Musculoskeletal condition and adaptation as the predictors of low back pain in sports games

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^{1Domenius University in Bratislava}

Faculty of Physical Education and Sports, department of Sports Games

²Comenius University in Bratislava

Department of Sport Educology and Sport Humanities

Musculoskeletal condition and adaptation as the predictors of low back pain in sports games

Ludmila Zapletalova¹, Gabriela Luptakova²

Braticlava, Slovakia

Abstracts

Objective. The objective of this systematic review of literature was to identify if the musculoskeletal condition and disorders caused by adaptation on specific movement patterns in sports games is as risk factors of low back pain (LBP).

Data sources. A comprehensive search of articles published in the last 20 years was conducted in four databases (PubMed®, Google Scholar, Web of Science).

Different combinations of keywords such as LBP, muscle imbalance, muscle strength, muscle endurance, musculoskeletal system and sport game were used, applying the Boolean operators.

After establishing the criteria of selection, 9 studies of 52 initially identified were analyzed.

Results. From the viewpoint of musculoskeletal condition and its functional adaptation as the possible risk factors of LBP in the sports games it is suggested that the musculoskeletal system, its functional disorders, endurance and maximal strength of the trunk muscles are not risk factors of LBP in every aspect.

The risk factors appear to be muscle imbalances combined with functional asymmetry of pelvic and its asymmetrical rotation as a result of unilateral overloading, as well as the low maximal lumbar flexion.

Low level of endurance of trunk and core muscles cannot be uniquely identified as a risk factor of LBP.

Similarly, the maximal isometric strength of trunk muscles do not act as a risk factor of LBP, either.

Conclusion. A detailed comparison of data between the sports games, within game, sex or age was not possible.

Further research is necessary. Nevertheless, based on the results of this review, it is obvious that in sports games LBP is a consequence of functional and structural changes of pelvic and related muscles.

There is less evidence for endurance and maximal isometric strength of trunk muscles to be a risk factor of LBP.

Key words: low back pain, musculoskeletal condition, adaptation, sports games.

Анотація

Умови адаптації опорно-рухового апарату як предика- торів виникнення болю в попереково-крижовому відділі в спортивних іграх

Людмила Заплеталова, Габріела Луптакова

Мета дослідження - з'ясувати, чи розлади опорно-рухового апарату, спричинені адаптацією до конкретних рухових вправ у спортивних іграх, є факторами ризику виникнення болю в попереку (LBP).

Джерела збору даних. Опрацьовано наукові статті, опубліковані за останні 20 років у чотирьох базах даних (PubMed®, Google Scholar, Web of Science). Застосовано різні комбінації ключових слів, такі як LBP, дисбаланс м'язів, сила м'язів, витривалість м'язів, опорно-руховий апарат і спортивна гра. Після визначення критеріїв відбору проаналізовано дев'ять із 52 наявних досліджень.

Результати дослідження. Із погляду стану опорно-рухового апарату та його функціональної адаптації як можливих факторів виникнення ризику LBR у спортивних іграх можемо вважати, що опорно-руховий апарат, його функціональні порушення, витривалість і максимальна сила м 'язів тулуба не є чинниками ризику виникнення LBR.

Натомість виявлено такі фактори ризику, як дисбаланс м'язів у поєднанні з функціональною асиметрією таза та його асиметричним обертанням у результаті одностороннього перевантаження, а також максимально сильним згинанням у попереку.

Низький рівень витривалості м'язів тулуба й основних м'язів однозначно не є визначальним фактором ризику LBR.

Аналогічно, що максимальна ізометрична сила м'язів тулуба не виступає фактором ризику LBR.

Висновки. Не вдалося детально зібрати дані про фізичний стан між спортивною грою, а також під час гри, зокрема порівняти їх за статтю чи віком.

Перспективи дослідження. Отже, виходячи з результатів нашого дослідження, бачимо, що очевидним є той факт, що в спортивних іграх LBR є наслідком функціональних і структурних змін тазових та супутніх м 'язів. Менш доказовим залишається той факт, що витривалість і максимальна ізометрична сила м'язів тулуба є фактором ризику LBR.

Ключові слова: біль у попереково-крижовому відділі, стан опорно-рухового апарату, адаптація, спортивні ігри.

Аннотация

Условия адаптации опорно-двигательного аппарата как предикторов возникновения боли в пояснично-крестцовом отделе в спортивных играх

Людмила Заплеталова, Габриэла Луптакова

Цель исследования - выяснить, являются ли факторами риска возникновения боли в пояснице (ЬВР) расстройства опорно-двигательного аппарата, вызванные адаптацией к конкретным двигательным упражнениям в спортивных играх.

Источники сбора данных. Обработано научные статьи, опубликованные за последние 20 лет в четырех базах данных (PubMed®, Google Scholar, Web of Science).

Применялись различные комбинации ключевых слов, такие как LBP, дисбаланс мышц, сила мышц, выносливость мышц, опорно - двигательный аппарат и спортивная игра. После определения критериев отбора анализировались девять с 52 имеющихся исследований.

Результаты исследования. С точки зрения состояния опорно-двигательного аппарата и его функциональной адаптации как возможных факторов возникновения риска LBR в спортивных играх можем считать, что опорно-двигательный аппарат, его функциональные нарушения, выносливость и максимальная сила мышц туловища не являются факторами риска возникновения LBR.

Зато наблюдаются следующие факторы риска, такие как дисбаланс мышц в сочетании с функциональной асимметрией таза и его асимметричным вращением в результате односторонней перегрузки, а также максимально сильным сгибанием в пояснице.

Низкий уровень выносливости мышц туловища и основных мышц однозначно не является определяющим фактором риска LBR. Аналогично максимальная изометрическая сила мышц туловища не выступает фактором риска LBR.

Выводы. Не удалось детально собрать данные о физическом состоянии между спортивной игрой, а также во время игры, в частности сравнить их по полу или возрасту.

Перспективы исследования. Таким образом, исходя из результатов нашего исследования, очевидным является тот факт, что в спортивных играх LBR является следствием функциональных и структурных изменений тазовых и сопут - ствующих мышц. Менее доказательным остается тот факт, что выносливость и максимальная изометрическая сила мышц туловища являются факторами риска LBR.

Ключевые слова: боль в пояснично-крестцовом отделе, состояние опорно-двигательного аппарата, адаптация, спортивные игры.

Introduction

Although sedentary lifestyle is considered to be one of the risk factors of back pain, on the contrary, also an extreme training load with a lack of sufficient regeneration might be the cause.

The back pain is a common problem in sports, a low back pain (LBP) especially. The LBP might be caused by the acute injuries as well as the overuse injuries.

However, the fact that the long lasting demands of sport training are connected with a higher prevalence of LBP is not unequivocal.

The research in this area is ambiguous. Some results confirm the correlation, but the others dispute it [1; 2; 3].

Regarding young athletes, it is well known that the spine abnormalities and LBP occur around 13 years of age. Prevalence of LBP increases throughout the growth spurt. The prevalence of repetitive LBP in adolescents occurs most often between 20 to 30 %, depending on the type of sport.

The cause might be also found in cases such as acute and overuse injuries and repetitive unilateral overload of soft and bony tissues, which is very often underestimated [4; 5].

Certain predispositions include musculoskeletal imbalance caused by imbalance between bone and ligaments growth, decreased flexibility, structural changes of spine and load extremes, although this has not always been confirmed [6].

The causes of back pain are mostly multifactorial. Even risk factors in sports games related to back pain, mainly LBP, represent a very wide range. The fundamental division is to internal and external factors (table 1).

Table 1

Fundamental Risk Factors of Back Pain in Sports Games [Modified by 7, 8].

However the range of both internal and external risk factors is much wider. Other familiar internal risk factors include body height which is significantly above-average in a number of sports games, pain occurred in the past, acute injuries of back and lower limbs, muscular imbalance, pelvic asymmetry, spine degeneration and flexibility, untreated microtrauma and back injuries, poor strength, muscular endurance of trunk and core.

Among other external factors belong e.g. history of back pain in the family, incorrect technique utilized, etc.

Due to a multifactoriality, it is often difficult to identify the risk factors without a comprehensive diagnosis.

Methods. A comprehensive search of articles published in the last 20 years was conducted in four databases (PubMed®, Google Scholar, Web of Science and Scopus). Two independent researchers undertook a computerized research regarding the specific functional adaptation and musculoskeletal disorders in sports games with high prevalence of LBP. Different combinations of keywords LBP, muscle imbalance, muscle strength, muscle endurance, musculoskeletal disorders and the names of particular sports games (tennis, golf, volleyball, beach volleyball, handball, ice hockey, field hockey, floorball etc.) with Boolean operators and, or were used. sports game endurance muscle

The including criteria were full text in a scientific journal, study in English, and age between 13 and 40 years. Exclusive criteria were abstracts, other sports than sports games, other overuse pains. After establishing the criteria of selection 9 studies of 52 initially identified were analyzed.

Results

The sports games in association with a nature of the training are connected to specific functional adaptation and musculoskeletal disorders due to demands on musculoskeletal system, what might serve as a prerequisite for the overuse injuries and back pain syndromes [9; 6; 10; 11; 12; 13; 14].

As the most common functional parameters representing risk factors of back pain are analysed hip muscle imbalance together with, inter alia, pelvic asymmetry and lower flexibility of hip joints, spine flexibility and muscle endurance of trunk and core (table 2).

Table 2

Musculoskeletal Condition and Adaptation as the Predictors of Low Back Pain in Sports Games

Pelvic Skeletal Asymmetry

Pelvic muscle imbalances are produced by imbalance between muscles which control the pelvic inclination or the pelvis in the frontal plane (pelvic inclination). Pelvic asymmetry has been thought to alter the body mechanics, what leads to overload of bone and soft tissues. Such a danger occurs particularly in unilateral sports combined with increased spinal flexion and rotation. These include almost all sports games to a less or greater extent. This fact has been supported for example by the research results investigating the groups of female field hockey players, ice hockey players and speed-skaters in comparison with the active university women and with athletes of bilateral sports (triathlon, cross-country running, single skull rowing). Significant declines in structural asymmetry have been found in 15 unilateral athletes, 4 bilateral athletes and 6 active university women, out of 20 participants in each group. Unilateral overloading appears to be a significant predictor of presumable functional pelvic asymmetry. There is some evidence to suggest that asymmetric body movement patterns are linked to unilateral sports and pelvic asymmetry [15].

Hip Mobility Deficits

Equally, hip internal rotation deficits and lumbar range of motion deficits in athletes are considered to be a factor which increases the risk of back injuries and influences sport performance.

The reason is that the deficits in hip motion may result in negative musculoskeletal adaptation. Repetitive load and pivoting at the dominant hip, the cycle of microtrauma and scar formation might lead to capsular formation and reduction in range of motion. As a result, these may cause the overuse injuries, LBP and, eventually, poor performance [16]. This has been confirmed by the research of the aforementioned author in a group of tennis players. Deficits in lumbar extension significantly correlated with LBP. The deficit in hip internal rotation in the lead hip comparing to the non-lead hip was in the symptomatic group by 4,4°higher than in the asymptomatic group. Moreover, the symptomatic group showed smaller distance about by 5 cm between the knee and the mat on the preferred body side than on the non-preferred side of the body, when compared to the asymptomatic tennis players. Similarly, the difference in FABERE's distance comparing the lead hip and non-lead hip was smaller by 5 cm in the symptomatic group than in the asymptomatic. Significant differences were also found in lumbar extension to the symptomatic tennis players' disadvantage, but not in lumbar flexion, on the contrary. It suggests that low individual physiological maximum of lumbar extension may overload the lumbar spine of the athletes that perform the extension very often, what leads to the back pain.

Similarly, the correlation between deficiency in lumbar flexion and LBP has been partially confirmed by a three-year study of young athletes. At the beginning of the intervention the limited maximal lumbar flexion served as a predictor of the LBP to a certain extent. It comprised 16 % of variability between the asymptomatic and symptomatic players [9].

Trunk and Core Muscle Strength and Endurance

Speaking of the functional condition of musculoskeletal system, trunk muscle strength, including core muscles, is considered to be another risk factor of the back pain. The core muscles play an important role in the stabilization of the peripheral joints and reduce the risk of injury during intense physical activity. The core stability enables an athlete to maximize force production while minimizing loads placed on proximal joints. Ability to stabilise the core while performing dynamic movements of extremities together with the ability to absorb the repetitive load by the trunk, play the key role in all sport performance. This is especially important during complex movements such as running, jumping, throwing and hitting or kicking for example in volleyball, handball, basketball, soccer etc. [19].

In trained athletes, it acts as a feedback mechanism shortly before the beginning of the movement of the upper and lower extremities and is the basis for the realization of motor skills. Insufficient trunk control is proposed to be a contributing factor of the nonspecific LBP [17; 18]. The research results in this field, are however, not unequivocal. It has been supported for example in the supervised core-strengthening programme emphasizing the muscles of the trunk, spine and hip extensors in NCAA Division I collegiate basketball, volleyball and soccer players with LBP. The Programme did not have fully significant impact on the decrease in prevalence of LBP in both female and male players [17]. However, the test values of core muscle endurance in collegiate athletes (basketball, volleyball, handball and soccer players) indicate that the players suffering from LBP showed significantly lower trunk muscle endurance in comparison to asymptomatic athletes [9].

On the contrary, a poor correlation between LBP and abdominal muscle thickness and cross -sectional area of multifidus has been found in young soccer players. Similarly, there was non-significant difference between hamstring tightness and isometric muscle endurance of trunk extensors and active forward lumbar flexion between LBP and non LBP athletes [20]. Despite the aforementioned findings, the multifidus size as a risk factor of back pain cannot be completely excluded. On the other hand, the study examining female university volleyball players indicates a significant decrease in multifidus cross section area (CSA) at the 5 th vertebral level in all the players throughout the season. Players with LBP showed significantly smaller multifidus CSA at the 4th vertebral level compared to players without LBP [21].

Insufficient strength endurance of the trunk muscles is of great importance in the occurrence of back pain, what has been indicated in quite a few studies. For instance, symptomatic players showed lower activation of extensor muscles, less co-contraction patterns and less abdominal endurance [22]. By contrast, the differences have not been found in maximal isometric strength of trunk muscles. When comparing trunk muscle profile in tennis players, no differences between the players with and without LBP were shown in maximal isometric strength of extensor, rotator, flexor and lateral flexor trunk muscles and lumbar spine flexibility.

In comparison to sedentary students, the tennis players showed a sport -specific profile determined by a significantly higher non-dominant lateral flexor and rotator strength than at the dominant side. That could result from the forehand and service actions which, that in righthanded players involve simultaneously left trunk rotators and lateral flexors, to generate more power [23].

Conclusion

In general, it would be unfounded to claim that the condition of musculoskeletal system in sports games acts as a risk factor of back pain, lumbar spine in particular, in all aspects. Most importantly, muscle imbalances together with functional asymmetry of pelvic and its asymmetrical rotation, which are produced by unilateral overloading, appear to be the key risk factor of back pain, as well as the low maximal lumbar flexion, particularly in association with low physiological maximum of lumbar flexion and extension.

On the other hand, the low level of strength endurance of trunk muscles, including core muscles, cannot be unambiguously considered a risk factor.

Similarly, maximal isometric strength of trunk muscles has not appeared to act as a risk factor of LBP either.

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