Welcome everyone to this installment of the National Fellow Online Lecture Series on St. Patrick's Day this week. So before we get started, I do wanna plug the next lecture, which is going to be on March 23rd at 3 p.m. Eastern time. It's gonna be on patellar and quadriceps tendinopathy. And Dr. Ken Moutner, who's with me here at Emory, will be the speaker. And he will teach all of you everything that I've taught him or the other way around. So today we have the honor of having Dr. Ellen Casey speak with us about low back pain in the athlete. So Dr. Casey is one of the team positions with the USA Gymnastics Women's National Team. She's Associate Professor of Physiatry and Sports Medicine at Hospital Professional Surgery in New York City. And you can see her Twitter handle down there. I'm Robbie Bowers. I'm a sports medicine physician and physiatrist here at Emory Sports Medicine in Atlanta. And I'll be moderating today's lecture. So just some housekeeping that we go through before each of these. This is to serve as an adjunct for your individual programs, educational programming. It's not to take the place of anything that you're gonna get through your program. And it's to help assist fellows in CAQ exam preparation. So you'll be muted during the course of the lecture today. Put your questions into the chat function and then we'll get to those at the end of the lecture. So as we go along, if you have any questions, just put it in the chat function and then I'll go through those at the end of the lecture today and go through them with Dr. Casey. And then after the program is complete, if you can please do the evaluation as well. So with that said, today's lecture on low back pain in the athlete, Dr. Ellen Casey. I will let Dr. Casey take it away from here. Okay, great. I'm gonna share my screen with you. Just let me know when you see that come up. Yep, looks good. Okay, perfect. All right, so wonderful to be with you all today. And we're gonna spend the next little bit of time talking about low back pain, really mostly in the adult athlete. And I'm gonna specify that because we are not gonna be talking about spondylolisthesis or spondylolisthesis in this talk as that, as you can imagine, is a talk in and of itself. And so I'll just advance here. Oh, so the objectives for the next hour are to spend a little bit of time reviewing the anatomy and biomechanics of the lumbar spine and what we know about how common low back pain is in athletes and what some of the risk factors are. We're gonna spend more time on some practical topics like what do you take into clinic the next time you see a patient with back pain? So that's really gonna talk about using the history and the physical exam to identify the most accurate pain generator and then how that drives your treatment. And specifically, how do we tailor that to an athlete's sport or activity or goals? So as you all know, this concept of the kinetic chain is extremely important in sports medicine. And it really starts from our proximal stability. And certainly the spine is a big component of that. As you probably are aware, when you go to throw a ball with your right hand, let's say the very first thing that happens in that chain of events is that you contract your transversus abdominis on the left side to stabilize the spine and then obviously do your complete throwing mechanism. So proximal stability we know is critically important not only to protect the spine itself, but protect the further distal segments like the elbow, the wrist, the knee and the foot and the ankle. And so that's really why beyond back injuries in and of itself, the spine is so integral to sports medicine. If we look at the epidemiology, excuse me, of low back pain just in all comers, not athletes, we know that it's extremely common. Up to 80% of the general population will have an episode of low back pain in their lifetime. The great thing about back pain is it often gets better. The bad thing about back pain is it usually recurs. So you need to educate patients even on that first episode for ways to prevent it and hopefully minimize future occurrences. Anywhere from three to 10% of patients with episodes of low back pain are less like that up and down kind of intermittent flares, but actually go on to develop more chronic pain. So that certainly can be a big component of disability. And we know low back pain is the most common cause of job related disability in the United States. If we think about athletes specifically, a couple of different studies, and these are older studies. There's not a lot of apparently interest in doing epidemiology studies in low back pain in athletes recently. So that's a great idea for future work to redo some of these. But what we know is that low back pain constitutes about 15% of all athletic injuries. Almost 10% of collegiate athletes report being treated for low back pain in any given time in college or across a competitive season. There are some studies that suggest that low back, or sports is a risk factor for low back pain. Like this one that shows that 45% of athletes report low back pain compared to 18% of sedentary population. However, we also know that being sedentary is not ideal for the spine. So it's certainly not a reason to participate in sports, but yet another example that this is common. And when we look at football players in particular, which is relevant to the case that I'll present, low back pain accounts for lost playing time in approximately 30% of college football players. So it's certainly a big issue. Rates of low back pain, though, differ by sport. As you can imagine, the mechanisms that you're asked to do in any given sport might relate itself to lower or higher rates of back pain. No surprise that in gymnastics, it's extraordinarily high, up to 80% of gymnasts report back pain, probably 100% if you ask across their careers. Wrestling, also pretty high, up to 60%. And then in the 30 to 40% range, we have sports like tennis, football, weightlifting, and golf. The more time you're spending doing these sports and certainly like professional level golf, probably these rates are far higher, but this is sort of all comers across all levels of expertise. So why is the diagnosis challenging? Well, because there's multiple pain generators in the spine, but also outside of the spine that can mimic back pain or have overlapping pain patterns. And we'll talk more about that in a few slides. Also, there can be coexisting pathology. You might've heard of, for example, the hip spine syndrome, which in golfers, for example, can be important. So you can have arthritis in the spine and arthritis in the hip, and they can sort of drive each other. If you're limited in your hip range of motion and you're a golfer, you're gonna need to get more motion from your back and that may load your facet joints, for example. So you can have different areas of pathology interact with each other. Imaging findings might not be helpful, and we'll talk more about that later on in the talk. And then an athlete's perception of the pain, what the injury means to her performance or his goals is really an important part of any pain picture, but low back pain, certainly this comes into play. So when we think about kind of a broad range of causes for back pain, it's often helpful to try to put patients in buckets that you think they fall so that you can refine your differential. So in athletes, overwhelmingly, we're gonna be talking about mechanical low back pain, but you do need to consider non-mechanical, so cancer infection and rheumatologic conditions, and certainly visceral organs can refer and mimic spine conditions. So we don't wanna forget those, but today we'll be focused on mechanical low back pain. This is not a completely comprehensive list, even though it's kind of long, there are other pain generators, but these are things that we're gonna commonly see in athletes, and even though, like I said, spondylolisthesis is on this list, we won't be talking about that today. So when you see in your EMR, you've got an athlete with back pain, the things that I think are the most helpful before you walk into the room are to think about, okay, how am I gonna sort out with my history, what's going on? And pain location is a really great place to start. So we say the back, but what we wanna know, is it just in the back or is it axial low back pain? And in that case, then we're thinking of things like a muscle strain, a sprain of a ligament, potentially like the supraspinous or interspinous ligaments, disc pathology, spondylolisthesis in a younger person, a ring apophysis fracture, especially if the ring apophysis has not fused, facet or zygopapaseal joint, arthropathy, which you can see, you think arthropathy is gonna be in old people, but you can certainly see it in quite young athletes. And then something like Bostrop's disease, which is the idea is kissing spinous processes. So you usually see it in older patients where the disc has degenerated, there's less space between the vertebrae and the spinous processes and with extension, those bump into each other, but you can see it in young gymnasts, for example, doing a lot of repetitive extension. So those are the kinds of things, if you look at their pain diagram and you know that the pain is just in the back, this is where you wanna sort of focus your history taking an exam. However, a lot of times there will be radiating pain. And so clarifying, is there both back and radiating pain? If so, how much is in the back? How much is in the leg? And then where in the leg is important? But if we know that it's radiating pain, you can think about a nerve root problem or radiculopathy, which we'll talk much more about. Discogenic pain certainly can be in the back, but it can refer as well into the lower limbs. Facet or zygopaphyseal joint pain also has what's called sclerotomal referral patterns, that have been well-established and that can go into the sort of the buttocks and the upper thigh. The sacroiliac joint, while not technically part of the spine is certainly that connector between the lower limb and the spine, and that certainly can be in the buttock region, but also radiate and as well the hip joint can. So if you look at these pictures, this just gives you an example of, let's say an athlete comes in with low back and right buttock and a little bit of posterior thigh pain. Well, if you look at the picture here, hopefully you can see my cursor over radiculopathy, that's an example of what an S1 radiculopathy might look like. But here the facet joint, as I mentioned, can refer down the leg and into this region as well. The hip joint, which we often think of certainly being groin or lateral hip can be posterior and can refer all the way to the foot, as can the SI joint. So this buttock pain presentation could be a spine, could be a spine source and there's multiple that would be the case there, but it also could be outside of the spine. It's important to always keep that in mind. So once you clarify is the pain in the back or the leg, and if it's both, what the relative percentages are of those, the next thing you wanna ask is what makes it worse? It's a very common question obviously, but what this does for you is it allows you to refine that differential even further. So let's say you figure out from asking them questions, what hurts? And they may say something in the weight room or when I'm kind of, I'm a volleyball player and every time I go down and into a little bit of squat and I'm doing some drills or sort of jumping and landing those things hurt. So flexion-based pain, meaning when they flex the lumbar spine, their pain is worse. The things you wanna think about would be disc, vertebral body, like a compression fracture, for example, which certainly not as common as disc pathology, paraspinal muscle, as well as ligaments, like I mentioned the supraspinous and the intraspinous ligaments would come to mind. So flexion-based pain allows you to narrow that differential a little bit more. And next, I just, before we get to the other kind of sources of pain, it's worth it to just review this study by Nockhamson from the 1960s. So essentially what the study was is they took a bunch of med students, put pressure sensors into their lumbar intervertebral discs and then had them lie and move and sit in different positions. And what you're looking at here is basically everyday positions and some exercise. And on the Y-axis, it's the percent of intradiscal pressure. So you can see way over on this lower left side of the graph here, if you're lying supine, it's very low intradiscal pressure. Standing with good posture is about 100% of that intradiscal pressure. Again, all sort of relative here. Standing up, bent forward with a weight in your hand, for example, like doing, you know, a kettlebell exercise, depending on your form, that escalates the intradiscal pressure even further. And then, you know, sitting for hours upon hours at a desk with not ideal posture, you get into some fairly high intradiscal pressures. And so if you're thinking about disc pain or, you know, flexion-based pain, you not only want to ask what in their training and their performance and competition hurt, but what are they doing the other times, you know, outside of their training? Because what they're doing in their cross training in the weight room, and then, you know, if they're student athletes sitting and studying or working, really probably matters as much, if not more, to their disc health. All right, so if they don't have flexion-based pain, but they're telling you they hurt when they are a diver and they're arching into the pool or a rhythmic gymnast and doing an arabesque, you know, switch-leap type motion, then you want to think about more of the posterior element structures. So the pars interarticularis, like in a spondylolisis, the facet joints don't usually like extension, so they tend to hurt with that. I did mention disc is usually flexion-based pain, but there is a caveat to that, and sometimes central disc herniations hurt with extension, so you keep that on your differential. Bostrop's disease, like I mentioned, with the kissing spinous processes or a lamina impaction. So anything in the posterior elements usually tends to fall under our differential for extension-based pain. They might not have a very clear direction, what we call directional preference, like I hurt when I go this way or that way. You want to also then ask about transitional activities. In the non-athlete setting, this is rolling over in bed, getting up out of a chair, up and downstairs, in and out of a car. What we think is going on there is there's some micro, usually instability, where you can see in this picture here, when the disc gets a little bit degenerative, then the facets have some arthritic-type changes, and you're getting some micro motion between that disc and two-facet joint segment. And so you might think if they have transitional pain, or in sports, kind of cutting, changing directions, planting and turning, it might be something like spondylolisthesis, where there's some instability. And again, this doesn't mean they have huge translational instability and need effusion, but they're not maintaining stability in that segment well. Sacroiliac joint pain tends to be transitional, and then in some cases, discogenic pain as well. So you can see there's some overlap here. And so, you know, once you have taken your history, you kind of have a sense of where this person is probably going to fall. I will say that there are a lot of people, when you ask them these questions, they'll say, everything hurts. You know, I can't differentiate. And that's fine, they may be in a lot of pain, but I would try to probe that a little bit further, say, okay, fine, every position hurts, but if you had to do one for an hour, what would you pick, standing or sitting, for example? And then you're able to kind of tease out which is the worst. And then really you use your exam to confirm that you are on the right track, that flexion does indeed make them worse, or extension, for example. Okay. So to confirm that, you know, directional preference also, what positions make the pain better? So if a person has, say, they say they have extension-based pain, and then they tell you if they like lie on their back and pull their knees to their chest, that feels great. Again, you're sort of reinforcing that you're on the right track with their direction. Like all sports medicine injuries, we want to know about training errors or changes or sort of kind of shifts in their workload. So is anything going on with their training, coaching, recovery that might be at play here? And as always with any injury, but certainly in the spine, we think of red flags. Where are we, you know, where we would need to say, okay, we need some immediate imaging and potentially an intervention. So intractable pain is a little bit of a kind of yellow-red flag, but certainly progressive neurologic decline, like weakness particularly, or maybe a reflex change, bowel and bladder dysfunction, and then systemic complaints that just don't really fit with a mechanical cause of back pain. And then yellow flags are just information as always when we're treating athletes about, you know, what does this pain mean to them? What are they worried about? Where are we in the season? But what is their level of coping, their insight? You know, how anxious and fearful are they about this injury? And knowing that upfront, you know, certainly doesn't change the prognosis necessarily. They're still probably going to do well, but you might spend more time counseling. If you know that somebody has some amount of high anxiety or fear about this injury. We'll go through a more detailed exam with the case, but some of the things that I, or the way that I usually do it, as anything is very systematically, I move from standing to sitting to supine to prone so that I'm always doing the same exam. In standing, you want to have them move their spine in multiple directions. Was the history right about a directional preference? So, you know, does the person actually hurt when they extend their spine? Can they heel walk? Can they toe walk? Can they do a single leg squat? Looking for, you know, any subtle weaknesses that might clue you into more of a radiculopathy picture. In seated, of course, you're going to do your manual muscle testing, your reflexes and your sensory testing, as well as the seated slump. And I'll talk a little bit more about that test. In supine, you can do the straight leg raise and a hip and an SI joint exam, because of course you don't want to just assume that it's a spine condition and not examine those other, you know, those other structures. Or they might have hip impingement that's not symptomatic, but like a rower, if they have really restricted hip range of motion and they're trying to get into the boat and row, then they're going to need more motion and more loading on their spine. So that may not be a cause of their pain, but maybe a driver for why they have a spine condition. And then prone, you want to see if you think they have flexion-based pain, do they feel better in extension, which sometimes standing, it's hard to tease it out, but prone, you get a little bit more information from that. So the seated slump test versus the straight leg raise. I think we're usually, historically in med school, certainly we're taught the straight leg raise far more than the seated slump. You know, if I can only do one, I would definitely do the seated slump, partly because of the increased sensitivity, which you can see at the bottom there. But also I think you're able to sort of manipulate the test a little bit better to get more information. So what you do in the test is I usually just tell the patient, you know, go ahead and put your arms behind your back or to the side to sort of get them out of the way of their, you know, their ability to do lumbar flexion. And then I say, just slouch like you have bad posture. So they do that, bring your chin down to your chest. At that point, they might have back and leg pain, but they might not, and then what I do is I bring their, usually the non-symptomatic side first, up into knee extension and ankle dorsiflexion, and what you're trying to do is increase dural tension and reproduce the pain that they're coming in for. Usually, this is the radiating pain case. If that reproduces their typical pain, you hold that position, and then you just tell them to stay slumped, but look up to the ceiling. Is your pain better, worse, or no different? If it's better, then that reinforces that you probably have an element of increased neural or dural tension, because you're not changing anything about the hamstring, for example. If you're considering a high hamstring tendinopathy as part of your differential, all you're doing is cervical extension, which is changing the dural tension, so it's a pretty helpful test to do in that regard. Certainly, there's nothing wrong with the straight leg raise, and you could do both. You can try to do ankle dorsiflexion and a little bit of femoral adduction to try to increase that dural tension, but like I said, if I only picked one, I'd go with the slump sit. Diagnostic testing, especially in the spine, if we're thinking certainly of, we're going to usually start with plain films, but oftentimes, we're going to get an MRI if we're needing to work this up further, and what I would say is just be very clear about why you're getting it, and what you're looking for, and how it's going to change your management, because we know if we take 100 people off the street with no back pain, these are not athletes, but just regular people, we're going to find stuff in their spine, and then we have to deal with that and figure out what we're going to do, and does it matter, and is it relevant? So the Bowdoin study from 1990, which is represented here, is certainly one of the most well-cited, but there's others that support this, and basically what this shows is this breaks patients up by sort of the 20 to 39 group, 40 to 59, etc., and you can see that, again, these are people with no back pain. You know, you've got 21 percent of the people in their 20s to 40s with disc herniations, disc bulges more than half, and 34 percent of disc degeneration, which is probably not a great term, but that's what we're stuck with at this point, and as ages go up, this gets much more significant. So this is, again, in normal people, so you're going to find things with spine MRIs, and you need to be prepared to help kind of put that in perspective for patients. This is not really just asymptomatic athletes, but what this data represents is from the 2016 Olympics in Rio, any athlete that got a cervical, thoracic, or lumbar spine MRI, they basically just characterized how severe degenerative disc disease was in this population. So in the first column, that's the cervical spine, so the majority of people with abnormalities were in the mild category. Thoracic, there was some mild disc degeneration, and then in the lumbar spine, you can see the mild, again, is the light blue, and then the moderate is the orange, and then severe is in the gray. So these are people competing certainly at the highest level, and you're going to find things, so you really, like I said, need to decide if it's going to change your management, open up some type of other treatment, like an injection, for example, and if not, you might not want to get the imaging unless you need to. So with rehabilitation, just some general tenants, like anything we do in sports medicine, you want to be really specific, like when you're prescribing a medication, so the type, the dose, the frequency, duration of the exercise, and if this is a high school or college athlete or somebody, you know, in an NGB, you want to be really open in communication with the physical therapist, athletic trainer, whoever is working with this athlete, so you're getting a sense of how they're responding to the exercise and if things need to be, you know, tailored, or if you need to add in medications or an injection, for example, to allow them to participate fully in physical therapy. This is just sort of an overall schematic of the way you might want to approach kind of phases and return to full activity, so the initial phase in an athlete with back pain is you're going to want to do a couple, pull from different, you know, strategies to reduce their pain and improve their function initially, so we'll talk more about mechanical diagnosis and treatment, but in some cases, some mobilization is useful, and certainly beginning with that core strengthening. Moving into the restorative phase are what are some deficits that would limit their return to play once pain is improved, and then integrative phase, you want to make sure that their mechanics, not only in the spine, but throughout their ability to, you know, move back into sport-specific activities is functioning, and then, of course, the return to sport. One of the things that can be tricky if you have an athlete, let's say, with flexion-based pain, they might get the messaging that I should never flex, and if I flex, it will hurt my disc, which, of course, you have to flex your lumbar spine to return to pretty much any sport we can think of, so you don't, initially, you might avoid flexion to reduce pain, and then you have to be able to add that back in and make sure that it's tolerable before, of course, you're returning to sport, so that's one of the hiccups that I see a lot, you know, with people that have struggled with back pain is they hear messaging that I can't ever do x, y, or z, and that is not realistic or functional, so certainly, we want to be clear that we're going to avoid a movement in the short term and then work our way back to it as we're getting back to sport, so just some general take-home points here about low back pain in athletes. It's very common. It can feel a little bit overwhelming sometimes if the pain is severe. You're not sure what the pain generator is, but the more specific you can be about that pain generator certainly helps with education and counseling and management, and really, the history and physical are going to be your best tools to do that, imaging when you need it, and then really trying to make, you know, the rehab plan, as always, as specific to the athlete's specific injury, you know, their directional preference and what they need to do to be successful in their sport as you're sort of working through things, so what I wanted to do is just use a specific case to highlight these more general concepts and sort of how this might look when you're seeing athletes in clinic, so this is a case that now is from a couple years ago when I was working in Chicago, but it highlights a couple themes pretty well, so I think it's worth going through, so when I first met this patient, he is a 22-year-old Division I collegiate football player. His position was defensive tackle. He had reported that he had a history of back pain last season. He said it was just in the back, no radiation previously, but then four weeks prior to when he presented, he developed the back pain again because it kind of came and went, and then pain radiated into his left posterior thigh and the back of his lower leg, so in the calf. At rest, he was still having pain, so not even with sport, he was kind of four out of ten pain, and the pain was both in the back and the leg, and then it got up to what he rated as ten out of ten with more dynamic activities like running, lifting in the weight room, sneezing. He also said it was quite painful. He denied any numbness, tingling, or weakness that he had noted, no bowel or bladder dysfunction. When he had seen me, what he had tried so far was some non-steroidal anti-inflammatories over the counter, not really helpful. One of the other treating physicians, I think in the training room, gave him some Flexeril or cyclobenzaprine, and that was really helping him sleep, which had been a problem for him due to pain, but it wasn't really relieving the pain, you know, significantly during the day, and it made him pretty sleepy, so he couldn't take it all the time, and as always, you know, we want to know about what the patient's goals are, so he was looking at his senior season, and after that, his plan or dream was to be drafted into the NFL. So when you're thinking about, now we have back pain radiating into the leg, and certainly it sounds like, you know, it could be a radiculopathy, and so a chart like this is sort of helpful in your mind as you're thinking through and, you know, starting to do the exam. What's nice is, like, this is pretty systematic, so you know if somebody is telling you they've got groin pain, and, you know, it's back pain and groin pain, you start to think higher up in the lumbar spine, sort of L1, L2. L2, we know there's overlapping myotomes that innervate muscles, of course, but if somebody is weak in hip flexion and have pain in the groin, you're thinking, okay, this could be an L2, maybe an L3 problem. If they've got some quadriceps weakness, then, you know, you may start thinking, kind of, more moving into the L3, L4 range. When you get to L4, you also have a patellar reflex to help you to see if there's any abnormalities of that, to sort of identify what might be going on. So you're really looking at the distribution of pain, is there weakness or a reflex change that matches that, and trying to pinpoint one specific nerve with your history and physical. So with our football player, on inspection, he had what's called a mild right shift. Now the picture I'm showing you here is not him, and this is not particularly mild, but what you see is this person is shifted to the right, and so, again, our patient has this left leg pain. So oftentimes, in an acute disc herniation or radiculopathy, you will get this almost, like, kind of functional or pain-mediated scoliosis. This person doesn't have normally a spine curvature, but the pain is so significant that the body is sort of shifting away, so that gives you a little bit of a clue that this might be disc-related issue. And so he had that shifted, usually it's a contralateral shift away from the side of the leg pain, really only tender in the left lumbar paraspinal. Sometimes you'll really feel some hypertonicity in those muscles, so you can think that they're having a muscle spasm situation, which certainly there is an element of that, but the underlying driver is usually something deeper. In this case, we're thinking possibly a disc herniation. So range of motion, we're trying to figure out does he have a directional preference. So when you ask him to bend forward like he's going to touch his toes as far as he's comfortable, I saw in him, he was kind of, you know, moderately restricted. He really couldn't get past 90 degrees without developing worsening left leg pain. So that tells us that he's kind of a flexion-biased person, meaning when he flexes, the pain gets worse, goes down his leg, his leg, excuse me. In extension, he's slightly restricted, meaning he's got a little bit limited range of motion, but you want to clarify, does it hurt? And if so, where? So for him, extension caused back pain, but not leg pain, which will be important when we're deciding on therapy for him. And then he also, when we had him lie on his stomach and push up into extension, had reduced left leg pain. So all that is important in figuring out, one, do we think this might be a disc herniation? And two, what type of therapy maybe he will respond to. For the strength exam, he had full strength for hip flexion, knee extension, ankle dorsiflexion, and great toe extension. But again, this is a collegiate football player. When I asked him to do 10 heel raises, he could do that easily on the right, and by eight on the left, he was fatiguing. And so as you know, it's really hard to break plantar flexors in manual muscle testing, so a standing heel raise is a nice way to do that. Plus, you can send the patient home saying, today you could do eight, do these once a day. If you wake up and you can only do one or two, you need to call me. So you're giving them a way to sort of monitor their strength. His sensation was intact to light touch. Sometimes people can have altered sensation, but he did not. And the reflexes were all two plus, except for on the left Achilles reflex, he was one plus. So slightly reduced responsivity compared to the other side. The special tests that were notable, we did a slump sit on the left, which was positive, which means as you brought his leg up into knee extension and ankle dorsiflexion, it reproduced his left leg pain. And when he lifted his head up into cervical extension, the pain improved. And we did check his hip and SI joint maneuvers and those were all normal. So if we think back to our chart here, you can see the bolded at the bottom, we've got some weakness or myotomal strength reduction seems to be with the standing heel raise or gastroc soleus. His reflex on the left was reduced compared to the right and his seated slump test was positive. So at this point, our working diagnosis as it makes sense would be a left S1 radiculopathy with a subtle strength and reflex deficit, meaning, you know, his reflexes it wasn't absent. He's not having marked strength deficit, but still he should be able to do 10 heel raises easily like he is on the other side. And we don't know without imaging what, you know, the anatomy is there, but we're presuming in a 22 year old person that this is likely an acute disc herniation. So when we use the term radiculopathy, what do we mean? What we mean is it's a basically a dysfunction of the nerve root or the spinal nerve. And so in these pictures here, you can see, this is just a schematic where the disc material is squirting out. And in this picture, it's basically compressing the ventral spinal nerve or the root here. So what you have in the anatomy, this is the spinal cord and this red portion is going to be the ventral root, which is usually the motor, mostly motor contribution. The blue here is the dorsal root, which is mostly sensory. The dorsal root ganglion is this kind of purpley structure here. That's where the cell bodies for the sensory nerves live. And then it combines into the spinal nerve and then into the ventral and dorsal rami. I hate to take you back to neuroanatomy here, but it really is relevant because if the disc is pushing into one or both of these structures, that determines sensory deficits, motor weakness, where the pain is, obviously. But if you are to refer a person with a radiculopathy for an EMG, oftentimes the sensory nerve conduction studies are normal. And that's because the dorsal root ganglion here, that you can see nice and clearly over here, is usually spared. So the disc material is getting at the root level, but not the dorsal root ganglion. So you can have sensory alterations, but you're not going to have abnormalities on EMG because the cell bodies are intact with the rest of the nerve. Whereas the cell bodies for the motor contribution are more proximal to where the disc herniation occurs. So that's why you might have abnormalities of the nerve conduction study of the motor nerves. And so that kind of gives you a little bit of just sort of background on why EMG may be useful in these cases. But it really depends on where the disc herniation is, what type of pathology and findings you're going to have, certainly on exam. And radiculopathy, radicular pain, and radiculitis are often used synonymously. And I think that's okay. I don't differentiate this to the patient, but I do think it's worth for me clarifying in my notes so I know immediately. If I use the term radiculopathy, then I know I'm talking about a spinal nerve root dysfunction, usually due to direct compression, let's say from a disc. And in addition to having pain and maybe numbness and tingling in a specific dermatome, there also would be some weakness and or a reflex change. That is what the definition of radiculopathy is. If you have the pain and the numbness and tingling in a specific dermatome, but you don't have any weakness and you don't have any reflex change, then that is radicular pain. And it's kind of on a continuum, but radiculopathy, you know, has some motor changes with it. And that might change how you're going to treat the athlete, how you're going to intervene, and maybe how closely you monitor them. So I do think it's worth differentiating and at least certainly understanding the difference between the two. And patients, of course, will use sciatica, which really doesn't, I mean, it's fine for a lay term perspective, but it's not what it is because we're talking about the spinal nerve roots. We're not talking about the sciatic nerve. That would be a sciatic mononeuropathy. So they, those are really different entities and it's important to understand that. All right. So, you know, we're thinking that our athlete is dealing with a disc issue and it's worth just kind of touching base on the spectrum of disc pathology. And discs can hurt from any of these reasons, but they're all, you know, a little bit different as far as their anatomy. So this here, this picture, this first one shows you a normal disc. And then here you can see that there is disc material that's sort of extended beyond the normal confines, these dotted lines of the disc. If that extension is greater than 50% of the circumference of the disc itself, that is a disc bulge. So if you hear or read that in a radiology report, that's what that means. In addition, you can also have these tears in the lining of the disc or the annulus fibrosis, also known as annular tears. Those can show up as like bright signals on, usually you can see them on the sagittal axial cuts of a T2 weighted MRI. And they can't, they certainly have been, you know, cited as a source for usually back pain, not radiating pain. When we start talking about herniations, we get down into this group here. So this one is an example of a protrusion. And basically it's sort of because of the size distinguishes what it is. So if this is a broader or a longer segment horizontally than it is kind of pushing back, you know, in the AP, view, then that is a protrusion. If there's much more of a narrow base, then, and it go extends a lot further again in that sort of AP plane, then that's an extrusion. And then if it breaks off, that extrude, usually extruded piece is sequestered. So you'll see a lot of these terms within, you know, the MRI reports. Quite frankly, if I don't usually differentiate this with patients, it doesn't certainly in a very clear way affect how they're going to respond to treatment. You know, so it probably isn't worth going through it with them, but it's worth knowing, you know, where the radiologist is certainly getting these terms. And then, you know, when you're looking at the images yourself, making sure you can see those changes. So that's sort of like the shape of the disc herniation matters too. So what we're looking at in this first image here, this is the L4 vertebral body. This is the L5 vertebral body. These semicircles or these ovals here are the pedicles. We have the disc in between. So this disc is named the L4, L5 disc. This is the L4 nerve root on either side. And then this is the L5 nerve root, which is gonna exit below the L5 pedicle. So one level below. So if you have an L4-5 disc herniation that's over just to the side of the midline, that's most likely not going to affect the L4 nerve because that has already exited the foramen and is in the clear. But the L5 nerve, which exits below, is the one that's getting compressed with that L4-5 disc herniation. On the other hand, in this picture in the middle here, you have a disc herniation between L5 and then S1. And what you see is that depending on where the disc is, if it's kind of in just to the side of the midline, it's probably going to get the S1 nerve. If it's more in the foramen or far lateral, you potentially could get both or you could get the L5 nerve root here. So one, I think a really fun thing is when you're seeing patients is to try to predict what the MRI is going to show. And based on what you know, in our athlete, for example, we think it is an S1 radiculopathy. So the most likely source of that problem is going to be just a kind of a paracentral disc herniation that's going to affect that S1 nerve root. And then you get the MRI to see if you're correct. This here is just a picture of a more proximal disc herniation that could compress all the nerve roots and cause Cauda Aquinas syndrome. Certainly these are the more common situations, but knowing where that disc herniation is really helps you understand, does it make sense with the exam or not? All right, so here's the imaging that we got for our 22-year-old football player. What you can see in these more proximal segments, so here's L5, L4, L3, L2, and L1. The discs here all look pretty good. You know, you have your black or annulus fibrosis and the more gray nucleus pulposus. You start to have a little bit of degenerative wear and tear change here at the L4-5 segment. So you start to have a little bit of posterior protrusion or pushing back there, which is lifting off the posterior longitudinal ligament. So you know there's some backward motion there. If you get down to the L5-S1 level, that clearly looks different than the others. There's less space, so the disc has flattened. There is not as much lighter material in the middle, so there's either, you know, dehydration or drying of some of the nucleus pulposus or it has squirted backward, and therefore it's not in the, you know, the main space that it usually is in the disc. And as you know, of course, you always look at these more fluidly, but we'll take it one by one. As we move to one side or the other, we don't always know in the sagittal plane yet. What we see is this posterior prominence of disc material at the L5-1 level. And we kind of follow that through. Now we're in the foramen. These gray things here are the nerve roots at each level, and you start to get a sense of how close is this disc material to the nerve in the foramen, and then you use what we're gonna look at now, the axial images to differentiate left versus right and what that looks like. So now we are at in the sacrum. This is going to be the right side. This is the left side. These are more the SI joints there. And here we see the paraspinal musculature. What you will find even in young, very fit athletes, if they've had back pain in particular, that you might notice some atrophy of the paraspinal muscles. So you'll see it be much more fatty than muscular tissue. And that's just something that you kind of follow. You can see that he does have some fatty atrophy of the paraspinals here. So as we come up, we're getting into the L5-S1 disc space. This is the S1 nerve on the right. This is the S1 nerve on the left. Here's the right facet. Here's the left facet. And what we see here is this again is the S1 nerve on the right. We can't really see the S1 nerve on the left because this disc material that we saw on the sagittal cut is sitting basically right on top of it. And this is an extrusion, just based on those pictures that we looked at before. Now we go further up, getting into the L4-5 disc space, which looks a little bit of a bulge there. He's got a little bit of facet arthritis that kind of causes some thickening of the ligamentum flabum, but clearly looks different than this disc material sitting in the middle on the left S1 nerve than that. So we confirmed what we thought, and it's a left S1 radiculopathy with subtle strength and reflex deficit due to a left L5-S1 paracentral disc extrusion. So what do we tell him about this? Like what's the natural history of lumbosacral radiculopathy? There are not a ton of studies that have looked at this natural history question. You can see some of these are crazy old, like 1970, but these basically, for the most part, were minimal intervention and what happens to people over the course of time. As you can see in the outcome column, overall, it's a pretty good prognosis. So we do like to tell people, you get better from this, it hurts right now, but almost regardless of what we do, you're gonna get better. But obviously the things that we do in the short term are to help reduce pain and hopefully get them functioning better, faster. The natural history of low back pain in athletes is even more sparse in the literature. This study by Iwamoto in 2006 is a nice one, but it's one of the few that we have. So basically they looked at 71 athletes. You can see the variety of sports that were included and overall, almost 80% returned to sport. The time that it took, the mean was 4.7 months, which is not insignificant certainly, but they didn't differentiate axial pain versus radiating pain, radiculopathy versus radicular pain. And they really didn't follow it out to look at recurrences, but really this is one of the few natural history studies that we have for athletes. So for our football player, what do we do initially? Well, I mean, he's in 10 out of 10 pain with performing sport-like activities at this point and having interruptions in sleep. So we definitely need to get the pain calm down. As always, we try not to take athletes completely out of their sporting environment, but we do want to do some modification so we're not making things worse. He has a little bit of weakness that we want to monitor and not push through that. So you want to maintain obviously their cardiovascular, their fitness and strength as much as possible, really understanding that flexion doesn't feel good. So we're going to work in sort of that extension and neutral spine plane and monitor his neurologic function. So back to this kind of overall scheme, we're going to start at this initial phase. And mechanical diagnosis and treatment is one of the techniques that can be employed from a rehabilitation perspective. So basically what this is, is if somebody has radiating pain, you want to figure out which movements make the pain go further down the leg, which is known as peripheralization here, when what activities make it go up the leg into the spine, centralization. So the goal is centralization. And so in our athlete, when he bends forward, it goes down the leg, when he arches back, it centralizes. So we'll work with that and incorporate that into his physical therapy. But this is also known as McKenzie therapy. And a lot of people think McKenzie means extension. It absolutely does not. What you do, you have to figure out which direction does the athlete move in to centralize their pain. So they may respond to a side glide. They may respond to flexion. They may respond to a combination of movements. It is not just extension, although a lot of people do respond to extension. There's not a lot of great studies out there, that have investigated this, but the Donaldson one is pretty good. What this shows in this chart down here is basically they had 87 patients in this study and they looked initially to see, do they have a directional preference? And if so, if we give them exercises, like they hurt with flexion and we give them extension, how do they do? So, basically what was great in this study is that the majority of patients did show a directional preference. And you can see if you match the outcome, the movement with their direction, they do really well. So it's kind of like a predictive concept. If you see a directional preference in the office and you know they're probably gonna respond to a certain movement, that's a great sign for physical therapy, especially if you match them up with the right direction as they're getting them back into activity. So this is just an example. For our football player, we would wanna do for core stability, we wanna do extension based or biased. We don't wanna do flexion, cause that is what we think is making that disc extrusion sort of move further out or impinge on the nerve more. It's hard to say for sure, but if you're getting changes in leg symptoms, you wanna go with that. Versus somebody that gets worsening leg pain with extension, maybe a central disc herniation, and then you want them to work in the flexion plane. And so that really drives the exercises that you're gonna choose. He's having a lot of pain. So certainly we wanna consider medications. This is just a list of the types of medicines we might consider in this case. So many people do use a short course of oral steroids, like a MedDRAL dose pack. There is some debatable efficacy for that, but sometimes it certainly is reasonable to use if the patient is in a lot of pain and you're not getting relief with even prescription strength NSAIDs. Certainly you wanna counsel about the risks of oral steroids if you were to do that. Oftentimes, if somebody is having trouble sleeping and having what we think is neuropathic pain, then people will use off-label to be clear, not FDA approved for radiculopathy, but people might try pregabalin or gabapentin. Other analgesics in the mix, again, if pain is severe, nerve pain, as I'm sure are all aware, is it can be really, really uncomfortable. So a short course of opioids, if you're working them up and trying to figure it out, I rarely use it, but sometimes will. And then like our athlete had already tried a muscle relaxant, which really just helps you sleep for the most part. They're working centrally, not all of them, but it's like LeBron Supreme that he was using certainly is. So you may favor a gabapentin over a muscle relaxant, depending on what you're trying to achieve. So spinal injections certainly are used for radiculopathy. The rationale for this is not that you're changing the anatomy. You're not taking away the disc herniation or changing anything about that, but you're changing the environment or the milieu around the nerve. So the point is to decrease pain by exerting an anti-inflammatory effect with the corticosteroid and usually the numbing agent that you're using around the spinal nerve root. And there are a variety of approaches available. These are done under fluoroscopic guidance. On the left, you see the interlaminar approach, on the right, the transforaminal. Generally, there's evidence to support using both of these, but if you have one specific nerve root, like in our case where you have the S1 that we know is the one that's affected by that disc, usually you would, I think many people would go with a transforaminal approach to target that specific nerve root rather than the interlaminar, which basically spreads the medication in a broader distribution in the back of the epidural space rather than the front where the nerve tends to live or that nerve root. There's a few studies that talk about the efficacy of transforaminal epidural steroid injections. This one is a good one to know if you're interested. So Dr. Dan Rue, who was at WashU at the time, basically had 50 or so patients that were planning on having a discectomy, and they randomized them into getting a transforaminal injection with an anesthetic versus transforaminal with a steroid. 67% of the patients that had the transforaminal anesthetic group went on to have surgery, and only 29 who were planning to have surgery who received steroid went on to have surgery, so they decided not to have it. So this is one of the studies that is cited to talk about this might be a surgery-sparing procedure or at least certainly reduce pain so that the body's innate ability to recover from this and natural history can occur. There is very little in the literature about epidural steroid injections in professional football players. Our guy is college, but this was close enough. So Crike, I hope I'm saying that right, in 2012 looked at 17 NFL players who had ESIs in the 2000s. Basically, they collectively had 37 injections, 88% returned to play. Of the four players that needed a repeat injection, three of those went on to have surgery. So it also kind of gives you an idea maybe of how you're gonna counsel about surgery or not. If somebody responds really well to an epidural steroid injection, that might buy you time and potentially avoid surgery in the future. What I did with this patient, because he was having trouble sleeping, we did use gabapentin for a short amount of time at night. We did a right S1 transforaminal injection. We asked them immediately when just the anesthetic obviously is at play, what their pain relief was. So he had 100% pain relief at that time. We got him into physical therapy in an extension biased approach because he hurts with flexion. At his two week follow-up, he had 90% pain relief. He was only having back pain, no more leg pain at that time. And he was able to do the full 10 heel raises on the left. At his nine month follow-up, which was the last time I saw him, he still had pretty, I mean, he had no more leg pain. He had rare axial back pain, which was more stiffness than pain. He did attend the NFL Combine and was not drafted, but it didn't seem to be related to this spine injury, although it's, I guess, impossible to say. So surgery, when do you need surgery for, in this case, for our football player? When would we have thought that he needed to move to surgery? Progressive weakness. So he had mild weakness initially, but if he couldn't do any heel raises or that really changed while we were monitoring him, that's an indication for surgery. Intractable pain that doesn't respond to anything else. That's certainly reasonable. Cauda equina is, you know, that's clearly an indication for surgery. Many, many studies, including some of the ones mentioned here, recommend conservative treatment for two to three months. Again, unless one of these things is happening above, because the natural history is so favorable. Just for the sake of time, we'll just quickly tell you there's very little on return to play. Iwamoto did the study in 2010, which compared mostly retrospective studies, you know, case series, small numbers. But if you look here, you know, most athletes return to play, and then the period of return seems to certainly vary everything from seven weeks to, you know, three to 12 months in some of these studies. But these are, some are older and mostly retrospective. So we got to take it with a little bit of a grain of salt. This is a more recent study by Wellington Hsu at a Northwestern who looked at pro athletes in the NFL, NHL, MLB, and NBA. And I think the big take home here is if you look at the return to play rate, regardless of operative or non-operative treatment, about 80% are returning to play. And that's kind of what we see in, you know, the non-athlete is the overall prognosis is favorable, but it's how you kind of treat people in the short term so that they can, you know, kind of tap into that natural recovery. So conclusions on this case, nerve root dysfunction, because we were talking obviously about this radiculopathy case, can exist on a continuum and at least knowing why there's a differentiation between radicular pain with and without weakness and anatomically why that is as useful. The diagnosis certainly, you know, ties in the history of the physical exam and imaging findings as always. And the more you can match up the therapy and the rehab with what positions, you know, reduce their leg pain, the better. And the good news is for counseling is the natural history is favorable in non-athletes and athletes. And certainly return to sport is favorable as well. And our job is to, you know, help with that process as much as possible. Oops. So yeah, when I'm not at HSS, I have the privilege of getting to take care of athletes who sometimes have back pain, but certainly have other things too. We had our first camp in this pandemic time just last weekend. So we're looking forward to hopefully a lot of exciting gymnastics in this hopeful Olympic year. Thank you very much. Great. Thanks so much, Dr. Casey. If anyone has questions, please put it in the chat here within the next few seconds and I'll make sure that they get asked. One thing I was gonna ask, when you are putting together your physical therapy prescriptions for low back pain, is there anything else? So besides looking for, you know, what centralizes the pain, is there anything else that you'll put on there that you find has been significantly helpful for these athletes with low back pain? Yeah, I mean, I think the other thing would be, especially if we're talking about radiculopathy, adding stuff like neuromobilization or nerve glide or flossing. If they have that positive slump sit, sometimes the PT could add some exercises where you're, I mean, in essence, you're kind of trying to detether or free up that nerve a little bit with some different techniques and that can provide a lot of relief too. I think, you know, certainly talking with the PT or the athletic trainer about what that kind of stage return is and how you will reintroduce flexion, for example, or what things in the weight room you might modify. If this is something that's a big issue for somebody and you get them feeling better, you just may choose to do different exercises, right, than the kettlebells or some of the deadlifts. And not to say you can't do those things with a disc problem, but, you know, do the risks outweigh the benefits and at what point in time would you reintroduce those? So I think those are a lot of the, whether or not that goes directly into the prescription or in your conversations are pretty important parts of the plan. Okay, great, thanks. So at this point, I don't see any other questions. So just wanted to reiterate that this talk will be uploaded either later today or tomorrow to the AMSSM YouTube page for viewing as much as you see fit to do. And then also one more time, just want to plug the next installment of the Fellows Online Lecture Series, which will be March 23rd with Dr. Ken Mautner on patellar and quadriceps tendinopathy. So with that said, Dr. Casey, thanks again. Great talk. We appreciate you helping out with this and everyone have a great rest of your day. Thanks for having me, take care.

3rd Edition, CASE 55

3rd Edition

Spine

low back pain

athletes

Dr. Ellen Casey

biomechanics

risk factors

kinetic chain

diagnosis

rehabilitation

imaging challenges

S1 radiculopathy