Low Back Pain in the Aging Athlete

Eeric Truumees, MD
The term mature athlete carries different meanings in different contexts. For some, this term denotes a 35-year-old nishing a career in a professional team sport. For others, mature athlete refers to the 50-year-old weekend warrior playing golf. Finally, with increased participation among older citizens, this term can apply to active seniors in their seventies and beyond. This article concentrates on sports-related back pain seen in the second two groups. Back pain is pervasive, but usually benign and self-limited. In older athletes, transient back problems occur in the context of nearly universal, radiographic evidence of lumbar degeneration. These radiographic ndings, and the increased likelihood of dangerous conditions such as cord compression, osteoporosis, metastatic disease and atherosclerosis, complicate the clinical evaluation in this patient group. The epidemiology of back pain and both known and suspected risk factors for back pain are examined. For example, the controversial relationship of sports participation in youth is addressed. The pathophysiology of back pain in this age group is related with a strategy for clinical and radiographic evaluation. For example, assessing mature athletes may require bone density or vascular testing. Finally, treatment and return-to-play issues are discussed. Standard recommendations of relative rest, graduated return to play, physical therapy and judicious use of anti-inammatories apply in this age group. Interestingly, overall aerobic tness and sport-specic technique should also be considered. For example, the mature golfer with low back pain may benet more from swing mechanics instruction from a golf pro than from weeks of physical therapy. Semin Spine Surg 22:222-233 2010 Elsevier Inc. All rights reserved. KEYWORDS back pain, geriatrics, sports, spondylosis, return to play

lder adults are athletically more active than a generation ago. Low back pain (LBP) in the aging athlete refers to a wide range of patients presenting with a wide range of underlying disorders. In the medical literature, older athlete may to refer to individuals from 30 to 90 years old. Athlete can refer to anyone from weekend warriors to elite athletes on a senior professional tour. These athletes may exhibit typical sports injuries, but this group carries additional risk for other, specic problems as well. For example, acquired cervical stenosis confers a small, but real risk of central cord syndrome with hyperextension. Older athletes are more likely to have had previous surgery, peripheral arterial disease, and Pagets disease. As bone mass decreases, sacral insufciency or vertebral compression fractures can manifest. Most LBP in older athletes represents benign and self-limited mechanical dysfunction. However, red ag conditions,
Brackenridge University Hospital, and Seton Health System, Austin, TX. Address reprint requests to Eeric Truumees, MD, Seton Spine and Scoliosis Center, 1600 W. 38th St, Suite 200, Austin, TX 78731. E-mail: etruumees@gmail.com

falsely attributed to sports, are more likely here than in younger athletes. Potentially, life-threatening intra-abdominal disease may manifest as back pain: posterior penetrating ulcers, pancreatitis, renal calculi, or abdominal aortic aneurysm. Older athletes may exhibit other mimic conditions, such as overlapping shoulder or hip disease. These additional risks necessitate careful evaluation and decision making from the clinician. Return to activity is often more gradual. After injury, mature athletes more often return to sports at a lower participation level. In this article, relevant epidemiology, pathophysiology, evaluation, treatment, and return-to-play issues for the older athlete with LBP are discussed.

Epidemiology
The pervasiveness of LBP coupled with the near universality of radiographic degenerative changes renders the assessment of older athletes especially difcult (Table 1). Back pain is pervasive with 80% to 90% of adults reporting LBP episodes.1,2 At least 2% to 5% have major pain episodes yearly.

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1040-7383/$-see front matter 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.semss.2010.06.009

Low back pain in the aging athlete

Table 1 Differential Diagnosis of Low Back Pain in the Athlete Diagnosis Low back strain Degenerative disc disease Lumbar transitional vertebra Facet mediated pain Spondylolisthesis Traumatic fracture Disc herniation Lumbar spinal stenosis Cauda equina syndrome Spinal infection Tumor Intra-abdominal or Intrapelvic processes Renal disease/stones Hip pathology Sacro-iliac pathology Abdominal aortic aneurysm Presentation

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Belt-line or paravertebral pain with motion Midline pain with sitting or loading Midline low back pain Midline and paramedian pain with extension Mechanical midline and paramedian pain Midline pain at the level of injury Pain, numbness and weakness radiating into the leg Low back, buttock, and leg pain, improved with exion Radicular symptoms with bowel and bladder dysfunction and saddle anesthesia Constant LBP with fevers, chills, night sweats, recent infection or dental procedure Night pain, fever, older age (>60), weight loss Boring non-mechanical pain, GI disturbance Colicky pain, GI disturbance Groin pain, pain with rotation or weight bearing Buttock and posterior superior iliac spine area pain, pain with loading Constant boring front to back pain

These episodes are often attributed to low-energy trauma, such as a lifting or a sports injury. Only a small percentage of these sports-related LBP episodes translate into true, radiographically evident trauma. Although the pars injuries seen in younger athletes do give way to vertebral compression fractures in older athletes, most typically, only degenerative changes are seen. The clinical importance of these degenerative changes is unclear as nearly everyone in this age group has radiographic degeneration. Although only 34% of 20- to 29-year-old patients have evidence on magnetic resonance imaging (MRI) of disk degeneration, these changes are seen in 93% of those 60 to 80 years of age.3 Identication of a specic pain generator is rendered more difcult because radiographically abnormal structures may not cause symptoms.2 In cross-sectional studies, only 15% of LBP patients are given a specic diagnosis. In that the vast majority of LBP episodes are benign and self-limited, a wait-and-see attitude often is reasonable. Within the wide swath of the population that could be considered mature athletes, the relative risk for different subgroups should be considered.4,5 These subgroups can be stratied by sport and mechanism of loading, age and gender, or through clinical features, such as anatomic region involved or presence of radicular symptoms. Although radiographic changes worsen with age, the incidence of back pain increases to a peak at 60 years of age. Then, the incidence begins to wane. In a cross-sectional survey of 34,902 Danish twins, aged 20-71 years, back pain was self-reported by area.4 At least 30 days of pain in past year was reported in the low back in 12%, the neck in 10%, and in the midback in 4%. The pain was limited to 1 area in 20%, 2 areas in 13%, and all 3 areas in 8%. A subset of these patients reported radiating pain. Leg pain was the most common (22%), followed by arm and trunk symptoms in 16% and 5%, respectively.

Risk Factors
LBP is more likely in the mature female athlete. Not only are women more likely to report pain episodes, these episodes last longer and affect more areas (eg, neck and back). In women, the pain tends to be more functionally incapacitating. In one study, among those with severe back pain, women were 3 to 4 times more likely to have great difculty with light housework, shopping, mobility tasks, and basic activities of daily living.5,6 In one study in which the authors compared LBP with repetitive activity, women were at greater risk for LBP even though they were less often exposed to lifting and other heavy work.7 Although the relative risk conferred by age and gender is important, the relationship between the patients symptoms and activities is of more interest to the clinician. Older athletes much more likely to injure themselves than younger athletes performing the same sport.8 Twisting injuries more likely than falls to cause pain.9 When older athletes experience pain, it tends to last longer. Even accounting for this increased likelihood of injury, older athletes are physically better off than age matched peers. Other predictors for LBP in older athletes include previous surgeries, lifelong heavy work, lower functional levels, and greater body mass index.9-11 For example, surgical menopause or inadequate rehabilitation after pelvic or abdominal surgery puts patients are greater risk for later LBP.12 Back pain sufferers have less lumbar-extension strength and decreased range of motion. Increasing that strength, in one study through 20 sessions with a MedX lumbar extension machine, signicantly decreased back pain.13 In cross-sectional studies, strength and tness correlate not only with back pain but also with mood and depression. In a study of 1387 patients from 70 to 100 years of age, the relationship between LBP and physical performance, grip strength, cognitive function, and depressive symptomatology was prospectively assessed during a 2-year period.11 Of initially LBP-free individuals, 7% experienced more than 30 days of LBP in the

224 preceding year, 7% altered or decreased their physical activities as the result of LBP, and 11% received treatment for LBP. The top 50% had good overall physical function and were relatively protected from LBP episodes as well as lost function or careseeking due to LBP. In adults, a vicious cycle arises from the impact of lower tness on increased pain. That pain further limits activity and tness. Ultimately, mental stress, dissatisfaction with life, and sleep problems result.14 High depression scores both increase the incidence of pain and the disability associated with a given amount of pain.11 This close relationship between physical and psychological factors has been theorized to result from fear avoidance behavior.15 In general, older patients demonstrate less fear avoidance behavior than their younger counterparts.16 Individual personality factors modulate catastrophizing, pain-related fear, depression, perceived disability, and pain severity. When pain leads to fear that fear prevents the patient from returning to the inciting activity resulting, nally, in core weakness. Electromyography (EMG) studies show decreased fatigue strength in LBP patients.17 Pain or even the fear of pain affects EMG ring patterns.18 Patients with LBP may lose cocontraction patterns of the multidus.19 Computed tomography (CT) and MRI studies also demonstrate decreased core muscle cross sectional area and increased fatty inltration in patients with chronic LBP (CLBP).20,21 Unfortunately, age alone is another factor leading to loss of core muscle strength.22 By contrast, EMG can demonstrate a training effect in patients using a bike ergonometer.23

E. Truumees
sports as an adolescent predicted for less pain later.30 In later adulthood, former elite athletes report less back pain than control groups.31 Nicholas and co-workers32 studied the perception that retired professional football players have poor health. Thirtysix of 41 members of the 1969 Super Bowl winning team were studied through use of the SF-36, medical history, and football-specic questionnaires 35 years after that event. SF-36 scores for physical and mental health were not different from age-matched norms (physical health P 0.69; mental health P 0.49). The most prevalent health problems were arthritis (24 of 36 players), hypertension (13 of 36 players), and chronic LBP (13 of 36 players). Both arthritis and LBP decreased SF-36 physical health scores about 20%. The authors concluded that these professional football players had long and fullling careers with no apparent long-term detrimental effects despite a high prevalence of arthritis.

Pathophysiology
Beyond the rate of injury, the types of injuries seen are also gender, age, and sports specic.33 As with back pain generally, LBP in athletes often goes without a specic diagnosis. In one study of LBP in athletes, an up to 30% incidence was reported.34 In those patients, more than 90% improved without medical attention. Most short-term, acute LBP stems from myofascial inammation or injury. More than one-half of the athletes involved demonstrate some improvement within 1 week, and more than 90% will recover within 3 months. Muscular pain is less common in older adults, although their muscles are less healthy and exhibit sarcopenia.35 In older athletes, by contrast, muscle pain takes longer to recover. In patients with persistent and more diffuse symptoms, myofascial pain syndromes like bromyalgia should be considered, although common overall, nonspecic back and neck pain syndromes less frequently affect active adults.36 Many muscular pain syndromes include tenderness at the insertion of the gluteals and extensors at the posterior superior iliac spine. Pain in this area is often mistaken for inammation of the sacroiliac joint. Other categories of athletic spine injury range include trauma to the boney, ligamentous, and articular processes of the spine.37,38 The specic injury depends on the spines position at the time of impact and the force vector imparted. The increased stiffness and decreased bone mineral content of the older spine further impacts the relative frequency of injuries seen. For example, in the cervical spine, stingers and burners are less likely. Exacerbation of underlying spine problems and central cord syndromes are more common. With annular disruption, intervertebral disk injuries can be seen in mature athletes. Acute disk herniations in football are rare but are probably more common with torsional injuries.39 Avulsion fractures can include the spinous or transverse processes or disk level osteophytes. With increasing axial loads, failure of the vertebral centrum can occur. These injuries affect the thoracolumbar junction more frequently.

Impact of Sports in Youth

Older athletes with LBP often question the role of the sports they played in youth. Here, too, it is important to distinguish changes in the incidence of radiographic degeneration from symptomatic changes. In 1972, the spines of 109 ex-military parachutists and 112 sport (free-fall) parachutists aged 50 years or older were analyzed.24 Of the ex-military parachutists x-rayed, 84.7% had lumbar disk degeneration of all grades of severity, 17.4% had moderate changes, and 10.8% had severe changes. Interestingly, although several patients with occult spine fractures were identied as was a high rate of lumbar spondylosis, the study did not implicate parachuting as a cause of painful disk degeneration. In this group, a history of back pain was signicantly (P 0.01) associated with body weight but not with the number of descents or with the subjects age. Despite the frequency of the spinal trauma sustained, the authors concluded that serious long-term disability was uncommon among parachutists. Since then, several studies have reported an increased incidence of degenerative changes in athletes compared with age matched norms. Sports cited include Olympians, gymnasts, wrestlers, and water ski jumpers.25-28 Even excessive competitive swimming was found to increase rates of degenerative disk disease rates, especially at L5-S1.29 In most of these studies, radiographic changes did not correlate with increased back pain. In one study, participation in multiple

Low back pain in the aging athlete

225 As the disk anteriorly begins to collapse, facet loading patterns are compromised (Figs. 1 and 2). Facet degeneration includes subluxation and osteophytosis. The facet capsules hypertrophy and become lax with associated ligamentum avum enlargement. Together, these changes narrow the spinal canal and represent the main causes of neurogenic claudication and radiculopathy in older athletes. Of these spinal motion segment structures, the disk is most vulnerable to athletic injury. These injuries are more likely in the older athlete who demonstrates changes in ligamentum avum elasticity.42,43 The degenerative disk itself may be a source of pain in that the outer third of the annulus receives branches of the sinuvertebral nerve.44 Even when the pain generator lies outside the muscles, their function continues to dene the types of injuries to which patients are subject and the recovery prole. Thus, it is important to understand the impact of the static and dynamic spinal stabilizers. For example, while any direction of loading can affect the disk, the spine is most vulnerable to rotational and combined force vectors (such as rotation with axial loading).10 Static spinal stabilizers include the longitudinal ligaments, intervertebral disks and facet joint capsules. The core and supercial muscles provide the dynamic stabilizers. Although the lumbar extensors are critical, so are the abdominal and hip muscles, including the hip exors, extensors, and abductors. Well-balanced dynamic stabilizers act synergistically to reduce the shear forces. How the stabilizers function together and the vectors of spinal loading are determined by spinal alignment.45 Increased lordosis typically results from anterior pelvic tilt, which can be caused

Figure 1 This AP radiograph demonstrates a lumbar transitional vertebra in a patient with sports-related low back pain. This patient has mechanical abnormalities which may impact their prognosis and likelihood of improvement with observation alone.

Compression fractures are associated with anterior vertebral height loss with preservation of the posterior vertebral cortex and the spinal canal. Vertebral burst fractures result from severe axial loading in combination with hyperexion forces. Clinically burst fractures cover a spectrum from injuries minimally intruding into the spinal canal to devastating injuries with marked body comminution and severe neurologic injury. Injuries to the sacrum are frequently missed because of the difculty visualizing the affected anatomy. Acute fractures of the sacral ala can lead to L5 radiculopathy as the nerve passes over ala anteriorly. Sacral injuries can stem from acute trauma or from chronic, overloading. Bone injury may occur more readily in older patients because of the combination of bone loss and decreased shock absorption.40 Thus, older athletes are predisposed to both stress and acute fractures. Most catastrophic spine injuries result from contact sports, such as football, hockey, rugby, and wrestling. Older athletes continue to participate in hockey and other aggressive contact sports, but, in this age group, signicant spinal column injuries are more likely with noncontact sports, such as: skiing, diving, surng, power lifting, and equestrian sports. Risk factors for major, destabilizing spine injuries include high-velocity collisions between players or sudden acceleration or deceleration mechanics.38 In the mature athlete, exacerbation of degenerative spine condition more frequently leads to LBP than high-energy spinal column injury. Aging produces unrelenting changes of the entire spinal unit.41 These changes render the vertebral endplates, disks, facet joints and capsules, and ligamentous structures more vulnerable to injury. At the disk level, these degenerative processes start early during the rst decade of life. Biochemical changes in the disk are followed by macroscopic alterations, including annular tears and ssures.

Figure 2 This sagittal T2-weighted MRI demonstrates multilevel disk degeneration in a patient with recurrent low back pain. Note the end plate anomalies at L2-3 and the disk height loss at L5-S1. These changes, although common in asymptomatic patients, may affect normal loading mechanics.

226 by weak abdominals or tight hip exors. Increased lordosis increases shear loading to the posterior spinal elements, such as the facets. Decreased lumbar lordosis typically results from posterior pelvic tilt which can be caused by weak extensors or tight hamstring muscles. Decreased lordosis increases shear loading to the disk anteriorly. The aging process decreases motor control over the spine, particularly via reduced feed-forward control of paraspinal muscles.46 This function steadily decreases from youth to middle age and into older adulthood.6 In older patients, muscle bulk primarily in the form of type IIa, or fast-twitch, muscle bers also declines (sarcopenia).35 Theoretically, these older adults lose some of their ability to control muscle activation leading to loss of coordination and strength and decreased ability to self-protect and an increased rate of injury.47 There remains some question as to whether this trend can be reversed with testosterone.48 Other changes in older patients include declines in proprioceptive function and reaction times.6 These neurophysiologic changes modulate how much back pain a given amount of degenerative disk disease causes and how much functional limitation is associated with a given amount of pain.49 Further, the increase in spinal stiffness occurs with increased stiffness in the appendicular skeleton. This decreased exibility forces the joints to bear stresses rather dissipating them to the surrounding muscles. Older adults with CLBP were increasingly likely to have degenerative changes in the hips and knees.6 Outside of acute spinal column trauma and exacerbation of degenerative conditions, older athletes are vulnerable to a wide array of problems far rarer in their younger counterparts.19,37 Some of these problems confer signicant medical risk, including malignancy, aortic aneurysm, Paget disease, and polymyalgia rheumatic, all occur almost exclusively in persons older than 50 years. Red ags that may indicate a more serious medical condition need to be identied and properly diagnosed. When returning older athletes to play, other changes of aging also should be considered. Cardiopulmonary changes50,51 include a decrease in maximum heart rate and maximum cardiac output. In older patients, the cardiac muscle is less able to increase wall muscle size as in younger athletes. To increase cardiac output with exertion, an increased heart rate is required.52 Older patients have a decreased lung capacity and decreased temperature regulation. They are also vulnerable to delirium from dehydration.
Table 2 Clinical Red Flags

E. Truumees

By patient group Age >50 years Patients with a history of cancer or recent infection Patients with a recent history of major trauma Patients who have had prior spine surgery Immunocompromised patients Patients on blood thinners Patients with a history of intravenous drug abuse Patients with a history of metabolic bone disease (osteoporosis, osteomalacia) Patients with a history of inammatory conditions (rheumatoid arthritis, lupus, IBD) Worrisome complaints for major spine pathology Progressive neurologic decit Gait disturbance, history of falls Bowel or bladder difculties Constitutional symptoms: malaise, fever, chills, weight loss Nonmechanical pain pattern (worse when supine or at night) Worrisome complaints for intraabdominal, intrapelvic, and other nonspine pathology Colicky pain Radiation to testes or groin Vaginal or penile discharge Gastrointestinal or genitourinary blood Change in appetite, nausea, constipation Pain from front to back Other groups that may need special attention Peripheral vascular disease Patients at risk for osteoporosis (steroid use) Diabetics Psychosocial overlay: depression, active legal proceedings, etc.

tients, old or young, early establishment of neurological and mechanical stability allows expedited return to play.

History
This clinical evaluation begins with a thorough history. Ask: where does it hurt? What type of pain is it (sharp, aching, burning, etc)? How long has it hurt? Often adults attribute onset of pain to specic, often athletic event, but true correlation is limited. In patients with constant, unremitting, or night pain, consider tumor or infection. Underlying spine problems, especially stenosis, cause signicant disability in older athletes.53 Seek radiating radicular, funicular, or sclerotomal symptoms. Herpes zoster (shingles) is more common in older patients. Radiating pain may precede rash onset. Precipitating and palliating factors often allow partial differentiation of potential pain generators. For example, disk pain usually worsens when sitting. Symptoms that worsen with Valsalva maneuvers, such as coughing, sneezing, and straining, imply space-occupying lesions. Ask the patient about weakness, particularly more subtle difculty, such as trouble getting out of a chair or ascending the stairs. Myelopathy is a great mimic. Painless weakness warrants an aggressive work-up

Evaluation of the Mature Athletes Spine

Given the frequency of benign, self-limited axial LBP, the challenge for the clinician lies in early detection of the rare but dangerous lesions when they occur. Of course, these lesions are more common in older athletes. Begin by excluding nonspinal pain generators, such as neoplasm, infection, and medical conditions (Table 2). Next, differentiate root and cord compression from mechanical problems. In athletic pa-

Low back pain in the aging athlete

and may represent: myelopathy, paraneoplastic syndrome, or other neurologic diseases like multiple sclerosis or amyotrophic lateral sclerosis. An important risk factor for future pain relates to previous occurrences and their resolution. In older athletes, women in particular, previous activity levels and bone health are critical issues. New-onset back pain in a patient who has recently increased their activity level may include a wider differential diagnosis than a patient with a long history of aggressive sports participation. On one hand, lifelong training improves lean body mass and bone health. In women that have had long amenorrheic episodes, by contrast, osteoporosis is more likely. In patients with known osteoporosis, some activity restrictions might be appropriate.54 Medical history and review of systems are more relevant to back pain in the greater elements in the mature athlete than in younger patients. Specically ask about cancer, immunocompromise, trauma, neurologic problems, and major infections. Relevant family history includes spine problems, osteoporosis, and spondylolisthesis. Review of systems should include fevers, chills, night-sweats, unanticipated weight loss. Understand a patients history of or risk for inammatory spondylarthropathies, such as rheumatoid arthritis or ankylosing spondylitis. These and related disorders will confer additional risk during sporting activities.

227 examiners arm strength. Look for difculties with single toe raise, sitting to standing, or Romberg testing. Test reexes and look for long tract signs. Provocative testing includes nerve tension signs, such as straight leg raising and femoral nerve stretch. Older patients require an abdominal examination to assess for abdominal aneurysm or visceral problems. When considering return to athletics, a battery of sport specic tests.55,56 These tests seek to evaluate components of functional spinal stability, such as postural control, proprioception, and muscle activation. Golf is the most common sport associated with low back pain in the older athlete. Of touring members of the Professional Golfers Association, 10% to 33% reported playing with back complaints.53 These complaints are even more common in amateurs. The golf swing has frequently been implicated as a major source of injury. The swing requires lumbar spine rotation at the top of the backswing, with the subsequent uncoiling and hyperextension through the downswing and follow-through. Forces generated include rotational, anterior-posterior (AP) shear, axial compression, and lateral bending. Amateur golfers generate greater forces than professionals.57 The loads measured were similar to those required to disrupt the lumbar disk in cadaveric studies. Ensure proper mechanics and lumbar strengthening before returning older athletes to golf. Cycling is another common sport in this age group. Although older athletes do well with cycling, the clinician should be aware of issues, such as seat height. In those with low back pain, try lowering the seat. The lower seat can lead to neck extension, however. Saddle problems can also lead to radicular irritation.

Examination
The examination in the mature athlete with LBP begins with observation. Note the patients pain and distress level. Understand the patients gait. Look for use of assistive aids, a wide-based gait, ataxia, or a Trendelenburg limp. Effective heel-toe walking excludes several pathologies. Note the spinal alignment. Assess iliac crest heights to screen for functional leg length discrepancy or listing. Record paraspinal spasms, scoliosis, muscle atrophies, or asymmetries. Hamstring or gluteal tightness or spasm will lead to posterior tilt of pelvis reducing lordosis. Tightness of the rectus femoris and iliopsoas muscles anteriorly can cause an anterior tilt to the pelvis, increasing the lumbar lordosis. In mature athletes are more likely to have thoracic hyperkyphosis, which may leads to malalignment above and below. Palpate the spine and the paravertebral musculature. Look for tenderness, uctuance, or skin changes. Then, assess the patients active versus passive arc of motion. Through the arc of motion, test extensor muscle strength. Patients with true or functional core weakness often demonstrate an instability catch. This catch manifests when patients press their arms against their thighs when extending back to neutral. Older patients are more likely to have associated pathology in the appendicular skeleton. The examination should therefore include assessments of shoulder, hip, and knee motion, stability, and pain. A Patrick test can be useful in assessment of sacroiliac pathology or sacral stress fracture.5 As with a potential spinal pathology, a close neurovascular examination is required. This patient group is at greater risk for meralgia paresthetica and obturator nerve dysfunction. In the motor examination of the lower extremities, remember that functional tests are better than assessments against the

Radiographic Evaluation
Radiographic evaluation in the mature athlete begins with plain lms. Absent red ags, radiographs are necessary only after a trial of symptomatic treatment.58 The standard series in this patient group includes standing AP and lateral views. Obliques and lateral L5-S1 cone-down views are often helpful. Flexion-extension radiographs are ordered in patients suspected of instability. An AP of the pelvis is useful to check the hip and sacroiliac joints. The cardinal ndings of spondylosis include end plate sclerosis and disk space loss. Other ndings include loss of lordosis, subluxations, vacuum phenomenon, and osteophytes. Disk space loss with end plate disruption or in the absence of other evidence of spondylosis, should alert to possibility of infection (Fig. 3). The ubiquity of painless spondylosis limits specicity of plain radiographs. In one study, disk degeneration was present in 90% of the adults examined. On-half of those adults had no pain. In a study of parachutists, by contrast, spondylolysis was found in 2 subjects (4.3%) and spondylolisthesis unassociated with spondylolysis in 4 (8.7%). Although most degenerative changes were asymptomatic, spondylolisthesis was always associated with LBP.24 In other series, spondylolisthesis accounts for up to 5% of CLBP. In older patients, closely examine bone integrity. Note the location, quality, and pattern of any bone destruction. Dan-

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E. Truumees

Figure 3 These lateral radiographs demonstrate gradual disk height loss and end plate erosion in a patient with constant back pain in April (A) and September (B) of the same year. Recommendations to obtain an MRI had been made, but unfortunately this patients diskitis was not diagnosed until an abscess formed with lower extremity weakness in the ensuring month.

ger signs include cortical erosion or expansion, vertebral collapse, or a winking owl sign. On the AP view, the winking owl represents unilateral pedicle destruction. Note that 30% bone loss is needed for radiographic visualization. Assess the paraspinal soft tissue contours, such as the psoas shadows on lumbar AP view. In patients not responding to management or in those with red ags, an MRI is ordered. Here too, however, the sensitivity of the scan to nearly universal degenerative changes may lead to over referral or over treatment. L5/S1 degenerative change signicantly more prevalent (P 0.01) in older age group (52%) than in the younger age group (27%).59 Although LBP was more prevalent in the older subjects, there was no relationship between LBP and disk degeneration. No differences in the MRI appearance of the lumbar spine were observed between the 5 occupational groups. During the 12-month follow-up period, 13 subjects experienced LBP for the rst time. However, there was no change in the MRI appearances of their lumbar spines that could account for the onset of LBP (Fig. 4). In mature athletes with sports injuries, order short inversion time recovery (STIR) sequences to assess ligament integrity and end plate injuries. Gadolinium contrast should be considered in patients with previous spine surgery or those suspected of infection or tumor. Typically tumors demonstrate decreased T1 and increased T2 intensity. Other tests occasionally considered include bone density testing, scintigraphy, and CT. Technetium bone scans are useful to exclude pathologic processes, such as tumor, infection, stress fracture, or rib injuries. CT demonstrates degenerative changes in the lumbar spine, but is not particularly useful in the evaluation of spondylosis. CT is useful to look for subtle pars or end plate disruptions (Fig. 5). Like MRI,

extensor muscle thinning on CT has been related to increased low back pain.60

Treatment
Specic, high-energy trauma to the spine typically confers specic treatment recommendations beyond the scope of this article. For mature athletes with mechanical back pain, by contrast, treatment recommendations vary as a function of symptom duration and severity. Treatment may also be divided into acute, rehabilitative, and maintenance phases.19,61 Management of acute LBP in mature athletes begins with pain control. Traditionally, medications for pain control include nonsteroidal antiinammatory drugs, narcotics, and muscle relaxers. Narcotics should be employed sparingly (especially until a diagnosis is made). There is no role for opioids in CLBP, where risks are greater but outcomes are no different from in patients on nonopioid agents.62 Role of muscle relaxers is also controversial, but probably less so. Steroid dose packs may be useful in those with acute radicular pain. A wide variety of other agents are used. Even intravenous pamidronate has been shown to decrease the symptoms of neurogenic claudication.63 In the acute phase, activity limitations are recommended. Bed rest, however, is not indicated. Active radiculopathy patients should avoid bending, lifting more than 5 lbs, twisting, and overhead activities. Osteoporotic patients probably benet from similar restrictions as a function of their bone mineral density. The mainstay of more severe mechanical pain is physical therapy. In the acute phase, therapy focuses on reducing pain symptoms with modalities, such as transcutaneous electorneurostimulation.45,61 Some recommend ice for acute symp-

Low back pain in the aging athlete

229

Figure 4 These sagittal MRI images demonstrate other red ag conditions to be considered in mature athletes presenting with low back pain. In both cases, a history of minor trauma was reported. In (A), constant, unrelenting pain was associated with increased radicular symptomatology. In patient (B), focal tenderness was noted in the midline over the palpable slip at L4-5. Back and leg pain complaints were noted. Subsequent evaluation demonstrated signicant, but previously undiagnosed, osteoporosis.

toms. The patient is instructed in proper posture and body mechanics to protect injured structures, reduce symptoms, and prevent further injury during activities of daily living. Specically, they must avoid positions that increase loading on injured structures. For disk-mediated pain, for example, patients should avoid excessive sitting, bending, and lifting. Pool therapy has been shown to be helpful, but not more so than other treatments.64 Some clinicians recommend pool therapy to allow an earlier return to activity. Although rigid bracing is typically reserved for patients with active fracture or active infection, semirigid bracing can occasionally be helpful in sports patients. Rigid braces are recommended for acute spondylolisthesis and osteoporotic injury. Use of a rucksack type orthosis has been described to relieve LBP and fatigue during prolonged standing and walking.65 Assistive devices, such as a cane, walker, or wheelchair can be used to assist return to ambulation in patients with severe pain. Insoles have been shown to reduce LBP.66,67 In one study, a viscoelastic heel signicantly decreased vertical strain transients in the lumber spine.66 Older patients are more sensitive to shoe wear. Runners, in particular, need good mid-sole cushioning and should change shoes every 250 to 500 mi.68 Grass, dirt, and wooden tracks are less stressful to the body and are particularly recommended for older runners. In the rehabilitation phase, active stabilization is sought.61 Many strategies seek the position that centralizes any referred pain symptoms. Then, move quickly to spine stabilization exercises. Teach the patient how to nd and maintain a neutral spine during everyday activities. This neutral position is specic to the individual and is determined by the pelvic and

spine postures that place the least stress on the spine and supporting structures. The stabilization process provides control and protection by emphasizing the synergistic activation of the trunk and spinal musculature in the midrange position. Abdominal and gluteal muscle strengthening are stressed.60 For older patients in particular, an assessment of the entire kinetic chain is useful.69 Restriction or weakness in one part of the chain manifests as problems in another region. For example, lost hip range of motion increases lumbar spine stress. For sports that include upper extremities should have both upper- and lower-extremity closed-kinetic chain exercises included in the rehabilitation program. Lower extremity and core strength are intricately linked.52,70 Core strengthening programs improve lower extremity rotational control, thereby decreasing risk of anterior cruciate ligament and other lower extremity injuries, especially in female patients. LBP also increases the risk of other lower extremity problems by changing gait and ground reaction force.71 The maintenance phase of rehabilitation focuses on eccentric muscle strengthening exercises.60 Dynamic conditioning exercises (eg, with a large gym ball) and endurance exercises are added. A number of endurance programs have been described. In a bicycle program studied specically for older adults with CLBP, a set wattage was achieved 3 times a week for 12 weeks. Of the 65% that completed the trial, the exercise was effective in decreasing LBP and improving functional status.38 Rehabilitation outcomes have been described variously as more impressive in less and more active individuals. In one series, the best response to treatment in patients with

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E. Truumees

Figure 5 These CT images demonstrate a chronic pars fracture in the coronal (A), sagittal (B), and axial (C) planes. The loss of the pars affects the spines resistance to shear loading. In the absence of spondylolisthesis, its not clear whether the pars defect places the patient at signicantly increased risk during sports.

lowest initial levels.72 In another, individuals participating in strenuous exercise at least once a week had the best outcomes.36 No one type or frequency of exercise could be recommended. Patient education and preseason, sport-specic training are important in the prevention of reinjury.45 Sport-specic training minimizing forces on the spine through proper mechanics. In addition, strengthening the dynamic stabilizers of the spine to counteract the signicant forces exerted on the spine during certain athletic activities also is important. Maintaining proper exibility also is believed to play a signicant role in the prevention of back injury in

athletes of all ages. In addition, improvement in aerobic tness can increase blood ow and oxygenation to all tissues, including the muscles, bones, and ligaments of the spine, and it would be a reasonable addition to any rehabilitation and prevention program.25 Seasonal athletes should be encouraged to cross-train yearround or at least undergo preconditioning before participating in their particular sport. In older athletes, address deteriorating balance by adding balance exercises to the workout regimen. For more chronic, or recurrent pain, more aggressive intervention is occasionally sought. These treatments can range from injection therapies to surgical stabilization.

Low back pain in the aging athlete

Table 3 Risk Categories for Return to Sports in Mature Athletes (After Watkins) Low risk of reinjury Asymptomatic bone spurs Healed nondisplaced fractures Stingers/burners Healed disk herniations or asymptomatic foraminal stenosis Low-grade slips Moderate-risk conditions Facet and lateral mass fractures Nondisplaced, healed odontoid and C1 ring fractures High-grade, kyphotic, or mobile slips High-risk conditions Os odontoideum, odontoid fractures Ruptured transverse atlantal ligament Occipitocervical or cervical fracture-dislocations Cord anomalies Central disk herniations with high-grade stenosis

231 and when they can return. Generally, a well healed 1 level fusion should provide little impediment to return to sports. Older athletes may have irremediable issues, such as poor bone quality, spondylolisthesis and spinal canal stenosis that would preclude some, but not all athletic pursuits. Uncommon in younger athletes, mature athletes medical comorbidities have to be considered. Before nal activity recommendations are made, address major health problems, such as hypertension, heart disease, lung disease, and hearing and sight loss. Other specic issues seen mainly in older patients include ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, Klippel-Feil, and degenerative autofusion. These conditions alter the spines mechanics and its response to sudden loading. The clinician should be very cautious about high impact sports in patients with multilevel fusions, abnormal sagittal alignment or poor bone quality. There is increasing evidence that achievement of good sport-specic mechanics is critical in the prevention of recurrent injury.45 Return to golf serves as a useful case in point. LBP is common among golfers. LBP recurrence with return to sport is also common. Much this risk stems from the signicant stress imparted on the lumbar spine by the golf swing.78 Coordination of transversus abdominus and multidi muscle function and golf swing technique have been identied as major predictors of LBP. At this point, however, few studies separate the effects of swing modication from physical rehabilitation. One study examined the impact of skill level in forces generated during the golf swing.79 Twelve golfers with LBP were compared with 18 asymptomatic golfers. These cohorts were further divided by handicap. During 20 drives, the erector spinae and external oblique myoelectric activity was recorded via surface EMG. Low-handicap golfers with LBP tended to demonstrate reduced erector spinae (ES) activity both at the top of the backswing and at impact, whereas greater external oblique activity was seen throughout the swing. Using a triaxial electrogoniometer, the authors of another study compared spinal motion in 3 planes during swings in professional golfers with and without LBP.80 Golfers with LBP demonstrated more spinal exion and signicantly more side bending on the backswing. Overall, lower amount of trunk rotation were noted, resulting in supramaximal spinal rotation during the swing. In the downswing of golfers with no history of LBP, over twice as much trunk exion velocity was demonstrated. The authors felt this difference related to increased abdominal muscle activity. In the high-handicap group, golfers with LBP demonstrated more ES activity. Reduced ES activity was associated with a reduced capacity to protect spine and its surrounding structures at the top of the backswing and at impact, where the torsional loads are high. The authors conclude that the distinct differences in swing mechanics between golfers with and without low back pain provide valuable guidance to facilitate recovery from golf-related low back pain. When developing a program of returning mature athletes with LBP to activity, 4 elements should be incorporated81: 1. Injury rehabilitation coordinated by physical therapy

Return to Play
In older athletes with back pain, each course of treatment ends with questions about return to activity in general, and their sport in particular. Unfortunately, there is a striking lack of objective data in the literature and no level one evidence to guide these recommendations.73,74 The grading system by Watkins et al75 for neurologic injury in sports, attempts to tabulate risk of return (Table 3). Most of that classication addressed head and neck issues are not relevant here. Even where literature-based recommendations are available, they are only marginally used in clinical practice. In a survey of 113 practitioners there was a marked lack of consensus among treating physicians76,77 Although one-half reported using published guidelines in practice, in a case review, only 1 in 10 consistently used the guidelines. Trends noted included more aggressive return-to-play recommendations from spine specialists and a more conservative approach from physicians with longer practice histories. When guidelines discuss return in older athletes, many authors guidelines vary little from those for younger athletes, such as full symptom resolution and a return to full range of motion.19,37,38,45 Certainly, resolution of neurologic signs and symptoms is critical. Complete resolution of low back pain, by contrast may not be achievable. Similarly, older athletes may return to their previous arc of motion, but not, perhaps, full range of motion. Unlike younger athletes that often quickly resume their previous sports at full participation, mature athletes are best served with a gradual return to their sport. They must be aware of their own limitations and the variation of their symptoms over time.19 By contrast, older athletes are more reliable and less likely to be involved in high energy or high impact sports. The older athlete with low back pain carries a greater likelihood of previous regional surgery. The surgeon must decide which sports remain appropriate to the postoperative patient

232 2. Preactivity warm up routines 3. Coaching on proper, sport-specic technique 4. Preseason conditioning programs When seeing a mature patient, a discussion of the benets of physical activity should include educational materials about injury prevention strategies that enhance long-term participation.

E. Truumees
ability in older women: independent association with difculty but not inability to perform daily activities. J Gerontol A Biol Sci Med Sci 54:M487-M493, 1999 Yagci N, Cavlak U, Aslan UB, et al: Relationship between balance performance and musculoskeletal pain in lower body comparison healthy middle aged and older adults. Arch Gerontol Geriatr 45:109-119, 2007 Alcouffe J, Manillier P, Brehier M, et al: Analysis by sex of low back pain among workers from small companies in the Paris area: severity and occupational consequences. Occup Environ Med 56:696-701, 1999 Hubert H, Fries J: Predictors of physical disability after 50: six year longitudinal study in a runners club and a university population. Ann Epidemiol 4:285, 1994 Gnudi S, Sitta E, Gnudi F, et al: Relationship of a lifelong physical workload with physical function and low back pain in retired women. Aging Clin Exp Res 21:55-61, 2009 Hangai M, Kaneoka K, Kuno S, et al: Factors associated with lumbar intervertebral disc degeneration in the elderly. Spine J 8:732-740, 2008 Hartvigsen J, Frederiksen H, Christensen K: Physical and mental function and incident low back pain in seniors: a population-based twoyear prospective study of 1387 Danish twins aged 70 to 100 years. Spine 31:1628-1632, 2006 Ericksen JJ, Bean JF, Kiely DK, et al: Does gynecologic surgery contribute to low back problems in later life? An analysis of the womens health and aging study. Arch Phys Med Rehabil 87:172-176, 2006 Holmes B, Leggett S, Mooney V, et al: Comparison of female geriatric lumbar-extension strength: asymptotic versus chronic low back pain patients and their response to active rehabilitation. J Spinal Disord 9:17-22, 1996 Miranda H, Viikari-Juntura E, Punnett L, et al: Occupational loading, health behavior and sleep disturbance as predictors of low-back pain. Scand J Work Environ Health 34:411-419, 2008 Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, et al: Fear of movement/ (re)injury in chronic low back pain and its relation to behavioral performance. Pain 62:363-372, 1995 Cook AJ, Brawer PA, Vowles KE: The fear-avoidance model of chronic pain: validation and age analysis using structural equation modeling. Pain 121:195-206, 2006 Takahashi I, Kikuchi S, Sato K, et al: Effects of the mechanical load on forward bending motion of the trunk: comparison between patients with motion-induced intermittent low back pain and healthy subjects. Spine 32:E73-E78, 2007 Lamoth CJ, Daffertshofer A, Meijer OG, et al: Effects of experimentally induced pain and fear of pain on trunk coordination and back muscle activity during walking. Clin Biomech (Bristol, Avon) 19:551-563, 2004 Buschbacher R: The aging athletes spine. J Back Musculoskel Rehabil 5:55-74, 1995 Hicks GE, Simonsick EM, Harris TB, et al: Cross-sectional associations between trunk muscle composition, back pain, and physical function in the health, aging and body composition study. J Gerontol A Biol Sci Med Sci 60:882-887, 2005 Ranson CA, Burnett AF, Kerslake R, et al: An investigation into the use of MR imaging to determine the functional cross sectional area of lumbar paraspinal muscles. Eur Spine J 15:764-773, 2006 Mannion AF, Kaser L, Weber E, et al: Inuence of age and duration of symptoms on bre type distribution and size of the back muscles in chronic low back pain patients. Eur Spine J 9:273-281, 2000 Watanabe S, Eguchi A, Kobara K, et al: Electromyographic activity of selected trunk muscles during bicycle ergometer exercise and walking. Electromyogr Clin Neurophysiol 46:311-315, 2006 Murray-Leslie CF, Lintott DJ, Wright V: The spine in sport and veteran military parachutists. Ann Rheum Dis 36:332-342, 1977 Durall CJ, Udermann BE, Johansen DR, et al: The effects of preseason trunk muscle training on low-back pain occurrence in women collegiate gymnasts. J Strength Cond Res 23:86-92, 2009 Hellstrom M, Jacobsson B, Sward L, et al: Radiologic abnormalities of the thoraco-lumbar spine in athletes. Acta Radiol 31:127-132, 1990 Horne J, Cockshott WP, Shannon HS: Spinal column damage from water ski jumping. Skeletal Radiol 16:612-616, 1987

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Conclusions
The mature athlete refers to a wide range of patients from 40- to 90-year-olds engaging in activities from walking programs to professional tennis. When they have LBP, the potential etiologies range from transient myofascial irritation to pathologic fractures from vertebral metastasis. Typically, however, as spine specialists, we see activity-mediated symptoms in patients with imaging evidence of lumbar degeneration. Given the ubiquity of both low back pain and asymptomatic individuals with radiographic degeneration, establishing the true pain generator in most athletes without focal injury remains challenging. Concordance between historical, examination, and imaging elements is key. Although older athletes carry higher risks of injury and LBP with sports participation than their younger peers, this participation confers several advantages. Active adults have lower pain and higher functional levels than their less active peers. Despite relatively more free time, older adults have been reluctant to take up new activities. Injuries and fear avoidance behaviors most typically lead to a gradual attrition from previous activities. In the clinical setting, understanding the risk factors for back pain in this population guides a complete evaluation. Although most back pain is transient, recurrent or recalcitrant symptoms should be explored aggressively to offer treatment that allows earlier return to activity. This patient population carries a higher risk of red ag conditions and other mechanical issues, such as bone loss, that require a different algorithm of management and return than in younger patients. In the appropriate mechanical milieu, return to activity requires rehabilitation of both the core muscles and associated downriver joint and muscle groups (eg, hip and knee). Endurance exercise and preseason conditioning, appropriate warm-up, and sport specic technique instruction all covey additional benet.
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