Lumbar Spine Problems in Elite Athletes

Odds Elite Athletes Can Return From Low Back Problems

Part of being an elite athlete is managing injury. When I meet with young athletes facing injury for the first time, I often talk to them about learning to manage injuries, and not letting them get the best of you. Every athlete who has achieved success has done so by learning to prevent injury, recover from injury, and manage injuries. Whether you are a high school cross country runner or professional baseball player, I have no doubt you have a story (or two, or three...) to tell of the injuries you have faced in your athletic career.

If there's one injury that seems to cause more concern for an athlete's future, it seems to be back problems. Back pain, spinal conditions, and lumbar issues strike fear in athletes because of a number of factors, including the following:

  • First, there is a lot of mystery. The mechanics of the spine, the muscles and ligaments that surround the spinal column, and the complex nature of this part of our body make understanding spine conditions difficult for doctors and patients alike.
  • Second, many spine problems have no simple treatment. Often there isn't a pill or a procedure that will simply fix the pain.
  • Third, recovery can take a long time. For athletes, patience is seldom an asset, and missing games, practices or training may seem unacceptable.

For all of these reasons, and likely others, athletes of all levels are concerned when diagnosed with a lumbar spine condition.

But what does it actually mean to be diagnosed with a lumbar spine problem? Are your athletic days over? Can professional athletes return to sports? Should college athletes hang it up? According the the research, the answer is very clear: the vast majority of athletes are able to return to sports at the same level as before their injury. In fact, even professional athletes make a full comeback from the most common lumbar spine conditions the vast majority of the time.

So don't despair, you may have to learn to manage your condition, you may have some intense rehab ahead of you, but it's ok: you're an athlete. Here you can learn about some of these common spine conditions that can impact an athlete's participation in sports, and what you can do to recover from these injuries.

Lumbar Disc Herniation

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The spinal column is made up of rectangular shaped bones, called vertebrae, stacked on top of each other. The lower segment of the spinal column is called the lumbar spine. Each of the spinal vertebrae are separated by a cushion of tissue called the intervertebral disc. This disc helps to absorb energy and at the same time allows for motion between adjacent vertebrae.

The intervertebral disks are susceptible to injury, and are not equipped well for self-repair. The disc has a very limited blood supply making damage to the disc material often something the body has difficulty healing on its own. 

The most common type of disc damage is called a herniation. When a herniation occurs, some of the intervertebral disc material is pushed away from its normal boundary, and can press up against the nerve roots and spinal cord. The most common symptoms of intervertebral disc herniation are signs of nerve irritation such as pain, numbness, and weakness extending down the lower extremity. Back pain is not the most common symptom of a disc herniation.

Herniation of a lumbar intervertebral disc can be a very serious problem. If the disc is pressing on the central portion of the lumbar spinal nerves, there are two conditions called cauda equina syndrome and conus medullaris syndrome that can occur. These are important problems to diagnose, as the results of treatment become much worse when there are delays in surgical treatment. Symptoms of these conditions may include inability to control bowel or bladder function, and numbness around the genitals. While these conditions are very rare complications of a disc herniation, they are ones that need to be diagnosed quickly and treated efficiently.

Nonsurgical treatment is effective for more than 90 percent of athletes who sustain a lumbar disc herniation. Often oral anti-inflammatory medications can help relieve symptoms of acute inflammation. Oral steroid medications have not been shown to provide better treatment than placebo. Physical therapy is a typical treatment that is important to help restore core and back muscle strength, and hopefully prevent further problems down the road. If the symptoms become difficult to control, an epidural steroid injection may also be used and often has effective results.

Surgical treatment is typically reserved for athletes who do not improve after a minimum of 6 weeks of nonsurgical treatment. Interestingly, studies have not shown any significant difference in length of time to return to athletics, length of athletic career, or overall results of treatment of a lumbar disc herniation when comparing surgical and nonsurgical treatment. Clearly, most patients, even elite athletes, should start with nonsurgical treatment. Regardless of treatment type, about 90 percent of athletes returned to their pre-injury level of activity.

Degenerative Disc Disease

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Degenerative disc disease is a very common problem, both in the athletic, and nonathletic population. A normal intervertebral disc is composed largely of water, and is something like a spongy cushion. A degenerative disc loses much of its water volume, and becomes more rigid, absorbing less energy with normal movements.

The most important factors in the development of degenerative disc disease appear to be aging and genetic predisposition. Older athletes are much more prone to developing degenerative disc disease, and those who have a family history of degenerative discs of the spine are much more likely to have this condition. However, there is evidence to support the notion that aggressive sports activities can also contribute to the development of early signs of degenerative disc disease.

Degenerative disc disease is typically diagnosed in athletes who complain of back pain and ultimately have imaging studies, possibly including x-rays and MRIs. Most all athletes who are diagnosed with degenerative disc disease can be managed with nonsurgical treatment. The typical treatment consists of physical therapy focused on core and lumbar spine strengthening. The goal is to improve the strength of the muscles surrounding the spine to better offload the damaged lumbar discs.

There is little evidence to support the use of other treatments. Oral medications and epidural injections have not been shown to be helpful. Alternative treatments such as acupuncture, chiropractic treatment, massage, and others have been used historically, but there is little evidence to suggest that these alter the long-term prognosis. Many athletes swear by these treatments, and most are very safe to perform. Each athlete may be slightly different, and it is reasonable to try these different treatment options to find the right one for you.

Surgical treatment is generally not helpful for people with degenerative disc disease, and typically is reserved for athletes who are unable to return to sports after a minimum of 6 months (if not much longer) of nonsurgical treatment. Even in these athletes, surgical treatment has very guarded results in terms of getting elite athletes back to sports activities. The usual surgical treatment of degenerative disc disease involves a lumbar fusion procedure. There are some surgeons performing disc replacement although the use of disc replacement in an elite athlete has not been specifically investigated.

Spondylolysis

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Spondylolysis is a repetitive use injury to the bone of the vertebrae of the lumbar spine. This condition occurs as a result of repetitive microtrauma, and causes a stress fracture of part of the vertebrae called the pars interarticularis. If the spondylolysis occurs on both the right and the left side of the spinal column, a condition that leads to instability of the vertebrae, called spondylolisthesis, can occur.

Spondylolysis is most common in specific sports including gymnastics, diving, wrestling, and weight lifting. While it can occur in young athletes in other sports, it is much more common in the aforementioned activities. Most often, this stress fracture of the pars interarticularis occurs in adolescence, and then becomes symptomatic later. Often, when activity levels are increased in high school or collegiate athletics, or even thereafter, the spondylolysis becomes more symptomatic. It may have been present for a decade or longer, but only becomes problematic when activity levels increase in an athlete's late teens or twenties.

The most common symptom of spondylolysis is activity related pain. When the condition called spondylolisthesis occurs, it is more common to have nerve symptoms causing pain, numbness, and weakness going down the leg. Diagnosis can sometimes be made with an x-ray test, but sometimes a stress fracture may only be seen on either a CT scan or MRI. CT scans are also helpful when assessing for healing of a stress fracture in the spine.

Treatment most often begins with activity modifications and physical therapy. If it is determined that the injury just recently occurred, and not a flareup of an old injury, some physicians will elect to brace an athlete in order to try to allow for healing of the bone. In these situations where the injury is caught in this acute phase, the healing rate of a spondylolysis can approach 90 percent. If the injury is chronic, the likelihood of spontaneous healing is low, even when a brace is worn.

As mentioned, the vast majority of athletes can improve with nonsurgical intervention. Only after a prolonged, minimum 6 month trial of nonsurgical treatment should any type of surgical intervention be considered. Surgical treatment options varied depending on the appearance of the bone injury. If the bone is lined up well, then a repair of the stress fracture can be considered. If the stress fracture has led to shifting of the spinal alignment (spondylolisthesis), then a lumbar fusion surgery would be the usual treatment.

Muscular Back Pain

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Muscle strains and ligament strains are by far the most common source of back pain, including in athletic individuals. While these injuries do not cause structural problems with the lumbar spine, they can cause significant disability and difficulty with athletic endeavors.

Making the diagnosis of muscular back pain is typically accomplished by examining the patient. Typical muscular low back pain is not accompanied by the same symptoms as some of the aforementioned problems. Athletes often complain of symptoms including muscle spasm, aching sensations, weakness, and discomfort that is hard to alleviate.

Seldom are imaging studies such as x-rays or MRIs helpful, and in many cases, obtaining these studies can only serve to complicate the situation. "Abnormal" findings are typical on MRIs, yet they may have nothing to do with the source of discomfort, and obtaining studies sometimes confuses the situation and leads to a delay in the most appropriate treatments while a diagnostic workup is taking place.

The treatment of muscular low back pain is best accomplished with early mobilization, gentle movements of the lumbar spine, and efforts to increase core strength and lumbar biomechanics. Physical therapists can be helpful, as can athletic trainers, strength coaches, and sports coaches. Many athletes, particularly younger athletes, don't know to discuss these conditions with their coaches and trainers, when good communication can ensure that athletes with a back problem can be managed with some simple modifications.

A Word From Verywell

There are number of potential causes of low back pain that can be caused by problems with the lumbar spine. While lumbar spine conditions can be extremely frustrating for an athlete and may cause anxiety about ability to return to sports, the truth is that most athletes will recover and return to their full activity level.

In addition, surgical treatment is the exception, rather than the rule, for treatment of most lumbar spine conditions in athletes. It is exceptionally rare that an elite athlete will require surgery for a spine condition, and when they do there is still a good chance they will return to sports. Working with therapists, trainers, and coaches, and ensuring all are collaborating with the treating physician and the athlete, will help return the athlete to their sport as soon as possible.

Sources:

Hsu WK, Jenkins TJ. "Management of Lumbar Conditions in the Elite Athlete" J Am Acad Orthop Surg. 2017 Jul;25(7):489-498.

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