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Epidemiology, Treatment, and Prevention of Lumbar Spine Injuries in Major League Baseball Players

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Epidemiology, Treatment, and Prevention of Lumbar Spine Injuries in Major League Baseball Players A Review Paper Epidemiology, Treatment, and Prevention of Lumbar Spine Injuries in Major League Baseball Players Christopher L. Camp, MD, Matthew S. Conti, BS, Terrance Sgroi, PT, Frank P. Cammisa, MD, and Joshua S. Dines, MD resulted in a mean of 1016 disabled list days per Abstract season from 1995 to 1999.1 Similarly, core and In recent years, increased attention has back injuries were responsible for 359 disabled list been paid to injuries occurring in Major designations from 2002 to 2008. This represented League Baseball (MLB) players. Although 11.7% of all injuries resulting in time out of play most of the current orthopedic literature during that time span.2 During that time, back injury regarding baseball injuries pertains to the prevalence ranked 6th highest of all possible body shoulder and elbow, lumbar spine injuries regions (out of 17), and both position players and are another common reason for time pitchers were similarly affected (7.8% and 7.4% out of play. Back and core injuries may of all injuries, respectively).2 These injuries often represent as many as 12% of all injuries result in a significant time out of play and can have a that result in time out of play from MLB. tremendous impact on player This high rate of injury is likely related health. A healthy, stable, and to the critical role that the spine plays in well-functioning lumbar spine every major baseball-related movement. is a prerequisite for nearly all Linking the upper extremities to the hips baseball-related activities, and lower extremities, a healthy, strong, including pitching, throw- and stable spine and core is a prerequisite ing, batting, and running. for performance in all levels of baseball. Accordingly, even minor It has been well documented that base- lumbar spine injuries may ball players with poor spinal control and profoundly influence baseball stabilization are at increased risk for future performance. Despite this, injury. Common etiologies of lumbar inju- less is currently known about ries include stress fractures, muscle injury, the true epidemiology and annular tears with or without disc hernia- impact of back injuries in pro- tion, facet joint pain, sacroiliac joint pain, fessional baseball compared and stenosis. This review discusses the to other professional sporting epidemiology of spinal injuries in baseball. organizations.3 Special attention is paid to the role of the The most common causes spine in baseball-related activities, com- of low back pain and injury in mon injuries, tips for making the correct elite baseball players include diagnosis, treatment options, outcomes, muscle strains, stress rehabilitation, and injury prevention. fractures (spondylolysis), an- nular tears, disc herniation, stenosis, transverse process or the last 20 years, injuries resulting in time out fractures, facetogenic pain, and sacroiliac (SI) joint of play have been on the rise in Major League arthropathy.4-8 These injuries present in a variety of Baseball (MLB), and those affecting the back ways with varying symptomatology. Accordingly, F 1,2 are no exception. In the first comprehensive a thorough understanding and comprehensive ap- report on injuries in MLB players, back injuries proach to the diagnosis and treatment of these in- Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com March/April 2016 The American Journal of Orthopedics ® 137 Epidemiology, Treatment, and Prevention of Lumbar Spine Injuries in MLB Players juries is necessary. The purpose of this article is to work diligently to stabilize the entire kinetic chain. discuss the current state of lumbar spine injuries in Of all the trunk muscles (paraspinal, rectus abdom- professional baseball players. Specifically, we will inis, obliques, and glutei), the lumbar paraspinal discuss the critical role of the spine in baseball ac- muscles often work the hardest during the pitching tivities, common causes of injury, tips for making motion, demonstrating activity increases ranging the diagnosis, treatment options, outcomes, and from 100% to 400%.10 Accordingly, it is not uncom- injury prevention and rehabilitation strategies. mon for pitchers to develop SI joint or lumbar facet joint pain due to this high degree of torsional strain Role of the Spine in Baseball exerted on the low back.4 Poor lumbopelvic control The spine and core musculature are responsible has been shown to be a predictor of subsequent for positioning the head, shoulders, and upper injury, and the degree of lumbopelvic dysfunction is extremities in space over the hips and lower ex- proportional to injury severity in MLB pitchers.5 tremities. Proper maintenance of this relationship is required during all phases of throwing, pitching, Hitting running, and hitting. During these activities, the Similar to pitching, hitting involves a complex com- spine may dynamically flex, extend, rotate, and lat- bination of movements from the upper and lower erally bend as needed to keep the body balanced extremities that must be balanced by the core and with the head centered over the trunk. spine. Although numerous movements occur si- multaneously, rotational motion is primarily respon- Pitching and Throwing sible for generating power. The trunk rotates an Whether pitching from the wind-up or the stretch, average of 46 ± 9° during the swing and reaches the head begins centered over the hips and pelvis. a maximal angular acceleration of 7200 ± 2800°/ As the pitching motion progresses, the hips under- s2 just after contact.9 During this period of rapid go rotation, flexion, extension, abduction, and cir- torsion, the spine must rotate in conjunction with cumduction. While this is occurring, the shoulders the hips and shoulders to create a stable cylinder and upper truck must bend, rotate, and translate and axis of rotation. The spine and core are respon- toward home plate with the body. Just prior to front sible for synchronizing rotation to ensure that hip foot contact, trunk rotation averages 55 ± 6° with and shoulder parallelism is maintained from swing a maximal mean angular acceleration of 11,600 ± initiation to ball contact. If the body does not rotate 3100°/s2. 9 In order for the body to remain balanced, as a unit, the position of the head is affected and controlled, and synchronized throughout this deliv- the batter’s ability to see the ball may be compro- ery, the lumbar spine and core musculature must mised. Additionally, if delivery of the shoulders lags too far behind that of the hips, the position of the hands Table. Common Lumbar Injuries in Baseball (and bat) in space is adversely Etiology Typical Features affected. The entire kinetic chain must remain balanced, Stress fracture/ Common in athletes undergoing repetitive back extension coordinated, precisely timed, spondylolysis Present in up to one-third of athletes with low back pain and standardized throughout Best diagnosed with bone scan the entire swing from initial Muscle injury Generally follows acute, inciting event trigger to final follow-through. May have history of prior, similar injuries The lumbar spine plays a criti- cal role in each of these steps. Annular tears/ Result from combined compressive and rotatory forces disc herniation Pain can be severe and radiating If lumbar spine mechanics If disc protrusion progresses, radicular symptoms may follow are not sound, this can have significant adverse effects on Facet joint pain Facet joints are typically injured during rotation of the extended back batting performance and may Pain often reproduced by loading facet joint (back extension) predispose hitters to injury.4 Sacroiliac joint pain Presents with deep pain localized to sacroiliac joint Often associated with ankylosing spondylitis and human leukocyte antigen B27 Common Etiologies for Spinal Injury Stenosis Often presents with slowly progressive pain +/- radicular symptoms The vast majority of baseball Athletes with congenital stenosis may be at increased risk for injury players who experience lumbar 138 The American Journal of Orthopedics ® March/April 2016 www.amjorthopedics.com C. L. Camp et al pain will have injuries that can be classified as me- lower back pain that may be accompanied by chanical back pain (ie, spondylolysis, annular tears, spasm and pain radiation into the buttock or lower facetogenic pain, SI joint arthropathy, or muscle extremities. Pain is usually worsened by valsalva, injuries) (Table). Although less likely to occur, nerve coughing, sneezing, or bearing down.4 Although entrapment or impingement syndromes (ie, disc annular tears can occur in isolation, they can also herniation, stenosis, and peripheral nerve entrap- lead to herniation of the nucleus pulposus into the ment) have been observed in professional baseball spinal canal (Figure 2). Depending on the location players. Finally, more concerning pathologies such and severity of the herniation, nerve entrapment or as infection and tumor are extremely rare, but impingement can occur. This may initially present they must not be overlooked in this high-demand as pain that radiates into the lower extremities in a patient population. dermatomal fashion. As the herniation progresses, decreased sensation and weakness may develop. Stress Fracture or Spondylolysis In young athletic patients, up to one-third of those Facet Joint Pain with low back pain may have evidence of a lumbar Facetogenic pain can occur stress fracture on bone scan.11,12 This is partic- as the result of degenerative ularly true for athletes who undergo repetitive changes, trauma, or joint in- lumbar extension and rotation, such as linemen, flammation. Facet injury typ- gymnasts, wrestlers, weight lifters, and baseball ically occurs during rotation players.4,13 Although the majority of lumbar stress while the back is extended.4 fractures occur at the pars interarticularis, they can This results in localized pain occur in the pedicle or articular process (Figure and tenderness that can be 1). Most spondylolytic lesions do not progress to reproduced by loading the spondylolisthesis, especially once patients reach facet joint (lumbar exten- skeletal maturity.
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