This case report describes a Division I volleyball player who was diagnosed with idiopathic scoliosis at age 13 and later developed degenerative disc disease. MRI imaging at age 19 revealed disc extrusion and spinal stenosis. A core stabilization program and electrotherapy were implemented to manage pain, allowing her to continue playing volleyball without loss of participation. While the rehabilitation showed some success, adherence was inconsistent. Core stabilization programs have been shown to effectively treat low back pain, but compliance is important for achieving optimal outcomes.

1. Scoliosis with Degenerative Disc Disease in a Collegiate Women’s
Volleyball Player: A Case Report on Decreasing Pain Without Loss of
Play Time
Allison M. Corcino
California State University, Fresno
ABSTRACT
Background: A 19-year-old NCAA Division I
women’s volleyball player diagnosed with
idiopathic scoliosis during elementary school
screening in fifth grade, that ultimately caused pain
while participating in competitive volleyball for 13
years. As she transitioned into NCAA Division I
Intercollegiate Volleyball, she complained of sharp,
aching pain in the upper thoracic and lower lumbar
spine. The supervising athletic trainer treated the
pain and consulted the team physician.
Differential Diagnosis: Muscular imbalance,
Spondylosis
Treatment: The patients existing condition of
idiopathic scoliosis prompted the team physician to
refer for an anteroposterior Magnetic Resonance
Image (MRI). The MRI revealed extensive disc
disease and extrusion, central spinal stenosis,
annular tears and osteophytes in multiple levels of
the lumbar spine. A core stabilization program was
implemented with the help of a chiropractor, while
the athletic trainer utilized neuromuscular electrical
stimulation, heat therapy and cryotherapy to
manage symptoms associated with degenerative
disc disease.
Uniqueness: Although diagnosed at a young age
with spinal curvature measuring 45º, the patient was
not treated with surgical intervention or typical
bracing techniques. Patient has participated in
competitive volleyball for 13 years and continues to
participate in Division I intercollegiate women’s
volleyball with interventions used daily for
treatment of pain.
Conclusions: Increased success with secondary
treatment denotes that both patient and clinician
adherence to rehabilitation is important in the
treatment of pain associated with idiopathic
scoliosis. The Schroth method is a rehabilitation
protocol that can be utilized for scoliosis patients
who have not been treated surgically or with
bracing techniques, but is impractical for treatment
in the athletic training setting due to the amount of
treatment time necessary for success.
diopathic scoliosis is identified as scoliosis with
no underlying disease causing the deviation of
the spinal axis (Trobisch et al, 2010). A criterion
for diagnosing scoliosis is a spinal curvature
exceeding ten degrees, viewed on an anteroposterior
radiograph imaging machine (Trobisch, 2010). This
particular case is unique in that the patient is a 19-
year-old female competing in intercollegiate
Division I Volleyball with scoliosis convex to the
right, diagnosed as a child at a 45º
curvature. Extensive disc disease with central disc
extrusion is present in her spine at the L3-4 central
and left paracentral disc extrusion at the L4-L5
level. Left paracentral disc extrusion is also present
at the L5-S1 level. Research has shown that middle-
aged patients with idiopathic scoliosis have an
increased frequency of disc degeneration and back
pain
(Trobisch, 2010). Although the patient is not
middle aged, she suffered from spinal stenosis as
well as disc extrusion as complications from her
diagnosed idiopathic scoliosis. This case report will
discuss the rehabilitation methods used to decrease
pain while the patient continued to participate in
intercollegiate athletics.
CASE REPORT
During
an
examination
in
the
fifth
grade,
a
NCAA
Division
1
women’s
volleyball
player
showed
signs
of
scoliosis
during
a
routine
elementary
school
screening
for
early
detection.
Upon
the
visit
to
Children’s
Hospital,
radiographs
showed
Idiopathic
Scoliosis
present
in
the
spine.
The
physician
stated
that
her
case
was
a
very
unique
form
of
scoliosis
and
that
she
had
curvatures
in
both
her
upper
thoracic
and
cervical
spine.
The
physician
mentioned
that
it
I

2. was
unusual
that
the
sacro-­‐iliac
joints
were
unaffected.
During
her
freshman
year
of
high
school
competition,
noticeable
spinal
changes
and
left
shoulder
elevation
caused
a
sharp
shooting
pain
that
affected
her
upper
thoracic
and
lumbar
spine.
As
she
matured,
she
noticed
when
competition
and
time
on
the
court
increased,
pain
also
increased.
At
this
time,
the
student-­‐athlete
also
noted
that
repeated
shoulder
and
vertebral
flexion
and
extension
caused
sharp,
shooting
pain
in
her
lumbar
and
upper
thoracic
spine.
She
competed
in
high
school
volleyball
as
a
starter,
but
had
no
treatment
or
rehabilitation
during
these
years.
During her sophomore year in college, the
student-athlete complained of sharp, aching pain in
her upper thoracic and lower lumbar spine that
increased during practice when she performed
excessive hitting. She also noted an increase in pain
when she felt “overworked”, having multiple
practices daily paired with multiple games in a
week. Upon evaluation, the Certified Athletic
Trainer (ATC) found that trunk rotation placed
stress on the intrinsic muscles of her spine, causing
muscle cramping and sharp pains. The athlete and
ATC met with the team physician during a weekly
physician clinic held at the University, and the
physician referred the patient to receive a Magnetic
Resonance Image (MRI) of the lumbar spine.
Findings of the MRI results showed
extensive disc disease, central spinal stenosis,
central disc extrusion, and annular tears located in
the lumbar spine. Extensive disc disease and
extrusion measured 6mm the L3 and L4 levels. Also
at this level, moderate central spinal stenosis was
present along with minimal inferior extension of
discal material measuring 4mm. Increased signal is
shown at the L3-4 level that suggests an annular
tear. A 6mm central and left paracentral disc
extrusion was noted at L4 and L5, along with an
increased signal that represents an annular tear and
spinal stenosis at this level. At the L5-S1 level there
was a median disc extrusion that measured 4mm,
and increased signal suggesting an annular tear. The
origin of the left S1 nerve root at the L5-S1 level
appears posteriorly displaced to the right.
Osteophytes deposited at L3-4, L4-5, and L5-S1
suggest degeneration of cartilage in the vertebral
joints. Right and left sacro-iliac joints appeared
maintained.
REHABILITATION
The supervising Athletic Trainer consulted
the team chiropractor to assist in the design of a
rehabilitation program. A modified Watkins-
Randall core stabilization program was created to
lengthen the spine and decrease muscle spasm
symptoms (see Table 1). The athlete remained in
competition at full participation, and was only
limited when necessary. Records indicate that this
rehabilitation program began in August 2014, but at
the time, adherence to rehabilitation was
documented only once per week. It is unknown if
the athlete was scheduled daily, and was not
compliant with the schedule, or if the supervising
athletic trainer did not schedule her consistently. In
February 2015, Crossover Symmetry (see Image 1)
was added into the rehabilitation protocol, and was
done on average 3x per week. However, it is
unknown if the athlete came into treatment greater
than three times per week for treatment of
symptoms associated with diagnosed idiopathic
scoliosis. Before participation in practice or weekly
weight training, interferential electrical stimulation
was utilized on the lumbar region to treat sharp
aching pain in combination with a moist heat pack.
Hi-Volt electrical stimulation was also used in
combination with a moist heat pack on the right
upper thoracic portion of the spine to treat muscle
spasms and aching pain before practice. On days
where the athlete felt overworked and sore,
electrical stimulation was used in combination with
cryotherapy to reduce pain and symptoms
associated with her diagnosis.
Image 1. Crossover Symmetry Rehabilitation

3. Table 1. Daily Stabilization Protocol - Modified Watkins-Randall
Exercise Level 1 Level 2 Level 3 Level 4 Level 5
Superman 2 min
Alternate arms
2 min
Alternate
Opposite
Arms/Legs
3 min
Arms/Legs up
2# legs
4 min
Arms/Legs up
3# legs
5 min
Arms/Legs up
4# legs
Partial Sit-ups
Forward &
Diagonal
3 x 10 each 3 x 20 each 3 x 30 each
2.5#
3 x 30 each
5#
3 x 50 each
5#
Dying Bug
3 x R, 1 x L
2 min
Slow Pace
One foot on the
ground
2 min
Moderate pace
2 min
Straight Leg
Slow pace
2 min
Straight Leg
Moderate
pace
3 min
Straight Leg
Moderate Pace
Bridge 3 min
Both feet on
floor
Hold 10 sec
3 min
Alternate legs
Hold 10 sec
4 min
Alternate legs
Hold 10 sec
5 min
Alternate legs
7 min
Alternate legs
Hold 10 sec
Child’s Pose
Traction
15x 20x 25x 30x 35x
Quadraped 2 min
Slow reps
Knees flexed
2 min
Slow reps
Flexed knee to
extension
2 min
Slow reps
Leg extended
3 min
Slow reps
Leg extended
4 min
Leg extended
Moderate
transition
Wall Squat 1 min hold 1.5 min hold 2 min hold 3 min hold 5 min hold
Lunges 1 min
Slow reps
Partial dips
Slow transition
2 min
15 sec hold
Partial dips
Moderate
transition
3 min
15 sec hold
90° dips
Quick
transition
3 min
15 sec hold
90° dips
Quick
transition
3# arms
5 min
15 sec hold
90° dips
Quick
transition
5# arms
Prone Plank 30 sec 1 min 2 min 3 min 5 min
Sitting Thoracic
Rotation
10x each way 20x each way 25x each way
5#
30x each way
7#
30x each way
10#
Bridge W/ Reach
3 x R, 1 x L
2 min
Arm by side
3 min
Arm by side
3 min
Arm at 90°
ABD
4 min
Arm at 90°
ABD
5 min
Arm at 180°
ABD

4. DISCUSSION
There
are
many
limitations
to
this
case
report.
Although
the
ATC
utilized
multiple
available
resources,
it
seems
that
the
athletes
non
compliance
affected
the
possible
positive
outcomes
of
the
rehabilitation
process.
It
is
important
to
note
that
core
rehabilitation
can
positively
affect
the
symptoms
associated
with
low
back
pain.
In
a
systematic
review
reviewing
the
clinical
effectiveness
of
core
stabilization
exercises
in
the
reduction
of
chronic,
acute
and
subacute
low
back
pain
LBP,
it
was
found
that
segmental
stabilizing
programs
are
more
effective
in
the
treatment
of
LBP
in
reducing
long-­‐term
recurrence
of
low
back
pain
than
comparison
to
treatment
by
general
practitioner
alone
(Standaert,
C.,
Herring,
S.,
2007).
In
terms
of
rehabilitation
programs,
it
is
safe
to
assume
that
athlete
compliance
will
increase
positive
effects
if
utilizing
evidence
based
literature
to
treat
injuries.
Half
of
interventions
seem
to
fail,
although
successful
adherence
interventions
exist
(Dulmen
et
al,
2007).
Poor
health
outcomes,
low
quality
of
life,
and
increased
health
care
costs
are
repercussions
of
non-­‐adherence
to
medical
treatment
resulting
in
the
inability
to
gain
maximum
benefits
of
medical
treatment
(Dulmen,
2007).
A variety of conservative treatments are
utilized in the conservative treatment of idiopathic
scoliosis. Interventions such as physical exercises,
neuromuscular electrical stimulation, manipulation
techniques, physical therapy, bracing, and insoles
are common in the treatment of adolescents with
developing scoliosis. These treatments are aimed at
reversing or diminishing the curvature of the spine
while the patients are still maturing, with literature
to support the impact of physical exercise on
decreasing spinal curvature associated with
scoliosis. Intensive inpatient physiotherapy protocol
was introduced in rehabilitations of 107 patients
between the ages of 10.9-48.8 with average curves
of 43º (Fusco et. al., 2011). Treatment included the
rehabilitation of 4-6 weeks at 6-8 hours per day of
elongation of the spine, realignment of trunk
segments, positioning of the arms, the use of
specific breathing patterns with proprioceptive
control exercises (Fusco, 2011). An improvement
was found in 44% of patients with a worsening in
only 3% (Fusco, 2011). This intensive inpatient
physiotherapy protocol was mirrored off of the
Schroth method originally proposed by Katharina
Schroth in 1921 (Weiss, 2011). Schroth developed
her program inspired by a balloon, correcting it by
inflating the concavities of her body in front of a
mirror and recognized that “postural control can
only be achieved by changing postural perception”
(Weiss, 2011). Implementation of this method in the
athletic training setting is impractical due to the
amount of rehabilitation time needed for success of
the Schroth method.
There is a lack of clinical trials and research
information on the Watkins-Randall lumbar trunk
stabilization protocol; no peer-reviewed original
research has been done or could be found.. Due to
this, it was difficult to verify if this is a quality
treatment option utilized for core stabilization.
CONCLUSION
After
the
initial
treatment
of
core
stabilization
program
and
treatment
by
use
of
NMES
as
well
as
heat
and
cryotherapy,
the
patient
went
home
for
summer
and
returned
the
following
year
with
the
same
signs
and
symptoms.
The
position
of
athletic
trainer
has
recently
changed,
and
the
implementation
of
rehabilitation
by
Watkins-­‐Randall
techniques
has
been
successful
in
the
decrease
of
symptoms
associated.
Part
of
the
success
is
that
the
athlete
is
required
to
complete
the
exercises
at
least
three
times
per
week,
and
has
been
required
to
come
in
for
treatments
every
day
before
and
after
games.
The
supervising
athletic
trainer
has
decided
to
implement
cross
symmetry
three
times
a
week
during
the
off-­‐season
and
suspects
positive
results
as
she
has
used
this
rehabilitation
protocol
for
athletes
with
back
pain
in
the
past.
Due to the athletes success of decreased pain
and increased mobility, it is important to note that
the only factors that changed was the amount of
rehabilitation sessions, as well as patient education
as to why it is important to utilize compliant
rehabilitation in combination with treatment by
general practitioner.
Through researching the Schroth method, it
it is found that it is a rehabilitation technique that
should be considered when working with athletes
and patients alike that are diagnosed with Idiopathic
Scoliosis. As a future clinician, these rehabilitative
techniques will be researched and utilized to
increase evidence-based practice in the treatment of
spine related injuries in the future.

5. With the treatment of idiopathic scoliosis,
the athletic trainer will usually come in contact with
this patient when they are almost fully developed
and have gone through other conservative or
surgical treatment options. It is important to
research and utilize evidence based practice as well
as clinician and patient adherence to rehabilitation
for increased results.
REFERENCES
1. Dulmen, S., Sluijs, E., Dijk, L., Ridder, D.,
Heerdink, R., Bensing, J. (2007). Patient
adherence to medical treatment: a review of
reviews. BMC Health Services Research 2007,
7(55).
2. Fusco, C. , Zaina, F. , Atanasio, S. , Romano,
M. , Negrini, A. , et al. (2011). Physical
exercises in the treatment of adolescent
idiopathic scoliosis: An updated systematic
review. Physiotherapy Theory and Practice,
27(1), 80-114.
3. Standaert, C. , & Herring, S. (2007). Expert
opinion and controversies in musculoskeletal
and sports medicine: Core stabilization as a
treatment for low back pain. Archives of
Physical Medicine and Rehabilitation, 88(12),
1734-1736.
4. Trobisch, P. , Suess, O. , & Schwab, F. (2010).
Idiopathic Scoliosis. Deutsches Arzteblatt
International, 107(49), 875-U27.
5. Weiss, H. (2011). The Method of Katharina
Schroth - history, principles and current
development. Scoliosis, 6(1), 17.