Clinical Review

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

Am J Orthop. 2016 March;45(3):137-143

In recent years, increased attention has been paid to injuries occurring in Major League Baseball (MLB) players. Although most of the current orthopedic literature regarding baseball injuries pertains to the shoulder and elbow, lumbar spine injuries are another common reason for time out of play. Back and core injuries may represent as many as 12% of all injuries that result in time out of play from MLB. This high rate of injury is likely related to the critical role that the spine plays in every major baseball-related movement. Linking the upper extremities to the hips and lower extremities, a healthy, strong, and stable spine and core is a prerequisite for performance in all levels of baseball. It has been well documented that baseball players with poor spinal control and stabilization are at increased risk for future injury. Common etiologies of lumbar injuries include stress fractures, muscle injury, annular tears with or without disc herniation, facet joint pain, sacroiliac joint pain, and stenosis. This review discusses the epidemiology of spinal injuries in baseball. Special attention is paid to the role of the spine in baseball-related activities, common injuries, tips for making the correct diagnosis, treatment options, outcomes, rehabilitation, and injury prevention.

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References

1. Conte S, Requa RK, Garrick JG. Disability days in major league baseball. Am J Sports Med. 2001;29(4):431-436.

2. Posner M, Cameron KL, Wolf JM, Belmont PJ, Owens BD. Epidemiology of Major League Baseball injuries. Am J Sports Med. 2011;39(8):1676-1680.

3. Makhni EC, Buza JA, Byram I, Ahmad CS. Sports reporting: a comprehensive review of the medical literature regarding North American professional sports. Phys Sportsmed. 2014;42(2):154-162.

4. Watkins RG III, Watkins RG IV. Chapter 36: Lumbar injuries. In: Sports Medicine of Baseball. Dines JS, Altchek DW, Andrews JR, ElAttrache NS, Wilk KE, Yocum LA, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2012; 383-398.

5. Chaudhari AMW, McKenzie CS, Pan X, Oñate JA. Lumbopelvic control and days missed because of injury in professional baseball pitchers. Am J Sports Med. 2014;42(11):2734-2740.

6. Earhart JS, Roberts D, Roc G, Gryzlo S, Hsu W. Effects of lumbar disk herniation on the careers of professional baseball players. Orthopedics. 2012;35(1):43-49.

7. Hamid KS, Nwachukwu BU, Hsu E, Edgerton CA, Hobson DR, Lang JE. Orthopedic resident work-shift analysis: Are we making the best use of resident work hours? J Surg Educ. 2014;71(2):205-210.

8. Nair R, Kahlenberg CA, Hsu WK. Outcomes of lumbar discectomy in elite athletes: the need for high-level evidence. Clin Orthop Relat Res. 2015;473(6):1971-1977.

9. Fleisig GS, Hsu WK, Fortenbaugh D, Cordover A, Press JM. Trunk axial rotation in baseball pitching and batting. Sports Biomech. 2013;12(4):324-333.

10. Watkins RG, Dennis S, Dillin WH, et al. Dynamic EMG analysis of torque transfer in professional baseball pitchers. Spine (Phila Pa 1976). 1989;14(4):404-408.

11. Micheli LJ. Back injuries in gymnastics. Clin Sports Med. 1985;4(1):85-93.

12. Papanicolaou N, Wilkinson RH, Emans JB, Treves S, Micheli LJ. Bone scintigraphy and radiography in young athletes with low back pain. AJR Am J Roentgenol. 1985;145(5):1039-1044.

13. Elliott S, Hutson MA, Wastie ML. Bone scintigraphy in the assessment of spondylolysis in patients attending a sports injury clinic. Clin Radiol. 1988;39(3):269-272.

14. Kubiak EN, Moskovich R, Errico TJ, Di Cesare PE. Orthopaedic management of ankylosing spondylitis. J Am Acad Orthop Surg. 2005;13(4):267-278.

15. Miller KJ. Physical assessment of lower extremity radiculopathy and sciatica. J Chiropr Med. 2007;6(2):75-82.

16. Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology. 1991;180(2):509-512.

17. Radcliff KE, Kalantar SB, Reitman CA. Surgical management of spondylolysis and spondylolisthesis in athletes: indications and return to play. Curr Sports Med Rep. 8(1):35-40.

18. Morita T, Ikata T, Katoh S, Miyake R. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br. 1995;77(4):620-625.

19. Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. J Bone Joint Surg Am. 2008;90(3):656-671.

20. Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop. 2009;29(2):146-156.

21. Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. 2004;86-A(2):382-396.

22. Dreisinger TE, Nelson B. Management of back pain in athletes. Sports Med. 1996;21(4):313-320.

23. Hsu WK, McCarthy KJ, Savage JW, et al. The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Spine J. 2011;11(3):180-186.

24. Dreyfuss PH, Dreyer SJ; NASS. Lumbar zygapophysial (facet) joint injections. Spine J. 2003;3(3 Suppl):50S-59S.

25. Slipman CW, Bhat AL, Gilchrist R V, Issac Z, Chou L, Lenrow DA. A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain. Spine J. 2003;3(4):310-316.

26. Prather H. Sacroiliac joint pain: practical management. Clin J Sport Med. 2003;13(4):252-255.

27. Graw BP, Wiesel SW. Low back pain in the aging athlete. Sports Med Arthrosc. 2008;16(1):39-46.

28. Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. Handb Clin Neurol. 2014;119:541-549.

29. Frank C, Kobesova A, Kolar P. Dynamic neuromuscular stabilization & sports rehabilitation. Int J Sports Phys Ther. 2013;8(1):62-73.

30. Cholewicki J, Juluru K, McGill SM. Intra-abdominal pressure mechanism for stabilizing the lumbar spine. J Biomech. 1999;32(1):13-17.

31. McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol. 2003;13(4):353-359.

32. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball: 1991-2010. Am J Sports Med. 2012;40(3):650-656.

33. Chaudhari AMW, McKenzie CS, Borchers JR, Best TM. Lumbopelvic control and pitching performance of professional baseball pitchers. J Strength Cond Res. 2011;25(8):2127-2132.

For the last 20 years, injuries resulting in time out of play have been on the rise in Major League Baseball (MLB), and those affecting the back are no exception.^1,2 In the first comprehensive report on injuries in MLB players, back injuries resulted in a mean of 1016 disabled list days per season from 1995 to 1999.¹ Similarly, core and back injuries were responsible for 359 disabled list designations from 2002 to 2008. This represented 11.7% of all injuries resulting in time out of play during that time span.² During that time, back injury prevalence ranked 6th highest of all possible body regions (out of 17), and both position players and pitchers were similarly affected (7.8% and 7.4% of all injuries, respectively).² These injuries often result in a significant time out of play and can have a tremendous impact on player health. A healthy, stable, and well-functioning lumbar spine is a prerequisite for nearly all baseball-related activities, including pitching, throwing, batting, and running. Accordingly, even minor lumbar spine injuries may profoundly influence baseball performance. Despite this, less is currently known about the true epidemiology and impact of back injuries in professional baseball compared to other professional sporting organizations.³

The most common causes of low back pain and injury in elite baseball players include muscle strains, stress fractures (spondylolysis), annular tears, disc herniation, stenosis, transverse process fractures, facetogenic pain, and sacroiliac (SI) joint arthropathy.^4-8 These injuries present in a variety of ways with varying symptomatology. Accordingly, a thorough understanding and comprehensive approach to the diagnosis and treatment of these injuries is necessary. The purpose of this article is to discuss the current state of lumbar spine injuries in professional baseball players. Specifically, we will discuss the critical role of the spine in baseball activities, common causes of injury, tips for making the diagnosis, treatment options, outcomes, and injury prevention and rehabilitation strategies.

Role of the Spine in Baseball

The spine and core musculature are responsible for positioning the head, shoulders, and upper extremities in space over the hips and lower extremities. Proper maintenance of this relationship is required during all phases of throwing, pitching, running, and hitting. During these activities, the spine may dynamically flex, extend, rotate, and laterally bend as needed to keep the body balanced with the head centered over the trunk.

Pitching and Throwing

Whether pitching from the wind-up or the stretch, the head begins centered over the hips and pelvis. As the pitching motion progresses, the hips undergo rotation, flexion, extension, abduction, and circumduction. While this is occurring, the shoulders and upper truck must bend, rotate, and translate toward home plate with the body. Just prior to front foot contact, trunk rotation averages 55 ± 6° with a maximal mean angular acceleration of 11,600 ± 3100°/s².⁹In order for the body to remain balanced, controlled, and synchronized throughout this delivery, the lumbar spine and core musculature must work diligently to stabilize the entire kinetic chain. Of all the trunk muscles (paraspinal, rectus abdominis, obliques, and glutei), the lumbar paraspinal muscles often work the hardest during the pitching motion, demonstrating activity increases ranging from 100% to 400%.¹⁰ Accordingly, it is not uncommon for pitchers to develop SI joint or lumbar facet joint pain due to this high degree of torsional strain exerted on the low back.⁴ Poor lumbopelvic control has been shown to be a predictor of subsequent injury, and the degree of lumbopelvic dysfunction is proportional to injury severity in MLB pitchers.⁵

Hitting

Similar to pitching, hitting involves a complex combination of movements from the upper and lower extremities that must be balanced by the core and spine. Although numerous movements occur simultaneously, rotational motion is primarily responsible for generating power. The trunk rotates an average of 46 ± 9° during the swing and reaches a maximal angular acceleration of 7200 ± 2800°/s²just after contact.⁹ During this period of rapid torsion, the spine must rotate in conjunction with the hips and shoulders to create a stable cylinder and axis of rotation. The spine and core are responsible for synchronizing rotation to ensure that hip and shoulder parallelism is maintained from swing initiation to ball contact. If the body does not rotate as a unit, the position of the head is affected and the batter’s ability to see the ball may be compromised. Additionally, if delivery of the shoulders lags too far behind that of the hips, the position of the hands (and bat) in space is adversely affected. The entire kinetic chain must remain balanced, coordinated, precisely timed, and standardized throughout the entire swing from initial trigger to final follow-through. The lumbar spine plays a critical role in each of these steps. If lumbar spine mechanics are not sound, this can have significant adverse effects on batting performance and may predispose hitters to injury.⁴