This case report describes an uncommon case of a 25-year old male football lineman who presented with low back pain. MRI revealed a herniated disc at L5-S1. Surgery was expected to be a microdiscectomy but had to be changed to a discectomy with laminotomy due to extensive damage. During surgery, the surgeon had to repair the dura and bundled nerves around the herniated disc. Though an uncommon presentation, the patient made a full recovery after surgery and returned to normal activities.

1. Low back injury in a football lineman: A case report
Nielsen, Jayson, Weber State University
Background: A 25 year old male football lineman presented with low back pain but it became
worse as he started to lift heavier weights. He had decreased range of motion in all planes and
decreased strength in his lower extremity. Differential Diagnosis: The problems that it could be
was a disc herniation, right SI Pain, and back pain. Treatment: The patient went through 4
months of rehabilitation with included range of motion exercise, strengthening and therapeutic
modalities. The patient still had pain and so surgery was requested. An MRI showed a herniated
disc at L5/S1. The patient was scheduled to have a microdiscectomy but it turned into a
discectomy with a laminotomy because of the extensive damage. The surgeon also had to cut
part of the dura and he noticed that there were nerves that were bundled up on his disc. These
were repaired and the patient returned to his normal activates of daily living. Uniqueness: This
patients uniqueness is that he had to have his dura cut in surgery which is uncommon and that
there was a bundle of nerves that were wrapped around his herniated disc that had to be fixed.
Conclusion: This patient showed the common signs of a typical low back pain injury. An MRI
resulted in diagnosing that it was a disc herniation. The surgery that was expected had to be
changed because of the extensive damage to the patients L5/S1 disc. This was uncommon but
was able to be repaired by the surgery and the patient is back to his activities of daily living.
Word Count: 278

2. Low back pain can be a common problem among athletes especially football players.1 Many
studies have shown that athletes with low back pain usually end up with different abnormalities
in their spine such as spondylolysis, spondylolisthesis, schmorl’s node, disc space narrowing,
scoliosis, and apophyseal abnormalities.1 There are many reasons why athletes can have more
back pain but one reason could be that the kinetic chain in the lower extremity can acquire more
laxity or overuse injuries in the lower extremity.2 Another option for low back pain is that here
can be degenerative changes in the spine.3 The facet joint is usually the most common
degenerative change that occurs in the spine but degenerative changes usually are uncommon
among high school and college athletes.3
A Lumbar disc herniation can be problem for patients that have back pain problems. A common
cause from lumbar disc herniation’s is a condition called sciatica.4 Sciatica is a condition where
there is pain and numbness down the leg because of the sciatic nerve being compromised.4 Disc
degeneration in the lumbar spine can also be one of the common factors for low back pain.5
There are different ways to see if someone has a lumbar disc herniation. A computed
tomography (CT) is a common way to see if there is a disc herniation.3 Another option is to use
an MRI or a bone scan to see if there is any bone growth going on.3 Bone remodeling can occur
if there are changes to the stresses that are on the vertebral bodies.6
A common way to treat this is to do surgery. There is a couple options when is comes to getting
surgery. One option is to do a microdiscectomy. This is where they go in and remove any bone
or disc material that may cause any impingement on the nerve root.7 This has been shown to

3. have a high success rate.8 Another option is a discectomy and that is where they go in on the
anterior side and remove some of the herniated disc.9,10
Surgeries vs. non-surgical treatments have been looked at and it appears that has been
improvements in both groups. Surgury was seen as a better option for people with leg pain or
disc herniations.11
Case Report
A 25-year-old male football athlete presented with low back pain that began last summer when
he was lifting weights. The patient said that the pain that he sustained while lifting in the summer
carried over to the fall football season. During that season he said that the pain went away and
then he sustained an ACL injury, which ended his football season. The patient rehabbed his ACL
injury to full strength and then when he started to lift heavy weight again he started to get low
back pain again.
This patient said that he doesn’t remember any MOI but that he has had pain when he wakes up
in the morning. The pain is aggravated when he is sitting and when he squats or attempts to bend
his hips to parallel. The location of his pain was in the right SI joint and it radiated down to his
priformis. He described the pain as being achy and sharp especially with truck flexion. Some of
the things that alleviated the pain was stretching, rest, and joint mobs.

4. When looking at the patient’s range of motion he was lacking 90% of trunk flexion, 50% of
trunk extension, 50% of right trunk rotation, 50% of left trunk rotation, 25% of right trunk side
bend, and left trunk side bend. Some of his flexibility restrictions were in his right hip flexors,
left hip flexors, right hamstring, left hamstring, right pirformis, and left piriformis.
On the patients manual muscle tests he was a 4/5 on his right hamstring, left hamstring,
abdominals, right hip adductors, left hip adductors, right hip internal rotators, and left hip
internal rotators. The patient was a 4-/5 on his right gluteus medius, left gluteus medius, right hip
external rotators, and left hip external rotators. The special tests that were negative were the
unilateral straight leg raise test on the left and right side. The tests that were positive were the
piriformis test and the SI joint stress test. Joint mobility was assessed and it was determined that
he had a hypomobile sacrum.
The short term goals for this patient were to increase AROM in the trunk to be within normal
limits in all planes, have no tenderness to palpation in the low back and pelvis, and to be
independent with home exercise program for progress toward long term goals. The long-term
goals were to increase his strength in the trunk and lower extremities to be a 5/5 in all planes of
motion, to exhibit good biomechanics in the spine and pelvis with negative special tests and no
pelvic asymmetries, and to return to all activities of daily living and recreational activities
without pain or deficit.
Rehabilitation

5. Rehabilitation and treatment began immediately under the medical direction of the physical
therapist and the athletic trainer. The plan of care was manual therapy, therapeutic exercise,
neuromuscular reeducation, functional training activities, soft tissue massage, patient education
and a home exercise program. The estimated amount of time in therapy was biweekly for 8-10
weeks.
Table 1 illustrates some of the rehabilitation exercises that this patient went through. Each week
the patient went through a series of exercise in order to gain strength, increase range of motion,
and to have less pain in his back. The equipment that was used was an exercise ball, therabands,
weights, and body motions. Joint mobs were also done to help increase range of motion and
decrease pain along with traction. The patient progressed through rehabilitation and increased
intensity and reps where pain would allow.
Table 1
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
Exercises
Mckenzie
press ups-
sacral mobility
3 x 12
Mckenzie
press ups-
sacral mobility
3 x 12
Rhythmic stab
on BOSU red
3 x 1 min.
Prone
press
ups 3 x
10
Prone
press ups 3
x 12
Prone press
ups 3 x 12
Lateral
shuffles 3 x
locker room
Bird Dogs 3 x
8
Supine LTR
with opposite
UE rotation
Blue 3 x 12
D1/D2
2 lbs 3
x 12
Supine
Tball walk
out 3 x 12
Rhythmic
stabilization on
BOSU red 3 x
1 min.
Supine flutter
kick 3 x of 30
sec.
Tball crunches
with march 4 x
12
Side plank
with hips up
and down 3 x
10
Prone
hip ext
with
knee
flexion
4 x 8
Kneeling
Tball 4 x 1
min
90 degree
lunge 4 x 10
Bridge with
ER red 4 x 10
Rhythmic Stab
(Red) Dina
Disc 4 x 1 min
Supine DL
straight 4 x 8
Oblique
crunch
on
Tball 3
x 10
Duck
Walks
retro/latera
l (red) 3
down and
Seated Tball
trunk rotation
red 4 x 10

6. backs
D1/D2 3 lbs 3
x 10
Prone
swimmers 3 x
1 min
Supine Tball
walk out 4 x 8
Tractio
n 41 lbs
5 off,
15 min.
Wide
stance
bending 3
x 12
Qaudruped hip
opener 3 x 10
Wall lunge
with Tball 3 x
10
Quadruped hip
opener 4 x 15
Quadruped hip
opener 3 x 10
Nerve
glides 3 x
10
Check
pelvis/sacrum/j
t mobs
Bridge with
marching on
BOSU 3 x 1
minute
Heel sits 3 x 1
min
Heel sits 3 x 1
min.
Prone traction
65 lbs, 5 off,
15 minutes
Quadruped hip
opener 3 x 12
Check
pelvis/sacrum/j
t mobs
Check
pelvis/sacrum/j
t mobs
Heel sits 3 x 1
minute
Traction 34 lbs
5 off 15
minutes
Check
pelvis/sacrum/j
t mobs
Surgery
The patient still wasn’t recovering from his back pain and he was starting to have pain go down
into his hamstring. He had an MRI done and it showed that there was a disc herniation at L5-S1.
He opted to have surgery to repair the disc. The surgery that was scheduled to be done was a
microdiscectomy, where they go in and remove any bone or disc material that may cause any
impingement on the nerve root.7 The microdiscectomy turned into a discectomy with
laminotomy, which is surgery on lamina to help with lumbar disc injuries.12 The nerves were
mangled around the herniated disc and were stuck to the disc. The surgeon shaved a hole in the
lamina and removed the herniated part of the disc and sutured that up. Next the surgeon had to
tear the dura in order to release the herniation that was stuck to the dura. Because of this the
patient was leaking cerebral spinal fluid so they had to suture up that area. The nerves in his back

7. were so displaced from being so wound up in the disc and from the other parts of the surgery that
they had to suture them back into place.
The patient complained of pain for about a week after the surgery and then started to have relief
from his pain. The patient said that after about 3-4 weeks after the surgery that he has no back
pain that he used to have and can go about his activities of daily living with no problems.
Discussion
This patient condition is uncommon. He presented with pain in his low back that he has had for
an extended period of time and it became worse because of the heavy lifting he was doing. This
is common for patients that have any type of low back.13 The patient elected to have surgery after
the non-surgical treatments did not help with his pain. Surgery is a common option for people
that have lumbar disc pain and has been seen to be the better option compared to non-surgical
treatment for patients with disc herniation and leg pain.14 The interesting thing is that the patient
had all the signs and symptoms of a common disc herniation but when the surgery took place
they had to do a discectomy with a laminotomy. They also had to repair the dura which is
uncommon to tear15 when doing a discectomy but it had to occur in order to get the herniation
out of the area. The other uncommon thing is that the nerve roots were so mangled in the
herniated part of the disc that they had to be removed and put back together.
Conclusion

8. Low back pain is common for football players and can lead to other problems if not treated. Non-
operative treatments have been seen to work well but surgical treatments seem to be the best for
people with low back pain that extends into the leg.14 This patient had an unusual disc herniation
that was suppose to be surgically repaired by a microdiscectomy but it turned into a discectomy
with a laminotomy. They also had to repair the dura as it had part of the disc attached to it. There
was also a lot of nerves that were bundled around the herniated area that had to be repaired. The
patient has had a full recovery and his activities of daily living have improved.
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