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R E V I E W A R T I C L E Open Access
Lumbar Spine Injuries in Sports: Review
of the Literature and Current Treatment
Recommendations
Jacob R. Ball, Colin B. Harris
*
, Jonathan Lee and Michael J. Vives
Abstract
Low back pain is one of the most prevalent complaints of athletes at all levels of competition. The purpose of this
literature review is to provide an overview of sport-specific injuries and treatment outcomes that can be used by
healthcare providers to better recognize injury patterns and treatment options for different groups of athletes. To
our knowledge, no prior comprehensive review of lumbar spine injuries in sports is currently available in the
literature, and it is essential that healthcare providers understand the sport-specific injury patterns and treatment
guidelines for athletes presenting with low back pain following an athletic injury. Injury mechanisms were found to
vary significantly by sport, although some broad recommendations can be made with regards to optimal treatment
for these injuries and return to play. Additionally, it was found that certain treatments were more beneficial and
resulted in higher rates of return to play depending on the specific sport of the injured athlete. Healthcare
providers need to be aware of the different injury patterns seen in specific sports in order to properly evaluate and
treat these injuries. Furthermore, an individualized treatment plan needs to be selected in a sport-specific context in
order to meet the needs of the athlete in the short and long term.
Keywords: Lumbar, Spine, Athlete, Injury, Sport
Key Points
Lumbar spine injuries are common in athletes.
Different injury types are seen more frequently in
specific sports.
Treatment options need to be considered in a sport-
specific context for the best outcome.
Background
An estimated 10–15% of all athletes are expected to ex-
perience low back pain [1]. Sports such as football and
dancing, which place increased stress on the lumbar
spine, are believed to have higher rates of low back pain
compared to less physically demanding activities [2,3].
The repetitive flexion, extension, and axial load type
movements that athletes place on their spine contributes
to their low back pain even though they often possess
superior strength and flexibility when compared to the
general public [4]. Numerous studies have shown mul-
tiple injury patterns in the lumbar spine, demonstrating
the increased stresses that elite athletes place on the
lower back.
The purpose of this review is to evaluate different
sports and the lumbar spine injuries associated with
them. Furthermore, this review will evaluate treatment
options in a sports specific manner to assess optimal
treatment for the athlete with a lumbar spinal injury.
Main Text
General Considerations
Lumbar spine injuries that occur during play require
proper on-field treatment and management to prevent
serious complications. Most authors focus on the cer-
vical spine when discussing on-field back injuries, but
the general principles can also be applied to the lumbar
spine. The most important step in managing on-field in-
juries is developing an appropriate protocol that speci-
fies the medical equipment needed at every sporting
event, the person responsible for evaluating the injured
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
* Correspondence: harrisco@njms.rutgers.edu
Department of Orthopaedics, Rutgers New Jersey Medical School, 140
Bergen St., ACC D1610, Newark, NJ 07103, USA
Ball et al. Sports Medicine - Open (2019) 5:26
https://doi.org/10.1186/s40798-019-0199-7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
player, and who will contact emergency medical services
[5,6]. The athlete requires a focused musculoskeletal
and neurologic exam, but it is essential to minimize
spinal movement to prevent further injury [5,6]. As op-
posed to cervical spine injuries, logrolls should be
avoided when transferring the patient to a spine board
[5]. The most important prognostic factor is the time it
takes for the athlete to be taken to a healthcare center
that is properly equipped for spinal injuries [5] (Fig. 1).
The first steps to evaluate an athlete who presents
with low back pain involve a thorough history and phys-
ical examination in order to elicit the injury mechanism,
identify any neurologic deficits or signs of more serious
injury, and to direct the physician to the appropriate
workup. Pain due to spondylolysis and facet (posterior
element) injuries is reproducible with extension, whereas
discogenic pain is reproduced with flexion. A thorough
neurological examination is mandatory, including motor,
reflex, and sensory testing in addition to provocative
tests such as the Spurling’s test and straight leg raise
(Lasegue’s) test. When radicular pain or neurological
deficits are present, MRI is necessary to detect spinal
cord and nerve involvement. For lower back pain, lack-
ing neurological signs, upright AP, and lateral X-rays are
generally the initial study of choice but may be non-
diagnostic for several common conditions. For pars
stress reactions, MRI is useful when plain radiographs
including AP, lateral, and oblique views are negative and
has the added benefit of not exposing patients to ioniz-
ing radiation as seen in CT with SPECT imaging [7]. CT
is recommended to assess for fracture, anterolisthesis, or
alignment abnormalities in cases of acute trauma and is
the first line imaging modality to assess for bony detail
of a pars defect or to follow the healing of the pars with
conservative treatment. The muscular or ligamentous
strain should be suspected when imaging studies are
negative for anatomical abnormalities, and before
returning to play a brief course of rest and anti-
inflammatory medications followed by strength and
flexibility training is indicated. The following provides
an overview of sport specific injuries which is summa-
rized in Table 1.
Fig. 1 Treatment algorithm for the athlete with a suspected lumbar spine injury
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American Football
Football is a very popular sport in the USA, with many
players becoming involved in the early teenage years and
participating in high-level practice and competition by
ages 15–18. Although cervical spinal cord injuries sus-
tained during football are high profile due to their po-
tentially catastrophic nature and have received the
greatest media attention, lumbar spine injuries are com-
mon (30.9% of injuries in one study) and can lead to
considerable morbidity and lost playing time [8,9]. Disc
herniations account for about 28% of lumbar spine injur-
ies in football, with the majority located at L5-S1 and
L4-L5 [9]. Mechanism of injury is not well understood
but is related to blocking and tackling, with offensive
and defensive linemen being the most commonly injured
players by position. Non-contact injuries also account
for about 20% of lumbar spine injuries, likely from
avulsion due to sudden changes in the direction [8]. An-
other common injury sustained by football athletes is
spondylolysis, secondary to extension and rotation forces
in the lumbar spine. These injuries generally respond
well to bracing in the adolescent population but often
require direct pars repair or fusion in adults in order to
expedite return to play.
Ice Hockey
While ice hockey is a popular sport in the USA, few
studies have investigated the prevalence and mechanism
of lower back pain in the sport. One small study found
that 95% of ice hockey players reported lumbar spine
pain in their final year of play [12]. However, MRI
changes in thoracolumbar vertebrae in ice hockey
players were studied over a 15-year interval and it was
found that new abnormalities from baseline were
Table 1 Sport specific lumbar spine injuries and treatment outcomes
Sport Epidemiology Prognosis
American football Up to 30.9% of injuries are lumbar spine related [8].
Twenty-eight percent of lumbar injuries are disc
herniations [9]. Avulsions, spondylosis, and strains
are also prevalent.
Surgical repair of disc herniation may have return
to play advantages [10]. Similar outcomes with
microdiscectomy and non-surgical treatments [11].
Ice hockey Ninety-five percent of players report lumbar pain in
final year of play [12]. Thoracolumbar and
lumbosacral account for approximately 12% of
on-ice spine injuries [13]. Lumbar spondylolysis
was diagnosed in 44% of youth ice hockey players
complaining of lower back pain [14].
Surgical repair of disc herniations was associated
with decreased return to play rates [15,16]. Return
to baseline level of performance during second
and third season post-injury [16].
Basketball 10.2% of all injuries involve the lumbar spine [17].
Sprain and strain, lumbar disc degeneration, and
lumbar contusions account for 7.9%, 0.9%, and
0.9% of the total injuries respectively [17].
Surgery for disc herniation resulted in decreased
performance during the first season after injury.
Pre-injury skill returned during second and third
season post-surgery [15,16].
Baseball 89.5% of players report lower back pain during
career [18]. 35.1% and 22.8% of players showed
signs of L5/S1 or L4/L5 disc degeneration
respectively [18].
Hitters and infielders had faster return to play
time with nonsurgical interventions whereas
there was no difference for pitchers [19].
Soccer (European football) 76.6% of players report low back pain during
career [18]. Three percent of injuries occurring in
soccer are lumbar spine related [20]. Strains, sprains,
spondylosis, and fractures occur in soccer. The
most serious injuries are often the result of contact
with another player which can lead to fracture.
Fractures resulted in the longest recovery time
followed by bony and soft tissue injuries.
Repetitive wear and tear type injuries also occur
and tend to persist.
Dance The lumbar spine is the second most commonly
injured site [21]. Spondylolysis is the most common
injury type seen [22]. The combination of repetitive
hyperflexion and poor technique contribute to injury
[23]. Males are prone to injury due to lifts they
perform [21].
Forty-six percent of injured dancers had to limit
up to half of the activity and 5% needed to limit
more than half of activity [24].
Gymnastics Evidence of disc degeneration is as prevalent as
75% in elite athletes [25]. Studies demonstrate an
11% incidence rate of spondylolysis [26].
In general, these injuries are well managed
non-surgically, but there is not currently data
specific to gymnasts.
Skiing and snowboarding Lumbar spine is the most common site injured,
includes compression, burst, and transverse or
spinous process fractures [27,28]. In snowboarders,
injury is associated with failed jumps and the
subsequent axial loads. The mechanism of injury in
skiers is associated with downhill falls forward at
high velocities [27,29,30].
Spinal cord injuries are more commonly seen
with cervical spine injuries, and less common
with thoracic and lumbar spine injuries [31].
Most injuries are managed non-operatively.
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infrequent [32]. A more common mode of injury was
that existing vertebral abnormalities continued to degen-
erate over the 15-year period [32]. The baseline charac-
teristics of these players were that they had a median
age of 24 and had been playing hockey since the age of
10 [32]. These inclusion criteria and the results of the
study led the investigators to conclude that most of the
injuries sustained to the thoracolumbar spine occurred
during the growth spurt phase of their adolescence and
it is these injuries that persist throughout their career
[32]. A study of Canadian ice hockey leagues found that
for injuries that occur during play, 82% were cervical,
7.3% were thoracolumbar, 5.1% were thoracic, and 4.8%
were lumbosacral [13]. Further investigation revealed
that being checked from behind was the most common
cause of injury at 35% [13]. Another small study
followed a single elite youth ice hockey program over a
period of 9 seasons and found that of the players who
complained of lower back pain, 44% were diagnosed
with lumbar spondylolysis [14]. Furthermore, 73% of
spondylolysis occurred on the shooting side of the player
which suggests that the directional rotation of the spine
may lead to specific injury patterns [14]. Future studies
investigating specifically the causes of lumbar spinal in-
jury in ice hockey would be beneficial to better under-
stand injury and prevention.
Basketball
Injuries in basketball are common due to the increas-
ingly physical nature of the game. Studies have not spe-
cifically evaluated the mechanisms of lumbar spine
injuries in basketball, but it is likely related to a combin-
ation of torsion, loading, and trauma. In a study that
tracked all injuries in the National Basketball Associ-
ation (NBA) over a 17 year period, researchers found
10.2% of all injuries were in the lumbar spine [17]. Lum-
bar spine injuries were second only to ankle injuries,
which accounted for 14.7% of total injuries [17]. On fur-
ther analysis of the total injuries in the NBA over the 17
year period, lumbar sprain and strain accounted for 7.9%
of injuries, lumbar disc degeneration accounted for 0.9%
of injuries, and lumbosacral contusion accounted for
0.9% of injuries [17]. Even though lumbar disc degener-
ation only resulted in 0.9% of total injuries, it accounted
for 3.6% of the total games missed, which indicates how
serious these injuries are when they occur [17]. Follow-
ing surgical repair of a lumbar disc herniation, multiple
studies have shown that the return to play rate and the
games played the following season both decrease [15,
33]. Furthermore, for the players that were able to return
the next season, their player efficiency ratings were sig-
nificantly reduced [33]. Interestingly, games played and
player efficiency ratings for the second and third sea-
son post-injury returned to their preinjury level,
indicating that players do well in the long term from
these surgeries [33].
Baseball
Baseball is a physically demanding sport due to the kin-
etic chain needed for successful throwing and batting
motion. Unfortunately, few studies have directly exam-
ined the mechanisms of baseball injuries, but there are
some data on epidemiology and injury specific treatment
outcomes. One study examining the Major League Base-
ball (MLB) injury list between 2002 and 2008 found that
11.7% of the players had sustained either a spine or core
injury [34]. Interestingly, both pitchers and fielders expe-
rienced spine and core injuries at a similar rate during
this time period [34]. In another study that evaluated
college athletes in Japan, T2 MRI revealed that 59.7% of
baseball players showed signs of disc degeneration [18].
Furthermore, 35.1% of baseball players showed signs of
disc degeneration at L5/S1 and an additional 22.8% of
players showed disc degeneration at L4/L5, suggesting
that the lumbar spine is most susceptible to injury [18].
Lastly, 89.5% of the baseball players studied reported
having low back pain at some point during their life
[18]. In a study assessing lumbar disc herniation and
treatment, it was found that players who underwent sur-
gery had a significantly longer recovery period than
players who received non-operative treatment (8.7 vs
3.6 months) [19]. Interestingly, the treatment plan and
the return to play time varied depending on player pos-
ition [19]. For pitchers, there was no significant differ-
ence in the return to play time for surgical versus
nonsurgical management, but hitters and infielders had
a significantly shorter return to play time with nonsurgi-
cal treatment [19]. While this was a small study, the data
suggest that there are also worse performance outcomes
in the surgical group compared to the nonsurgical group
[19]. Future studies should focus on specific mechanisms
of lumbar spine injury in baseball as well as a wider var-
iety of injury types and treatments.
Soccer (European Football)
Soccer is the world’s most popular sport, and low back
injuries are not uncommon. A study by Hangai et al.
found that in college athletes in Japan, the lifetime inci-
dence of low back pain in soccer players was 76.6% com-
pared with 53.5% of non-athletes [18]. One study that
took place in the UK followed more than 12,000 highly
competitive youth soccer players for five complete sea-
sons and found that out of the 10,225 injuries that oc-
curred, only 310 (3%) were related to the lumbar spine
[20]. Of the 310 lumbar spine injuries, 49.4% were classi-
fied as low back pain, 15.2% as sprains, and 4.2% as
spondylolysis [20]. Furthermore, lower back injuries re-
corded by anatomical site resulted in the lumbar region
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accounting for 44.5% followed by erector spinae and
quadratus lumborum at 11.9% and 5.8% respectively
[20]. With respect to recovery time from injury, frac-
tures took the longest with a median of 148.5 days
followed by bony tissue and soft tissue injuries at 15.5
and 13 days respectively [20]. Not surprisingly, contact
with other players was found to cause significantly more
injuries than non-contact play [20]. Another study that
identified 137 consecutive cases of spondylolysis in New
York City youth athletes found that the largest percent-
age (19%) of these children were soccer players [35]. The
authors stressed the importance of understanding which
sports are most prevalent in a given region because even
though spondylolysis may be rare in soccer players, the
volume of players in a region makes certain injuries
more prevalent [35]. Lastly, in a study that included 70
former professional soccer players, they found that the
incidence of osteophytes in the lumbar spine was signifi-
cantly increased when compared to control groups [36].
This finding suggests that through competitive play, the
mechanical forces on the lumbar spine ultimately result
in osteophyte development [36]. Given the global popu-
larity of soccer and the lumbar pathology experienced by
players throughout their career and in retirement, future
studies are needed to better understand the mechanisms
of injury to create a safer environment [18–20,35,36].
Dance
While participation in dance is less than in some of the
sports discussed above, it is technically demanding and
physically challenging which increases the risk of injury.
Past studies have suggested that the body positions re-
quired for dance cause dangerous hyperflexion of the
lumbar spine, but more recent literature trends towards
improper technique as the main cause of injury [23]. In
a study that followed professional ballet dancers for 10
years, researchers found that the injury incidence per
dancer per year was 1.1, which suggests that dancers can
expect at least one injury every year [23]. The foot and
ankle were the most frequently injured area (38%),
followed by the lumbar spine (20%); however, the lumbar
strain was the single most common diagnosis made dur-
ing this period [21]. The authors of the study claimed
that male dancers have higher rates of lumbar strain be-
cause the lifts they perform cause intense lower back
stress [21]. Another study that specifically evaluated
youth dancers found that lumbar spine injuries made up
11.7% of all injuries occurring during dance [22]. Fur-
thermore, the most common skeletal injury to occur in
this population was spondylolysis [22]. There have also
been case reports of pediatric ballet dancers who pre-
sented with bilateral pedicle fractures without spondylo-
lysis, which demonstrates the wide differential diagnosis
needed when assessing a dancer presenting with lower
back pain [37]. For dancers who experienced an episode
of lower back pain, one study reported that 46% of the
participants had to limit up to half of their dance activity
with another 5% limiting more than half of their activity
[24]. Due to the nature of dance, the injury rate remains
high and the lumbar spine is especially vulnerable as evi-
denced by previous studies.
Gymnastics
While the posterior column injuries, specifically spondy-
lolysis and spondylolisthesis, are the most written about,
other studies have noted anterior and middle column in-
juries in gymnasts to include disc herniation, compres-
sion fractures, disc degeneration, and Schmorl’s nodes
[25,38]. In a study assessing magnetic resonance im-
aging in 33 competitive female gymnasts without regard
to the presence or absence of back pain, evidence of
degenerative disc disease was found in 24%, with in-
creasing rates of degeneration as age and competitive
level increased to 63% of 8 national or Olympic gym-
nasts with an average age of 25.7 years [38]. Similarly,
in a study of 24 elite male gymnasts with an average
of 23 years of age, there was a 75% prevalence of disc
degeneration seen on MRI compared with 31% in
control populations [25].
Lumbar isthmic spondylolysis in gymnasts is well de-
scribed. These injuries were noted to be chronic in na-
ture, without a specific inciting event, as a result of
repetitive hyperextension in back walkovers and rotation
in dismounts, vaults, and flips. A classic study involving
lumbar radiographs of 100 competitive gymnasts with
ages ranging from 6 to 24 found an 11% incidence of
lumbar spondylolysis [26]. This represents a four times
higher incidence of pars interarticularis defects than the
2.3% found in the general female Caucasian population.
Furthermore, 6 of these 11 had first-degree spondylo-
listhesis of L5 on S1. With continued vertebral slip-
page above 50%, the gymnast’s ability is hampered by
a vertical sacrum, decreased flexibility, and hamstring
tightness.
Skiing and Snowboarding
Traumatic brain injury and vertebral injuries represent
the most common injuries among severely injured skiers
and snowboarders [39,40]. The mechanism of injury is
different between snowboarders and skiers [27,29,30].
In snowboarders, injury is associated with failed jumps
and the subsequent axial loads. The mechanism of injury
in skiers is associated with downhill falls forward at high
velocities.
Multiple studies have investigated spinal injuries in
skiers and snowboarders. In a 6-year retrospective re-
view of a tertiary trauma center in Switzerland, the most
common site of severe spinal injury for skiers and
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snowboarders combined was the lumbar spine [28]. Out
of 148 total spinal fractures identified in 73 patients,
there were 55 severe lumbar spine injuries with a break-
down of 16 burst fractures, 15 compression fractures, 22
transverse process fractures, and 1 incident of traumatic
spondylolysis. Severe spinal injury occurred most com-
monly in skiers, with 17 requiring intervention for the
lumbar spine. In another retrospective study, over the
course of 11 years, 41 skiers and snowboarders with
spinal fracture or dislocations were identified with 12
cervical, 25 thoracic, and 20 lumbar injuries [41]. This
represents an overall incidence of spinal trauma of 1 per
100,000 skier days. Within the lumbar injuries, 17 were
compression fractures (all with height loss < 25%) and 3
were transverse process fractures; no burst fractures
were noted. None of the patients required surgery. A
study based in Japan which evaluated 13,490 cases of
ski- or snowboard-related injury identified an incidence
of 5.73 per 100,000 visits for snowboarders and 0.69 per
100,000 visits for skiers [27]. Across skiers and snow-
boarders, lumbar injuries were the most common at
64.8% and 69.4% respectively. The most common frac-
ture patterns were anterior compression and transverse
process fractures. Spinal injuries occurred more com-
monly in snowboarders, with risk factors including be-
ginners with simple falls, and intermediate or experts
jumping. In a study evaluating both thoracic and lumbar
injuries only in Colorado, out of 146 fractures, the ma-
jority of fractures were simple compression fractures
(n= 81), as well as burst fractures (n= 26) and transverse
and spinous process fractures (n= 32) [42]. Only 1 pa-
tient in the compression and burst fractures group re-
quired surgical stabilization. A study evaluating an
inpatient database of skier and snowboarder injuries
found that skiers were more likely to injure the cervical
spine and snowboarders were more likely to injure the
lumbar spine [31].
Many of the studies pointed out that injuries com-
monly occurred at multiple levels. Spinal cord injuries
are more commonly seen with cervical spine injuries,
and less common with thoracic and lumbar spine injur-
ies [31]. There have been no studies regarding soft-tissue
injuries such as disc herniations, facet capsule tears, and
muscle strains. In summary, lumbar spine fractures are
the most common type of spinal injuries in skier and
snowboarders.
Other Sports
Repetitive flexion, extension, and torsional stress of the
lumbar spine also occur in sports beyond those detailed
in this review. However, a thorough literature search un-
covered insufficient data to allow conclusions to be
drawn about the prevalence or pattern of lumbar injuries
that can be discerned in other sports.
Treatment guidelines
Fractures
Minor fractures are the most common type of lumbar
spine fracture seen in athletes and are due to repetitive ac-
tivity or low-energy impact. Major fractures are much
more serious and often lead to functional or neurological
deficits and result from high-energy mechanisms. The se-
verity of the fracture can be categorized by which seg-
ments of the spine are involved, based on the three-
column spine model [43]. Minor fractures are defined as
involving the pars interarticularis, articular process, trans-
verse process, or the spinous process but do not result in
instability [43]. Major fractures tend to be unstable and in-
clude compression fractures, burst fractures, seat-belt-
type injuries, or fracture-dislocations [43,44]. The thora-
columbar junction is susceptible to injury during high-
energy impact as the more stable thoracic spine transi-
tions to the mobile lumbar spine [45].
Major fractures which are unstable enough to necessi-
tate surgery are rarely seen in sports, given the high en-
ergy required to cause such an injury. Most lumbar
fractures seen in sports can be treated non-operatively
[45]. In terms of medical care, symptomatic treatment
such as rest, NSAIDs, muscle relaxants, and the use of
bracing is sufficient for fractures limited to one column
of the spine such as the spinous process, transverse
process, or the vertebral body [45]. Facet fractures are
also known to occur in isolation but usually only require
bracing if unilateral and have no additional fractures
present. Non-surgical techniques may improve return to
play rates, but more data are needed to better guide
treatment.
Spondylolysis and Spondylolisthesis
It has been reported that up to 47% of young athletes
with low back pain will ultimately be diagnosed with
spondylolysis [46]. One study using MRI found that
39.7% of children younger than 19 who complained of
LBP for more than 2 weeks had spondylolysis [47]. Of
the children who presented with LBP, 9.3% of elementary
students, 59.3% of junior high schoolers, and 31.5% of
higher schoolers were confirmed with MRI to have
spondylolysis [47]. The repetitive extension and twisting
of the lumbar spine required in soccer, gymnastics, and
football are the reasons why these sports are most com-
monly associated with spondylolysis. The most common
presentation is a patient with low back pain that is exac-
erbated by spinal extension but rarely has neurological
involvement. More serious injuries such as spondylo-
listhesis can also present similarly, but neurological defi-
cits may be seen most often in the L5 distribution.
Definitive diagnosis begins with PA and lateral upright
radiographs of the lumbar spine followed by MRI due to
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its superior capability to detect pars edema (stress frac-
ture) which is missed by plain radiographs and CT [48].
Use of oblique views and CT with SPECT imaging is less
common due to the radiation exposure to the athlete.
Interestingly though, small studies have found that MRI
alone would not have been sufficient for a successful
diagnosis of spondylolysis in the pediatric population
[49]. There is some evidence to suggest that it is import-
ant to incorporate CT and plain radiographs in the
screening protocol for LBP [49]. Bilateral pars defects,
which occur the majority of the time (85%), are likely to
progress to spondylolisthesis. Conservative treatment
options for acute pars defects or stress reactions include
a combination of stabilization and physical therapy such
as using a full-time Boston brace for 8–12 weeks, a grad-
uated exercise program, and isometric core and ham-
string exercises [50,51]. One study using CT imaging
separated spondylolysis patients into categories of early,
progressive without high signal intensity, progressive
with high signal intensity, and terminal defects [52].
Using a hard brace, the investigators found that 94% of
patients with early spondylolysis responded well to this
conservative treatment [52]. The efficacy for the pro-
gressive groups was significantly lower, with 64% for
progressive without signal intensity, 27% for progres-
sive with signal intensity, and 0% for terminal spon-
dylolysis, demonstrating that the effectiveness of
conservative treatment varies with the progression of
theinjury[52]. Furthermore, the use of bracing itself
is questionable, with some studies showing no signifi-
cant difference in outcomes when no brace is used
during conservative therapy [53]. Surgery is consid-
ered in athletes who fail to improve or still have
symptoms after bracing, continue to experience pain
and inability to return to sport for longer than 6
months, or have worsening spondylolisthesis to
greater than 50% slip [51,54]. For athletes with spon-
dylolisthesis or disc degeneration, anterior and poster-
ior fusion is often required; however, if there is no
pathology of the disc, pars repair and debridement of
the fibrous defect is sufficient [51]. When deciding on
the best surgical technique, there are multiple consid-
erations. Posterior lumbar interbody fusion (PLIF) has
been associated with more consistent results than
posterolateral fusion (PLF), but PLF has been found
to be associated with greater patient satisfaction [55,
56]. In addition, anterior interbody fusion was associ-
ated with less morbidity than posterolateral inter-
transverse process fusion but had similar patient
outcomes [57]. In terms of recovery, athletes can ex-
pect to return to play after 6–12 months but if lum-
bar fusion was performed, this may be a career-
ending option and return to contact sports is not rec-
ommended by many practitioners [58].
Lumbar Disc Herniation
Sports that require repetitive flexion and compression
such as football, ice hockey, basketball, and soccer are
often associated with lumbar disc herniation. Common
signs of lumbar disc herniation are lower back pain with
progression to radicular pain and occasionally neuro-
logic deficits, depending on the severity of injury. In the
National Football League (NFL), approximately 28% of
spinal injuries are due to lumbar disc herniation [9].
Linemen were the most susceptible to this type of injury
because of repetitive spine extension due to blocking as
well as a weight training program [9]. The most com-
mon site of disc herniation was between L4 and L5,
followed by L5 and S1 [9]. A thorough history that as-
sesses for signs of urinary or bowel incontinence is es-
sential to rule out cauda equina syndrome which
requires urgent attention [59]. Additionally, a complete
neurological exam is needed to identify signs of dysfunc-
tion that may require further investigation. Positive
nerve root tension signs are an indication for imaging of
the lumbar spine which includes upright radiographs
and MRI [59]. In one large study of 342 professional ath-
letes, 82% of players were able to return to play after
sustaining a lumbar disc herniation, which indicates a fa-
vorable prognosis [10]. The mainstay therapy is conser-
vative management including early activity and core
strengthening with additional sport-specific activity as
symptoms improve. While epidural corticosteroid injec-
tions may have a role in shortening the duration of treat-
ment, there is not enough evidence currently available
for this to be conclusive [60]. Athletes who undergo
laminotomy and disc fragment excision have a return to
play rate that is consistent with patients treated with
non-surgical options and 81% of these patients will play
for an additional 3.3 years [10,61]. However, the benefi-
cial or harmful effects of surgery are variable, depending
on the sport [10]. For NFL players, it was found that sur-
gery resulted in a significant increase in games and years
played when compared to conservative therapy [10].
Furthermore, there may also be a significant return to
play advantage for NFL players who undergo surgical
intervention for lumbar disc herniation [62]. However,
for MLB players, surgery resulted in fewer games and
years played when compared to conservative therapy,
which demonstrates the need to tailor therapies to indi-
vidual athletes [10]. Data regarding new minimally inva-
sive techniques is not yet conclusive but decreased soft
tissue manipulation could lead to faster recovery and re-
turn to play times for athletes [11]. Studies have found
similar results when comparing microdiscectomy to
nonsurgical treatments in elite NFL players [11]. Recov-
ery from lumbar discectomy in elite athletes has been re-
ported to range from 2.8 to 8.7 months with an average
career length of 2.6 to 4.8 years [63].
Ball et al. Sports Medicine - Open (2019) 5:26 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Return-to-Play after Lumbar Injuries
Return to play after sustaining one of the lumbar spine
injuries listed in Table 2requires resolution of symp-
toms, full range of motion of the lumbar spine, and the
ability to perform sports-specific movements without
pain. Both surgical and non-surgical treatment for lum-
bar disc herniation in athletes have a comparably high
recovery and return to play rate. One study found that
at 3, 6, and 12 months post-surgery, 50%, 72%, and 84%
of patients were eligible to return to play, respectively
[64]. However, it was found that only 38 to 65% of
players who underwent surgical treatment for a lumbar
disc herniation were able to return to the same level of
play as prior to the injury [65]. Additionally, one meta-
analysis has noted that the age at which a player under-
goes surgery is an important factor in determining car-
eer length post-operatively, but the relationship is sport-
dependent [65]. In the National Hockey League, regard-
less of surgical versus non-surgical treatment, players
with a lumbar disc herniation played in 56.2 games per
season pre-injury versus 39.0 games per season post-
injury [66]. This suggests that sustaining an injury is a
more critical factor in a player’s career than the type of
treatment that is selected. Interestingly though, when
compared to healthy controls, it was found that players
in the National Basketball Association who underwent
surgical intervention for lumbar disc herniation had a
more normal career length than players who underwent
non-surgical interventions [16]. Different physical re-
quirements imposed upon athletes by different sports
may explain the career length differences in the surgical
versus non-surgical interventions. For the conservative
treatment of lumbar spondylolysis, some investigators
recommend between 4 and 12 weeks of rest and
immobilization [51]. Conservative treatment is associ-
ated with a return to play rate of 80%, which is why it is
often tried prior to surgical intervention [67]. At 6–12
months after a pars repair, return to play at pre-injury
level is possible, but after fusion for spondylolysis and
spondylolisthesis there is a less predictable course of
returning to contact sports. [68]. An important consider-
ation for return to play that is specific to fusion for
spondylolysis and spondylolisthesis is whether radio-
graphs show bony union [58]. Players who undergo
lumbar fusion may require up to 12 months of rehabili-
tation prior to returning to play.
Conclusions
Lumbar spine injuries can range from minor strains to
high-energy fractures, and each of these requires their
own set of treatments and return to play guidelines.
Additionally, team physicians need to have algorithms
that can rapidly assess on-the-field injuries that require
vastly different interventions depending on type and se-
verity. The recovery process and ultimately return-to-
play by athletes largely depends on the type of injury
sustained as well as the athlete’s progression back to
pre-injury level of activity. Furthermore, and most im-
portantly, the risk of further injury always needs to be
paramount when deciding on appropriateness of return
to play.
Abbreviations
AP: Anteroposterior; CT: Computerized tomography; LBP: Low back pain;
MRI: Magnetic resonance imaging; PLF: Posterolateral fusion; PLIF: Posterior
lumbar interbody fusion; SPECT: Single-photon emission computerized
tomography
Acknowledgements
Not applicable.
Authors’Contributions
JB performed the literature search, contributed to writing the manuscript,
and read and approved the final manuscript. CH performed and revised the
literature search, contributed to writing the manuscript, and read and
approved the final manuscript. JL contributed to writing the manuscript,
and read and approved the final manuscript. MV contributed to writing the
manuscript, and read and approved the final manuscript.
Funding
No sources of funding were used to assist in the preparation of this article.
Availability of Data and Materials
Not applicable.
Ethics Approval and Consent to Participate
Not applicable.
Consent for Publication
Not applicable.
Competing Interests
The authors, Jacob Ball, Colin Harris, Jonathan Lee, and Michael Vives, declare
that they have no competing interests.
Table 2 Common lumbar spine injuries in sports and their treatments
Injury type Treatment
Fractures Minor fractures are best treated with rest, NSAIDs, muscle relaxants, and bracing.
Spondylolysis and spondylolisthesis Full-time Boston brace is the first line treatment for early spondylolysis [52]. Physical therapy alone that includes
exercise programs and stretches is acceptable [53]. Posterior lumbar interbody fusion, posterolateral fusion, or
anterior interbody fusion are used as surgical management [56,57].
Disc herniation Early activity and core strengthening are first-line treatments for conservative management. Laminotomy and
disc fragment excision have an 81% return to play rate [10,61]. NFL players benefited from undergoing surgical
correction, but MLB players were less well off than players who underwent nonsurgical therapy [10,62].
Ball et al. Sports Medicine - Open (2019) 5:26 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Received: 5 March 2019 Accepted: 7 June 2019
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