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 Identify the most common lumbar spine injuries that occur in sports, including which sports are at the greatest risk  Differentiate between treatment in an initial care vs. tertiary care environment  Discuss the key elements to an appropriate rehab progression for this patient population  Recognize when an athlete is not ready to safely return to sport

 Affects at least 85% of the world’s population  20-25% of all sport-related injuries are low back  Top 4:  1. Muscle strains  2. Discogenic LBP  3. Spondylolysis  4. Spondylolisthesis

 Affects the pars interarticularis  Most common occurrence is at L5  Ages  Defect creates a separation in the joint  Usually brought on by repetitive spinal stress; can also be due to trauma

 Ages most susceptible  Most are low grade (about 90%)  Typically caused by a bilateral pars fracture in young adults/athletes  Many cases of documented spondys on radiographs that are asymptomatic  Severity of sx’s does not always correlate with severity of the slippage

 Caused by repetitive loading in flexed positions; can also be the result of trauma  Excessive strain weakens the posterior annulus, creating fissures-may or may not compromise the annular wall, depending on severity  Increased laxity in the annulus leads to migration of nucleus pulposus, creating a bulge or herniation  Will create an obstruction to movement and possible nerve root entrapment

 Watch for Red Flags  Neurological Exam  Stability Tests  MD FOR IMAGING  Bracing if needed  Activity Modification  Neutral Postures  Continuous monitoring of neurological signs  Wean off bracing  START MOVING

 Spondylolysis/Spondylolisthesis  Brace/Immobilized usually 4-6 weeks  Should not be cleared to start active rehab phase until radiographs show the site has adequate healing to start loading the structures  Discogenic Back Pain  EARLY INTERVENTION  Once bony pathology is ruled out, they do great if they start moving early, especially when radicular symptoms are present

 Limit/modify flexion activities  PROGRESS towards end range extension  Focus on posterior chain first, start incorporating anterior  MONITOR neurological s/sx’s throughout rehab

UNSTABLE SURFACESDIAGONAL PATTERNS  BOSU  Airex Pads  ½ Foam Rolls  Swiss Balls  PNF D1 and D2 for UE and LE  Great to incorporate with squats and lunges

 Progression:  1.Supine  2.Seated  3. Standing

 Literature is all over the place…6 weeks to 6 months  Use normal guidelines for fracture healing (6-8 weeks), PLUS…  Take into consideration the length of time to successfully remodel soft tissue (minimum 4-6 weeks)  They should have full ROM, no neurological signs, and be able to pass sport-specific return- to-activity testing without pain during or after testing

 Let the diagnosis lead you, not limit you  If the condition were unstable, they will have already been referred to a surgeon for fixation  Continuously reassess their neurological status …always look for red flags and you are less likely to cause harm  Full, painfree spinal ROM IN ALL PLANES is key to successfully returning them to sports

Thank You! Thank You!

 Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine; 18 (13): 1993, pp  Improvement in the extension group was significantly greater, regardless of type of radiographic abnormality, than flexion or control group.

 Daniels J. MD, Pontius G. MD, El-Amin S. MD, Gabriel K. MD. Evaluation of Low Back Pain in Athletes. Sports Health, 2011, July 3(4),  Bono CM. Current concepts review: low back pain in athletes. J Bone Joint Surg Am. 2004;86(2):  Mortazavi J, Zebardast J, Mirzashahi B. Low Back Pain in Athletes. Asian J Sports Med, 2015 Jun 6(2), e24718.