CHAPTER 130 Return to Competition Following Prolonged Injury
INTRODUCTION
Athletes can experience a variety of spinal injuries depending upon the nature of the sporting activity. Most injuries are relatively benign in nature, typically involving muscle strains. These injuries can be treated in a brief period of time with limited resources, allowing the athlete to quickly and safely return to competition. More serious or chronic injuries, including fractures, radiculopathies, or spondylolysis, may require an extensive evaluation and treatment plan prolonging the athlete’s recovery period. With a prolonged recovery comes the potential for deconditioning, further delaying the athlete’s return to competition. The challenge to the physician involves balancing the prompt recognition and treatment of the spine injury against the pressure to return quickly to competition and potential for recurrent injury.
EPIDEMIOLOGY
It is important to understand which sports have an increased risk for more severe injuries. Overall, it has been estimated that cervical spine injuries account for 2–3% of all athletic injuries.1 Fortunately, severe or catastrophic cervical spine injuries are rare. Typically the mechanism of injury involves cervical hyperflexion with concurrent axial loading. In football players,2 cervical hyperflexion, as may occur with spear tackling, has been proposed as the primary mechanism of cervical spine injury leading to spinal cord neurapraxia3 and cervical fractures. Similar cervical flexion-type injuries have been noted in athletes involved in gymnastics, diving,4 ice hockey, wrestling, trampoline, somersaulting, rugby,5 cheerleading, and motor sports. Fortunately, the use of protective equipment and improvement in equipment design in some sports has helped decrease the incidence of cervical spine injuries.6
Similar to cervical spine injuries, the incidence of low back injuries varies depending on sports and mechanism of injury. Several studies have suggested that lumbar spine injuries represent 10–15% of competitive sports injuries.7 Compared to cervical spine injuries, the mechanism of injury is more variable, relating to hyperflexion, hyperextension, and rotatory motions. Hyperflexion injuries can typically occur in football, ice hockey, and rowing. Gymnasts have been shown to have a higher incidence of spondylolysis compared to nonathletes, most likely due to repeated hyperextension and axial loading of the lumbar spine.8 Twisting and rotatory motions can contribute to lumbar pain in racquet sports and golf. It has been estimated that 10–30% of tour golf players experience lumbar spine pain.9 As with cervical spine injuries, lumbar spine injuries with neurologic compromise are rare, representing less than 1% of all sports injuries.9
ASSESSMENT
Examination of an athlete with a spine injury requires a fundamental knowledge of the underlying functional anatomy in relation to the rehabilitative process. The initial priority should include the assessment of spinal stability. A more aggressive evaluation of the spine may occur only once the physician is 100% certain there is no underlying spinal instability. The reader is referred to the previous chapters in this textbook for a complete discussion relating to the clinical evaluation of the cervical and lumbar spine. In addition, resources such as the PASSOR Musculoskeletal core competency list will provide a more detailed outline of the various physical examination tests.10
Of note, injuries in children are of particular concern due to the inherent ligamentous laxity. Cervical radiographs should be interpreted with caution as spinal cord injury can be seen without radiographic abnormality. Beck et al. concluded that children and adolescents who have neurological deficits and spinal cord injuries without radiographic abnormalities (SCIWORA) require close following of their deficits and further evaluation to define structural pathology and often require prolonged therapy.11
GENERAL TREATMENT PRINCIPLES
An appropriate treatment plan will depend upon the etiology and severity of, and secondary maladaptations associated with, the spinal injury. After an acute injury, the focus is on inflammation and pain control with the goal of promoting tissue healing. After prolonged injury, treatment interventions should be utilized in a systematic manner focusing on: (1) pain control, (2) correction of inflexibilities and strength deficits, (3) maintenance of cardiovascular stamina, (4) assessing any psychological barriers, and (5) reintegration into sports-specific activities. The general treatment outline is summarized in Table 130.1.
Table 130.1 General Principles for Recovery from Prolonged Spine Injuries
| I. INITIAL PHASE: PAIN CONTROL | |
| Activity modification | |
| Antiinflammatory medication | |
| Physical modalities | |
| Peripheral or axial injections | |
| II. RESTORATIVE PHASE: CORRECTING FLEXIBILITY AND STRENGTH DEFICITS | |
| Truncal and extremity stretching | |
| Soft tissue mobilization | |
| Cervical or lumbar stabilization strengthening exercise | |
| Maintenance of cardiovascular fitness | |
| III. INTEGRATIVE PHASE: FUNCTIONAL ADAPTATIONS | |
| Normalization of spine mechanics | |
| Progression towards sports-specific activities | |
| IV. RETURN TO COMPETITION | |
| Pain free | |
| Pain-free range of motion | |
| Pre-injury strength | |
| Ability to perform sports-specific maneuvers |
Pain control
Muscular strains and ligamentous sprains usually occur as a blow to the head or body creates rotary, sidebending and flexion–extension forces to the spine. Trying to maintain the head and neck in normal alignment by strong eccentric contraction creates muscle and ligamentous tearing by overcoming their tensile strength.12 It is during the acute pain period that the athlete may learn protective compensatory posturing, resulting in abnormal posture, thus leading to a chronic pain mechanism. The head protruded forward is commonly seen in those with poor posture secondary to habit or body habitus. A cycle of biomechanical derangements occurs, resulting in an alteration of the normal anatomy and alignments. Muscles meant to stabilize come to function as movers of the spine, leading to a further pattern of chronic myofacial pain syndrome.
In general, injury to a musculoskeletal structure such as a muscle or ligament will lead to a systematic process of degradation and repair. During the initial inflammatory phase, micro/macro tears and localized hematoma formation give way to phagocytosis and enzymatic degradation with subsequent tissue necrosis. Modalities to control the inflammatory process may play a role in limiting the extent of tissue damage during the initial stages. During the reparative phase, the body attempts to repair the injured area through collagen formation. However, the reparative process will lead to disorganized fibrous tissue without the appropriate applied stressors. Prolonged pain symptoms will inhibit the rehabilitative process by limited the amount of stress one can tolerate during the recovery process. Therefore, adequate pain control is imperative during the management of an athlete with prolonged injury. It is the basis for early mobilization and is the reason why soft tissue is not immobilized for a prolonged period, unless absolutely indicated by the injury.13
Unfortunately, evidence supporting the use of specific pain modalities in the athlete is lacking. In the general population, there is strong evidence that prolonged bed rest is detrimental to the functional recovery of individuals with acute low back pain without radiculo-pathy.14 It could be surmised that the principle of relative rest and the avoidance of bed rest in athletes will also facilitate earlier functional recovery. Fellander-Tsai et al.15 suggested some benefit from the use of modalities for pain relief in individuals with spondylolysis, including activity modification and electrical stimulation. However, the study had several design flaws including small sample size and selection bias. Various studies provided conflicting support as to the efficacy of interventional spinal injections.16,17 Finally, O’Sullivan et al.18 showed a signification reduction in pain intensity and utilization of pain medication at 30-month follow-up in a treatment group that underwent a 10-week exercise treatment program compared to controls. Future, randomized, controlled studies are need to better support or refute the utilization of these various modalities in managing a specific spinal injury in athletes.
Correction of inflexibilities and strength deficits
Spinal flexibility
However, evidence is limited as to the role of spine flexibility and injuries in athletes. In addition, a review of the literature pertaining to nonathletes yields conflicting reports as to the role of spine flexibility and range of motion in the treatment of spine injuries. Several recent studies outlined below have suggested that there is no correlation between spinal flexibility and disability or function. Kuukkanen et al. suggested that flexibility does not play an important role in the functional ability of individuals with back pain that is not severe in nature.19 Similarly, Sullivan et al. studied the relationship of active lumbar spine range of motion and disability. Using the Roland-Morris Back Pain Questionnaire and therapist assessments, they suggested that active lumbar spine flexion should not be used as a treatment goal.20 In contrast, Magnusson et al.21 studied a group of patients’ with chronic low back pain. The study suggested that increased trunk motion could be achieved by participation in a 2-week, full-time rehabilitation program. The authors suggested that motion was of ‘greater magnitude and was done at an increased velocity.’ In addition, patients who demonstrate a pain avoidance behavior can achieve the confidence to recover in spite of their pain. More comprehensive randomized, prospective studies are needed to better assess the role of spinal flexibility in the recovery process in athletes. Despite these limitations, the authors still advocate that athletes work on correcting any loss of spinal flexibility or range of motion. These flexibility exercises may be initiated at the beginning of the recovery period and in combination with the strength training once the pain is controlled. A flexion- or extension-based program will depend upon the specific limitations as per the physical examination.
Strength deficits
Addressing strength deficits is another primary focus of spine rehabilitation. Similar to the previous discussion of spinal flexibility, prolonged injury and pain can lead to muscle atrophy, altered spine biomechanics, and decreased athletic performance. There are a variety of spine exercise programs including spine stabilization exercises, McKenzie exercises, and Williams’ flexion exercises which are utilized to treat spine injuries based upon the etiology of the spine pain.22 However, there is limited study of the utility of these programs in the management of prolonged spine injuries in athletes. The following is a review of the various studies that have attempted to analyze the role of the spine muscles in supporting the spine, anatomical changes which occur from an exercise program, and efficacy in treating individuals with prolonged spine injuries.
In the lumbar spine, the superficial and deep truncal muscles are strengthened to assist with the control of the lumbar spine. Various studies have yielded conflicting results as to changes involving the superficial muscles of the lumbar spine. In contrast, the multifidus muscles are believed to be important in maintaining stiffness and strength of the lumbar spine.23,24 Zhao et al. suggested that functional inactivity may contribute to selective type 2 atrophy of the multi-fidus muscles in patients with lumbar disc herniations.25 Antigravity postural muscles have been shown to atrophy to a greater extent than lower extremity muscles in microgravity simulation models.26 Changes in muscle composition in healthy subjects who stopped normal repetitive low-level activity patterns is thought to result in transformation of the muscle towards a more fatigable type of muscle fiber.26,27 The implication is that muscles situated on the trunk and lower extremities are affected most by prolonged inactivity and deconditioning. Fortunately, it is believed that these changes are reversible with adequate therapy.
Various studies have looked at the anatomical changes in spinal muscles after a treatment exercise program. Hides et al. attempted to assess the recovery of lumbar multifidus muscles after treatment with an exercise program consisting of isometric contractions of these muscles with cocontraction of the abdominal muscles compared to medical treatment only for individuals following a nonradicular acute lumbar spine injury.28 These authors noted a more rapid and complete recovery of the multifidus muscles as measured by an improvement in the muscle symmetry. Sung studied the endurance of multifidus muscles and functional status of chronic low back pain patients after participation in a 4-week spinal stabilization program.29 Although the authors believed it was difficult to measure the isolated effect on the multifidus alone, they suggested the evidence did show a change in the multifidus strength in conjunction with other spinal extensor muscles. Finally, Danneels et al. analyzed effect of three different 10-week exercise training programs on the cross-sectional area of the paravertebral muscles in individuals with chronic lumbar spine pain.30 The authors suggested that a lumbar stabilization program combined with dynamic resistance training was necessary to restore the size of the paravertebral muscles. These studies would suggest that a structured lumbar exercise program can lead to anatomical improvement in the lumbar multifidus muscles.
Other studies have attempted to define the functional efficacy of a structured strengthening exercise program in the management of individuals with chronic lumbar spine pain. Unfortunately, there are few prospective, randomized studies. O’Sullivan et al.18
