Radiculopathy

Radicular pain in athletes is most commonly related to disk herniation. Recent research has found only a weak correlation between disk degeneration and herniation. In the middle-aged or elderly athlete reduced disk height and facet joint degeneration contribute to radicular pain. Inhibited motor function indicates nerve root compression. The association between pain or a positive Lasegue's test and nerve root compression is more uncertain [32]. Current knowledge indicates that acute radicular pain is caused by an inflammation induced by an autoimmunologic process involving the herniated disk and irritation of the dorsal root ganglion [33,34]. Under chronic conditions ischemic, inflammatory, metabolic and neurophysiologic changes affecting the nerve root or the dorsal root ganglion and central inhibiting or enhancing mechanisms may contribute to the pain-producing process.

Symptoms and signs. Pain radiation below the knee that is provoked by coughing. Prolonged standing and sitting is difficult. At consultation the patient may present with a limp, the upper body forward flexed, and a protective scoliosis. The diagnosis is supported by positive neurologic signs in a nerve root pattern and a positive straight-leg raising test.

Diagnosis. The diagnosis is based mainly on clinical symptoms. CT is indicated if the complaints do not improve within 2 weeks or in patients with progressive paresis.

Treatment. A patient with a large central herniation producing bladder disturbance, diminished perineal sensation and even paraplegia is a surgical emergency, and immediate exploration is imperative.

All other patients are first treated with conservative methods. Anti-inflammatory medication is recommended. Corticosteroids, 40-60 mg prednisolone for 3-7 days is usually well tolerated. Analgesics (including opiates) are indicated in patients with pain-related sleep difficulties. The patient should be informed that the prognosis is good without surgery, and that improvement is not delayed by ordinary activities or improved by bed rest. In the long term extrusion of disk material leads to narrowing of the disk space.

Participation in competition should normally be delayed until the athlete is able to conduct his normal training program although this may sometimes be controversial. Recently a Norwegian cross-country skier won the World Championship title despite sciatica with motor disturbances.

Reduced activity is recommended in patients with unaltered or progressive complaints. Twisting and bending when lifting should be avoided. The physiotherapist should motivate the athlete to remain active, to use and flex his back in order to maintain general physical fitness, and to maintain a positive attitude. In general there is no reason to be overcautious. The effect of traction is limited at best to short-term pain relief, and has no documented effect on recovery. Exercises to improve the function of the deep stabiliz ing trunk muscles have no documented effect on recovery, but may reduce the risk of relapse. In dancers and in athletes in other sports that include lifting a partner, a corset or a stabilizing belt can make it possible to maintain performance.

Progressive pareses or muscle weakness and radicular pain for 6-12 weeks indicate surgery. The effect of extirpation of the herniation with or without arcotomy or laminectomy improves radicular pain and muscle weakness in about 80% of the patients, but the effect on back pain is more variable. Therefore, the indication for surgery in patients with a disk herniation and back pain (but no radicular pain) is more controversial. Percutaneous nucleotomy is not indicated.

There is no consensus about rehabilitation after surgery. A recent study suggests that the patient should resume ordinary activities as soon as the operative wound is healed [35]. From this baseline, the athlete should gradually increase his training volume and intensity.

Absence from sports in athletes with radiculopathy is highly variable. In patients without muscle weakness we expect a setback of 6-12 weeks; in patients with objective neurologic signs the setback is commonly 12-24 weeks or longer. Therefore, long-term planning is an important part of the rehabilitation process, preferably in agreement with the physiotherapist, coach and athlete. In some cases it may be wise to recommend reduction of ambitions and eventually giving up the sports career in order to set new, more realistic goals in another arena.

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