Posts tagged athletes
High Percentage of Positive MRI Findings Among High Performing Olympians
lumbar-MRI-treatment-disk-injury

In the absence of rare spine pathology the only abnormal low back MRI is a normal MRI.  After age 30 many of our spines will age and positive findings will become more common in patients with and without back pain.  MRIs have tremendous sensitivity and can find even the smallest amount of pathology, but their specificity is lacking in patients with low back pain.  Multiple studies have shown high rates of spinal pathology among asymptomatic groups of individuals.  A recent study highlighted the presence of spinal pathology among an elite group of athletes.  

Wasserman and colleagues retrospectively analyzed spinal MRIs of Olympic athletes from the 2016 Rio Summer Games (BMJ. 2018).  The authors reported 100 olympic athletes underwent a spinal MRI during the games and half of these high performing athletes were diagnosed with moderate to severe spinal disease.  Consistent with previous MRI studies, athletes over 30 years old had the highest rates of spinal disease on MRI.  The majority of athletes likely had positive findings on MRI before they had back pain and will have the same findings when their back pain is resolved.  Patients are encouraged to have their MRI findings read in light of their subjective and clinical examination to determine which spinal changes are due to age and which may be causing their current symptoms.

Return to Sport and Back Surgery

We have previously written on low back pain and the dramatic rise in surgeries with this patient population, despite evidence of superior outcomes over conservative treatment and Physical Therapy.  Prior research has documented the dramatic rise in the number of lumbar MRI imaging for the low back and a corresponding increase in the number of lumbar surgeries (figure 1 below).  One of the main predictors of spinal surgery over age or degree of injury in the spine remains how many MRI machines are in your area.  These images are highly sensitive and find even the smallest pathology, but often lack the specificity (high false positives) to correctly diagnosis every patient without an appropriate clinical examination.  The high false positives, finding pathology in asymptomatic people, is noted on the 2nd figure below in a study of 3,000 people.  As we age there is a higher probability of finding pathology making a negative image less likely past age 30.   Interestingly, many of these severe injuries on our spine heal and improve if given time (3rd figure). 

louisville physical therapy, low back pain
boulder physical therapy, low back pain, MRI results
low back pain, MRI, healing, louisville physical therapy

Tiger Woods has experienced a difficult recent history of injury with missed tournaments due to injuries including back pain.  He recently underwent a discectomy to remove disc material from his spine, but has yet to return to prior levels of play.  His upcoming return highlights a key question, what is the likelihood an athlete return to the same level of play following a lumbar surgery.  A recent review article in the British Journal of Sports Medicine reviewed the recent literature to answer this question (Reiman et al. 2015).  The authors reviewed 14 articles on the return to sport rate after either conservative (including physical therapy) or surgical treatment for lumbar disc herniations.   The authors reported no difference in the return to sport rate between surgical and conservative treatments.  Only 59% of the athletes undergoing surgery return to the same level of play after this procedure.   

This study highlights the limitations of focusing on only pathology/MRI scan in the treatments of patients with low back pain and injury.  Given the equivalent outcomes between Physical Therapy and surgery patients should consider conservative treatments prior to surgical interventions for disc injury.  

Predicting Injury in Runners from the Physical Therapy Exam

We have previously written about the functional movement screen (FMS) and its' ability to predict injury although more recent research has called its' predictive ability into question.  The highest quality research on the FMS has occurred in NFL athletes or those training for the NFL combine.  The research demonstrates the predictive value of these tests may be less powerful in endurance athletes.  As the diagnostic utility of these 7 tests falls it requires the clinician to incorporate other data from the subjective and objective examination to determine an athlete's injury risk.  An important aspect of the FMS that should not be overlooked, regardless of an athlete's sport, is their emphasis on movement quality.  Poor movement patterns may be secondary to a loss of joint mobility, strength, coordination, or balance and can lead to injury if not corrected.  In a runner, a poor movement examination on the treadmill may indicate the need for gait retraining by a Physical Therapist.  

A recent article by Hotta et al. examined the ability of the FMS to predict injuries in 18-24 year old competitive male runners (J Strength Cond Res. 2015).  Each athlete was scored on the 7 examination items during the preseason then followed through the running season to determine the predictive ability of these 7 tests on the development of future injury.  Prior authors have reported a score of less than 14 indicating poor movement patterns is predictive of future injury.  Hotta et al. found this composite score had a low predictability for running injuries.  Conversely, two tests including the active straight leg raise and deep squat had high predictability for running injuries.  A runner with a poor score of these tests had a 10 times greater risk of injury during the season.  

This article continues on prior research indicating the complete 7 tests may not be appropriate for all sports and athletes.  Instead, specific examination tools like the overhead squat can be combined with gait analysis and other running specific examination tests for a more predictive injury screening.  

Sports Injuries and the Functional Movement Screen

Athletic Injuries

More than 10,000 athletes seek treatment for sports, recre- ation, and exercise based injuries on a daily basis(12).

7 million Americans received medical attention for sports and athletic injuries between 1997-1999(1).

Incidence of athletic injuries has been reported as 15.4-25.9 injuries per 1000 in the population(2,3).

50-80% of these injuries have been described as overuse in nature and may be prevented through the utilization of pre-participation screens(13). 

Functional Movement Screen                                

FMS is a ranking and grading system that documents move- ment patterns that are key to normal function3. It requires individuals to move through all 3 planes of motion allowing the examiner to document both the quantity and quality of the movement pattern.

Risk factors associated with injury in athletic events including muscle imbalances, balance and proprioception impairments, and pain are assessed with each movement.

The screen allows Physical Therapists to objectively score and grade individuals for injury risk prior to participation as well as follow and reassess these at risk individuals after Physical Therapy treatment is initiated. 

FMS Evidence

Plisky et al. identified an anterior side to side reach difference of greater than 4 cm on the star excursion test placed a high school basketball athlete at a 2.5 times greater risk of lower extremity injury in their season. Further, in females a compos- ite reach <94% of their limb length placed them at a 6.5 times greater risk(11).

Kiesel et al. reported a score of <14/21 was able to predict serious injury in a group of professional football players. (Specificity .91, Sensitivity .54 (+) LR 5.92 (-) LR .51)(4).

These individuals were almost 12 times (odds ratio 11.67) more likely to sustain a serious injury versus an athlete scoring higher on this testing(4).

Chorba et al. found similar findings among a group of female Division II athletes where a score of <14/21 placed the individual at a 4 times greater risk of lower extremity injury(5).

Authors have reported a 7 week (4-6/week) supervised off season conditioning program was able to improve professional football players FMS scores in previously at risk athletes. A low score on the deep squat was most predictive of a lack of success with this program(6).

Peate et al. has also reported on the impact of the FMS screen and an 8 week intervention program on a group of 433 inter- national firefighters. This program reduced the time off work due to injury by >60%(8).

Lower sensitivity values (.08), but higher specificity (.95) were found among recreational runners training for a half mara- thon scoring < or > 14/2110. These higher specificity scores may be explained by a low number of individuals scoring <14.

Letafatkar et al. indicated an almost 5 times greater risk of injury among recreationally active college students scoring <17/21(7). 

Boulder FMS testing, sports and athletic injuries, screening, prevention

Testing

The 7 tests utilize a variety of basic positions and movements, which are though to provide the foundation for more complex athletic movements to be performed efficiently(4).

Individuals are graded and assigned a level of injury risk based on these 7 movements with a total possible score of (21).

Teyhen et al. has described moderate to good inter and intra rater reliability and acceptable levels of measurement error with the FMS(9). 

References

1. Conn JM, Annest JL, Gilchrist J. Sports and recreation related injury episodes in the US population, 1997–99. Inj Prev. 2003;9(2):117-123.

2. Gotsch K, Annest JL, Holmgren P, Gilchrist J. Nonfatal sports- and recreation- related injuries treated in emergency departments—United States, July 2000–June 2001. MMWR Morb Mortal Wkly Rep. 2002;51(33):736-740.

3. Functional Movement Systems. Functionalmovement.com

4. Kiesel, K. et al. CAN SERIOUS INJURY IN PROFESSIONAL FOOTBALL BE PREDICTED BY A PRESEASON FUNCTIONAL MOVEMENT screen? N Am J Sports Phys Ther. 2007. 2(3):147-158

5. Chorba RS, Chorba DJ, Bouillon LE, Overmyer CA, Landis JA. Use of a Functional Movement Screening Tool to Determine Injury Risk in Female Collegiate Athletes. N Am J Sports Phys Ther. 2010; 5(2):47-54.

6. Kiesel K, Plisky P, Butler R. Functional movement test scores improve following a standardized off- season intervention program in professional football players. Scand J Med Sci Sports. 2011; 21(2):287-92.

7. Letafatkar, A. et al. Relationship between functional movement screening score and history of injury. International J Sp Phys Ther. 2014. 9(1):21-27.

8. Peate WF, Bates G, Lunda K, Francis S, Bellamy K. Core strength: a new model for injury prediction and prevention. J Occup Med Toxicol. 2007; 2: 3.

9. Teyhen DS, Shaffer SW, Lorenson CL, Halfpap JP, Donofry DF, Walker MJ. The functional movement screen: A Reliability Study. J Orthop Sports Phys Ther. 2012; 42(6): 530-540.

10. Hoover D, Killian CB, Bourcier B, Shannon L, Jenny T, Willis R. Predictive validity of the Functional Movement Screening in a population of recreational runners training for a half marathon. Med Sci Sports Exerc. 2008; 40(5): 219.

11. Plisky et al. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. JOSPT. 2006. 36(12):911-919.

12. National Center for Injury Prevention and Con- trol, Centers for Disease Control and Prevention. CDC Injury Research Agenda. Atlanta, GA: US Department of Health and Human Services; 2002.

13. Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999;31:1176-1182. 



Overuse Injuries in Adolescent Athletes

High school fall sports are around the corner. Recently sports medicine professional have noticed an increase in the rates of overuse injuries among adolescent (13-17 y.o.) males and females. Growth factors; lack of cross training and increased volume of training may contribute to this increase in injuries. In particular, these last two factors may allow clinicians to identify individuals most at risk for overuse injury and loss of practice and competition time. A recent article in the Journal of Pediatrics (Schroeder et al. 2015) analyzed athletes in 20 sports over a 7 year period and found females were found to be a greater risk of injury than males and in particular female track and field hockey athletes were at the greatest risk of overuse injury. Half of these injuries resulted in greater than 1 week off of training and competition. For more information on how to prevent adolescent overuse injuries contact the experts at MEND.