Low Back Pain in the Gymnast - visit at PREP Performance Center in Chicago, Illinois

Low Back Pain in the Gymnast

Gymnastics is an extremely intense sport both emotionally and physically. The physical demands of this sport unfortunately leave gymnasts susceptible to almost any injury under the sun. Low back [lumbar] pain, specifically, is one of the many ailments common amongst gymnasts due to the sport’s repetitive nature. There are a number of diagnoses that may explain this low back pain experienced by so many gymnasts, but one of the most common diagnoses that may be relieved by physical therapy is Spondylosis or even Spondylothesis.

Diagnosis in Low Back Pain:

– Spondylosis is the degeneration of the spine due to overuse
This unilateral or bilateral overuse involves the pars interarticularis of the posterior vertebral arch. This pars interarticularis defect, also referred to as a stress fracture, consists of fibrous tissue. 85-95% of defects occur in the lower lumbar region at L5, with L4 being the next most common vertebra. 
Lumbar instability may progress to spondylosis or even spondylothesis
– Spondylolisthesis is a progression of spondylolysis leading to forward displacement of one vertebral body in relation to the one below it, usually secondary to a bilateral pars defect. This displacement is progressive, especially during rapid growth spurts of early adolescence. It is most common at L5-S1. 

Common Symptoms of Low Back Pain:

Gradual onset of pain, progressively worsens 
Pain is a dull ache and worsens with activity
Occasional sharp pain with certain activities or changing positions 
Pain with prolonged positions such as sitting or standing 
Pain restricts activities of daily living or sports performance 
May feel unstable or have a catching pain through motions not at end range
Rest usually relieves symptoms 
Possible history of local trauma or a previous injury, but usually not from a specific incident

How Spondylosis occurs:

Spondylosis occurs over time with a higher incidence in the young athletic population (gymnasts, football players, divers, wrestlers, weight lifters)
It is commonly from excessive or repeated hyperextension activities which are extremely common in gymnastics, along with generalized laxity and lumbar hypermobility
Weak core stabilizers, especially the transverse abdominis can also contribute to back pain. If the core is not stabilized with movement, the spine becomes the victim of excess motion and increased loading. 

Differential Diagnoses:

Spondylolisthesis 
Sprain/ Strain Injuries 
Disc Pathology
Facet Joint Pathology
SIJ Dysfunction
Stress Fracture 

Pertinent Tests/Diagnostic Imaging:

Referral to MD for further imaging and evaluation 
Spondylolysis defect is known as the “Scottie Dog” appearance on X-rays 
If it has progressed to Spondylolisthesis, the severity will be graded on a I-IV scale depending on the amount of forward displacement of the vertebra 
Clinical Tests in PT
+ Prone Instability Test
+ Gower Sign
+ Reverse Spinal Rhythm deficits 
Clinical Prediction Rule for Stabilization Protocol: aberrant motion observation, excessive flexibility in a straight leg raise (hamstring flexibility), 
+ Prone Instability Test

Risk Factors of Low back pain:

History of low back pain 
History of traumatic hyperextension 
Generalized hypermobility or diagnosis of a hypermobility disorder such as Ehlers-Danlos Syndrome 

When To Seek Medical Attention: 

Persistent pain that does not improve with rest over time 
Palpable step off along the back (if the vertebra has slipped forward, an indent may be felt along the lower spine)
Numbness or tingling sensation in the lower extremities (if the vertebra has slipped forward, it may be pressing on a nerve root and could cause sensation deficits) 

Principles of Treatment:

Course of anti-inflammatory medication may assist with pain relief and inflammation
Osseous healing is not absolutely necessary for excellent clinical outcome
Limit any activities that increase pain- modify practice/ training program, extension typically avoided 
Find rest and relief postures when sustaining positions that increase pain 
Spinal brace may be necessary if imaging suggests Spondylolisthesis
      – Prevent motion at that spinal segment to allow the bone to heal 
      – Possible 3 months in brace with no PT, followed by PT with progressive return to sport 
Focus PT on gluteus and core strengthening 
      – Strengthening, stabilization, and motor control is usually the focus of treatment 
Safe extension activities- limit hyperextension in practice 
Safe return to gymnastics and proper loading patterns
      – Movement analysis to address contributing factors 
      – Address movement deficits to prevent this from reoccurring 

Maintenance of strong supportive trunk muscles is very important, as well as sport specific training with a neutral spine, postural education, and sensorimotor control
Do not progress to new levels of rehab unless there is successful completion of the previous level without provocation of pain and normalized active range of motion
It is also very important to address any psychosocial components that could be contributing to the gymnast’s pain. Young gymnasts often train at a high intensity from a very young age and are under a lot of pressure from coaches and teammates 

Goals of Treatment to Low Back pain:

Decrease pain
Normalize tissue palpation and length 
Improve strength of individual muscles as well as overall functional strength  
Postural education and correction 
Improve dynamic stabilization 

Return to Sport:

Total rehabilitation time for return to sport is between 2-6 months 
Phase 1: Rest and Protect 
Phase 2: Static Stabilization 
Phase 3: Dynamic Trunk Stabilization and Coordination 
Phase 4: Athletic Enhancement and Gradual Return
Phase 5: Independent Exercise Program and Re-Injury Prevention Program 
Return to gymnastics requires:
      – Pain free ROM
      – Improved functional strength 
      – Proper spinal awareness and body mechanics 
      – Technique refinement to ensure proper body mechanics when performing skills repetitively or when fatigued 

PT Role and How to Prevent Spondylosis:

Improve core and lumbar stabilization 
Postural education 
Education on training modifications 
Education on proper technique and body mechanics 
Screen for psychosocial risk factors

 

References:
– Cavalier, R., M. J. Herman, E. V. Cheung and P. D. Pizzutillo (2006). “Spondylolysis and spondylolisthesis in children and adolescents”
Dankaerts, W., & O’Sullivan, P. (2011). The validity of O’Sullivan’s classification system (CS) for a sub-group of NS-CLBP with motor control impairment (MCI): overview of a series of studies and review of the literature. Manual therapy, 16(1), 9–14. doi:10.1016/j.math.2010.10.006
– Jackson DW, Wiltse LL, Cirincoine RJ. Spondylolysis in the female gymnast. Clinical orthopaedics and related research. 1976(117):68-73.
Hoffman, S. L., Johnson, M. B., Zou, D., Harris-Hayes, M., & Van Dillen, L. R. (2011). Effect of classification-specific treatment on lumbopelvic motion during hip rotation in people with low back pain. Manual therapy, 16(4), 344–350. doi:10.1016/j.math.2010.12.007
– McNeely, M. L., G. Torrance and D. J. Magee (2003). “A systematic review of physiotherapy for spondylolysis and spondylolisthesis.” Man Ther 8(2): 80-91.
– Newell, R. L. (1995). “Spondylolysis. An historical review.” Spine (Phila Pa 1976) 20(17): 1950-1956
– Winslow JJ, Jackson M, Getzin A, Costello M. Rehabilitation of a Young Athlete With Extension-Based Low Back Pain Addressing Motor-Control Impairments and Central Sensitization. Journal of athletic training. 2018;53(2):168-173.

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