Low back pain in running-based sports.

Annotation: Low back pain is ubiquitous in all strenuous sports efforts at all levels and ages. Pars fractures (often stress fractures) require careful management and usually referral. Most complaints can be handled by the trainer and therapy methods.

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Each year, low back pain (LBP) and its sequelae contribute significantly to lost work hours and medical expenses, as well as discomfort and frustration for affected individuals. LBP is one of the most common musculoskeletal system complaints with a reported lifetime cumulative incidence of 60 to 80%. (1-3) One estimate suggests 101.8 million workdays are missed annually due to back pain related to occupation and the prevalence of lost-workday back pain among the working population is estimated to be 4.6%. (4) LBP has significant economic repercussions, and much attention has been given in the literature to the etiology and risk factors concerning work-related symptoms.

Occupational activities such as repeated heavy lifting, pulling, or rotational movements are thought to contribute to disk and facet degeneration and ultimately to LBP, (5-8) although the significance of such factors in the etiology of low back pain has been questioned. (9-11) Previous history of LBP is a known risk factor for future occurrences. (12) Smoking is considered to be a risk factor, as is the chronic cough that often accompanies such behavior. (2,13-16) Other potential factors that have been proposed include spinal biomechanics and geometry, (17,18) obesity, (13,19-21) physical inactivity, (1) and psychosocial/familial influences. (7,11)

Background

Athletes, whether recreational "weekend-warriors" or elite competitors, are not immune from back pain. Numerous investigators have studied LBP via clinical and radiographic evaluations of athletes involved in various leisure and competitive activities. (22-26) Investigations dedicated to examining relationships between LBP and factors specific to running-based sports are rare, however.

LBP is probably exposure-related and risk increases with age. Lively (27) studied over 1,000 college athletes during their initial physical examination and found only 20 young athletes (1.9%) who reported a previous history of back pain. There was no relationship between specific events and LBP. In a prospective study of musculoskeletal injuries, Glick and Katch (5) surveyed 120 adult joggers at the onset and conclusion of an eleven-week training program. Back pain accounted for 11 new injuries reported among the 108 subjects who became injured during this period. This resulted in an occurrence rate for back pain of about 10% among all injured subjects. Croft et al (20) found a slight increase in relative risk for primary episodes of LBP among women who were obese as well as in those who were involved in regular sporting activities. Jacobs et al (28) followed 1,680 runners over the course of a year and found 11% of all injuries reported among this cohort to be back related. Twenty-nine percent of these back injuries were new problems that had occurred during the year. The authors reasoned that the relatively low percentage of new complaints suggests that back problems among runners are more often chronic or episodic compared with acute injuries. In a survey of elite middle and long distance runners, nearly one third with LBP began having symptoms in their first year of training. Most (73%) who had already experienced LBP did not feel their symptoms had worsened with running. (29)

Videman et al (26) surveyed 937 former elite male weight lifters, runners, shooters, and soccer players in a study of the long-term effects of various types of exercise on back pain and back-related outcomes. Overall, LBP was less common among the former elite athletes compared with a control group of healthy, age and location-of-residence-matched males. However, the conclusions in this study should be interpreted with some degree of caution since only male athletes were evaluated. In addition, these were former elite competitors, a unique group that may 'self-select' for those who are anatomically resistant to developing LBP and thus able to withstand years of rigorous training. The study further reported that evidence of degenerative changes found on magnetic resonance imaging (MRI) was equivalent between long-term runners and shooters, whose training was generally less physically demanding than for other sports. Soccer players had a relatively increased degree of disk degeneration and bulging in the L4-S1 region.

Furthermore, compared with other sports, jogging does not appear to increase the risk for developing lumbar disk disease. Mundt et al (23) interviewed 297 patients who had developed a documented lumber disk herniation within the previous year, and compared these to matched-controls free of herniation or other back-related symptoms. They found no increase in the relative risk for a disk herniation among the 63 subjects who jogged 10 or more times in the 2 years before the development of disk problems. Their results indicated most sports were not associated with increased risk for lumbar disk herniation. Furthermore, participation in some leisure activities, including baseball, jogging, and racquet sports may be protective. Raty et al (30) found that runners did not have a significantly higher risk for LBP. There is evidence that physical and aerobic fitness are actually protective, (31-33) and that running does not contribute substantially to degenerative changes in the spine or to disk disease, either of which can lead to LBP. (23,34-36)

Although the available literature would suggest those involved in running-based sports do not experience a significantly higher risk for LBP, few studies have identified or addressed specific risk factors among those who do experience this condition. In a study published last year in the Southern Orthopaedic Journal, Woolf et al (37) sought to elucidate the prevalence, natural history, and possible etiologies of LBP among competitive and recreational runners and walkers. In this study, specific risk factors were hypothesized which might predispose certain runners and walkers to LBP despite the low risk for these athletes in general. The study population was derived from participants who registered for either a 10-kilometer run or 4-mile walk. A total of 539 event participants were surveyed about well-studied factors such as history of smoking, body habitus, and prior history of LBP. Other possible factors were also considered, including overall athletic participation, conditioning, training habits, flexibility exercises, shoe wear characteristics, and use of inserts/orthotics.

Among respondents, a previous history of LBP was reported by 74% (75% of runners; 68% of walkers), and the prevalence of LBP at the time of survey completion was 13.6% overall (Fig. 1). The mean effect reported by study participants was 3.0 and 3.4 for females and males, respectively (Fig. 2). Twenty-two percent of respondents denied any episodes of LBP at all in the past year and most of those who did have pain reported only a few episodes (Fig. 3). Consultation with some type of practitioner was sought by 54%. Physicians were seen most commonly (30%) followed by chiropractors (23%) (Fig. 4). Sixty-six percent had used medications to treat LBP at some point, with more than half using over-the-counter (OTC) forms of medications (Fig. 5). Sixty-one percent engaged in further treatment, usually in the form of exercises to stretch or strengthen the back musculature.

The use of inserts or orthotics did not correlate with either current or previous LBP, and shoe size was not a factor. Body mass index (kg/[m.sup.2]), average 10-kilometer race time, weekly training mileage, and number of days spent training weekly did not appear to correlate in any way with LBP risk. As noted in other studies, (6,19,21) regular participation in aerobic activity appears to reduce the lifetime risk for developing LBP. Runners who perform aerobics at least weekly were 13% less likely to report a prior history of LBP. Likewise, walkers who were regular aerobics participants were 33% less likely to report a history of LBP. In neither case was participation in aerobics found to reduce the risk for current LBP.

Walkers who lift weights regularly were more likely to report current LBP than the rest of the study population, and showed a trend toward having a greater risk of previous LBP. The runners who reported playing contact sports (football, soccer, basketball, wrestling, boxing, rugby) regularly were less likely to have had LBP in the past, but those presently experiencing LBP were less likely to participate than those who were pain-free. Regular participation in other athletic pursuits, including swimming/aquatics, yoga, racquet sports, bicycling, skiing, and skating did not correlate with current or previous LBP. The findings concerning participation in both noncontact sports and weight training may indicate an avoidance of participation due to LBP. Alternatively, these athletes may be exposed to other risk factors such as poor technique, poor skills, or mechanical factors related to other athletic activities.

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Evaluation of Back Pain in Athletes

A practical and systematic approach to assessing LBP in the athlete begins with a detailed history. LBP can be related to osseous, muscular, or nerve root injury (Table 1). The history will often lead the clinician to a diagnosis.

For LBP patients with trauma, chronic pain, pain at rest or bedtime, and findings that do not suggest simple muscular strain, imaging should begin with plain film of the lumbar spine. Standard views include anteroposterior, lateral, and possibly oblique images as well as an anteroposterior view of the pelvis if hip pain is noted. Supine/upright or flexion/extension views can be useful to assess stability of spinal segments. These plain radiographic studies will aid in the diagnosis of a number of osseous problems, including vertebral body fractures and insufficiency fractures, stress fractures, degenerative disk disease, scoliosis, facet degeneration, spondylosis/spondylolisthesis, sacroiliac joint involvement, osteoarthritis of the hip, infection, tumor, and metabolic bone disease.

All of the osseous elements of a vertebral body should be observed (Fig. 6). Bone scan may be useful to confirm many of these diagnoses, particularly when plain films are equivocal, but is often not necessary. MRI is indicated when findings suggest nerve root or cord involvement. However, this study is most useful after a patient has been referred to a pain management specialist or spine surgeon and intervention is considered. The MRI is most useful for planning therapeutic injections or for surgical decompression of a nerve root or stenotic spinal canal.

Most lab studies will not be helpful in pinpointing the specific diagnosis in patients with LBP. When the history and physical examination suggest other pathology, though, specific tests (ie, complete blood count, urinalysis, sedimentation rate, PPD) may be indicated. In the young male, an HLA-B27 assay may prove helpful in assessing for ankylosing spondylitis, although this condition is typically rare in the general population.

Management

The initial management of those with muscle strains, disk-related pain, and mild degenerative conditions may include a brief period of rest and restricted activity. Usually 1 to 3 days should suffice. Athletes should be encouraged to begin gentle activity and mobilize as soon as possible. Most respond well to nonsteroidal antiinflammatory drugs as tolerated. Acetaminophen can augment pain control. Narcotic pain medications may address the pain, but do not affect the inflammatory processes that typically instigate LBP. Recalcitrant inflammatory pain, such as that experienced with severe muscle strains, acute disk herniations or annular tears, may respond to a short course of oral steroids such as tapering methylprednisolone.

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As the acute pain resolves, athletes should be instructed on preventive exercises. Specific instructions should include beginning new exercise regimens slowly using proper technique, equipment, and warm-up periods; incorporating lumbar stabilization exercises in their fitness routine; maintaining aerobic fitness both on- and off-season; and practicing sport-specific lifting techniques by using hips and knees to keep the load closer to the center of gravity of the body rather than simply bending over at the waist.

An athletic trainer and/or physical therapist can be useful both for current pain management and prevention of recurrence. There must be an excellent resource for instructing patients in how to maintain a healthy low back both in and out of athletic competition.

Finally, referral to a spine specialist may be necessary when conservative measures fail to alleviate the athlete's LBP or when examination findings and imaging studies lead to the diagnosis of more serious pathology. A spine specialist should be consulted when rest, activity modification, nonsteroidal antiinflammatory drug therapy, and physical therapy fail to alleviate symptoms or when disk, facet, or sacroiliac joint pathology exists.

Conclusion

The goals of the clinician are to manage the acute episode of LBP and to minimize future recurrence so the athlete can continue his or her respective sport(s) without limitation due to pain and without fear of causing further injury. Most sports likely offer some protection against LBP, and aerobic fitness certainly has proven to be beneficial. It is important to counsel new athletes to begin slowly and work up to a competitive level. Proper technique and training are essential.

When an athlete presents with a complaint of LBP, a thorough history and physical examination are essential. Conservative measures should be initiated early in the management of LBP when indicated. Physical therapy is a useful and effective adjunct in managing LBP. Referral to a specialist is indicated after conservative measures have been exhausted and in the presence of certain conditions.

Resources

* Watkins RG (ed). The Spine in Sports. St. Louis, Mosby, 1996.

This text provides a comprehensive overview of back-related injuries and complaints in the athlete. Chapters are dedicated to specific sports and address concerns unique to individual athletic activities.

* www.spine.org

This is the official web site of the North American Spine Society (NASS). From the NASS home page, physicians and patients can navigate to the "For Spine Patients" page to find information on specific conditions as well as tips on how to maintain a healthy back.

Fig. 1 Lifetime cumulative incidence and prevalence of low back pain
among all survey volunteers and among runners and walkers alone.
Copyright [C] 2002 by the Southern Orthopaedic Association, originally
published in the Journal of the Southern Orthopaedic Association 2002
11: 136-143 and reproduced here with permission.

         Lifetime Incidence  Prevalence

Overall     73.6                13.6
Runners     75                  13
Walkers     68                  15

Note: Table made from bar graph.

Practitioner Sought

                    % of Respondents

Any Practitioner          54
Chiropractor              23
Massage Therapist         21
Physical Therapist        19
Medical Doctor            30
Acupuncturist              2
Other                      4

Fig. 4 Frequency of consultation with various practitioners.

Note: Table made from bar graph.

Medications Used

              % of Respondents

Any Meds            66
Herbal               6
OTC                 54
Prescription        28
Other                3

Fig. 5 Types of pharmacologic intervention reported for low back pain
among all survey respondents.

Note: Table made from bar graph.

Table. Differential diagnosis of low back pain (LBP) by tissue

Muscle/nerve
  Muscle strain
  Overuse injury
  Sciatica
  Nerve root impingement
  Spinal stenosis
Bone/disk
  Fracture--insufficiency, stress, traumatic
  Herniated disk/annular tear
  Degenerative disk disease
  spondylolysis/spondylolisthesis
  Facet degeneration
  Degenerative scoliosis
  Seronegative spondyloarthropathy (ie, ankylosing spondylitis)
  Hip osteoarthrosis/impingement
Other
  Infection
  Tumor
  Metabolic bone disease
  Intra-abdominal pathology (ie, appendicitis, urinary tract infection,
    pyelonephritis, nephrolithiasis, abdominal aneurysm)

Accepted May 21, 2004.

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Shane K. Woolf, MD and John A. Glaser, MD

From the Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC.

Reprint requests to Shane K. Woolf, MD, Department of Orthopaedic Surgery, 96 Jonathan Lucas Street, Suite 708, Charleston, SC 29425. Email: [e-mail]