Treatment of Sports Injuries in the Young Athlete
Although not common, back and neck injuries can occur in young athletes who participate in sports. Though injuries that cause back pain are not the most common cause of injury in the young athlete, they can cause frustration. Most athletic injuries to the back are sprains of the ligaments or strains of the muscles. However, several more serious conditions can have symptoms similar to a routine sprain or strain. Many injuries occur after repetitive overuse of the structures of the spine. Therefore, proper treatment of a young athlete always includes a good physician evaluation with imaging studies when necessary.
Muscle Strains and Ligament Sprains
Muscle strains and Ligament sprains are the most common injuries that cause back pain in the young athlete. They can be caused by athletic overuse, improper body mechanics and technique, lack of proper conditioning, insufficient stretching, as well as trauma. The athlete will complain of back pain with activity and will feel relief with rest.
Initial treatment may require a period of rest and removing the athlete from sports participation. Treatments may include medication and special exercise. Ice can be used along with pain medications, which should be used sparingly. In addition, other measures to control pain and restore motion are commonly used. Initially, ice and medications such as nonsteroidal anti-inflammatories can be used. For persistent symptoms, particularly those associated with muscle spasm, heat may also be very helpful.
As pain decreases, the injured athlete should be shown proper exercise to assist recovery. An exercise program can be very beneficial to improve flexibility and strength of the appropriate muscles for athletic performance as well as to help decrease risk for another similar injury. It is also important to maintain aerobic conditioning during treatment for back pain. Aerobic exercise needs to be tailored to the athlete and performed as pain allows. The repetitive overuse of the spine (particularly rotation) should be avoided, at least initially. Before being released to return to play, sport-specific exercises that mimic activities of athletic competition are often included in the exercise program. It is also always important to evaluate and correct poor technique and mechanics that may have predisposed the athlete to the initial injury.
Spondylolysis & Spondylolisthesis
Defects of a vertebra's pars interarticularis (spondylolysis) and the slippage of one vertebra in relation to another vertebra (spondylolithesis) are common causes of back pain in the young athlete. These injuries are often seen in athletes who participate in sports that require twisting and hyperextension of the spine, such as in gymnastics. The athlete usually complains of pain that worsens when arching the back. The physician must be alert because these injuries often appear to be a sprain or strain. X-ray images are often normal and special imaging studies such as bone scan and CT scan may be required to confirm the diagnosis.
Recovery requires a period of relative rest, ice, medication and specific exercises. It is important that inflexible muscles are stretched and the trunk muscles strengthened. In some cases, bracing may be necessary to allow for proper healing. Progression back to sports is similar to that for sprains and strains.
A few special considerations are important in an athlete who has developed a spondylolisthesis. Athletes with 50% or less forward slippage can usually return to all sporting activities after pain resolves and appropriate rehabilitation has been completed. Athletes with 50% or greater forward slippage are encouraged to participate in less aggravating sports. Also, athletes with a spondylolithesis should be monitored every six months for progressive slippage as they go through any adolescent growth spurt.
What is a Stinger?
A stinger is a sports related injury to the nerves about the neck or shoulder. It is sometimes called a burner or nerve pinch injury, but the term stinger is most descriptive of the symptoms that the athlete experiences including painful electrical sensations radiating through one of the arms. While the stinger is usually a spine injury, it is never a spinal cord injury. The stinger occurs most commonly in contact and collision sports, but is not as catastrophic as a spinal cord injury and does not result in paralysis in the arms and legs. A stinger is often not reported by the athlete to the coaches or the athletic trainers since the symptoms can spontaneously resolve within a short period of time. However, stingers tend to recur and if not properly diagnosed and treated can lead to persistent pain or even arm weakness, which can eventually result in extended lost playing time.
Athletes competing in various sports (most common in football and wrestling), playing specific positions (such as defensive back, linebacker or offensive line) or performing certain athletic maneuvers (such as tackling, blocking or executing a take down maneuver) are at greatest risk of sustaining a stinger. The injury occurs in one of two ways: either one of the nerves off the spinal cord in the neck is compressed as the head is forced backward and toward that side; or the nerves in the neck and shoulder are over-stretched as the head is forced sideways away from the shoulder. The athlete will experience sudden and severe painful, stinging sensations in one of his arms frequently lasting from seconds to minutes, occasionally hours and less frequently days or longer. There is often associated weakness of the muscles in the shoulder and arm that are supplied by the injured nerve. The arm symptoms are usually more severe than neck pain. First time stingers will usually recover quickly even without treatment, but there is a greater risk of recurrent injury if left untreated. Each additional stinger will likely result in continued neurologic impairment including muscle weakness. Stingers do not affect both arms at the same time, although each arm can be affected with different injuries. If both arms are symptomatic at the same time after a neck injury, a spinal cord injury is likely to have occurred which leads to a much different treatment plan.
How is it diagnosed?
The diagnosis of the stinger requires the expertise of a medical professional. Ideally, the first evaluation of the athlete occurs at the time of injury at the game or match. Because these injuries are not catastrophic, the athlete often exits the "field of play" without assistance. A sideline evaluation will be conducted by the athletic trainer, physical therapist and/or team physician that will include: a determination of the mechanism of the injury, the symptoms experienced by the athlete, and the physical examination findings including assessment of muscle strength. A decision will be made whether or not the athlete is medically cleared to return to that contest. Persistence of symptoms, stiffness or loss of full range of neck motion, muscle spasm and weakness would usually keep the athlete out of competition.
Careful medical follow-up evaluations are important and necessary. These examinations should take place regularly until the athlete's condition has normalized. If the symptoms and/or neurologic findings worsen during the first few days after the injury or continue beyond two weeks, then further medical assessment is necessary. The physician may order specific tests such as X-ray examinations, magnetic resonance imaging (MRI), and an electromyogram (or EMG) which is designed to evaluate for nerve damage. Occasionally a stinger can result from a disk herniation in the neck. If so, this should be confirmed on the MRI.
No matter how trivial the injury may appear, in order for the physician to make the correct diagnosis and prescribe the appropriate treatment it is very important for the athlete not to withhold information. If the injury was not witnessed by the medical personnel covering the event, then it is the responsibility of the athlete to report the injury even if the symptoms disappear quickly. In some situations, the effects of the stinger can lead to permanent nerve damage if left undiagnosed and untreated.
What treatments are available?
The goals of treatment are to reduce the pain and abnormal sensations in the arm, regain the strength of weakened shoulder and arm muscles, and prevent further injuries.
There are several nonoperative options for the treatment of an acute stinger. The order in which these treatments are utilized depends largely on whether the primary complaint is pain or weakness.
Treatment for acute pain usually includes activity restriction, ice or heat, anti-inflammatory and pain medications, a cervical collar and cervical traction. Following an acute injury, the athlete is not allowed to return to competition to allow time for recovery. Modalities such as ice and heat can be used both for comfort and to reduce inflammation. Ice is usually applied about the neck and shoulder region up to 48 hours post injury after which time heat is substituted.
Nonsteroidal anti-inflammatory medications are frequently prescribed for both reduction of swelling and inflammation as well as pain relief. Stronger analgesics (pain medications) are not usually necessary, but muscle relaxants may be utilized for a short period of time to treat muscle spasm.
A cervical collar may also be used for a short period of time to prevent further nerve root injury or irritation. Cervical traction helps to reduce pressure on the nerve root. It can be applied manually or mechanically under the guidance of a physical therapist. Often, trunk strengthening and chest-out posture correction exercises are started.
For persistent pain, cortisone injection around the injured nerve root ("nerve root block") performed with X-ray guidance can be helpful to reduce inflammation of the nerve. If weakness is the main problem, then the acute treatment includes modified activities, ice or heat and anti-inflammatory medication.
The majority of stingers are treated successfully without surgery. Surgery is only considered if the injured nerve root is found to be severely compressed by either a disc herniation or bone spur and there is severe persisting pain or worsening weakness. The two surgical options are removal of the disc (discectomy) or bone spur, or discectomy followed by a fusion. In each case, the surgical decision is individualized to the athlete's symptoms and signs and the results of additional diagnostic tests.
Many athletes who sustain a stinger are found to have substantial postural deviations which may interfere with full recovery. Some of these abnormal postures include the head jutting out too far forward from the neck and the shoulders too rounded. These postures will cause more pressure to be placed on some of the nerve roots in the neck making them more likely to be injured and to recover slower after injury.
A comprehensive physical therapy treatment program will be of value to correct the various areas of muscular and soft tissue tightness and weakness throughout the neck, upper back and shoulder region. Trunk stabilization and chest-out posture correction exercises are usually the basis of the treatment program.
Physical therapy may also include manual therapy treatments in which the therapist provides deep tissue massage to release tight soft tissues and joint mobilization to loosen stiff spinal joints. Forceful spinal manipulation should be avoided so as not to further injure the cervical nerve root. Therapy includes specific exercises to strengthen the weak muscles of the neck, upper back and arms. Athletes who undergo surgery must also complete a full rehabilitation program.
Return to Play
Before the athlete can return to regular athletic competition, several goals must be met.
- First, the athlete must be completely free of pain and weakness and must regain full range of motion of the neck.
- Second, the diagnostic tests such as the EMG and/or MRI should not reveal any active nerve damage or severe nerve compression.
- Third, the athlete must be reconditioned for the sport especially if he has not competed for awhile.
- Fourth, improvement in the athlete's playing technique (such as blocking and tackling) and equipment modifications should be made to protect the athlete from further injury.
In football, special pads and neck rolls can be fitted to the helmet or shoulder pads, which can help prevent re-injury. However, this type of equipment change does not replace the most important part of prevention, which is building strength and endurance of the neck and shoulder muscles. That is why athletes who have had surgery will usually take longer to return to play.
Finally, in some cases, the decision to return to play must be delayed especially if the athlete has suffered several stingers in the same season. Healing is usually slower after multiple injuries. The key concern is to avoid permanent nerve damage, which could cause problems in the young athlete's personal as well as athletic life. Rarely does a history of multiple stingers signal the end of an athletic career. The sports medicine physician, working together with the athletic trainers, should provide counseling regarding how serious the injury is and discuss early or delayed return to play.
Though it is a common cause of back pain in the adult population, disc injury is relatively uncommon in the young athletic population. Back pain from a disc injury may or may not be associated with sciatica (pain that shoots down the leg). A careful history and examination is very important in determining if a disc problem may be the cause of the athlete's complaints. Magnetic resonance imaging (MRI) can also be helpful in determining if a disc is a cause for the pain and to rule out other potential causes that may mimic disc injury in an adolescent.
Treatment is similar to treatment of a disc herniation in the adult population. (See the NASS Patient Education Brochure on Herniated Disc for more information about this condition.) Injections (epidurals) can be used but are not necessary in most cases. If symptoms do not improve with a comprehensive rehabilitation program, then surgery may be indicated. This is necessary only in a small percentage of young athletes with disc injury.
Scheuermann's Disease (juvenile kyphosis)
Another common problem seen in the young athlete with back pain is juvenile kyphosis, known as Scheuermann's Disease. Pain associated with this occurs during puberty and is in the mid back, rather than the low back. The athlete demonstrates a roundback deformity that worsens to a "dome" appearance of the back with bending forward. Diagnosis is made by X-ray examination that shows at least three consecutive vertebra show a wedging of 5° or more.
Treatment in most cases is aimed at relieving symptoms. Extension-based back exercises and postural exercises are essential. These can provide significant symptomatic relief, but it is important to note that the structural curve cannot be corrected with these exercises. For curves of 50° or greater, bracing can be helpful if the athlete is able to tolerate wearing the brace. For athletes with severe curves who continue to have debilitating pain despite bracing, surgical correction and stabilization may be required. It is important to note that this may limit the athlete's ability to return to their given sport. As with all spine-based injuries, a complete rehabilitation program is essential prior to return to athletic competition.