Clin Sports Med 23 (2004) 367 – 379

Return to play after lumbar spine conditions

and surgeries
Jason C. Eck, DO, MSa,*, Lee H. Riley III, MDb
a
Department of Orthopaedic Surgery, Memorial Hospital, 325 South Belmont Street, Box 129,
York, PA 17403, USA
b
Department of Orthopedic Surgery, Johns Hopkins Outpatient Center, Johns Hopkins University,
601 North Caroline Street, Suite 5235, Baltimore, MD, USA

Low back pain is a common problem, with a prevalence of 60% to 80% in the
general public [1]. Although the majority of these cases will be self-limiting and
resolve within 6 weeks regardless of treatment, 5% to 10% of patients will de-
velop chronic back pain [1]. Injuries to the spine in athletes are relatively un-
common, accounting for 9% to 15% of all athletic injuries [2,3]. The majority of
reports related to spine injuries in athletes focus on the cervical spine, due to a
greater likelihood of catastrophic injury. This provides few data concerning lum-
bar spine injuries in athletes.
Several investigators have reported on the prevalence of lumbar spine injuries
related to specific sports. Approximately 30% of college football players miss
games due to lumbar spine problems [4– 6]. Injuries were found to be more
common as the level of play increased. The majority of injuries were simple
lumbar sprains; however, lumbar spondylolysis was a significant problem, es-
pecially for inner linemen, who undergo repetitive axial loading of a hyper-
extended lumbar spine.
Lumbar spondylolysis is also more common in gymnastics, due to repetitive
hyperextension movements and axial loading during dismounts [7,8]. Incidence
of injury to the pars interarticularis is 11% in young gymnasts, as compared with
less than 3% in the general age-matched population [7]. These athletes also have
increased incidence of degenerative changes on lumbar spine MRI [9].
There are few data regarding criteria for when athletes may return to com-
petitive play following lumbar spine injuries. This article is reviews the work-up
of lumbar spine injuries in athletes and provides a framework to determine the
appropriate criteria for return to play after conservative or surgical treatment for
these patients.

* Corresponding author.
E-mail address: jason-laurie@suscom.net (J.C. Eck).

0278-5919/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.csm.2004.03.002
368 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379

Anatomy and biomechanics

To effectively discuss the effect of various spinal conditions on athletes, it is
necessary to briefly review the relevant anatomy and biomechanics. The lumbar
spine articulations consist of a three-joint complex made up of the intervertebral
disc and two facet joints. It is this complex that allows for normal movement
within the lumbar spine. The intervertebral disc is arranged in four concentric
layers: (1) outer annulus fibrosus, composed of dense collagen fibril lamellae
oriented at approximately 45°; (2) fibrocartilaginous inner annulus fibrosus;
(3) transition zone; and (4) central nucleus pulposus. Collagen fibers in the annu-
lus provide tensile strength, and the proteoglycans in the nucleus provide stiffness
and resistance to compression. The outer one third of the annulus is innervated by
the ventral rami and gray rami communicans anteriorly, and by the sinuvertebral
nerve posteriorly [10]. Facet joints are composed of the superior and inferior
articular processes of neighboring vertebrae surrounded by a thick capsule.
Orientation of the facet joints determines the motion of individual vertebrae.
The pars interarticularis is the portion of the lamina that connects the superior
and inferior facets. Defects in the pars interarticularis are referred to as
spondylolysis, and are known to result from repetitive axial loading, as occurs
in many athletes. Injury to the pars leading to anterior translation of one vertebral
body on another is spondylolisthesis.
Low back pain in athletes often originates from the intervertebral disc, facets,
or pars interarticularis. Injury to the intervertebral disc can lead to internal disc
disruption, annular tears, or herniated disc. This can cause pain from the disc
itself, or from the disc impinging on the neighboring nerve roots or spinal cord.
Compression of nerve roots leads to impaired circulation through their intrinsic
blood vessels, as well as increased permeability and edema [11,12].

History and physical examination

The evaluation of any athlete with complaints of low back pain should begin
with a thorough history and physical examination. The medical history should
elicit details of the pain, including location, character, onset, duration, exacer-
bating and relieving factors, radiating pain, constitutional symptoms, and past
medical history. Details of the patient’s athletic activities, including any recent
trauma or change in training program, should also be investigated.
It is crucial to first identify the possibility of any serious cause of the patient’s
low back pain by the presence of any ‘‘red flags.’’ Infection or tumor should
be considered in patients younger than 20 or older than 50 years of age, with a
history of cancer, with constitutional symptoms (fever, chills, weight loss), recent
bacterial infection, intravenous drug usage, immunosuppression, or night pain.
Findings that suggest a possible fracture include history of major trauma. Saddle
anesthesia, recent bowel or bladder dysfunction, or severe or progressive neu-
rologic deficit suggests cauda equina syndrome.
 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379 369

Table 1
Specific neurological deficits of the lower extremities according to nerve root
Disc level Location of pain Motor deficit Reflex
L1 Inguinal region, medial thigh Hip flexion None
L2 Anteromedial upper thigh Hip flexion None
L3 Anterior thigh Quadriceps Patellar
L4 Posterolateral thigh, anterior tibia Foot dorsiflexion Patellar
L5 Dorsum of foot Extensor weakness great toe Posterior tibial
S1 Lateral foot Foot plantar flexion Achilles

Physical examination should begin with inspection of the patient to identify

any skin changes, hair tufts, deformity, pelvic tilt, or loss of normal lumbar
lordosis. Next, palpation should be performed to elicit any areas of tenderness or
muscle spasm over the spinous processes, paraspinous muscles, or sacroiliac
joints. Any step-off of the spinous processes may suggest spondylolisthesis.
Range of motion should be assessed for any limitations, as well as exacerbation
and alleviation of pain during specific positions. Increased pain with flexion is
typical of disc herniation, whereas pain with extension suggests spinal stenosis.
A complete neurologic examination is performed, including sensory and
motor testing, and deep tendon reflexes. A quick screening examination can be
achieved by asking the patient to first squat and then walk on heels and toes.
These maneuvers are able to identify weakness in each of the major motor groups
of the lower extremities. Testing for weakness of individual muscle groups and
deep tendon reflexes of the lower extremity is performed as detailed in Table 1,
and of sensory deficits as shown in Fig. 1 [13].
Nerve root tension signs should then be evaluated, including the straight-leg
raising test and the femoral nerve tension sign. The straight-leg raising test has
the patient supine while the physician elevates the straight lower extremity. This
action places tension on the nerve roots and is positive if symptoms are
reproduced at greater than 30° of elevation. In the femoral nerve tension sign,
the patient is prone, and the physician flexes the knee to 90°, and then extends the
hip while supporting the pelvis against the table. This test places tension on the
femoral nerve and can reproduce a patient’s radicular pain in the anterior thigh.

Imaging studies
In the majority of athletes with complaints of low back pain, imaging studies
are not initially indicated, unless the patient has any red flags, as discussed
previously. Radiographic findings should be interpreted cautiously, because ab-
normalities are common in the asymptomatic population. In asymptomatic
patients between 55 and 64 years of age, more than 60% of males and 45% of
females have radiographic evidence of disc degeneration. Approximately 30% of
these individuals have asymptomatic evidence of facet degeneration [14]. Also,
several investigators have shown no direct relationship between disc space
370 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379

Fig. 1. Dermatomes of the lower extremity. (From Humphreys SC, Eck JC. Clinical evaluation and
treatment options for herniated lumbar disc. Am Fam Physician 1999;59:579; with permission.)

narrowing and low back pain [15,16]. Athletes who remain symptomatic despite
a trial of conservative treatment should obtain a complete series of plain
radiographs, including anteroposterior (AP), lateral, and oblique images. Radio-
graphs should be evaluated for evidence of fracture, degenerative changes, loss of
normal lordosis, deformity, and the presence of any osseous pathology. Lateral
images can reveal spondylolisthesis, a relatively common cause of back pain in
athletes (Fig. 2). Oblique views can better visualize the facet joints and integrity
of the pars interarticularis. In cases in which spinal instability is suspected, lateral
flexion/extension view may be obtained. Defects in the pars interarticularis or
other stress fractures are more easily identified using either a bone scan or single
photon emission computed tomography (SPECT) scan. Each of these imaging
modalities will show increased uptake in the presence of a recent fracture [17,18].
Computed tomography (CT) scanning of the lumbar spine provides excellent
cross-sectional visualization of the bony anatomy, but should be reserved for
confirmatory diagnosis or in cases of significant trauma, to evaluate for the
degree of spinal canal impingement. CT scanning is also useful for evaluating
spinal stenosis (Fig. 3).
Magnetic resonance imaging (MRI) is indicated in patients with neurologic
deficit to evaluate any compression on the nerve roots or spinal cord. As with
 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379 371

Fig. 2. Lateral plain radiograph of an athlete with localized low back pain, with a palpable midline
step-off of the spinous processes showing spondylolisthesis.

other imaging modalities, any abnormalities should be firmly confirmed with

clinical findings, because asymptomatic abnormalities are common.

Lumbar spine conditions

There are several disorders of the lumbar spine that occur with relative fre-
quency in athletes. The following conditions are discussed, along with their
recommended treatment options and guidelines for return to play: lumbar strain,
herniated nucleus pulposus, spinal stenosis, and spondylolisthesis. Table 2
summarizes the recommended return to play criteria for these disorders based
on the treatment provided.

Fig. 3. CT scan of athlete with clinical signs of myelopathy revealing lumbar stenosis.
372 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379

Table 2
Recommendations for return to play
Condition Treatment Return to play
Lumbar strain Conservative After achieving full range of motion
Herniated disc Percutaneous discetomy 2 – 3 months postoperatively; full range of motion
Microdiscectomy 6 – 8 weeks for non-contact sports; 4 – 6 months for
contact sports
Fusion 1 year for non-contact sports; full contact sports not
recommended after fusion
Spinal stenosis Conservative Lack of neurologic symptoms and full range
of motion
Laminectomy 4 – 6 months postoperatively; lack of neurologic
symptoms or instability and full range of motion
Fusion 1 year for non-contact sports; full contact sports not
recommended after fusion
Spondylolysis Conservative 4 – 6 weeks for non-contact sports; full contact sports
after full range of motion and pain-free extension
Spondylolisthesis Conservative 4 – 6 weeks and pain free extension if grade 1 slip
Fusion If grade 2 or greater or progressive slip; 1 year for
non-contact sports; full contact sports not
recommended after fusion

Lumbar strain
As in the general population, the most common cause of low back pain in
athletes is simple lumbar strain. Patients generally notice gradual improvement
over 2 weeks, with 90% achieving total resolution of symptoms within 2 months.
Lumbar strain is responsible for 70% of all cases of low back pain [19]. The
etiology of lumbar strain is not completely clear. Ligamentous or muscle strain
secondary to either acute trauma or prolonged mechanical stress is thought to
play a role in the development of low back pain. During normal physiologic
motion, the majority of lumbar motion occurs at the L4 – 5 and L5 –S1 levels,
which correspond to the most commonly injured levels. During flexion, strain is
placed on the interspinous and supraspinous ligaments. In extension, the anterior
longitudinal ligament undergoes strain. During torsion, the capsular ligaments
and annulus fibrosus are affected. Mechanical strain on these ligamentous
structures and annulus leads to annular tears and produces pain. The production
of pain leads to muscle wasting and weakness secondary to decreased motor
unit recruitment, and decreased patient activity due to fear of producing pain.
This subsequent muscle imbalance leads to further mechanical disruption and
muscle wasting. This cycle must be broken during treatment to allow the patient
to recover.
Athletes presenting with lumbar strain typically relate a recent history of a
specific event that led to their pain. The athlete may report pain immediately
following the incident, with the severity increasing over several hours, secondary
to localized edema and reflex muscle contraction. The athlete may experience
significantly increased pain and stiffness the morning following the incident. Pain
 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379 373

is generally exacerbated on flexion and extension of the spine. Rest generally

relieves the pain. Physical examination generally reveals pain localized to the low
back, with possible referral to the buttocks and posterior thighs. Simple lumbar
strain should not include radicular pain below the level of the knees. Active and
passive stretching of the area exacerbates the patient’s pain. Lower extremity
muscle strength, sensation, and reflexes should be evaluated. These are generally
normal with simple lumbar strain. Straight-leg raising test should be performed.
A positive straight-leg raising test or radicular symptoms suggest the possibility
of herniated disc.
Imaging studies are generally not indicated initially for lumbar strain, unless
the patient has positive red flags for more serious etiologies, intractable pain, or
neurologic deficit. Because the majority of patients recover within the first
2 weeks, imaging is not helpful. Additionally, many asymptomatic individuals
have radiographic evidence of degenerative changes that can complicate proper
diagnosis. If there is no improvement within 4 weeks, plain radiographs are ob-
tained. Persistent low back pain may necessitate the use of CT, MRI, or bone
scans to detect other possible etiologies of the patient’s pain.
Because the majority of patients will gradually improve over time, treatment
is aimed at pain control, so that the patient can regain range of motion. If the
athlete is unable or unwilling to move or to exercise the low back, there will be
subsequent muscle wasting that will further delay the healing process.
Initial pain relief is achieved through the use of nonsteroidal anti-inflamma-
tory drugs (NSAIDS), with or without muscle relaxants, if the patient complains
of muscle spasm. Rest should be limited to 1 to 2 days to prevent muscle atrophy.
Physical therapy modalities, including ice and heat, and local anesthetic or steroid
injections, can control the patient’s pain and allow for the initiation of exercises.
Therapy should begin with isometrics and progress to isotonic exercises.
Extension exercises are generally begun first, followed by flexion exercises as
symptoms allow. Return to play is a gradual process. Athletes should be
encouraged to return to light play as soon as pain allows, in order to maintain
muscle strength. As pain and muscle spasms decrease, the athlete may advance
activity. Return to full play should be delayed until the athlete has sufficient range
of motion to prevent subsequent injury.

Herniated nucleus pulposus

Athletes will often report a long history of back pain, with or without minimal
radicular pain. Over time, the radicular pain becomes more severe than the back
pain. This is because initially the disc material is pushing on the annular fibers,
activating their pain receptors. As the disc material herniates through the outer
annular fibers, it compresses the nerve roots, causing more radicular pain. A
complete physical and neurologic examination can reveal defects at specific
levels. A search for any external manifestations of pain, including abnormal
stance, antalgic gait, and sciatic list, should be performed. The spinous processes
and interspinous ligaments should be palpated for tenderness. Range of motion
374 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379

should be evaluated. Generally, pain during lumbar flexion suggests discogenic

disease, whereas pain on lumbar extension suggests facet disease. Evaluation of
the lumbar spine by neurologic level is helpful in locating the source of the
patient’s symptoms, as shown in Table 1 and Fig. 1. Sciatic and femoral nerve
tension signs should be evaluated.
Radiographs have limited diagnostic value for herniated discs, because
degenerative changes are age-related. The gold standard for visualizing a her-
niated disc is MRI (Fig. 4). MRI evidence of disc degeneration is present in 35%
of subjects aged 20 to 39, and in nearly 100% of subjects aged 60 to 80 [20].
Because MRI can reveal bulging and degenerative discs in the asymptomatic
patient, all clinical decisions should be based on the clinical findings corroborated
by diagnostic test results.
Most athletes respond well to conservative therapy, including limited rest,
activity modification, exercise, anti-inflammatory medications, and lumbar epi-
dural steroid injections. Extension and isometric exercises are performed first,
and after sufficient strength and pain relief are achieved, flexion exercises are
begun. Flexion exercises are delayed, because flexion motion applies the greatest
load to the intervertebral disc. Indications for surgical intervention include cauda
equina syndrome, progressive neurologic deficit, profound neurologic deficit, and
severe and disabling pain refractory to conservative care. Surgery is deferred as
long as the patient continues to show improvement in symptoms. Outcomes
following surgery are more favorable for radicular pain than for patients with
back pain as their sole complaint.
The use of percutaneous discectomy for athletes with lumbar disc herniation
has been recommended, due to its less invasive nature and less disruption to the

Fig. 4. Axial (A) and sagittal (B) MRI images of athlete with lumbar disc herniation.
 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379 375

musculature, bone, and neural structures [4,21 –23]. Some studies have revealed
the outcomes of percutaneous discectomy to be worse for athletes than in the
general population [22]. It was felt that in most cases this was due to return to
play too quickly or the excision of too great a portion of the disc. The re-
commended protocol for return to play following percutaneous discectomy is to
wait at least 2 to 3 months following the procedure.
Traditional microdiscectomy for athletes with lumbar disc herniation has
also been extensively evaluated. Single-level microdiscectomy resulted in a
90% return-to-play rate, whereas results from multiple level microdiscectomy
were less likely to allow return to competitive play [24]. Return to play is delayed
until the athlete has sufficient pain relief and range of motion to compete without
increased risk of injury. This is typically 6 to 8 weeks for noncontact sports, and
at least 3 months for contact sports.
Spinal fusion for lumbar disc herniation is recommended for cases of multiple
recurrences, or with coexisting spinal instability. Spinal fusion eliminates motion
at the operated spine segment, and thus the motion and stress is shifted to the
adjacent levels, increasing the risk of degenerative change and injury to those
levels. The ability of athletes to return to play following spinal fusion is related to
the level of play and the type of sport involved. For limited contact sports or less
competitive competition, most surgeons would allow athletes to return to play
1 year following fusion. The chance of returning to full contact sports or highly
competitive (ie, collegiate or professional level) competition is much less likely,
due to the increased risk of subsequent injury to the adjacent levels [25].

Spinal stenosis
Spinal stenosis refers to a narrowing of the spinal canal leading to compres-
sion of the spinal cord and exiting nerve roots. As individuals age, normal
changes occur in the spinal anatomy. As the disc undergoes degenerative
changes, the biomechanics of the spine is altered, placing additional forces on
the facet joints. These increased forces on the facets can lead to foraminal
narrowing, osteophytes formation, cartilage erosion, and thickening of the facet
capsule. These changes lead to stenosis, both centrally and in the lateral recesses.
The majority of people have radiographic evidence of degenerative changes by
age 50, with or without related symptoms [26,27].
Patients with spinal stenosis generally report a gradual onset of generalized
low back pain, with increasing stiffness and reduced range of motion. Pain is
worse with activity, specifically during extension of the spine, and is relieved
with rest and flexion. Extension of the spine further narrows the foramen and
increases the force applied to the posterior elements. Flexion widens the foramen
and decreases the load on the facets. As a result, patients may complain of pain
with walking, but may notice a reduction in their pain if they walk while leaning
on an object such as a shopping cart; this places the spine in flexion and opens
the foramen. Pain can be localized to the low back, or can affect the buttocks
and posterior thighs, with radiation down the lower extremities. Spinal stenosis
376 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379

can lead to cauda equina syndrome, so patients should be questioned as to any

changes in bowel or bladder function.
Physical examination should include thorough testing of lower-extremity
motor strength, sensation, and reflexes. Often the neurologic examination is
relatively normal. Decreases in motor strength may be found in relation to the
nerve root being compressed. Sensation is generally intact. Reflexes may be
asymmetric, depending on the location of the stenosis. Straight leg raising and
Babinski tests are negative.
Imaging examination should begin with plain radiographs, which may identify
degenerative changes that include decreased disc height, osteophytes formation,
and bony sclerosis. Caution should be used in interpreting these findings, because
many asymptomatic individuals will have positive imaging finding of degenera-
tive changes. Flexion and extension films are used to evaluate for instability.
Translation of greater than 4 mm or rotation greater than 10° as compared with
the adjacent levels suggests spinal instability. CT with or without myelography is
useful in evaluating the bony structures to determine the extent of both central
and foraminal stenosis (see Fig. 3). MRI is used to evaluate the neural structures
and is used in cases of neurologic deficit. MRI is also used to rule out other
possible causes of symptoms, including infection or tumor.
Treatment of spinal stenosis is often initially conservative, and includes
exercises, physical therapy, and medication. Exercises should use activities that
place the spine in flexion, such as stationary bicycling. This will alleviate some of
the patient’s pain and improve conditioning. Physical therapy can provide heat,
massage, and stretching programs. Medication should include NSAIDS for mild
to moderate pain relief. Epidural steroid injections are also useful in many cases.
Athletes who do not respond to conservative care can be offered surgical
intervention. It is often helpful to perform surgery once symptoms start becoming
worse, before the point of severe pain and debilitation. In most cases, surgery
consists of decompressive laminectomy to increase the space available for the
spinal cord and nerve roots. Patients with coexisting spondylolisthesis should
undergo spinal fusion.
Return to play is based on the treatment provided. Patients without neurologic
deficits are able to return to full competitive play as soon as pain control is
achieved and they have sufficient range of motion. Athletes with neurologic
deficits, spinal instability, or spinal fusion should are typically not permitted to
return to contact sports.

Spondylolisthesis
Spondylolisthesis is a spinal condition in which one vertebra translates for-
ward on another. There are five categories of spondylolisthesis. Type I is a
congenital defect in the orientation of the facets. Type II is associated with
spondylolysis, a defect in the pars interarticularis. This occurs most commonly at
L5 and has predominance for young white men. Type III occurs due to in-
tersegmental instability resulting from degenerative changes in the facets. This is
 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379 377

most common in patients over 40, generally occurs at L4, and rarely progresses
beyond 25% slippage. Type IV is associated with an acute traumatic event to the
pars or facets, allowing for instability. Type V occurs in response to bone disease.
The severity of spondylolisthesis is graded on a scale from 1 to 4 by dividing the
percentage of slip from the posterior point on the inferior vertebral endplate.
The most common presenting complaint of athletes with spondylolisthesis
is low back pain. Pain is exacerbated with activity, specifically extension. The
grade of slip has not been shown to correlate with the degree of pain. Radicu-
lar pain to the buttocks and thighs is common, and correlates with the degree
of anterior vertebral translation. Radicular pain can result from either forami-
nal stenosis or concomitant herniated disc, both of which are associated
with spondylolisthesis. It is also possible for athletes to remain asymptomatic
with spondylolisthesis.
Physical examination findings include hamstring tightness, lumbar muscle
spasm, and a palpable step-off with grade 2 or greater slips. Hamstring tight-
ness is partially caused by the pull of these muscles from the pelvis. Patients
have an exaggerated lumbosacral kyphosis, with a compensatory thoracolum-
bar hyperlordosis.
The initial radiographic examination includes anterior-posterior and lateral
radiographs (see Fig. 2). In most cases, lateral radiographs show the anterior
translation and allow for grading of the slip. If there is a strong clinical suspicion
of spondylolisthesis with normal static radiographs, flexion and extension views
should be obtained. Dynamic translation of greater than 3.0 mm is considered
abnormal, suggesting spinal instability. Radiographs should also be assessed for
defects in the pars interarticularis, as found in Type II spondylolisthesis. Bone
scans and SPECT scans are useful in athletes who present with a recent acute
onset of pain. Positive scans represent metabolically active processes, suggesting
an attempt at healing is taking place.
The majority of athletes can be effectively treated conservatively. This in-
cludes a period of rest if the symptoms are acute. Physical therapy with flexion
exercises can improve abdominal strength and flexibility. Extension exercises
should be avoided. Bracing is controversial, however, it has been shown to re-
duce the degree of progression in some studies. Athletes with positive bone
scans, indicating an active bone turnover, may benefit most from bracing. In
most cases, defects in the pars do not heal well, because this is mostly cortical
bone with a poor blood supply. Anti-inflammatory medications are useful in
patients with radicular pain complaints. Surgical treatment is generally reserved
for athletes with neurologic deficit, persistent disabling pain failing conservative
care, high-grade slips, and traumatic spondylolisthesis. Return to play is based
on the individual athlete’s symptoms and treatment. Patients sufficiently man-
aged conservatively may return to full play after they achieve adequate pain
control and range of motion. Typically, all athletic activity is stopped for at least
2 months, or until the patient can achieve painless lumbar extension [28,29]. As
with the previous conditions discussed, athletes with neurologic symptoms or
undergoing fusion should be restricted from full contact sports.
378 J.C. Eck, L.H. Riley III / Clin Sports Med 23 (2004) 367–379

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