Common Etiologies for Spinal Injury
The vast majority of baseball players who experience lumbar pain will have injuries that can be classified as mechanical back pain (ie, spondylolysis, annular tears, facetogenic pain, SI joint arthropathy, or muscle injuries) (Table). Although less likely to occur, nerve entrapment or impingement syndromes (ie, disc herniation, stenosis, and peripheral nerve entrapment) have been observed in professional baseball players. Finally, more concerning pathologies such as infection and tumor are extremely rare, but they must not be overlooked in this high-demand patient population.
Stress Fracture or Spondylolysis
In young athletic patients, up to one-third of those with low back pain may have evidence of a lumbar stress fracture on bone scan.11,12 This is particularly true for athletes who undergo repetitive lumbar extension and rotation, such as linemen, gymnasts, wrestlers, weight lifters, and baseball players.4,13 Although the majority of lumbar stress fractures occur at the pars interarticularis, they can occur in the pedicle or articular process (Figure 1). Most spondylolytic lesions do not progress to spondylolisthesis, especially once patients reach skeletal maturity. Because the fifth lumbar vertebra represents the transition from the lumbar to the sacral spine, most stress fractures occur at L5. These typically present as localized low back pain that worsens with flexion, extension, and rotation.
Muscle Injury
One of the most common causes of low back pain in athletes is muscle strains and spasms. Because the lumbar paraspinal muscles are extremely active during throwing and hitting,10 they are particularly susceptible to injury. This is particularly true in deconditioned athletes or those who report to spring training having not adequately maintained strength and flexibility through the off-season.4,5 These injuries typically present in an acute fashion with an obvious inciting incident. Players may have a history of similar muscle injuries in the past. On examination, they tend to have difficulty maintaining normal posture or ranging the spine through a full arc of motion. Localized, superficial tenderness to palpation in the injured muscle is a key component of the diagnosis.
Annular Tears and Disc Herniation
These injuries typically occur as the result of a combination of compressive and rotary forces on the lumbar spine that overcome the ability of the annulus fibrosus to resist hoop stresses. Patients with annular tears typically present with severe lower back pain that may be accompanied by spasm and pain radiation into the buttock or lower extremities. Pain is usually worsened by valsalva, coughing, sneezing, or bearing down.4 Although annular tears can occur in isolation, they can also lead to herniation of the nucleus pulposus into the spinal canal (Figure 2). Depending on the location and severity of the herniation, nerve entrapment or impingement can occur. This may initially present as pain that radiates into the lower extremities in a dermatomal fashion. As the herniation progresses, decreased sensation and weakness may develop.
Facet Joint Pain
Facetogenic pain can occur as the result of degenerative changes, trauma, or joint inflammation. Facet injury typically occurs during rotation while the back is extended.4 This results in localized pain and tenderness that can be reproduced by loading the facet joint (lumbar extension) during the examination, and patients will often demonstrate discomfort and altered motion when extending the flexed back.
Sacroiliac Joint Pain
Although pain in the region of the SI joint is very common, much of this may actually be referred from more centrally located neuromotion segments.4 SI joint pathology can occur as a result of trauma, degeneration, or inflammatory processes as is seen in ankylosing spondylitis (AS). Patients with AS typically present with a gradual onset of progressive stiffness and pain in the low back and hips that is worse in the morning or following periods of inactivity. It is most common in Caucasian males in their second to fourth decades.14 Although 80% to 95% of patients with AS will test positive for human leukocyte antigen B27 (HLA-B27), it is important to note that the vast majority of people with HLA-B27 do not go on to develop AS.14 Regardless of the cause, SI joint pain can be very debilitating and negatively impact all baseball-related activities.
Stenosis
Lumbar stenosis may develop from arthritic changes, disc protrusion, facet hypertrophy, or ligament ossification. In this young, athletic population, congenital stenosis should also be a consideration. Patients with congenital stenosis at baseline are at increased risk for developing neurologic symptoms from disc protrusion or other acquired spinal pathology. Lumbar stenosis generally manifests as a gradual onset of progressive low back pain with radicular symptoms or neurogenic claudication.4