Among the
young college athletes and professional athletes alike, low back pain is
considered to be one of the most common complaints, estimated to affect more
than 30 percent of athletes at least once in their career. A wide number of
back injuries can affect the athlete, including muscle spasms and stress
fractures, spondylosis, spondylolisthesis, disc degeneration, facet joint
arthropathy and disc bulge or herniation.
 |
| Share Free Ebook |
Lumbar spine
disc herniation is a well-known type of injury which often causes impairing low
back pain, however, it can also compress the nerve roots in the area and
generate radicular pain and other symptoms along the lower extremities, such as
altered sensations and muscle weakness. Furthermore, this type of injury will
not only affect the athlete’s ability to perform during their specific sport or
physical activity, it may also become chronic and affect the athlete in the
future.
Conservative
treatments are frequently utilized when managing lumbar disc herniation in
athletes, although surgical options may be considered if the injury is too
severe. Many elite athletes often request faster recovery methods for their
type of injuries and symptoms in order to minimize their time spent away from
training and competition. As a result, a wide number of athletes will seek
surgical alternatives earlier than recommended, provided they meet the criteria
for lumbar spine surgery. The most popular surgical procedure for athletes with
a low back disc herniation is the lumbar disc microdiscectomy.
Anatomy & Biomechanics of the Lumbar Spine
The
intervertebral discs of the lumbar spine perform an essential biomechanical
role within the spine. These function to provide mobility between the segments
of the spine while distributing compressive, shear and torsional forces. These
discs are made up of a thick, outer ring of fibrous cartilage, known as the
annulus fibrosis, which surround the gelatinous core of the disc, known as the
nucleus pulposus, which is contained within the cartilage end plates.
Each
intervertebral disc consists of cells and substances, such as collagen,
proteoglycans and scattered fibrochondrocytic cells, which function to absorb
and conduct increased forces from body weight and muscle activity. In order to
effectively perform its function, the disc depends immensely on the structural
condition of the annulus fibrosis, nucleus pulposus and the vertebral end
plate. If the disc is healthy, it will evenly spread the forces being applied
against the spine. However, disc degeneration caused by cell degradation, loss
of hydration or disc collapse, can decrease the disc’s ability to withstand external
forces and these will no longer be absorbed and conducted evenly across the
spinal structures.
Tears in the
annulus fibrosis of the disc along with extrinsic loads may ultimately cause
the disc to herniate. Alternatively, applying a large, biomechanical force
against a normal disc, such as a heavy compression on the spine due to a fall
on the tailbone or strong muscle contraction from heavy weight lifting, can
also damage the healthy structures of the disc and cause a rupture.
Disc herniation
is characterized when the nucleus pulposus, the soft, jelly-like material in
the center of a disc, pushes through a tear in the annulus fibrosis, the
fibrous exterior of the disc. If the protrusion does not compress the nerve
roots that travel along the spine, the individual may only experience back
pain. But, if the herniated disc pushes against the lumbar nerve roots or other
structures within the lower back, the individual may experience radicular pain
along with neurological symptoms, such as numbness and paresthesia.
The pain and
other symptoms associated with lumbar radiculopathy occurs due to a combination
of nerve root ischemia from compression and due to inflammation caused by the
chemicals released from a ruptured disc. During a herniation, the nucleus
pulposus places unnecessary pressure against the weakened areas of the annulus,
protruding through these weakened sites in the outer structure of the disc,
ultimately forming a herniation. It’s important to note that when a lumbar disc
herniation occurs, in a majority of cases, some form of disc degeneration may
have existed before.
The Process of Lumbar Disc Herniation
Unlike other musculoskeletal tissues of the body, intervertebral discs generally degenerate sooner than other structures. Some studies have shown adolescents between the ages of 11 to 16 with signs of degeneration. As people age, the discs will naturally degenerate further. In a research study conducted using normal, healthy subjects between the ages of 21 to 30, more than one third of the individuals presented degenerated discs.
While the
spinal discs may be at risk of injury in practically all fundamental planes of
motion, these are often more susceptible to damage or injury during constant
and repetitive flexion or hyperflexion along with lateral bending or rotation.
Trauma from an injury caused by an excessive axial compression can also harm
the internal structure of the discs. This can commonly result after the
individual has suffered a fall or due to strong muscular forces being placed
against the spine during specific activities, such as heavy weight lifting.
When it
comes to athletes, they are frequently exposed to conditions of higher loading.
A herniated disc can be categorized according to its location: central,
posterolateral, foraminal or far lateral. Herniation varieties can also be
classified as: protrusion, extrusion or sequestered fragment. Finally, disc
herniation may be identified according to the level where they occurred on the
spine. Most develop along the lumbar spine, often affecting the lumbar nerve
roots which may lead to symptoms of sciatica. Upper lever herniated discs are
rare, but when they do occur along with radiculopathy, they generally affect
the femoral nerve.
Disc Herniation in Athletes
Athletes who
participate in sports or physical activities which utilized combined trunk flexion
and rotation have an increased chance of experiencing herniated discs.
Individuals between 20 to 35 years of age are the most common group to herniate
a disc, most likely as a result of the nature of the nucleus pulposis and due
to behavior. This age group is most likely to be involved in sports which
require higher loads of flexion and rotation or they may practice improper postures
and positions when carrying weight.
The sports
most at risk of disc herniation include: hockey, wrestling, football, swimming,
basketball, golf, tennis, weight lifting, rowing and throwing activities,
because these sports involve either high loads or high exposure to combined
flexion and rotation mechanisms. Additionally, athletes who engage in more
intense, continuous training routines appear to be at an increased risk of
developing spinal injuries or conditions, similar to those involved in impact
sports.
Signs and Symptoms Indicating Discectomy
An athlete
is generally driven by motivation and goals when they choose to undergo surgery
to treat a lumbar herniated disc. Rather than waiting for the symptoms to
decrease over a period of rehabilitation, athletes prefer a relatively simple
microdiscectomy.
A
conservative period of management for symptoms of a lumbar herniated disc may
involve: medication therapy, epidural injections, relative rest and trunk
muscle rehabilitation, acupuncture and chiropractic care with massage. However,
athletes who experience low back pain with pain radiating down one or both
legs, neurological signs and symptoms, mild weakness of distal muscles, such as
extensor hallucis longus, peroneals, tibialis anterior and soleus and those who
demonstrated positive on the straight leg raise test, may meet the criteria to
follow through with a surgical intervention for their lumbar herniated disc.
Generally, elite athletes have a shorter time span in which to allow
conservative rehabilitation to be effective. For a majority of the population,
medical practitioners often prescribe a minimum 6-week conservative period of
treatment with a review at 6 weeks to decide whether they should extend the
rehabilitation or to seek treatment from a specialist. This particular
healthcare professional may then offer other alternative interventions to treat
the issue.
For athletes, however, these time frames are compressed. Epidural
injections are often offered to athletes to assess the issue quicker, and if
there are no results within a determined period, an immediate lumbar spine
microdiscectomy may follow.
Imaging
Magnetic resonance imaging, or MRI, are considered to be the preferred
method for identifying lumbar disc herniation, as these are also very sensitive
when detecting nerve root impingements. Because abnormal MRI scans can occur in
otherwise asymptomatic individuals, it’s essential to establish a clinical correlation
of symptoms before any surgical considerations. Additionally, individuals may
present clinical signs and symptoms suggesting the presence of a lumbar
herniated disc but they may lack sufficient evidence on MRI to meet the
criteria to follow through with surgical interventions. Accordingly, it’s been
proposed that a volumetric analysis of a lumbar herniated disc on MRI may be
potentially valuable for assessing an individual’s and athlete’s suitability to
receive surgery.
 |
| Lumbar Spine Disc Herniation |
Chiropractic and Massage
Fortunately, before considering surgical intervention, although more time
and patience may be required, there are several effective, alternative
treatment options that can help reduce and eliminate the symptoms associated
with a lumbar herniated disc. Chiropractic is a healthcare profession that
focuses on injuries and conditions of the musculoskeletal system and the
nervous system as well as the effects of these on general health. Chiropractic
care emphasizes the treatment of the body as a whole rather than focusing on a
single injury or condition. Through the use of spinal adjustments and manual
manipulations, two of the most common techniques used in chiropractic, a
chiropractor can carefully re-align the spine, helping to restore and reduce
the pain and swelling caused by a lumbar herniated disc.
Along with a combination of massage, chiropractic care can ultimately
help rehabilitate an injured athlete or individual. A massage, best referred to
as myofascial release, is a hands-on technique that involves applying gentle,
sustained pressure into the myofascial connective tissue restrictions, to
eliminate pain and restore function. Massage can increase blood flow, which
delivers more oxygen and nutrients to the muscles surrounding the affected
region of the spine. The increased blood flow may also help carry away unnecessary
substances which may have accumulated through time. Chiropractic care and
massage are safe and effective treatments that can help rehabilitate athletes
with lumbar disc herniation without side effects.
By Dr. Alex
Jimenez
