Sports Medicine: Just the Facts

INTERVERTEBRALFORAMEN

• The foramen lies between the pedicles of adjacent
  vertebra.


• The AP diameter is larger superiorly.
  •Nerve roots emerge in the upper portion and the inter-
  vertebral disc occupies the lower portion.


• This is clinically relevant because with respect to disc
  herniations, posterolateral herniations frequently will
  spare the nerve in the foramen because of this
  arrangement and will impinge on the roots that
  emerge from the lower intervertebral foramen.

LIGAMENTS

• The anterior longitudinal ligament traverses the axis
  to the upper sacrum and prevents hyperextension.


• It is twice as strong as the posterior longitudinal liga-
  ment.


• The posterior longitudinal ligament helps prevent
  hyperflexion.


• It is broader in the cervical region than in the lumbar
  region.


• Because of this narrowing, the lumbar region tends to
  be more susceptible to disc herniations as there is an
  inherent weakness in the posterolateral aspect of the
  intervertebral disc.


• Ossification of this ligament can contribute to spinal
  stenosis.


• The ligamentum flavum attaches lamina to lamina.


• It is continuous with the anterior capsule of the
  zygopophyseal joint and helps to resist flexion.


• This ligament can buckle and impinge on the spinal
  canal when there is intervertebral disc degeneration.


• The supraspinous and interspinous ligaments lie
  between the spinous processes and resist flexion and
  are generally weaker ligaments.

SPINALMUSCULATURE

• There are multiple vertebral column muscles and when
  describing them, they are often divided into layers.


• The most superficial layer can be divided into the
  trapezius, latissimus dorsi, and lumbodorsal
  fascia.


• The next layer can be divided into the levator scapu-
  lae, and the major and minor rhomboids.


• Below that layer is the erector spinae muscle group
  consisting of the spinalis, semispinalis, longissimus,
  and iliocostalis.


• The deepest layer can be divided into the multifidi,
  rotatores, and intertransversarii (Greenman, 1996).

NERVES

• The anterior primary ramus forms the lumbosacral
  plexus innervating the lower extremity muscula-
  ture.
  
  
  • The posterior primary ramus forms the cutaneous and
    muscular innervation to the back, erector spinae,
    fascia, ligaments, and facet joints.
  
  
  • The sinuvertebral nerve supplies the posterior and
    anterior longitudinal ligament, dural sac, posterior
    annulus fibrosis, and posterior vertebral body.
  
  
  
  

DIAGNOSTICASSESSMENT

• An assessment of an injured athlete or patient with
  low back pain should be comprehensive and deter-
  mine whether the injury is attributable to a traumatic
  or overuse mechanism.


• Please refer to Table 42-1 for historyand physical
  examination.
  •Evaluation of the entire lower extremity kinetic chain
  is a key component of the physical examination as
  distal involvement may result in future low back
  injury and residual functional deficits (Nadler et al,
  1998; 2002c).


• It has been determined that athletes with lower
  extremity acquired ligamentous laxity or overuse
  may be at risk for development of noncontact low
  back pain during athletic competition (Nadler et al,
  1998).
  •Effective diagnosis and management of athletes with
  low back pain must include an understanding of
  which injuries are often associated with particular
  sports and with the relative age of the athlete (Keene,
  1985).

X-RAYS

• X-rays can help to rule out fractures, dislocations,
  degenerative joint disease, spondylolisthesis, nar-
  rowed intervertebral disc joint space, bony disease,
  and tumors.


• An oblique view may be helpful for evaluating the
  neural foramina.


• Flexion and extension views are useful for evaluating
  subluxation and stability.

CT SCAN

• CT scan is useful for evaluating spondylolysis, herni-
  ated nucleus pulposus, neoplasm, facet arthrosis,
  spinal stenosis, and osteoporosis.
  •Overall, it is better for bony evaluation than a mag-
  netic resonance imaging (MRI).

MRI

• MRI is useful to evaluate a herniated nucleus pul-
  posus, neoplasm, spinal stenosis, and spinal infec-
  tion.
  •Overall, it is better for soft-tissue evaluation than a
  computed tomography imaging (CT scan).

250 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE