Sports Medicine: Just the Facts

• Synergistic activity of the right external oblique and
  the left internal oblique, along with the transver-
  sospinalis is demonstrated during rotation to the left
  (Sward et al, 1991).

DIFFERENTIAL OF BACK PAIN

• Muscle strains and sprains are common and can occur
  at any age and with any sport.


• Gymnasts and divers may experience interspinous
  process bursitis or stress fractures of the pars interar-
  ticularis (Keene, 1985).


• Swimmers, in particular those who swim the butterfly
  stroke, and weightlifters with upper thoracic or
  lumbar pain, may be diagnosed with a Scheuermann’s
  kyphosis (Keene, 1985).


• Spondylolysis—caused typically by repeated hyper-
  extension with wrestlers, ballet dancers, gymnasts,
  divers, and polevaulters—has also been found to be a
  cause of low back pain in swimmers (Nyska et al,
  2000; Gainor, Hagen, and Allen, 1983).


• Skiers, especially young elite alpine skiers and ski
  jumpers, demonstrate significantly higher rates of end
  plate lesions and this may be attributable to excessive
  loading and repetitive trauma of the immature spine
  under high velocity situations and performed in a for-
  ward bent position (Rachbauer, Sterzinger, and Eibl,
  2001).


• There have been case reports of football and rugby
  players with thoracic spine fractures, and rugby play-
  ers with acute disc prolapse (Bartlett and Robertson,
  1994; Davies and Kaar, 1993; Elattrache, Fadale, and
  Fu, 1993; Geffen, Gibbs, and Geggen, 1997).


• It has been reported that with respect to athletes with
  disabilities the most commonly injured area is the
  thorax and spine, generally secondary to a sprain type
  mechanism of injury (Ferrara et al, 2000).
  •Lastly, athletes of all ages and sports, with persist-
  ent midline lumbar pain, may have a disc injury or
  chronic instability secondary to a fracture of the
  vertebral body or posterior elements (Keene, 1985).


• Please refer to Table 42-2 for differential diagnosis.

GENERAL TREATMENT

CONSIDERATIONS

•With respect to modalities, more recently benefits

have been found with the use of a continuous low-

level heat wrap (Nadler et al, 2003).

• Core conditioning has recently come into prominence
  with focus on the stabilization of the abdominal,
  paraspinal, and gluteal musculature in order to improve
  the stability and control during sports participation.


• The theory behind core conditioning is based on past
  studies that have demonstrated the importance of pelvic
  stabilization in training (Pollock et al, 1989; Jeng,
  1999).


• At this time core conditioning has not yet been corre-
  lated to decrease the incidence of low back pain in the
  athlete; however, larger studies are required (Nadler
  et al, 2002a).
  •Overall, aggressive rehabilitation using nonoperative
  intervention and education should be the focus
  (Spencer and Jackson, 1983).
  •Surgical intervention is rarely necessary and should
  be reserved strictly for problems that are refractory to
  nonsurgical measures (Stanish, 1987).


• The goals of treatment for athletes are also different
  from the general population.


• The primary goal in athletes who have experienced
  an acute episode of low back pain is pain modulation
  and return to play and with episodes of chronic low
  back pain, return to play and the prevention of recur-
  rence are the primary concerns (George and Dellitto,
  2002).


• Return to play can be gradual and steady, and previ-
  ous performance levels can usually be obtained
  (Spencer and Jackson, 1983).

CLINICAL SYNDROMES OF THE

THORACIC SPINE

THORACIC DISC HERNIATIONS

• Thoracic disc herniations are often difficult to diag-
  nose and to treat.


• The thoracic spine anatomy is predisposed to
  impingement of the spinal cord secondary to its small
  ratio of thoracic canal area to spinal cord area.


• The incidence of clinically significant thoracic disc
  herniations is estimated at less than 1% of all disc rup-
  tures (Errico, Stecker, and Kostuik, 1997).


• The number of asymptomatic thoracic disc hernia-
  tions may have a prevalence of 11–13.3% (Errico,
  Stecker, and Kostuik, 1997).

252 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE

TABLE 42-2 Differential Diagnosis

Myofascial pain Sacroiliac dysfunction Herniated nucleus
pulposus
Facet pain Spondylosis/Spinal stenosis Spondylolysis/
Spondylolisthesis
Osteoporosis Neoplasm Paget’s disease
Radiculopathy Congenital vs. Developmental Medical (other)