International Orthopaedics

https://doi.org/10.1007/s00264-018-4261-8

REVIEW

Intervertebral disc herniation in elite athletes

Jonathan T. Yamaguchi 1 & Wellington K. Hsu 1

Received: 25 October 2018 / Accepted: 26 November 2018

# SICOT aisbl 2018

Abstract
Intervertebral disc herniations are a common cause of neck and back pain in athletes. It is thought to be more prevalent in athletes than
in the general population due to the consistent pressure placed on the spine and concurrent microtraumas that are unable to heal.
Prevention focuses on neck and trunk stability and flexibility, training on proper technique, and rule changes to minimize catastrophic
injuries. The evaluation for athletes includes a full neurologic exam and imaging. The imaging modality of choice is MRI, but CT
myelography can be a useful alternative. Standard management includes a six week trial of conservative treatment with hiatus from
injurious activity and anti-inflammatory medication. If nonoperative management fails, operative treatment has been shown to lead to
excellent clinical outcomes in this patient population. Special consideration to prevention needs to be further analyzed. Furthermore,
more robust studies on alternative non-operative and operative treatment modalities for this patient population are also needed.

Keywords Herniations . Elite athletes . Return to play . Intervertebral disc . Lumbar spine . Cervical spine

Introduction the cervical spine [5] and 35–54% in the lumbar spine [6, 7].
Competitive athletic activity on a repetitive basis may predis-
Neck and back pains are some of the most common reasons pose athletes to more risk for degenerative disc disease than in
for missed playing time among high-performing athletes [1, the general population [8]. In athletes, there are wide ranges of
2]. Aetiologies vary according to age and injury type such as reported lifetime prevalence ranging from 33 to 84% [9, 10] in a
acute versus overuse injuries. Many of the injuries from minor variety of professional North American athletes and 47–90% in
impact are self-limiting and due to muscle strains [2, 3]. Olympians [11]. Collision sports such as American football
However, significant spinal pathology such as disc herniation, players in the National Football League (NFL) and rugby
degenerative disc disease, and spondylolysis warrant prompt may increase the risk of disc herniations; however, noncontact
medical evaluation to ensure player safety and to minimize sports may be more protective against herniations by improved
long-term impact on players’ career [4]. dynamic muscular support for the spine that decreases inju-
The mechanisms, timing, and prevalence of neck and back rious forces on the discs [12]. The most common levels
pain are unique to each sport. In the general population, lifetime injured in the lumbar spine are L4–5 and L5–S1 which
prevalence of degenerative changes on MRI in asymptomatic account for more than 90% of symptomatic lumbar disc
patients younger than 40 years old has been reported as 25% in herniations (LDH) [13]. Unique to the collision athlete with
cervical disc herniations (CDH), C3–4 and C5–6 are the
most commonly injured levels (23% each) followed by
C4–5 (21%) [14]. The purpose of this review was to ex-
Jonathan T. Yamaguchi and Wellington K. Hsu have contributed in the amine the current literature on CDH and LDH in profes-
manuscript preparation and literature review. sional athletes. Thoracic disc herniations have a low inci-
dence rate and minimal amount of published data and thus,
* Jonathan T. Yamaguchi will not be discussed during this review.
[email protected]

Wellington K. Hsu Mechanism of injury

[email protected]

1
Department of Orthopaedic Surgery, Northwestern University,
Symptomatic disc herniations develop from the rupture of the
Feinberg School of Medicine, 676 North St. Clair Street, NMH/ intervertebral disc and the gel-like nucleus pulposus extrava-
Arkes Family Pavilion Suite 1350, Chicago, IL 60611, USA gating through the injured annulus fibrosis and compressing a
 International Orthopaedics (SICOT)

spinal nerve [2, 15, 16]. This degeneration occurs due to the LDH occurred in offensive linemen [22]. This position may have
relative avascularity of the discs, receiving its nutrients pri- higher risk for LDH recurrence because of the typical position at
marily through diffusion after adolescence. With age and the line of scrimmage that causes greater hyperextension on the
abuse, the gel-like nucleus pulposus dehydrates, increasing lumbar spine, placing enormous force on the posterior annulus
the compressive force on the annulus. These forces cause (Fig. 1). Additionally, the upright blocking position on passing
micro-radial tears that lead to delamination and eventually plays by the offensive lineman is meant to absorb the defensive
result in rupture. After herniation, the nucleus pulposus can lineman drive on the quarterback and can cause hyperextension
irritate or compress the adjacent nerve producing the radicular and rotation on the lumbar spine.
symptoms associated with disc herniations. Acute injury Collision sports are more likely to place large axial loads on
mechanisms of flexion and compression or rotational motion the athlete’s spine, which is the proposed mechanism of injury
can cause the annulus to rupture [17, 18]. Overuse injuries are for CDH [18, 23, 24]. Athletic activities that are most associated
thought to occur from repeated microtrauma to the annulus with CDH are tackling and blocking as seen in these collision
that is unable to heal before it erodes. In a biomechanical study sports [14, 25]. Positions that increase these types of activities
on porcine spines by Marshall and McGill, axial torque/twist such as defensive backs and linemen in American football or
motion plus repetitive flexion and extension led to radial de- front row forwards in rugby are associated with higher inci-
lamination within the annulus [19]. Notably, repetitive flexion dence of CDH. Interestingly, collision athletes may be more
alone led to posterior nucleus tracking through the annulus at risk for upper-level CDH, specifically at C3–C4. Although
while axial torque/twist alone was unable to initiate disc her- rare in the general population, Mai et al. found a high rate of
niation. Therefore, the authors inferred that axial torque/ C3–C4 herniations (35%) in the NFL [26]. Nevertheless, the
twisting motion can exacerbate pre-existing disc damage. upper-level CDH injuries had similar return to play (RTP) rates,
Type of sport and position play key roles in understanding recovery times, career lengths, and performance scores after
the mechanism of injury. Categorizing competitive athletics as injury compared to lower-level injuries. In a case series of 25
Bcontact vs noncontact^ may not be specific enough to the traumatic C3–C4 injuries in young athletes, Torg et al. noted
implications of return to play (Table 1). Rotational sports, such that C3–C4 injuries respond differently to axial loading com-
as baseball and golf, require greater trunk axial torque/twisting pared to other cervical spine segments [27]. Four football
motion which may have different considerations with recovery. players ranging from high school to professional level players
Fleisig et al. quantified the trunk axial rotation in baseball suffered C3–C4 acute posterior intervertebral disk herniation,
pitchers and batters, two positions that have high levels of all due to axial loading. Three of the four experienced transient
symptomatic LDH [20]. They found that the average maximum quadriplegia. All were treated surgically with successful single-
trunk axial rotation for both was around 50° (pitchers, 55 ± 6°; level fusion and complete neurologic recovery.
batters, 46 ± 9°). Since Major League Baseball (MLB) is a long
season consisting of 162 games over 6 months, repetitive lum- Prevention
bar axial rotation may be one explanation for disc injury.
Collision sports including American football, rugby, and There is still no set standard for prevention of intervertebral
wrestling require repetitive high-impact contact. In football, line- disc herniation. Recognizing dangerous activity and
men may be at highest risk to herniate a lumbar disc, likely from implementing rule changes are important in minimizing trau-
the combined effects of their body weight, weight training regi- matic spine injuries such as cervical quadriplegia (i.e., spear
men, and repeated forcible lower spine hyperextension during tackling) [24]. Advising athletes on proper technique and
blocking [14, 21]. Weistroffer and Hsu evaluated 66 NFL line- wearing protective equipment also helps to prevent injury.
men treated for LDH and reported that six of seven recurrent Due to the mechanisms that often lead to disc herniation,
stability and flexibility are two core components of prevention
Table 1 Type of sport breakdown with examples under each category and rehabilitation. Often targeted as the main form of initial
rehabilitation exercises, truncal stability and flexibility train-
Noncontact Contact Collision Rotational
ing prevent hyperextension and relieve some pressure on the
Running Basketball American football Baseball posterior annulus. Neck stability and flexibility minimizes the
Track Soccer Hockey Golf forced axial loading when the player’s neck is in hyperexten-
Cycling Handball Rugby Tennis sion or hyperflexion.
Volleyball Martial arts Field
Crew Water polo Evaluation
Fencing Equestrian
Swimming Evaluation for symptomatic neck and back pain is the same
Skiing for athletes as in the general population including full assess-
ment of range of motion and neurologic exam [17, 28–30].
International Orthopaedics (SICOT)

Fig. 1 Typical ready positions of

offensive (a) and defensive (b)
linemen. Offensive linemen
prepare in a squatting position,
causing more hyperextension of
the lumbar spine, whereas
defensive players typically
prepare in a crouched 3-point
stance [22]. Permission obtained
from American Journal of Sports
Medicine

Symptom presentation is variable by patient and typically in- injury. Facemasks should be removed, but helmets and other
cludes a combination of extremity pain, generalized neck or protective equipment should not be removed unless necessary.
back pain, numbness, and weakness. Severe neurological Traction should never be applied to the athlete’s head. If a
compression, such as the conus medullaris and cauda equina player is found in the prone position, the team should transi-
syndromes typically manifest with saddle anesthesia, auto- tion the athlete to supine for proper evaluation using the
nomic instability, and loss of reflexes and strength. More spe- Bprone log roll technique^ [34]. To transfer an athlete to a
cific signs for LDH include extremity pain in a myotomal backboard, use the preferred Blift and slide technique^ [34].
distribution, sensory disturbances in a dermatomal pattern, Appropriate transportation to the hospital can occur via am-
reduced reflexes, and pain that increases with Valsalva maneu- bulance or helicopter and should be based on clinical and
ver [15]. Provocative tests, such as the ipsilateral straight leg logistical factors that optimize care.
test, are highly sensitive, but less specific for LDH [1, 28]. In
contrast, the contralateral straight leg test is more specific. For Imaging
cervical radiculopathy, Spurling’s test is specific (93%), but
not sensitive (30%) [31]. As with the general population, in athletes with clinically diag-
When evaluating elite athletes, there are several additional nosed disc herniations, non-contrast MRI is the imaging modal-
factors to consider compared to the general population such as ity of choice (Fig. 2) [35]. It provides the best resolution of the
type of sport, position, and timing of injury. As we mentioned nerve roots and surrounding soft tissues with sensitivity and
above, the type of sport and position highlight the athletes specificity as high as 97% and 96%, respectively [15].
more prone to disc herniations. However, timing of injury However, caution should be applied to its interpretation since
should be noted as well. The timing of the injury can be cat- around 27% of patients have asymptomatic disc bulges and
egorized as acute, chronic, trauma-related to athletic activity, herniations [6, 36], which may be higher in the competitive
or at rest. If players have pain without playing, there are dif- athlete population. Radiography is not always necessary, but is
ferent considerations. recommended for disc herniations to evaluate for other underly-
Sideline physicians need to prepare for worst case scenar- ing conditions. If MRI is contraindicated, CT myelography is an
ios of acute spinal cord injury leading to on-field evaluation adequate alternative to assess the surrounding neural structures.
and management [23, 32, 33]. Proper preparation prior to the For patients with cervical injury, there is a lower threshold for
game includes requisition of appropriate tools for cervical imaging compared to the lumbar spine given the presence of
trauma (i.e., backboard, cervical collar, tools for removing adjacent central neurovascular structures [37, 38]. Additionally,
athletic equipment, and advanced airway management), re- acute injury has an even lower threshold for imaging to evaluate
hearsed protocols, and a relationship with a hospital with an for spinal cord injury, stenosis, and fractures [23].
available spine surgeon. Once spinal cord injury is suspected,
on-field evaluation begins with the standard BABCDE^ trau- Management
ma protocol, which involves immediate cervical spine stabili-
zation in the neutral position (unless moving the head/neck To return to play, each athlete should be evaluated on a case-
increases symptoms) and placement of a cervical collar. To by-case basis and consider the type of sport, player position,
maintain an airway, jaw thrust is preferred to prevent airway imaging characteristics, clinical symptoms, and physical ex-
obstruction prior to facemask removal and prevent additional amination. The combination of these measures will allow the
 International Orthopaedics (SICOT)

Fig. 2 Sagittal (a) and axial (b)

T2-weighted MRI images for
LDH (arrow) in a 33-year-old
elite athlete [67]. Permission ob-
tained from Contemporary Spine
Surgery

team physician to recommend a decision that is best for that abuse [45]. Counseling should establish the favorable progno-
particular athlete. sis of CDH and LDH, reaffirm the rehabilitation process, and
set a realistic expectation for recovery. Regardless of treatment
Non-operative modality, athletes with CDH typically have a longer recovery
period as compared to LDH [14, 21, 46].
In the general population, > 90% of patients with LDH will Typically, physical therapy is included for the rehabilitation
recover within 6 weeks [39]. Hsu et al. demonstrated in the of disc herniations [47]. Most LDH rehabilitation regimens
Professional Athlete Spine Initiative study of 342 professional focus on core and back strengthening and flexibility [48]. As
basketball, American football, baseball, and hockey players the athlete progresses, axial rotation and flexion are incorpo-
that RTP rates were 82% after LDH with comparable rates rated to minimize intradiscal pressure. Gradually, the athlete
between the operative and non-operative groups [39]. The returns to sport-specific manoeuvres to regain full range of
initial trial of conservative therapy should include cessation motion and build power. The Spine Patient Outcomes
of exacerbating activity, anti-inflammatory medications, mus- Research Trial (SPORT) demonstrated improvement in both
cle relaxants, and time. In particular, maintaining normal ac- non-operative therapy and open discectomy with 44% receiv-
tivity levels and minimizing bedrest are important for athletes ing active physical therapy and 67% having completed phys-
to minimize muscular atrophy. These measures offer symp- ical therapy prior to trial enrollment [49]. Additionally, other
tomatic relief while the injury heals. studies have shown that physical therapy is beneficial for pa-
Anti-inflammatory medications reduce the production of tients but the exact methodology is still under debate [50]. A
inflammatory cytokines and help relieve pain. While oral cor- phased rehabilitation protocol that aligns with the healing pro-
ticosteroids are commonly prescribed for acute symptoms, a cess of LDH has been described [51]. There is little literature
recent randomized control trial demonstrated that there was a on CDH rehabilitation in athletes, but similarly focuses on the
modest improvement in function, but no effect on pain [40]. In concepts of neck strengthening, flexibility, and gradual return
this study, the steroid group was more likely to have an ad- to sport-specific manoeuvres [52].
verse event compared to the placebo. In contrast, epidural
steroid injections have been shown to be beneficial for athletes Operative
with LDH and can be used to reduce local inflammation and
pain, allowing the player to return to play sooner than with Surgical management is often considered after failure of non-
conventional conservative treatment [41]. However, the operative management and can be indicated for prolonged
evidence-based literature also suggests that these types of in- pain and/or muscle weakness. While surgical treatment for
jections do not change the natural history of a LDH [41, 42]. this condition is primarily discectomy, there are reports of
Intralaminar epidural injections have not yet been studied in professional athletes who have successfully returned after
CDH for athletes, but there are promising results in the general both cervical and lumbar fusion [26, 27, 38, 53, 54].
population [43]. Strong analgesics should generally be Treating physicians should understand that fusion of a spinal
avoided to prevent masking of pain allowing over-vigorous segment can lead to stiffness, adjacent disc disease, and al-
activity [44]. Short-term narcotics are useful in decreasing tered spine mechanics [4, 36, 55]. Although these changes
pain, but should be prescribed judiciously to patients who potentially alter the players’ performance, physicians and ath-
struggle through rehabilitation to minimize addiction and letes should consider the recovery time, estimated ability to
abuse. Psychological support should be provided due to the return to high-level competition, career longevity, and quality
increased risk of depression, anxiety, and illicit substance of life after retirement.
International Orthopaedics (SICOT)

Cervical

In professional athletes, CDH is usually studied in collision

sports due to the risk of associated severe spinal cord injury. In
a systematic review of 80 reported surgeries for CDH in ath-
letes by Joaquim et al., most of these players were able to RTP,
with some studies demonstrating that patients undergoing sur-
gery had a higher rate and longer career than their conserva-
tively managed peers [38]. The vast majority of the procedures
were single-level anterior cervical discectomy and fusion
(ACDF) (85–95%), followed by posterior foraminotomy
(PF) (3–13%) and cervical arthroplasty (1–2%) [38, 54]. The
authors suggested that the anterior approach was preferred to
avoid muscular and ligamentous injuries associated with pos-
terior surgical approach. Recently, Mai et al. showed that for a
single-level CDH, ACDF was associated with better long-
term outcomes but lower RTP rates [54]. Posterior
foraminotomy was associated with a greater RTP rate and
shortest time to return after surgery but with an increased
association of re-operation. Regardless, there was no signifi-
cant difference in performance score after surgery for all co-
horts, except baseball, which had a decrease in performance Fig. 3 Sagittal T2-weighted MRI depicting cervical stenosis
score after surgery. Additionally, a meta-analysis by
McAnany et al. provided a pooled RTP rate of 73.5% for
ACDF [56]. In rugby, ACDF demonstrated a RTP rate of Lumbar
68.4% [25]. Evaluating CDH in the NFL, Hsu found a proce-
dure distribution similar to Joaquim et al. (ACDF 60.4%, PF Laminotomy with discectomy is the surgical treatment of
5.7%, unknown 34%) and RTP rate (72%) in the operative choice for LDH and is highly effective [15, 57–59]. In a sys-
group [4]. Furthermore, the operative patients compared to the tematic review, Nair et al. showed that after discectomy, 75–
non-operative group had a higher RTP rate (72% vs. 46%) and 100% of athletes successfully RTP at an average of 2.8–
longer mean career length of (2.8 years vs. 1.5 years). Notably, 8.7 months after surgery [60]. Player performance statistics
there was no significant difference in performance scores or ranged from 64 to 104% of baseline pre-operative statistics.
percentage of games started before or after treatment [4]. At A review by Iwamoto et al. showed that the treatment effect
the time, survey data showed that up to 50% of spine surgeons from microdiscectomy (RTP 85%) and conservative therapy
would not have cleared a player with ACDF to return to con- (RTP 79%) was comparable, but percutaneous discectomy
tact sports. Single- and 2-level fusions are cleared for RTP. (RTP 70%) was lower [61, 62]. In data published from the
However, more than 2-level fusions, myelopathy, and signif- Professional Athlete Spine Initiative, Hsu et al. noted 81%
icant muscle weakness and/or pain should be considered ab- RTP rate for all athletes treated with lumbar discectomy with
solute contraindications due to the risk for permanent neuro- no difference between RTP rates between the non-operative
logic damage or worsened injury. and operative groups with average post-operative career
Cervical stenosis also increases risk for severe, irreversible length of 3.4 years [39]. Variables such as younger age and
spinal cord injury in collision sports. Stenosis in the cervical more game experience predicted longer career length. In the
spine increases the frequency of transient neuropraxia and can NFL, offensive skill position players (quarterbacks, tight ends,
be present due to congenital formation, degenerative changes, running backs, wide receivers) had an RTP rate of 74% and
or Bfunctional^ stenosis which refers to a lack of cerebrospinal played at productive levels post-operatively [63]. Lumbar
fluid around the cord (Fig. 3) [8]. Any athlete with transient discectomy is effective even for positions at higher risk of
neuropraxia should be screened for cervical stenosis with an LDH and recurrence. Weistroffer et al. found NFL linemen
MRI. When cervical stenosis is found incidentally in an athlete, treated operatively had a higher RTP rate than the non-
there is little evidence for RTP recommendations. Expert opin- operative group (80.8% vs. 63.5%) [22]. In addition, 13.5%
ion suggests that congenital stenosis should not necessarily pre- of the surgical cohort required revision decompression with
vent an asymptomatic athlete from RTP to a contact sport [23, 85.7% of these players successfully RTP.
37, 38]. Symptomatic patients found to have cervical stenosis Multiple studies have shown that the RTP rates are similar
should always be informed of the risks associated with RTP. between operative and non-operative groups in other sports such
 International Orthopaedics (SICOT)

as basketball [64], hockey [53], baseball [46, 65], and Olympic American sports are comparable between non-operative and
events [66]. However, outcomes after surgery differ by sport. operative management. However, there is a lack of high-
Each of these sports has unique physical demands and stress quality evidence for the optimal treatment and prevention
on the lumbar spine. In the National Basketball Association strategies for these individuals to mitigate risk.
(NBA), Minhas et al. described a high RTP rate of 78% and
79% for non-operatively and operatively treated players, respec- Statement of authorship All of the following authors contributed signif-
icantly to the development of this manuscript through data analysis, man-
tively [64]. Basketball players had an initial decrease in perfor-
uscript preparation, or analysis and editing of the final manuscript.
mance statistics during the first season post-operatively, but these
changes leveled in seasons 2 and 3 with no difference in post-
Compliance with ethical standards
operative career length [64]. Taller players and those who played
center were more likely than not to RTP after LDH. Conflict of interest Author JTY has no conflicts of interest. Author
In hockey, skating may require smaller axial loads on the WKH has received research grant from Wright Medical and IP royalties
lumbar spine. Schroeder et al. had an RTP rate of 90% and from Stryker; advisory board for the Journal of Bone and Joint Surgery;
82% for non-operatively and operatively treated groups, re- consulted for Stryker, Medtronic, Mirus, Allosource, Biovenus,
Micromedicine, and Agnovos.
spectively [53]. There was significant decrease in games
played, points scored, and performance score, but no differ-
ence in performance measures between surgical and nonsurgi-
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