Muscle Injury
Management of lumbar sprains and strains typically includes restricting painful postures and a rehabilitation program that focuses on core strengthening within a pain-free arc of motion.21 Because acute injuries typically resolve quickly and spontaneously, a short interval of decreased activity, icing, NSAIDs, and stretching followed by focused strength training is appropriate before return to sports activity.22
Annular Tears and Disc Herniation
Initial management of baseball players with acute lumbar disc herniation and/or annular tears consists of rest for up to 5 days followed by physical therapy and NSAIDs, Medrol Dose pak, or epidural injections.4 Professional baseball players return to play at high rates following a herniated lumbar disc.6 Earhart and colleagues6 found that 97.1% of players returned to play at an average time of 6.6 months from the time of injury. When stratified by position, all pitchers (29 of 29) returned to competitive play after operative or nonoperative management, while 38 of 40 hitters returned.6 The average career length after lumbar disc herniation in the professional baseball player is between 4.1 and 5.3 years or between 256 and 471 games.6,23 Other work has suggested that players undergoing operative treatment for lumbar herniation had shorter career lengths; however, patients in the operative group tended to be older at the time of injury.23
Emphasis should be placed on nonoperative management of baseball players with disc pathology except in cases of cauda equina syndrome.4 Hitters and pitchers who require surgery have demonstrated decreased 1-year and 3-year postoperative statistical performance compared to preinjury levels.6 No significant changes in any performance statistic were seen in baseball following nonoperative management.6 Consequently, indications for surgery in the baseball player with lumbar disc pathology includes cauda equina syndrome, progressive neurologic deficit, sufficient morbidity, failure of conservative care, a lesion that can be corrected safely with surgery, and the ability for the patient to comply with a comprehensive postoperative rehabilitation program.4 Operative treatment typically consists of a lumbar microdiscectomy and/or laminotomy. 4,6
Facet Joint Pain
The mainstay of therapy in patients with facet joint pain consists of analgesia and a trunk stabilization program.24 Lumbar zygapophysial joint injections and radiofrequency denervation can be considered if the patient fails 4 weeks of directed conservative treatment.24,25 Injections may be useful in select patients; however, the literature supporting the use of lumbar facet joint injections or radiofrequency denervation for facetogenic pain is limited.24,25
Sacroiliac Joint Pain
Acute injury of the SI joint can be treated with NSAIDs, icing, and relative rest.26 Mobilization of the SI joint in addition to correcting any asymmetries in muscle length or stiffness should be started and progressed as soon as tolerated within a pain-free range of motion.26 Rehabilitation should correct biomechanical deficits and maladaptation with a special focus on agonist and antagonist muscle groups across the sacrum and ilium.26 Treatment of AS in the athlete should emphasize symptom control, as there is no definite treatment. For patients with AS, other long-term therapeutic options include sulfasalazine, methotrexate, thalidomide, and anti-tumor necrosis factor therapies.14
Stenosis
Lumbar spinal stenosis, whether congenital or acquired, should initially be managed conservatively.27 Although they do not alter the progression of the disease, epidural steroids and local injections may temporarily decrease symptoms in approximately 40% of cases.27 Those who fail conservative therapy after 3 months may be candidates for surgical decompression and/or fusion.27,28 However, surgical treatment for lumbar spinal stenosis in elite baseball players has not been thoroughly studied, so the long-term prognosis is not well documented.27
Rehabilitation and Prevention of Injuries
After an appropriate diagnosis has been made, a structured rehabilitation process should commence. During rehabilitation, it is of primary importance that deep core stabilization is established. As an initial step in this process, athletes are trained to initiate deep core stabilization with breathing techniques in a static, supine position.29 Proper diaphragm activation with co-contractions of the transverse abdominis (TA) and pelvic floor has been shown to increase lumbar spine stability.30 This will allow for an increase in intra-abdominal pressure (IAP) and improved stabilization of the lumbar spine, creating a muscular cylinder between the bottom of the rib cage and top of the pelvis. These activities are initiated in the supine position but are soon advanced as upper and lower extremity movement against resistance is added. It is important to make sure IAP and contraction of the TA is maintained throughout this sequence of progression.
Once deep core stabilization has been established, athletes are progressed to global muscle training and kinetic linking in all 3 planes of movement. This is an important phase, as lumbar stability is a result of coordinated muscle activation involving many muscles.31 This program progresses from supine breathing exercises to a modified side bridge position to enhance core activation along with frontal plane stability. Next, athletes are progressed to a half kneeling position and then on to standing. Rotational activities are introduced starting with isometric holds progressing to chops/lifts and rotational medicine ball toss. During these tasks, focus should be on quality of movement and maintenance of core activation. Endurance of these muscles should be trained during this process. Appropriate pain-free and safe cardiovascular exercise, such as walking, biking, swimming, and jogging, should be performed throughout each stage in the rehabilitation process. Activities should be halted with any increase in pain. At the completion of the rehabilitation process, it is important to observe the athlete while performing sport-specific tasks. Spinal stabilization must be translational and monitored by observing maintenance of the “cylinder” from the training room to sports specific movements.