Lumbar Radicular and Referred Pain in the Athlete

  • Jonathan T. Bravman
  • Hector Mejia
  • Vikas V. Patel
  • Venu Akuthota

Often numbness and tingling in athletes results from radicular or referred pain from the spine. Low back pain conditions are extremely common in athletes. Most spinal disorders cause axial low back pain, such as pain generated from facet and sacroiliac joints, muscles, and the disc itself. These structures may also cause somatic referred pain into the legs, usually above the knee. Somatic referred pain is typically described as a vague, dull pain in the leg, yet it can be confused with nerve-generated paresthesias. Radicular pain, on the other hand, is less common and is characterized by numbness and tingling that follows a particular dermatome. Radicular pain is exacerbated with dural tension maneuvers, such as straight-leg raising (SLR), seated slump test, and femoral nerve stretch test (FNST). Making the distinction between radicular and referred entities is important when initiating proper treatment. In sports, the following spinal conditions are seen with more frequency:


Single Photon Emission Compute Tomography Disc Herniation Sacroiliac Joint Radicular Pain Nerve Root Compression 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Gerbino PG, d’Hemecourt PA. Does football cause an increase in degenerative disease of the lumbar spine? Curr Sports Med Rep 2002;1(1):47–51.PubMedGoogle Scholar
  2. 2.
    Greene HS, Cholewicki J, Galloway MT, et al. A history of low back injury is a risk factor for recurrent back injuries in varsity athletes. Am J Sports Med 2001;29(6):795–800.PubMedGoogle Scholar
  3. 3.
    Lawrence JP, Greene HS, Grauer JN. Back pain in athletes. J Am Acad Orthop Surg 2006;14(13):726–35.PubMedGoogle Scholar
  4. 4.
    Tortolani PJ, Carbone JJ, Quartararo LG. Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists. Spine J 2002;2(4):251–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Slipman CW, Sternfeld E. The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil 1998;79(3):288–92.PubMedCrossRefGoogle Scholar
  6. 6.
    Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline. Agency for Health Care Policy and Research. Vol 14. Rockille, MD: U.S. Department of Health and Human Services; 1994.Google Scholar
  7. 7.
    Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med 2003;37(3):263–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Mundt DJ. An epidemiologic study of sports and weight lifting as possible risk factors for herniated lumbar and cervical discs; the Northeast Collaborative Group on Low Back Pain. Am J Sports Med 1993;21(6):854–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Dec KL. Nonoperative versus operative treatment of acute disc injuries in athletes. Curr Sports Med Rep 2002;1(1):35–42.PubMedGoogle Scholar
  10. 10.
    Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev 2007;(2):1350.Google Scholar
  11. 11.
    Watkins RG, Williams LA, Watkins RG 3rd. Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes. Spine J 2003;3(2):100–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Wang JC, Shapiro MS, Hatch JD, et al. The outcome of lumbar discectomy in elite athletes. Spine 1999;24(6):570–3.PubMedCrossRefGoogle Scholar
  13. 13.
    D’Hemecourt PA, Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000;19(4):663–79.PubMedCrossRefGoogle Scholar
  14. 14.
    Fredrickson BE, Baker D, McHolick WJ, et al. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 1984;66(5):699–707.PubMedGoogle Scholar
  15. 15.
    Wiltse LL, Newman PH, Macnab I. Classification of spondylolysis and spondylolisthesis. Clin Orthop 1976;117:23–9.PubMedGoogle Scholar
  16. 16.
    Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis. J Pediatr Orthop 1987;7(6):631–8.PubMedGoogle Scholar
  17. 17.
    Bellah RD, Summerville DA, Treves ST, et al. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology 1991;180(2):509–12.PubMedGoogle Scholar
  18. 18.
    Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine 1985;10(10):937–43.PubMedCrossRefGoogle Scholar
  19. 19.
    Anderson K, Sarwark JF, Conway JJ, et al. Quantitative assessment with SPECT imaging of stress injuries of the pars interarticularis and response to bracing. J Pediatr Orthop 2000;20(1):28–33.PubMedCrossRefGoogle Scholar
  20. 20.
    Sys J, Michielson J, Bracke P, et al. Nonoperative treatment of active spondylolysis in elite athletes with normal X-ray findings: literature review and results of conservative treatment. Eur Spine J 2001;10(6):498–504.PubMedCrossRefGoogle Scholar
  21. 21.
    Yeoman W. The relation of arthritis of the sacro-iliac joint to sciatica. Lancet 1928;2:119–22.Google Scholar
  22. 22.
    Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 1934;211:210–5.CrossRefGoogle Scholar
  23. 23.
    Robinson D. Pyriformis syndrome in relation to sciatic pain. Am J Surg 1947;73:355–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Pecina M. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat Basel 1979;105(2):181–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Pace JB, Nagle D. Piriformis syndrome. West J Med 1976;124(6):435–9.PubMedGoogle Scholar
  26. 26.
    Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop 1987; 217:266–80.PubMedGoogle Scholar
  27. 27.
    Parziale JR, Hudgins TH, Fishman LM. The piriformis syndrome. Am J Orthop 1996;25(12):819–23.PubMedGoogle Scholar
  28. 28.
    Goldner JL. Piriformis compression causing low back and lower extremity pain. Am J Orthop 1997;26(5):316–8.PubMedGoogle Scholar
  29. 29.
    McCrory P, Bell S. Nerve entrapment syndromes as a cause of pain in the hip, groin and buttock. Sports Med 1999;27:261–74.PubMedCrossRefGoogle Scholar
  30. 30.
    Barton PM. Piriformis syndrome: a rational approach to management. Pain 1991;47(3):345–52.PubMedCrossRefGoogle Scholar
  31. 31.
    Hughes SS, Goldstein MN, Hicks DG, et al. Extrapelvic compression of the sciatic nerve: an unusual cause of pain about the hip―report of five cases. J Bone Joint Surg Am 1992;74(10):1553–9.PubMedGoogle Scholar
  32. 32.
    Jankiewicz JJ, Hennrikus WL, Houkom JA. The appearance of the piriformis muscle syndrome in computed tomography and magnetic resonance imaging: a case report and review of the literature. Clin Orthop 1991;262:205–9.PubMedGoogle Scholar
  33. 33.
    Solheim LF, Siewers P, Paus B. The piriformis muscle syndrome: sciatic nerve entrapment treated with section of the piriformis muscle. Acta Orthop Scand 1981;52(1):73–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Vandertop WP, Bosma NJ. The piriformis syndrome: a case report. J Bone Joint Surg Am 1991;73(7):1095–7.PubMedGoogle Scholar
  35. 35.
    Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint Surg Am 1999;81(7):941–9.PubMedGoogle Scholar
  36. 36.
    Freiberg A. Sciatic pain and its relief by operations on muscle and fascia. Arch Surg 1937;34:337–49.Google Scholar
  37. 37.
    Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med 1983;74(2):69–72.PubMedGoogle Scholar
  38. 38.
    Melamed HM. Soft tissue problems of the hip in athletes. Sports Med Arthrosc 2002;10:168–75.CrossRefGoogle Scholar
  39. 39.
    Rich B. When sciatica is not disc disease. Phys Sports Med 1992;20:105–15.Google Scholar
  40. 40.
    Beaton L. Relation of sciatic nerve and subdivision to piriformis muscle. Anat Rec 1937;70:1–3.CrossRefGoogle Scholar
  41. 41.
    Melzack R. Prolonged relief of pain by brief, intense transcutaneous somatic stimulation. Pain 1975;1(4):357–73.PubMedCrossRefGoogle Scholar
  42. 42.
    Wyant GM. Chronic pain syndromes and their treatment. III. The piriformis syndrome. Can Anaesth Soc J 1979;26(4):305–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Kirkaldy-Willis WH, Hill RJ. A more precise diagnosis for low-back pain. Spine 1979;4(2):102–109.PubMedCrossRefGoogle Scholar
  44. 44.
    Dezawa A, Kusano S, Miki H. Arthroscopic release of the piriformis muscle under local anesthesia for piriformis syndrome. Arthroscopy 2003;19(5):554–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Mullin V, de Rosayro M. Caudal steroid injection for treatment of piriformis syndrome. Anesth Analg 1990;71(6):705–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc 1996;71(6):565–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Kingzett-Taylor A, Tirman PF, Feller J, et al. Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging findings. AJR Am J Roentgenol 1999;173(4):1123–6.PubMedGoogle Scholar
  48. 48.
    Collee G, Dijkmans BA, Vandenbroucke JP, et al. Greater trochanteric pain syndrome (trochanteric bursitis) in low back pain. Scand J Rheumatol 1991;20(4):262–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Arendt E. Growing pain in the athlete. In: Griffin L, ed. Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL: AAOS; 1998:281–9.Google Scholar
  50. 50.
    Generini S, Matucci-Cerinic M. Iliopsoas bursitis in rheumatoid arthritis. Clin Exp Rheumatol 1993;11(5):549–51.PubMedGoogle Scholar
  51. 51.
    Slawski DP, Howard RF. Surgical management of refractory trochanteric bursitis. Am J Sports Med 1997;25(1):86–9.PubMedCrossRefGoogle Scholar
  52. 52.
    Hays M. The trochanteric syndrome. J Bone Joint Surg Am 1963;45:657–61.Google Scholar
  53. 53.
    Walker P, Kannangara S, Bruce WJ, et al. Lateral hip pain: does imaging predict response to localized injection? Clin Orthop 2007;457:144–9.PubMedGoogle Scholar
  54. 54.
    Little H. Trochanteric bursitis: a common cause of pelvic girdle pain. Can Med Assoc J 1979;120(4):456–8.PubMedGoogle Scholar
  55. 55.
    Clancy WG. Runners’ injuries. Part 2: Evaluation and treatment of specific injuries. Am J Sports Med 1980;8(4):287–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Broadhurst N. Iliopsoas tendinitis and bursitis. Aust Fam Physician 1995;24(7):1303.PubMedGoogle Scholar
  57. 57.
    Schwarzer AC, Aprill CN, Derby R, et al. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine 1994;19(7):801–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Helbig T, Lee CK. The lumbar facet syndrome. Spine 1988;13(1):61–4.PubMedCrossRefGoogle Scholar
  59. 59.
    Dreyer SJ, Dreyfuss PH. Low back pain and the zygapophysial (facet) joints. Arch Phys Med Rehabil 1996;77(3):290–300.PubMedCrossRefGoogle Scholar
  60. 60.
    Schwarzer AC, Derby R, Aprill CN, et al. Pain from the lumbar zygapophysial joints: a test of two models. J Spinal Disord 1994;7(4):331–6.PubMedCrossRefGoogle Scholar
  61. 61.
    Revel ME, Listrat VM, Chevalier XJ, et al. Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil 1992;73(9):824–8.PubMedGoogle Scholar
  62. 62.
    Schwarzer AC, Wang SC, O’Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine 1995;20(8):907–12.PubMedCrossRefGoogle Scholar
  63. 63.
    Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997;336(23):1634–40.PubMedCrossRefGoogle Scholar
  64. 64.
    Lilius G, Laasonen EM, Myllynen, et al. Lumbar facet joint syndrome: a randomised clinical trial. J Bone Joint Surg Br 1989;71(4):681–4.PubMedGoogle Scholar
  65. 65.
    Bogduk N. Evidence-informed management of chronic low back pain with facet injections and radiofrequency neurotomy. Spine J 2008;8(1):56–64.PubMedCrossRefGoogle Scholar
  66. 66.
    Bernard TN, Cassidy D. The sacroiliac joint syndrome: pathophysiology, diagnosis, and management. In: Frymoyer JW, ed. The Adult Spine: Principles and Practice. Philadelphia: Lippincott-Raven; 1997:2343–66.Google Scholar
  67. 67.
    Grob KR, Neuhuber WL, Kissling ROI. Innervation of the sacroiliac joint of the human. Z Rheumatol 1995;54(2):117–22.PubMedGoogle Scholar
  68. 68.
    Fortin JD, Aprill CN, Ponthieux B, et al. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine 1994;19(13):1475–82.PubMedCrossRefGoogle Scholar
  69. 69.
    Fortin JD, Dwyer AP, West S. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine 1994;19(13):1483–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Fortin JD, Falco FJ. The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop 1997;26(7):477–80.PubMedGoogle Scholar
  71. 71.
    Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16(10):1539–50.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Jonathan T. Bravman
    • 1
  • Hector Mejia
    • 1
  • Vikas V. Patel
    • 1
  • Venu Akuthota
    • 1
    • 2
  1. 1.Resident Physician in Orthopaedic Surgery, Department of OrthopaedicsUniversity of ColoradoAuroraUSA
  2. 2.The Spine CenterDenverUSA

Personalised recommendations