Many studies in the more than 20 years have shown that spinal pathologies, certain types of posture and pelvic tilts, and similar structural “problems” do not always correlate or associate with pain, disability, and daily function. Even among elite Olympic athletes, MRI scans, and other types of scans found similar trends.

A recent American study, led by Dr. Michael Wasserman, who is a resident at the Boston Medical Center, found that 52 out of the sample of 100 athletes who competed in the 2016 Rio de Janeiro Olympic Games had various types of spinal pathologies. These athletes had their spine scanned during the event. Among this sample, athletes who were in “athletics”—track and field, for example—had the highest number of positive findings in the scan, with 15 out of 31 athletes (48%). Judo was the next highest with 5 out of 8 athletes (63%), followed by diving and weightlifting—both with 4 out of 6 positive findings (67%).

​But why do these sports have such high number of positive findings?

“Athletics accounted for the majority of athletes participating in the Rio de Janeiro 2016 Summer Olympic Games, approximately 21 percent of all athletes. It also accounted for the majority of MRIs and positive studies, but athletics did not have the highest sport-specific incidence of positive studies.”  Dr. Michael Wasserman explained in an online interview with Massage & Fitness Magazine.

“Multiple sports, including aquatic diving, judo, and weightlifting, had higher sport-specific incidence of positive studies. This finding is likely multifactorial and related to the large amount of physical stress and/or physical impact that is placed upon the elite athlete participating in these sports.

​“While diving may not sound like a contact sport, diving from a height of 10 meters can be devastating to the spine and other joints if not performed with adequate technique. When taking into account the twisting, flipping, and turning these athletes are performing, in addition to the standard technique of the sport, moderate to severe spinal pathologies do not seem too far-fetched.”

Wasserman et al. used the Pfirrmann classification system to evaluate the state of various spinal pathologies, such as degenerative disc disease, which ranges from Grade I to V, with I to III being a range of “normal” with various differences in disc height and distinction between the annulus, and nucleus pulposus, IV having hardly any distinction between the annulus and nucleus, and V having no structure distinction and the disc had lost nearly all of its height.

The study also examined the number of  chronic and acute spinal pathologies. The authors found that 35% of the positive findings had moderate to severe degeneration (grades IV and V). Eighty-four percent of the findings were of the lumbar spine while 16% were of the cervical spine. Interestingly, there were no findings of pathologies in the thoracic spine.

Other findings include:
– 10 of the MRIs found “moderate to severe [spinal] canal narrowing.”
– 6 out of these 10 scans were of the lumbar spine and the rest were from the cervical spine.
– Sports that were often associated with such narrowing include judo, sailing, tennis, rugby, water polo, and boxing.
– 14 of the MRIs found “moderate to severe neural foaminal narrowing.”
– 7 were from lumbar spine and the rest were from cervical spine.
– Sports that were often associated with this include diving, weightlifting, hockey, rugby, sailing, and shooting.

Acute spinal pathologies accounted for just 4% of the cases (4 out of 107 MRIs). All but one of these cases had endplate stress reaction in the lumbar spine (1 female rugby, 1 male runner, 1 female handball). That one remaining case had pars interrarticularis at L5 (female weightlifter). ​

When asked if this sample makes a fair representation of the entire athletic population of the 2016 Olympic Games, Dr. Wassermen told me that while the sample size isn’t very large, the fact that more than half of the imaged athletes have moderate to severe spinal pathologies is “impressive.”

“If a greater number of Olympic athletes were imaged, I think we would find that a high proportion of these athletes are living and performing amazingly well with moderate to severe spinal pathologies. Only by evaluating the MRIs of these athletes would we be able to determine specifically how many athletes are affected,” Dr. Wasserman said.

Although the severity of the spinal pathologies are present, it is not always an indication that these athletes have pain or performance inhibition. Various studies have shown that people can have less disc thickness, Grade IV and V spinal degeneration, and herniated discs with no pain or disability. (See image below.)

“Individuals who have severe debilitating pain do not necessarily have severe radiologic findings, and vice versa,” Dr. Wasserman explained. “This is also true for other joints such as the knee and hip. In general practice, we frequently encounter MRI studies for patients in severe pain that demonstrate only minimal degenerative changes of the spine. In contrast, oftentimes, we incidentally diagnose severe spondylosis, disc bulges, and degenerative joint disease in patients who are receiving scans for a completely different indication and are seemingly unaware of their severe degenerative spinal pathologies.

“That being said, I believe there are many factors that influence the sensation of pain — from physical activity and diet to one’s coping mechanisms. Not all spine pathologies detected on MRI need to be addressed and treated for Olympic athletes or the general population. However, when these pathologies are at risk of progression, may lead to permanent damage, or cause significant symptoms, it is recommended that athletes and individuals from the general population assess the management options available to them on an individual basis.”

Because of patient confidentiality reasons, Dr. Wasserman did not disclose whether the Olympic athletes who had imaging had pain or changes in performance or not. “In order to maintain athlete privacy and remain unbiased in assessment of the MRI studies, we were not presented with the athlete’s symptoms nor their performance outcomes during training and competition. We expect most of the imaged athletes consulted at the Olympic Clinic were because of symptoms such as back pain.”

“This study provides further evidence that structure is not destiny and that pathological findings do not preclude athletes from reaching world class levels in sport.” ~ Christopher Johnson, MPT

While the information in this study isn’t groundbreaking because similar research and findings were also conducted during the 2014 Sochi Games, 2012 London Games, 2010 Vancouver Games, 2008 Beijing Games, many physiotherapists had shared this on social media which had generated more discussions on the reliability of imaging for diagnosis of pain and other issues.

Physiotherapist Christopher Johnson, who practices in Seattle, Washington, and works with many running athletes, had some thoughts of what therapists and other clinicians should consider when reading this study.

“Considering the retrospective nature of the study and relatively little information provided beyond the results of the scans, age, sex, and discipline/sporting event, it’s difficult to draw any definitive conclusions aside from the fact that less than one percent of high-level athletes are likely to seek diagnostic imaging during the Summer Olympic Games, where a large percentage represented European countries,” Christopher explained in an online interview. “And over half of these athletes were identified as positive for spinal pathology.”

Christopher also added some questions that clinicians should ask:

1. Did the athletes who received imaging came at their own discretion or at the advice of a medical professional? What did the athletes tell the clinicians, such as the nature of their injury and complaints?

2. Was there an attempt to differentiate neuropathic and non-neuropathic  pain?

3. Was there a baseline to determine the prevalence of positive findings as described by the authors?

4. When were the imagings collected relative to the scheduled competitions or events?

“Finally, it seems shortsighted to simply conclude that, ‘Spine-conscious training, routines and maneuvers are recommended to prevent the development and progression of these acute and chronic spinal pathologies,’ as what specifically constitutes a spine-conscious training program, and what data exists proving their efficacy in preventing or delaying acute and chronic spinal pathologies?” Christopher reflected.

“One of the major takeaways, which has previously been shown in the literature, is the disconnect between structural pathology and function,” Christopher added. “This study provides further evidence that structure is not destiny and that pathological findings do not preclude athletes from reaching world class levels in sport. While diagnostics have an important role in healthcare and the comprehensive management of athletes, healthcare professionals should not necessarily be overly concerned about any ‘positive’ MRI findings unless they are consistent with a worsening in an athlete’s state or relate to a decline in functional abilities.

“Nonetheless, communication between athletes and their support team/staff (ATCs, PTs, DCs, MDs, etc.) should always take centerstage and results from image must always be plugged into context and the clinical reasoning process. Bear in mind that one cannot image pain and that there are various loads beyond the physical domain that must be considered to fully appreciate the overall health of the athlete beyond the state of their tissues.”

Massage & Fitness Magazine thanks Dr. Michael Wasserman for this time and effort for the interview, and Christopher Johnson for applying clinical reasoning with the research.

 

Reference

1. Wasserman MS, Guermazi A, Jarraya M, et al. Evaluation of spine MRIs in athletes participating in the Rio de Janeiro 2016 Summer Olympic Games [published correction appears in BMJ Open Sport Exerc Med. 2018 Mar 27;4(1):e000335corr1]. BMJ Open Sport Exerc Med. 2018;4(1):e000335. Published 2018 Mar 8. doi:10.1136/bmjsem-2017-000335