, there is a loss of some of the connective tissue fibers within the disc and an alteration in the properties of the nucleus pulposus. This causes less water to be drawn into the disc and, ultimately, may lead to impairment of nutrition. The water content of a disc in young persons is 88%, but it is reduced to less that 70% in elderly persons.
• The deterioration process leads to a stiffening of the intervertebral disc and a change in its shape, causing the disc to lose its ability to distribute load uniformly.
• • The fibers of the annulus run in different directions at different depths and allow the annulus to accommodate complex motions. Axial rotation of the spine or rotation of a flexed spine may isolate some of the annular fibers and cause small annular tears. These annular tears may or may not be symptomatic; however, in time, they may coalesce to weaken the annulus fibrosus. This can lead to disc bulging, disc space narrowing, or even frank herniation.
  • In addition, the loss of disc space height may lead to segmental instability and increased forces on zygapophyseal joints, resulting in sclerosis and hypertrophy. The loss of disc height also causes bulging of the annulus into the spinal canal and buckling of the ligamentum flavum. Ultimately, this degenerative cascade can lead to a narrowing of the spinal canal and intervertebral foramen, producing an acquired spinal stenosis.
• These degenerative changes begin as early as the second to third decade of life and progress with advancing age. The clinical consequences of this deterioration vary with the age of the patient.
• • In persons aged 30-50 years, degenerative changes and tears in the annulus of the disc may cause frank herniation of the disc material. This population usually has some compromise of the integrity of the disc, yet the nucleus is still pliable enough to be extrudable, and the spine is mobile enough to produce the required forces for herniation.
  • With aging of the spine, the nucleus pulposus becomes firmer, spinal motion lessens, and bony overgrowth increases. The intervertebral discs do not herniate as frequently, and spinal stenosis becomes the prominent clinical picture.
• Athletes and nonathletes alike are subject to these progressive degenerative changes. However, it is not completely clear how the potentially beneficial effects of training interact with the potentially harmful effects of loading experienced by athletes. The greatest incidence of discogenic disease would be expected to be found in those athletes participating in sports with the greatest axial stresses.
• • Hellstrom et al found that disc height reduction was much more common in athletes than nonathletes, and, specifically, it is most prevalent in wrestlers and male gymnasts.
  • Horne et al found a high frequency of disc space narrowing in the thoracolumbar spines of water-ski jumpers.
  • Other studies have failed to show a correlation between physical loading and increased spinal pathology or low back symptoms, and some evidence suggests that certain types of loading may slow down the degenerative process.
  • Videman et al reported that former elite athletes overall reported less back pain than control groups in later adulthood. However, they did find an increase in the degenerative changes throughout the entire spine in former weight lifters and in the lower lumbar levels in soccer players when compared to controls. Despite these increased degenerative findings, the former weight lifters and soccer players still had less reported back pain than those in the control groups. This study and others provide some evidence that certain forceful athletic activities may accelerate the degenerative process, but that the degenerative changes seen on imaging studies do not correlate well with clinical symptoms.

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