Tag Archive for: low back pain

Lumbar Spine Stress Injuries in Baseball Players

Low back pain can be very debilitating in an athlete, especially in an adolescent baseball player trying to make it through his season. More specifically, I have noticed an increase in lumbar spine stress fractures in baseball players and it is quite disturbing and frustrating!

I wanted to dive deep into this rabbit hole, as I always do. Low back pain is way too common in youth athletes. I wanted to know why it’s happening so often and try to figure out a solution for my clients.

It can get complicated so I will try to simplify the process.

My goals:

  1. What is a stress fracture or a stress reaction?
  2. How common is this injury in youth sports compared to other sports and age groups?
  3. What is the typical clinical presentation?
  4. What are some clinical tests that PT’s can use in the clinic?
  5. Demonstrate a typical treatment of a young athlete with a low back stress injury?
  6. What are the expected outcomes?

Pain is Complicated

Low back pain can take on many etiologies. Pain, in and of itself, is extremely complicated and very personal.

It can manifest in different ways for each person. In this post, I want to talk about the athlete with an acute injury. Specifically, the youth and adolescent baseball player.

Many factors can contribute to someone’s pain including stress, anxiety, medical history, their environment, support system, etc.

This topic is a bit more personal because of what do on a daily basis. I see a ton of youth athletes with a variety of injuries. Plus, I was diagnosed with spondylolisthesis (bilateral fracture in the spine and some shifting of the vertebral body) while a junior in college so I’ve lived it myself!

Recently, I’ve started to see a lot more athletes with low back pain as a result of a stress reaction or fracture. It really made me wonder what was truly causing this in the 12-18 year old athlete.

Video example

courtesy of pitching coach Anthony Meo of The Farm Baseball Waltham, MA

As you can see in the video, the pre-injury video shows how long the pitching motion is for this athlete. His throwing arm is wrapped around his body which forces him to keep his weight back.

His arm is trailing his body significantly and he tries to make up for it by hyperextending his back. His timing is way off and his arm is not keeping up with his forwardly moving body.

You can see in the post-injury video that he is much more balanced. His arm also has better timing with his body. He is driving toward home plate with his lower body while maintaining a better upper body sequence

There are many issues going on here but you can see the significant changes that were made after the injury to help him improve his mechanics and hopefully prevent a future injury.

LUMBAR STRESS INJURIES DEFINED

Stress Reaction Defined

Basically, a stress reaction is the early breakdown of the bone without a clinical diagnosis of a true fracture. Often times, a suspected fracture will be diagnosed as a stress reaction. On MRI, there is only edema noted in the area and not a true fracture.

I hear a lot of people talk about fractures in different terms. Simply stated, a fracture is a crack, break, defect in the bone. Whether it’s a hairline fracture or a gross disruption of the bone may determine prognosis but the bone has been compromised.

taken from: Link
taken from: Link

Obviously pain is an early sign but it needs to fit the clinical presentation. Has there been a history of excessive activity or a change in the volume of playing?

Factors to consider in a baseball player with low back pain

I usually have to dive a bit deeper into the player’s life to figure out the root cause. It’s often something very overlooked but is often the main contributor.

These are just some, off the top of my head, that may be involved in the athlete’s predicament and that may nee to be changed.

It is an early indicator that something is wrong and it can progress to a stress fracture if not carefully treated. We’ll talk treatment later on so be patient!

How common is a stress reaction in youth sports?

As with any research, it is quite mixed and will heavily depend on the sport that you are tracking. From what I can see, if a kid has low back pain for greater than a week, then that’s a pretty good sign that a more serious injury may be present.

For example, this retrospective case study from 2017 showed that 30% of pediatric cases with low back presenting to this hospital were diagnosed with spondylolysis.

Specializing in a single sport was not associated with an increased risk of spondylolysis when compared with multisport athletes. Male athletes were 1.5 times more likely to have a spondylolysis than female athletes.

Males with LBP who participated in baseball had the highest risk of being diagnosed with a spondylolysis, followed by soccer and hockey.

Females with LBP who participated in gymnastics had the highest risk of spondylolysis, followed by marching band and softball. I will refer to my good friend Dave Tilley and his website for his professional judgment on this one. Based on what I see at our facility, I’m not surprised.

As I usually tell my clients and their families…I’m going to treat this as a spondy until proven otherwise.

More Research on Spondylolysis Prevalence

According to recent research, it looks as if persistent pain for 1-2 weeks is associated with a positive MRI diagnosis for spondylolysis in 33-40% of the kids scanned. You can read the abstracts here and here if you’re interested in more.

This study out of New York showed that the most common athletic activities associated with spondylolysis were:

  • Soccer (19.3%)
  • Basketball (17.2%)
  • Lacrosse (9.4%).

Of note, 71% of the children in this study were male and the most common level to have the spondy was at L5.

Do keep in mind that false positive results are pretty prevalent in patients getting an MRI for low back pain.

Don’t treat the MRI (or x-ray!)

This systematic review looked at the incidence or prevalence of incidental findings on MRI in asymptomatic pediatric patients. The results are pretty eye-opening too!

  • Degenerative disc disease (prevalence 19.6%)
  • Disc herniation/protrusion (prevalence 2.9%)
  • disc height/narrowed disc space (prevalence 33.7%)
  • Spondylolisthesis/spondylolysis (prevalence 2.3%)
  • annular tear and/or nerve root compression (prevalences ranging from 4.5-51.6%)

Pretty amazing to see the prevalence of false positives read on an MRI in a pediatric population. We need to be able to clinically diagnose these first then use the MRI scan to further determine a course of action.

Baseball specific injury rates

In this study from 2015, the proportion of High School baseball players with a low back stress fracture was 3.3%. So, a typical AAU baseball club of 100 kids will have 3 kids that have a stress fracture.

They also reported that High School girls sustained more stress fractures (63.3%) than did boys (36.7%) but for overall injuries and not just in the low back. This seems consistent with what I see in my practice, as well.

In college, 12.1% of the stress fractures noted in this NCAA study from 2017 were in the low back. Women experienced stress fractures at higher rates than men, more often in the preseason, and predominantly in the foot and lower leg.

Baseball Specific low back pain

This nice review of the literature discusses low back pain in general athletes. They went on to further discuss baseball and “the asymmetric baseball postures and motions lead to asymmetric spondylosis in right and left sides and cause mechanical degeneration in intervertebral discs.”

In this study, “students who played baseball were 3.2x more likely to experience LBP in their lifetime only behind volleyball which had an odds ratio of 3.8. 

The repetitive nature of the baseball specific movements and a preponderance to specialize in one sport can definitely affect these injury rates.

The role of mental stress and low back pain

The role of stress, particularly mental stress on bone development, has been studied too. Our teenage athletes are under a tremendous amount of stress at home and socially. This study from 2017 discussed the emerging concept of mental stress as an important player in bone adaptation and its potential cross-talk with physical stress.

Essentially, mental stress can have a negative impact on normal hormone production. Hormones are needed to maintain normal bone health. A shift in normal hormone regulation can negatively affect a youth’s growth and healing capabilities.

They went on to say that there is “compelling evidence has recently emerged that biochemical and psychoneuroendocrinological maladaptations caused by mental stress are not only also relevant for bone quality, but may furthermore considerably interact with physical stress.”

Clinical Presentation of a Spondylolysis or Spondylolisthesis

Clinically, pain is the guide here. It’s often described as a pretty sharp pain that is localized to the site of the injury.

There is rarely a referred pain down the leg or the buttocks. The pain is often close to the spine at the level of the injury.

In this study, activities involving repetitive hyperextension and/or extension rotation of the lumbar spine were described as painful in 98% of the patients.

Pretty powerful statement. In my examination, I look to recreate these symptoms with these exact movements.

Many use a single-legged position, also known as the Stork Test, to test for spondylosis. I’ve simplified the test to just include regular standing on 2 feet to simulate regular daily movements.

A standing extension test can also be used to assess end range extension and rotation irritability. I find this test (see video below) is a great way to begin to hone in on a diagnosis.

I find that pain in full hyperextension and rotation is a pretty powerful indicator of a stress reaction or fracture. It is similar to the standing position that I described above. However, the prone position takes the postural component out of the picture and may help to better isolate the location of the lesion.

I also like to have the patient get in the prone position and use different levels of active extension to help guide my clinical examination.

Again, people will report pain that is very close to the spine and that replicates their pain.

Any young athlete with low back pain for greater than 1 week should be assessed for some kind of bony issue in their low back.

That’s not to say that we will always find something.

But I just think that in younger athletes, this prevalence is all too common and needs to be ruled out to prevent further low back issues.

Treatment for Spondylosis in Baseball Players

Muscle tenderness too

Patients will usually have tenderness right at the region in which they have pain. I suspect it’s the muscles that stabilize those lumbar segments.

The multifidi and most likely quadratus lumborum are often implicated. Soft tissue work of any kind can have positive effects on muscle tightness. The athlete should perform some self-myofascial release with a foam roller or light pressure with a baseball in the affected muscles.

Manual therapy can also be utilized to feel tissue density and help to pinpoint the exact location of their muscle soreness. By utilizing this, I can help to better educate the athlete for their home exercise programs.

Manual Therapy can be helpful

In this photo below, you can see I am applying direct pressure with my elbow right into the muscles of the low back. The patient will usually give me feedback and tell me if I am in the right area. Muscle soreness is often detected and after a short amount of time, the symptoms should decrease.

In the short term, manual therapy can help with some of the acute symptoms. For long-term changes to occur, activity modification and exercises that involve low back, hip and core strengthening are critical.

Soft tissue work to the muscles of the low back in an athlete with low back pain.
Soft tissue work to the low back in an athlete with low back pain.

My treatments for kids with low back pain are pretty simple. I want to rest them from the repetitive activities, such as swinging a bat or even throwing a baseball.

Brace or no brace?

Also during this time, the athlete will most likely have to wear some form of a back brace to prevent excessive lumbar extension and rotation. One particular brace is called a Boston Brace. It was developed by doctors at Children’s Hospital in Boston, MA.

The research is unclear and can favor both methods of treating with or without bracing. A study in 1986 showed that bracing ‘restricted at least some gross body motion to approximately ⅔ to ½ of no-orthosis values.’ The restrictions we’re most pronounced when wearing a larger Thoracolumbosacral orthosis (TLSO) versus just a corset.

If the goal is to restrict motion, then it seems as if a brace will accomplish that. Most research shows about 40-65% restriction in motion no matter the brace. This paper showed similar findings as well.

Here’s a version that our local docs have been using that is less cumbersome and not as embarrassing to wear as a teenager!

Brace used to help restrict motion during a low back stress fracture
Brace used to help restrict motion during a low back stress fracture

These are just some of my quick and easy exercises to help promote movement in the spine.

Obviously, I want to avoid painful motions like lumbar hyperextension and rotation. I still want to promote some sort of motion to build confidence and promote muscle recruitment in that area.

Specific treatment ideas for low back pain

I like foam rolling or some form of self-myofascial release to the area. This will help the muscles to feel better if done multiple times per day. See the video below

Some would say motion is lotion and I tend to agree! I like to use active range of motion through the cat-cow video below.

Cat-Cow exercise to promote active motion in the low back

Some general guidelines for returning to baseball

From what I’ve seen, most baseball players need at least 3 months of active rest.

I’ve written about my general low back treatment philosophies in a previous blog post.

You can find that post here .

Active Rest is key

I generally want to begin a general strength training program at around 6-8 weeks following the diagnosis. It Is critical to include restricted range of motion exercises to avoid painful hyperextension. These exercises are restricted to avoid excessive extension that may place extra stress on the low back. I prefer to bias flexion type exercises like squats, lunges and step-ups.

I like to closely monitor their form and symptoms. We don’t want any pain at all in that region…a very important concept!

I like to perform these exercises for at least six weeks to get a good base of strength in the lower body and core.

Lose the brace at 12 weeks

At about 12 weeks, they will come out of the brace and we can begin to be a bit more aggressive in our strengthening. Again, we are avoiding hyperextension type movements in the low back. We prefer to stay in a flexed or neutral spine as much as possible.

I also like a supine dead bug exercise to promote a flexed spine with active motion. See the video below.

Throughout this time, we encourage cardiovascular exercises that involve the stationary bike. This seems to be a safe modality that allows the athlete to work up some sweat but also maintain a relatively flexed spine, which is usually pain-free.

Unrestricted activities at 5-6 months

At around 5 to 6 months post-diagnosis, we encourage for pain-free activities that involve strength training for the whole body. There are no limits in range of motion in the athlete is free to work out. We then encourage more functional activities that involve rotation. This will allow them to replicate the motions involved with hitting and throwing.

Return to sports at 6-8 months

On average, it seems as if a patient recovering from a low back stress fracture will need at least 5 to 6 months before I would feel comfortable having them return to their support. These injuries usually happen in a younger population so the risk for re-injury is pretty high if they return to their sport too quickly.

I believe the risk is high because of their underdeveloped muscular system. Their bodies are growing and tremendous stress may be placed upon their joints with excessive activities. A slow progression back to their sport is critical.

Concluding thoughts on stress fracture injuries in youth athletes

Baseball players face numerous challenges during their training.

As you can see, numerous injuries can result and not just to the shoulder and elbow.

Low back pain injuries are all too common but are often preventable. It seems as if the volume of throws and hits may play a huge role. It is up to the coach, physical therapist, or athletic trainer to monitor this workload for each athlete.

There is no exact science but listening to the athlete is critical. A well-balanced training program that addresses some of the obvious weaknesses is key.

Treating Patients with Low Back Pain

My thoughts on treating low back pain

As many of you may know, I have been practicing physical therapy since 2003. Throughout that time, the clear majority of my patients have had injuries to their extremities. Yet, I somehow was able to ‘avoid’ treating patients with low back pain (LBP). As has been with most of my career, I wanted to share my thoughts on treating low back pain and how I went from completely confused, to utterly intimidated and finally to embracing a common injury.

My early years of LBP rehab and confusion

When I first graduated from PT school, I worked in an outpatient sports medicine practice in North Carolina. I saw a little of everything. There, I was mentored by a very senior PT who specialized in low back pain.

She tried to introduce me to the rotated innominate (didn’t even know what that meant at the time) and how she could fix people with those issues. I looked at the charts of her patients and they had been coming for years.

To me, that seemed like they trusted her and she was helping them. Then I realized quickly that maybe there was more to the story. Maybe she was or wasn’t helping them, but I could never say anything. Something was working so this new grad just went with it.

She would spend hours of her time explaining the pelvis and how we could influence its position. My mind just couldn’t grasp the biomechanics. To this day, I think I’ve blocked out many of the concepts because they just didn’t make sense to me.

They even sent me to an Institute of Physical Art class out in western NC. Again, I couldn’t grasp it which is ironic because I’m very much a biomechanics type guy when it comes to the extremities.

The back was just a mystery to me!

Nothing against the IPA course, but it didn’t jive with me. I just couldn’t apply it to my patients when I didn’t understand it in the 1st place.

Going back to my rotated innominate… I just faked it that I could feel the sacral torsion or the elevated ASIS.

As a new grad, I didn’t want to seem like my palpation skills sucked so I went along with the process. I just never applied it to my patients. I just did exercise with them, because that’s all I knew.

The Evolution of my LBP Fear

When I moved to HealthSouth in Birmingham, AL we had a separate spine department that was run by 2 PT’s. You know what that meant, I didn’t treat any spine patients!! Not sure why they did that, but I wasn’t going to complain.

This trend continued on when HealthSouth had a little accounting issue and Champion Sports Medicine was founded in late 2004.

Again, no spine patients on my schedule for ~ 10 years. Rarely, a patient would be on my schedule for more than a visit or 2 before I’d move them to the “Spine PT.”

Spine Scaries

I just didn’t have an interest in the spine and from what I had seen and heard, I didn’t agree with many of the ‘theories’ out there. I watched other PT’s look for limitations in individual spinal segments from the cervical spine to the sacrum…and even the coccyx (mind blown!).

Any time someone tried to teach me their assessments, I could never feel what they were feeling. No one felt limited or rotated unless I pushed a little harder with one thumb, then all of them were ‘rotated.’ I’m right handed so everyone seemed left rotated because I could push harder into the patient’s anatomy with my right hand.

So again, my faith in spine rehab dwindled and I built my practice around sports medicine and post-op injuries. That’s my niche but I knew that when I moved to Boston to help open Champion PT and Performance that I would have to make my skills better.

My current Approach to low back rehab

My career has been about simplifying my approach to physical therapy. In my earlier days, people were trying to help me (definitely grateful) but conceptually I just couldn’t grasp it.

I knew that there were very small the joints in the spine, but I just couldn’t ‘feel’ the millimeter or 2 of motion that was present. My palpation skills were dismal, but it turns out we may not be able to palpate what we think we’re palpating. (research) (More research) (even more research)

With that, I needed a game plan for my big return to my hometown, Boston.

My Macro Views

In my head, I could conceptualize watching someone move and trying to figure out if a movement dysfunction was the culprit. More of a macro view of the person instead of a micro view, like looking at individual joint segments.

My macro approach often came back to a strength issue or a simple overuse issue that led to back pain. We often blow this off and don’t account for it in our education and treatment.

Don’t Overcomplicate it!

In PT, we try too hard to complicate things.

Let’s think about it, if someone has pushed their tissues beyond their physiological limits (whatever that means), then something has to give.

In my opinion, most people that I see have overuse injuries as a result of overactivity or inactivity. It’s that simple. They’ve either pushed their muscles/joints beyond their capacity and the body is giving a warning.

Or they just don’t do enough to maintain, and the body is pissed off.

Answer in the details

For example, I see many people with non-specific low back pain that are active. Either playing baseball or working out. But, when you dive a bit deeper into their lives, they may have just started a new program that had more volume (weight training volume, more swings of the bat, more deadlifts).

It’s often stories of their (in)activities that are directly contributing to their current state. Never mind if you dive even deeper, then they reveal a stressor in their lives that MAY also be adding to their pain.

I am certainly not a pain science expert, but I can add up 1+1 and realize that life stress + physical stress can play a HUGE role in someone’s experiences of pain.

How I treat Low back pain

So what I do is pretty simple.

I assure my patients with lots of education and encourage early motions. Like any other joint, our body needs to move. Our joints need to move.

The last thing I want to do is discourage someone from moving.

I need to create an environment that is relatively pain-free and creates confidence in their ability to move. Trust me, I’ve been there!

What helped me, you ask?

I had an acute low back spasm a few years ago that was awful!

Advil, foam rolling my low back (what seemed to be my quadratus lumborum), soft tissue work to my low back (again, maybe my QL) and general low back/hip muscles and exercises. No one told me that I had a rotated innominate or that I had too much motion at L5/S1.

I don’t even know what that means.

All I did was try to move each day with a little less pain. I did things like Cat-Cow and dead bugs. I also did clams and bridging. I stretched my hip flexors and tried to squat a bit. I just did anything to promote a safe and pain-free movement.

It built confidence and it built function.

Most people need that after they hurt their back. I know we’re always looking for the reason why the pain occurs. We try to blame the anatomy or the biomechanics because we’re ‘movement experts’.

Keep it Simple

But I say we need to take a step back and realize that it can be even simpler than that. If we sit 8 hours a day, then we’re stagnant and our tissue capacity dwindles. Imagine sitting all day then randomly try to go play 18 holes of golf!

The muscles, tendons, ligaments and anything else in that area are not conditioned for the 90+ strokes it will take to finish the frustrating round.

You wouldn’t try to run a 10K without training for it 1st. Your legs and the cardiovascular system just wouldn’t allow it.

It’s the same thing with the concept of sitting all day then trying to be active. It often won’t work. You need to train the tissue!

Final Thoughts on Low Back Pain

If anything comes out of this blog, I hope it takes some of the scary thoughts that are out there and simplifies them a bit. The human anatomy is so much more complicated than we think. We can’t just blame a rotated innominate or left rotated lumbar spine segment for the dysfunction.

All of the systems seem to play a role but as PT’s we think we can control a couple of them.

I say build tissue capacity by a general strength training program that builds confidence in the client. Let them leave feeling super positive about themselves and I guarantee that your outcomes will be so much better.

No worrying about fake palpation, popping backs and charts that are years deep of short term relief. Hope I didn’t offend anyone but sometimes the truth hurts and I want my readers to hear my simple perspectives.

Now get out there and embrace your next low back pain patient (but don’t worry about the cavitation!)

The Week in Research Review, etc 12-24-18

The Week in Research Review, etc 12-24-18 only had two posts to social media this week but hopefully two very helpful posts for your practice.

The back pain post was a repost from a previous time but I thought it was very important to share it again. I also put a new post from my YouTube channel where I discussed patellar mobility assessment for instability. Check the post out at the link here or below to see the full version.

Physical Therapy First to Treat Low Back Pain

[ICYMI} Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Frogner et al Health Serv. Res. 2018

The Week in Research Review, etc 12-24-18This study compared the differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist as the first point of care, at any time during the episode, or not at all.

Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period.

Patients who saw a PT first had:

  • a lower probability of having an opioid prescription (89.4 percent),
  • any advanced imaging services (27.9 percent),
  • and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization.

Interestingly enough, 80% of the patients in the sample had no PT at all. Furthermore, 8.7% saw a PT first and 11.5% saw a PT later (avg 38 days). The most common provider seen 1st was a chiropractor.


Assessing for Patella Instability

Assessing Patella Mobility

💥Assessing for Patella Hypermobility💥

This Instagram snippet shows how I assess a patient with suspected patella hypermobility who may have sustained a subluxation, dislocation or instability episode.

To see the full video at my YouTube Channel, click the link here!

Basically, we’re looking at how mobile the patella is when the knee is locked at full extension compared to when the knee is flexed to about 25 degrees.

Normally, the patella should become relatively stable when the knee is flexed to 25 degrees because it engages the trochlea groove.

In patients with underlying patella hyper-mobility, the amount of mobility with the knee slightly flexed will be similar to when the knee is in full extension (and not locked into the trochlea groove).

This is often the case when the patient’s trochlea groove is too shallow to offer bony stability.

The test should help the clinician gain a better understanding of the patient’s anatomical make-up and prognosis for the long term.

Check out the full video at my YouTube Channel.