2. I do not have any relevant financial relationships with commercial interests to disclose.

3.  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

4.  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

9.  Affects the pars interarticularis  Most common occurrence is at L5  Ages 12-15  Defect creates a separation in the joint  Usually brought on by repetitive spinal stress; can also be due to trauma

11.  Ages 12-15 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

14.  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

17.  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

27.  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

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

29. 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

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

31.  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

32.  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

34. Thank You! Thank You!

35.  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 1839-1849.  Improvement in the extension group was significantly greater, regardless of type of radiographic abnormality, than flexion or control group.

36.  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), 336-345.  Bono CM. Current concepts review: low back pain in athletes. J Bone Joint Surg Am. 2004;86(2):392- 396  Mortazavi J, Zebardast J, Mirzashahi B. Low Back Pain in Athletes. Asian J Sports Med, 2015 Jun 6(2), e24718.