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ORIGINAL
Accurate diagnosis of low back pain in adult elite athletes
Kazuta Yamashita, Kosuke Sugiura, Hiroaki Manabe, Yoshihiro Ishihama, Fumitake Tezuka, Yoichiro Takata,Toshinori Sakai, Toru Maeda, and Koichi Sairyo
Department of Orthopedics, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan

Abstract : Background : There is few reports evaluated accurately the pain generator of low back pain in elite
athletes. The purpose of this report was to show case series and to investigate the cause of unidentified low backpain of elite athletes. Methods : Twenty-three adult elite athletes consulted our sports spine clinic to seek a second opinion for low back pain between April 2013 and March 2016. Their cause of low back pain had not been
identified by nearby doctor. Spine surgeons had diagnosed using diagnostic injection and STIR-MRI and the final
diagnosis made by the spine surgeon were collected. Results : The mean age of 23 patients (16 male, 7 female) was
30.4 years. The most common sport played was baseball. The final diagnosis made by a spine surgeon was as follows : disc related low back pain (n = 12), facet joint arthritis (n = 5), vertebral endplate injury (n = 4), early-stage
lumbar spondylolysis (n = 1), supraspinous ligament injury (n = 1). Conclusions : A thorough medical interview,
careful physical examination, appropriate diagnostic imaging, and injection block examination can effectively
identify the cause of low back pain. J. Med. Invest. 66 : 252-257, August, 2019
Keywords : low back pain, diagnosis, athlete, elite athlete, MRIINTRODUCTION
Low back pain (LBP) is common complaint in total population(1), but also among athletes (2, 3). A lot of studies have reported
that the prevalence of LBP is much higher in athletes compared
to non-athletes (4, 5, 6). It was reported that more than 30%
of athletes experience LBP during their carriers (7). Also in
elite athletes, LBP is one of the most common causes of missed
playing time. About 75% of elite athletes have one or more episodes of LBP (8, 9). It is said that the pathology most commonly
associated with LBP in athletes is degenerative disc disease, discherniation, and spondylolysis/spondylolisthesis (10).
Generally, it is not relatively difficult to diagnose LBP of
athletes as disc herniation and spondylolysis/spondylolisthesis.
However, some of them are in trouble with LBP the cause isunknown. The pain source may be often overlooked, and thenit may be concern with their athletic carrier for elite athletes.
Especially for elite athletes, it is important to specify what thecause of LBP is.
To our knowledge, there is little reports evaluated accurately
the pain generator of LBP in elite athletes. The purpose of thisreport was to show case series and to investigate the cause ofunidentified LBP of elite athletes.

MATERIALS AND METHODS
We experienced 23 adult elite athletes (16 male, 7 female) who
consulted our sports spine clinic seeking a second opinion forunidentified LBP between April 2013 and Mar 2016. Data onage, gender, type of sport played were collected retrospectively
from medical records. Experienced spine surgeons had diagnosed
these patients through detailed medical interview, careful physicalReceived for publication October 9, 2018 ; accepted March 18, 2019.
Address correspondence and reprint requests to Kazuta Yamashita,
MD, Department of orthopedics, Institute of Health Biosciences,
Tokushima University Graduate School, Tokushima, Japan, 3-18-15
Kuramoto, Tokushima 770-8503, Japan and Fax : + 81-88-633-0178.

examination, appropriate diagnostic imaging. As diagnostic imaging, we had taken plain X-ray in lumbar extension and flexion.
And reconstructed sagittal, axial, and coronal computed tomography (CT) images were taken as needed. We also routinely performed T1-and T2-weighted magnetic resonance imaging (MRI)and short tau inversion recovery (STIR) imaging. STIR-MRI isparticularly useful for detecting bone marrow edema (11). When
images did not show obvious evidence of pathology, we performed
diagnostic facet joint and disc block examination. And then, thefinal diagnosis was collected.

RESULTS
The mean age of the subjects was 30.4 ± 8.5 (20–54) years.
The most common sport played was baseball. The final diagnosis made by a spine surgeon was as follows : disc related LBP(n = 12), facet joint arthritis (n = 5), vertebral endplate injury(n = 4), early-stage lumbar spondylolysis (n = 1), supraspinous
ligament injury (n = 1). Table 1 shows the details of all cases.

CASES
We show 3 cases that were identified their pain source as disc
related LBP, facet joint arthritis, vertebral endplate injury.

Case 1 : Disc related LBP
A 34-year old man, professional baseball player (outfielder),had felt sharp low back pain while playing baseball for several
years. The pain would worsen during lumbar anteflexion. He
had consulted several hospitals, and all doctors had diagnosed
the deterioration of L5 spondylolysis. They had told him that hehad to be performed operation to disappear his low back pain.
Finally, he had consulted to our hospital. STIR-MRI revealed
central lumbar disc herniation at the level of L3/4 and L4/5 (Fig1). And high signal intensity zone (HIZ) had clearly appearedat posterior site of L4/5 disc. We had performed discography atthese levels, and the strong replicative pain had occurred in L4/5
discography. The pain disappeared temporarily just after disc

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253

Table 1. Details of all cases
Case

Gender

Age

1

Male

34

2

Female

33

3

Male

34

4

Male

5

SportsLevel

final diagnosis

BaseballProfessional

disc related low back pain

Track field (hammer throw)

Olympic-level

facet joint arthritis

Combined combative sports

Professionalvertebral endplate injury (Type 1 Modic change)

20

Ice skate (short track)

Top amateurvertebral endplate injury (Type 1 Modic change)

Male

22

Ice skate (short track)

Top amateur

facet joint arthritis

6

Male

54

Golf

Professionalvertebral endplate injury (Type 1 Modic change)

7

Female21

Track field (hurdle)

Olympic-levelspondylolysis (early stage)

8

Female26

Swimming (diving)

Olympic-level

disc related low back pain

9

Female25

Ski (mogul)

Olympic-level

disc related low back pain

10

Male

33

BaseballTop amateur

disc related low back pain

11

Male

29

BaseballTop amateur

disc related low back pain

12

Female30

Wrestling

Professionalvertebral endplate injury (Type 1 Modic change)

13

Male

40

BaseballProfessional

facet joint arthritis

14

Male

24

BaseballProfessional

disc related low back pain

15

Male

23

BaseballProfessional

disc related low back pain

16

Female48

Dance (tap dance)

Professional

supraspinous ligament injury

17

Male

29

BaseballTop amateur

disc related low back pain

18

Male

34

BaseballProfessional

disc related low back pain

19

Male

35

BaseballProfessional

disc related low back pain

20

Male

27

BaseballProfessional

facet joint arthritis

21

Male

36

BaseballProfessional

disc related low back pain

22

Male

22

BaseballProfessional

disc related low back pain

23

Female21

SoftballTop amateur

facet joint arthritis

Figure 1. Axial view of STIR-MRI in case 1 (disc related LBP)HIZ had clearly appeared at posterior site of L4/5 disc (arrow).

injection using 1% lidocaine. And then, we could diagnose thatthe cause of his LBP was disc injury at L4/5. He underwent fullendoscopic lumbar discectomy and thermal annuloplasty to HIZ
area of L4/5 under local anesthesia (Fig 2). After surgery, his
suffering LBP disappeared completely. Rehabilitation containedof core muscle training and lower leg stretching had done. Finally, he had returned professional baseball game with his full
activity level.

Figure 2. Percutaneous endoscopic surgery (Case 1)

2-a. Percutaneous endoscopic lumbar discectomy and thermal annuloplasty to HIZ area of L4/5 was performed.
2-b. The bipolar system was used in thermal annuloplasty.
2-c. The blue stained herniation nucleus pulposus was removed andcauterized.

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K. Yamashita, et al. Accurate diagnosis of low back pain

Case 2 : Facet joint arthritis
A 33-year-old female hammer throw athlete presented withseveral years history of LBP. First the pain occurred only while
playing hammer throwing. She had consulted several hospitals,
but doctors said the cause of her LBP was degenerative disc or
psychogenic factors. She had consulted to our hospital to second
opinion. At the first medical examination, she had LBP at theleft side and the pain had increased during lumbar retroflexion
and right rotation. T2 weighted mid-sagittal MRI showed thedegenerative change and slight bulging at the level of L3/4, 4/5,
5/S (Fig 3). And left para-sagittal and axial MRI and axial CT
showed lumbar lateral recess stenosis of L4/5 at left side becauseof facet hypertrophy and disc bulging (Fig 3). Her LBP disappeared temporarily after a facet joint injection, confirming a diagnosis of facet joint arthritis. After several facet injections, her
LBP disappeared. She had rehabilitation including core muscle
training. And finally she returned hammer throw national competitive meet after 6 months operation.

disappeared. Interestingly, signal change had occurred in MRI(Fig 5). T1 and also STIR-MRI showed low intensity of thesame site. This signal change was type 3 Modic change, which
demonstrated the bone sclerosis. After core muscle training, hereturned combative match.

Figure 4. Sagittal view of MRI and CT scan (Case 3)

Left panel ; T1 weighted MRI showed low signal intensity of vertebral
endplate at L5/S.
Middle panel ; STIR-MRI showed high signal intensity of vertebral
endplate at L5/S.
Right panel ; CT scan showed a deformity of vertebral endplate at L5.

Figure 3. Sagittal and axial view of T2 weighted MRI and axial CT
scan (Case 2)
MRI showed the degenerative change and slight bulging at the levelof L3/4, 4/5, 5/S.
Axial CT showed facet hypertrophy and osteoarthritis change in left
side of L4/5 (circle).

Figure 5. The Modic change from type 1 to type 3 (Case 3)

Case 3 : Vertebral endplate injury

In this case series, we evaluated data from 23 elite athletes
and revealed that the main cause of LBP of elite athletes wasdisc related low back pain, facet joint arthritis, and vertebral
end plate injury.
According to historical literature for elite athletes, Spencer
and Jackson reported that strains and sprains appear to be themost popular causes of LBP (12). Alexander et al. reported thatmost athlete injuries to the lower back involve a contusion or a
muscular strain related to a sudden contraction of the muscle(13). Spencer and Jackson indicated that athlete’s LBP wascaused by continuous radial tears in the annulus fibrosis of theintervertebral discs (12). Whereas, Bogduk considered that themost common sites of LBP are facet joint and the intervertebral
discs, and that the relationship of LBP to muscloligamentous
strain or sprain is tenuous (14,15).
In these two decades, there have subsequently been remarkable advances in the development of imaging systems, including

A 34-year-old male professional combined combative sports
athlete had felt severe LBP for several years. The pain occurredat the time of fighting position, which is lumbar anteflexion.
Though he consulted several hospitals, the cause of pain had
been unclear. So he finally consulted our hospital. His pain got
worse during lumbar anteflexion, but not during retroflexion.
Sagittal T1-MRI showed low signal intensity of vertebral endplate at L5/S, and sagittal STIR-MRI showed high signal intensity of the same site (Fig 4). This signal change was type 1 Modicchange, which demonstrated the inflammation of vertebral endplate at L5/S. Sagittal CT also revealed a deformity of L5 caudal
vertebral endplate. This pain disappeared temporarily just after
disc injection to L5/S using 1% lidocaine and steroid. And then,we could diagnose that the cause of LBP was vertebral endplate
injury at L5/S. After total 2 times disc injection, his LBP had

After total 2 times disc injection, signal change had occurred in MRI.

DISCUSSION255

The Journal of Medical Investigation Vol. 66 August 2019
MRI and CT. Using these imaging systems and various types offunctional diagnostic injections, it is now becoming possible toidentify the cause of LBP.
MRI is reported to be very useful for investigating inflammatory conditions (16,17). In general, T2-weighted MRI appears
able to detect abnormal findings, but sometimes the signs canbe missed. STIR-MRI is an inversion technique that nulls thefat signal change based on T1 values (18) ; furthermore, it is a
powerful visualization tool because the image can provide useful
information about intra-articular effusion or inflammation asa very clear high-signal area (19). In case 1 and 3, STIR-MRI
clearly showed a high intensity area at the disc and vertebral
endplate, respectively. We were then able to diagnose disc-related LBP in case 1 and vertebral endplate injury in case 3.
The reason that some physicians could not diagnose elite
athlete’s LBP might be the difference of elite athlete and normal
people. Severe symptoms that disturb normal daily life are notdifficult to diagnose. Images including X ray, CT and MRI shows
obvious abnormal findings, e.g. big disc herniation, spondylolysis, vertebral fracture and so on. In case the normal people have
LBP only in playing sports, some complains about it but theother is not in trouble because slight LBP doesn’t disturb daily
life. But elite athletes should be in trouble even if their LBP is
not severe because they always require their top performancein playing time. Actually in most cases, the LBP of top athletes
don’t disturb their daily life but they complain about their LBP
in playing time. If the physicians don’t know this difference, theymight tend to miss the cause of LBP of elite athletes because its
abnormal findings of symptom and images are not conspicuous.
The main cause of unidentified LBP in elite athletes, we reported in this case series, was disc related low back pain, facet
arthritis, and vertebral end plate injury. Details of these pathologies are below.

Disc related LBP
Disc-related LBP due to internal disc disruption is considered
to be the most common cause of chronic LBP (20, 21). Provocative
discography has been considered the gold standard for diagnosis
and management of disc related LBP in spite of its invasivenessand associated complications. In 1992, Aprill and Bogduk described HIZ on MRI for diagnosing disc related LBP (22). They
demonstrated a prevalence of 28.6% for HIZ, with sensitivity,
specificity, and positive predictive values of 71%, 89%, and 86%,
respectively, for diagnosing symptomatic LBP. Some histologicalstudies have shown inflammatory granulation tissue at sites ofHIZ (23-25). These inflammatory tissues produce pro-inflammatory cytokines and mediators that sensitize the nociceptors
within the disc and cause pain (23). In the 12 cases diagnosed
disc related LBP in this series, HIZ in STIR-MRI appeared in 7
cases. The positive ratio of HIZ was 58.3%.
In case 1, STIR-MRI was effective for detecting HIZ, and we
could diagnose his LBP was disc related pain because of temporary pain relief by disc injection block.

Facet joint arthritis
The facet joints are the only synovial joints in the spine, andeach consists of hyaline cartilage overlying subchondral bone, asynovial membrane, and a joint capsule. Because of their highlevel of mobility and the large forces impacting the facet joint,
especially in the lumbar area, the facet joints can develop significant degenerative changes and be a potential source of painand disability. In comparison with standard radiographs, CT
improves anatomic evaluation of the facet joints because of its
ability to image the joint in the axial plane and the high contrast
between bony structures and the surrounding soft tissue (26).
CT is the preferred imaging method for lumbar facet joint osteoarthritis. Lewinnek and Warfield reported that 96% of their patients with facet joint osteoarthritis responded to intra-articular
facet injections (27).
In case 2 here, it is possible that there is an increase in the loadon the left facet joint with twisted position in swinging hammer
before throwing. This may induce the facet hypertrophy andarthritis. After temporarily effective facet joint injection, a final
diagnosis of facet joint arthritis was made.

Vertebral endplate injury
Modic changes are signal intensity changes of the endplateand vertebral bone marrow that are seen on MRI and which
are differentiated into three types based on T1 and T2 weighted
MRI (Table 2) (28, 29). Mok et al. reported that Modic changes
were present in 5.8% of the population (30). These changes werehighly associated with the presence of disc degeneration andcorrelated with the presence of LBP. They had described that thepresence of Modic changes may be a marker for lumbar degenerative phenotypes associated with LBP. Cao et al. reported that
intradiscal steroids are an effective treatment for chronic LBP
patients with Modic changes on MRI (31). Type 1 Modic changes
are associated with an active inflammatory process, involving
vertebral endplates adjacent to the intervertebral disc, andstimulated by local proinflammatory mediators and cytokines(32, 33).
Table 2. Modic classification
Modic
classification

MRI T1

MRI T2

Represents

Type 1Low

High

Vascularized bonemarrow or edema

Type 2High

High

Proliferation of fatty tissue

Type 3Low

Low

Sclerotic bone

In case 3, after two times disc injection with steroids, hischronic LBP disappeared with signal change to Modic type 3.
Intradiscal injection with steroids might be effective not only tosymptoms but also to structural changes at lumbar vertebral
end plate. We believe that there is little deleterious effect of aneedle puncture on a disc that is already degenerated, probably
painful.
Table 3 shows the summary about the diagnosis of the LBP of
the athlete.

Table 3. Summary about the diagnosis of the LBP of the athlete
Diagnosis

Symptom

ImagesDiagnostic injection block

Disc related LBP

Pain with anteflexion

MRI ; Degenerative disc with HIZ

Temporary pain relief after disc injection block

Facet joint arthritis

Pain with retroflexion

CT ; Facet hypertrophy or deformity

Temporary pain relief after facet injection block

Vertebral endplate injury

Pain with anteflexion

MRI ; Type 1 Modic change

Temporary pain relief after disc injection block256

K. Yamashita, et al. Accurate diagnosis of low back pain

CONCLUSION
In this case series, we showed that the main cause of unidentified LBP in elite athletes was disc related low back pain, facet
joint arthritis, and vertebral end plate injury. A thorough medical interview, a careful physical examination and appropriate
diagnostic imaging, such as STIR-MRI, are important whenlooking for the cause of LBP.

CONFLICT OF INTERESTS-DISCLOSURE
nothing for all authors

ACKNOWLEDGEMENTS
None

FUNDING AND ALL OTHER REQUIRED STATEMENTS
None

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