Watch this video of Dr Matthew Cosgrave, Consultant Sports & Exercise Medicine Physician. Presenting on ‘Sports Medicine and Low Back Pain.’
This video was recorded as part of SSC’s Online Public Information Meeting, focusing on Back pain & the Spine.
MB BCh BAO MFSEM (IRL & UK) MSc (SEM)
Dr Matthew Cosgrave is a Consultant in Sports and Exercise Medicine. A graduate of Medicine from Queen’s University Belfast in 2011, Dr Cosgrave undertook an MSc in Sports and Exercise Medicine at The University of Bath before completing specialty training in General Practice in Belfast in 2018. Dr Cosgrave worked as a general practitioner with a specialist interest in musculoskeletal and sports team care and as a specialty doctor in pre-hospital medicine before moving to Dublin to complete Higher Specialty Training in Sports and Exercise Medicine in Ireland.
Hello everybody, good evening; I hope you’re enjoying the evening. I’m delighted to be able to join you and discuss the sports medicine doctor’s role in managing low back pain. My name is Dr Matt Cosgrave or Matthew, and by introducing a little bit of my background, I studied in Belfast at Queens University. I originally trained as a GP, working through various Specialties in the NHS. Then I moved down to Dublin to pursue a career in sport and exercise medicine and did my speciality training in Dublin outside of working in the clinic here at Santry. I work with a number of sports teams, but over the last three or four years, I’ve had the pleasure of mainly working with the Irish Women’s National Rugby team and, over the last couple of years, with Connacht rugby men’s senior team. From the point of view, what I hope for you to get out of my talk today is to answer these three questions do I need to see a sports medicine physician? Do I need an MRI, and do I need an injection? Before we get into things, I’d like to reassure you all that when we talk to patients, these are the three most common emotions that they present with in relation to low back pain worry over some underlying disease process or pathology that maybe they’re missing, confusion over often why their pain isn’t getting better or why their pain comes and goes unpredictably or apathy which is really a down to a lack of motivation around managing their pain and that no matter what they seem to do they’re always suffering. Interestingly enough, these three CM emotions are often what positions physiotherapists or General Practitioners experience with low back pain because it can be tricky. Still, hopefully, I will try and uncover some of the Hidden Truths Behind that today.
I don’t think we help ourselves by calling ourselves Sports Medicine Physicians; this is a common misconception that the only people that we treat are people who do sports or athletes; we are musculoskeletal Physicians, so yes, we do look out for teams, yes we do look after athletes, but we look after any active individual which from the point of view of day to day that’s the general public and the vast majority of the patients that we see in care are general public and are not high-flying athletes in any shape or form. About eighty percent of people at some stage in their life will experience low back pain. Interestingly, about eighty percent of these cases will improve on their own or with very little treatment within about six weeks. My rule comes into it whenever we have this huge chunk of 20 percent who are not improving over the three to six weeks or the three-month to six-month period, which can be a substantial number when you cross when you break it all down.
Really what the sports medicine physician does is considers do we need to order other investigations now this may be a scan of some description a CT an MRI or it may be some blood tests really the main role for us is to confirm a diagnosis often once we have the diagnosis actually managing the problem can be quite straightforward sometimes when we’re in the dark about the diagnosis we try and we almost have a trial and error process but if we can confirm a diagnosis it’s often fairly straightforward to get on a plan to recovery excluding severe pathology is a big part of this and this falls into the worry side of things for patients a big concern that patients often have is there some sort of underlying disease process such as cancer and that is extremely rare when it comes to low back pain but nonetheless when back pain has been going on for a long time it’s always something that we have in the back of our mind and it’s always something that we make sure we exclude we’ll also review the treatment plan that the physiotherapist or the GP has already put in place and we’ll see can we add to that we rarely change things significantly but we’ll make small adjustments and then finally we think about treatment adjuncts so rehab is a huge part of what we do here in the clinic but there’s always options for some additional help and often for us that falls in the way of injection therapy which I’ll discuss for you in a little bit further detail later.
The simple answer is no, not everybody needs an MRI, and most patients with low back pain don’t require an MRI. This great graphic explains why we don’t all need MRI. These are findings on individuals who are asymptomatic so people with no back pain have a variety of changes, and the percentage of patients who have changes increases with age; just for one example, this degeneration in this top area which is often reported on scans and often causes concern for patients nearly 100 percent of patients in their 80’s will have this degeneration but even more interesting at the age of 30 one in every two patients will have some degree of disc degeneration on their scan even if they are asymptomatic. Hence, a scan is not always necessary.
So when is the scan necessary?
We use scans; this is what the sports medicine position is looking for if we go clockwise from the top left; this is a condition called sacroiliitis. This is an inflammatory process where you get some inflammation in the base of the lumbar spine where the sacrum, a little triangular bone, fits into the pelvis; we look for sacroiliitis because it doesn’t normally respond to Conventional treatment. Usually, it’s caused by some inflammatory process in the Blood, and therefore we often need to give medication to reduce that inflammation in the blood, which will then reduce the inflammation in the joint; this is not very common and but when it does present it tends to be in the younger person. If we move over to the right, then we have this condition called facet irritation; this is a lumber spine from the side; the square blocks on the left are the vertical bodies, and they sit on top of intervertebral discs the vertebrae then communicate with each other and the back through something called a Facet Joint now this Facet Joint like any joint in the body a knee, a hip they can become irritated and inflamed so when we look at MRI scans of backs or patients who are not improving we’re often looking to see are there any individual joints that are irritated or inflamed that could be contributing the symptoms and therefore is there a Target for some injection therapy. In the bottom left, this is the view of a spine in cross-section, so this is like I’ve taken you lying down and then chopped you along, and I’m looking down the body; this pointy bit at the back is called a spinous process, and this is the area that we feel when we feel down in the back. In patients, again usually young patients who are very active and who do sports that involve a lot of bending off the back, so gymnastics or tennis, there is a risk of developing something called a porous fracture or a stress fracture, so in the younger patient especially this is always something that we want to exclude. Finally, which you’re probably most familiar with when it comes to low back pain is this condition in the bottom right called disc degeneration; the black circle in the center is the spinal cord the yellow marks to either side are the nerve Roots. When you get a disc bulge or a disc protrusion, the center of the disc, a jelly-like material, pushes out a little bit, and it causes the disc to bulge the disc itself doesn’t move. It creates a little bit of a bulging on the outside edge; now, this bulge can do a few things; one is it can create irritation around the nerve. The other is if it’s bad enough, it can put some pressure on the nerve, and then if we think about treating this often, what we think about doing is delivering some injection therapy, usually a steroid in and around this area to reduce inflammation and irritation and to reduce any pressure that’s on the nerve itself. Hence, these are the four main reasons why we do MRI scans, but we know specifically what we’re looking for; we’re not doing the scan and hoping that it gives us the answer we’re doing the scan because we think that we already know the answer and we’re trying to confirm or exclude that. From a disk point of view, I just wanted to give you a little bit more detail so from a disc bulge point of view, the reason this is important this is a spine on the left from the side this is the spine on the right from the front these grey areas that are running down the side and then are coming out on either side on the image on the right these are nerve roots your nerve Roots Supply your sensation and your part to different levels along your lower legs so when you come into us with symptoms what we do is we try to correlate whereabouts on the leg front, or back your symptoms are and then when we do your MRI scan we try to look at the disc at that level to see if it’s causing some pressure around the nerve root.
In many cases you will have disc bulging it doesn’t relate to your symptoms so you may have disc bulging at this L1 L2 level but your symptoms may be coming from L5 or L4 for that reason MRI’s are not useful in that they can create confusion for patients and sometimes for Physicians as well because we see disc bulging but it doesn’t marry up with what’s going on in the history .finally sorry I want to make a quick note on something which Katie has probably already discussed which is a degree of fatty infiltration in the low back when we are less active we see a change from the left hand side where the muscles are nice and grey kind of like a fillet steak to on the far right hand side when the muscles are not being used because other areas of the back are having to work harder for example the facet joints then the back becomes weaker and we see this fatty infiltration if we see this on a scan it’s a very good indicator to us that you’ll respond well to rehab so in summary from an MRI point of view we’re looking to exclude significant disease we’re trying to correlate what we see and what you tell us with what we find on the image or on the MRI scan it’s really not guesswork and we’re not asking for the MRI to give us the answer.
Finally, we’re looking essentially if there is an area for injection. Hence, if we see a disc bulge or a Facet Joint, that’s irritated. If it fits with where you’re sure and where we examine you, then that’s usually a good Target for us to inject the injection is only part of the treatment plan, which I’ll discuss and that brings us on nicely. Do I need the injection? Injections are not always straightforward, and often patients are a bit apprehensive about them. injection treatments are put into two major areas; one is for nerve root impingement, so if we have this disc pathology or there are other causes of nerve management, but if we have nerve root impingement, we’ve got two options, we’ve got a coral epidural injection, or we’ve got a more sophisticated CT guided nerve root injection again we’re correlating our MRI findings based on where your symptoms are. We are deciding on what level you need the injection.
Sometimes it’s not always clear exactly which level sometimes you might have a disc bulge at a couple of levels and sometimes you might have symptoms that correlate with a couple of levels when that’s the case we’ll often do a call to epidural injection this injection is done right down at the base of the spine we inject some steroid and it flows up along and around the nerve roots and it beads the nerve Roots at those lower levels in steroid and it reduces any inflammatory or Earth and change around there it’s a little bit of a broad brush stroke and we’re hoping to tackle a number of different areas in one go the CT guided nerve right injection however is much more selective we do that when we are very confident that the image that we see on MRI fits perfectly with the way the patient comes in now this is not always the case but when we have this sort of scenario you get much more relief from us a selective nerve root injection than by doing the broad brush stroke of what we describe as I called epidural injection technically we call the epidural is slightly easier than the CT guided nerve root we perform the seat they call epidural injections in the clinic here as Sports Medicine Physicians we do this under ultrasound scan the selective nerve roots however we have to refer to our Radiology colleagues in the main hospital for this because it’s slightly more sophisticated and we want to be exactly precise about where were placing that steroid.
The next group of injections then is for the joints I mentioned to you earlier about this condition, sacroiliitis or inflammation around your sacrum again, normally the way that we treat this is with some medication to reduce inflammation in the Bloods, but on occasion, if you have it on one side it can be because the joint is irritated without inflammation in the blood, in that case, a steroid injection over that area can be very helpful again we do this in the clinic here. We use an ultrasound scanner to guide where we place the needle.
Finally, then is the facet joint injection, the Joint between the different levels of vertebrae same principle as a knee joint, like a hip joint. If it gets inflamed, they often respond very well to cortisone steroids; it is not the main way of treatment; it’s an adjunct, so we try to improve your symptoms a little so that you can then progress on and do whatever rehab is necessary.
Are injections necessary?
Not always, but we use them when patients are not improving or deteriorating in some shape or form. We only do them if the symptoms that you’re telling us or the findings that we have on examination match up with what we see on the MRI scan; if they don’t match, there’s something else happening, and that’s rarely the case. Finally, we do them if your symptoms stop you from doing good rehab. Suppose you’re too sore to rehab, and we have a focus on injection. In that case, these can be extremely helpful in trying to get you some pain relief so that you can do the strength work it helps to take the pressure off the back it helps to get you moving more naturally, get you feeling more comfortable and then get you back to living a healthy and happy life.
Very straightforward self-referral, GP referral or physio referral, and you can forward an email or a referral to email@example.com, or you can call us at this number 015262030. You can have a discussion with one of the staff at the desk, and they’ll give you more direction about how to get in contact with us. I hope you found that helpful there’s a lot of information in there. You don’t need to take it all away. It’s really to give you a flavour of what we do here in the clinic and why our role as Sports Medicine Physicians helps to supplement the work that are very successful and very proficient strength and conditioning and Physiotherapy and Rehab teams do here in the field. Thank you very much.
what advice can you give the L4,5 disc care with lumbar spondylosis other than pain management?
I suppose it to a degree it depends on what the symptoms are if they are what we describe as radicular symptoms so symptoms that are not in the low back traveling down the leg then we have the option for some injections and if we have a good idea where the pain is traveling to and it correlates well with the MRI findings then we could do a selective nerve root block if it’s a little bit broader or a little bit more difficult the ascertain and exactly where the pain is radiating to or if there is a little bit of discrepancy between what we’re seeing in the patient and what we’re seeing on the scan then something like a cold epidural would be a good option and so that might give some symptom relief and then we would always do some follow-up rehab work and that would be along the lines of the stuff that Katie discussed uh strengthening of the low back strengthening of what we described as the posterior chain which is the bone muscles the hamstrings the calf and just you’re trying to get the patient to move more comfortably and confidently.
Is Botox successful in managing muscular spasms caused primarily by spinal fractures?
Botox we would use on in a very select group of patients and usually patients who have some form of muscular spasm or contracture so these tend to be limited to patients who have an underlying neurological condition like cerebral palsy or somebody who has maybe a long-term contracture following a stroke it’s not something that we use in the clinic to treat back spasm and Botox is a it has a very broad effect on the system so we can’t target it to any specific muscle and for that reason we’re very selective about the patient group that we use and we don’t use it for back spasm treatment.
Can a protruding discs in the lumbar region be the cause of constant knee pain?
It certainly can and if the lumber disc prolapses pressing on the nerve root that supplies the sensation over the knee then yes it can be the cause and often that is a case of patients who we see who have maybe had a long-term knee complaint for a number of years when we see them we assess their need we scan their knee we maybe don’t find much and we get a little bit more in depth into the history we find that actually they have some underlying back condition or back complaint when we scan their back and we’ll find a disk or a nerve root compression that’s actually the main source of their knee pain so in in short yes that can be the case yeah.
How could you get sciatica pain to improve?
It’s a multi factorial approach I suppose again it comes back to what are the exact symptoms of the sciatica what does the patient look like what are the Imaging findings do we have an option for injection therapy if we do have an option for injection therapy is it a selective nerve root injection or is it a call for an epidural injection and then following that can we get the patient comfortable enough to start to do some Rehabilitation and quite often this sciatica pain will resolve on its own if it’s very refractive then we do have oral medication options we have injection options and then we have some of the rehabilitation stuff that again Katie discussed that is often the next step to get patients over the line and back to full fitness.
what treatment exercise do you recommend for multi-level lateral stenosis?
Multi-level lateral stenosis again is quite a complex but broad diagnosis a lot of it really depends on what the symptoms are so the main aim is going to be getting the patient strong and getting the patient comfortable and confident moving again if they have some specific pain target or pain level in you know from that when we when we describe multi-level spinal stenosis we’re wondering is there an individual level in the spinal column that’s causing one problem more than the other if there is we have an option for a selective nerve root block again if the pain is coming from multiple levels and we’ve tried oral analgesia we’ve given it time and it’s not settling then a coral epidural might be an option to give a little bit of a broad cover of a number of nerve roots in a number of different levels.
For five years someone is suffering from severe chronic like joint pain after twisting her back badly misaligned pelvis which she tried to rehab with exercise and a joint dysfunction steroid injection it did not work and what do we do with the joint Fusion at the clinic in the in SSC Sports Medicine?
We don’t do joint fusion um that would be a surgical procedure and it’s not something that I can recall having referred a patient for normally we are able to get enough relief of symptoms through injection therapy and Rehabilitation but by all means if there are refractory cases then we may refer them to a surgical colleague for an opinion so that would be either an orthopaedic surgeon or a neurosurgeon.
How big of a factor is ongoing strength and conditioning to prevent a disc bulge l45 for long-term prevention?
long-term prevention I suppose the key here is trying to keep people moving as naturally and as comfortably as possible any strength work is going to reduce the risk of any recurrence of low back pain and disc bulges will happen regardless of whether or not you do any kind of strengthening program or preventative program but if you’re stronger and you have better functional movement patterns then you’re much less likely to get symptoms and long-term symptoms from something like a disc bulge and if they can take you back to the slide that I used in my presentation there’s a huge percentage of people out there who have disc bulges and that’s not the source of their pain and quite often that’s what we find in patients who come into the clinic so it’s not so much that the strengthening or rehab and exercise programs prevent this bulge but they prevent low back pain in general and they’re very good at doing that.
A patient is just asking, he has a pacemaker which is not compatible with MRI what other scans could be used.
– Again it depends on the diagnosis or at least the question that you’re asking and if you’re asking for information in relation to a disc or a nerve root then you would we would have a discussion with our Radiology colleagues as to whether or not there there’s an option to work around to get the patient an MRI and there are some MRI centers available that can do MRI for patients with pacemakers in terms of if the question is not related to a disc or to a nerve root and it’s a bony finding that we’re looking for that a CT scan would be an option and then thirdly we have options for x-ray or bone scan but they would be used much less frequently and I suppose we get much more detail from our CT scans on our MRI scans but really it all comes down to what what’s the question that we’re asking is it a bone related problem or is it a disc and nerve related problem.
How long will pain relief last from injections and how many can you have?
It depends on what the injection it is that you’re using typically we inject steroid with some local anesthetic the local anesthetic is relatively short acting you’ll get a few hours of relief symptoms from that but it’ll wear off over the course of the day a steroid injection builds up over the first few days and usually you get your most benefit at around about seven to fourteen days and then we hope for around about three months on average some patients come to us for a steroid injection or an epidural or a selective nerve root we’ll get they’ll get one injection they’ll get enough pain relief to allow them to do some form of Rehabilitation and their pain will resolve fully so they’ll never need to repeat occasionally we’ll have patients who come and get one injection get a repeat injection three months later and then follow that pathway where they go on the resolution and then unfortunately there are some cases that are much more resistant to treatment and may need an injection on a kind of repeat three to six months basis we would usually only inject about once every three months so maximum usually about four a year but we’re always reassessing the situation and trying the ascertain are we doing the injection for the right reason is it for the same reason have things changed so there’s a lot of thought that goes into the process rather than just looking out three months injections for the foreseeable future.
Is there any downside to steroid injections?
Yeah I mean there are side effects to any procedure that we do and in general anytime we use a needle to pierce the skin there’s a risk of creating infection in the clinic here we quote more than twenty five thousand and we use a lot of stringent infection control procedures to try and reduce that risk but that’s the biggest concern anytime we do an injection is introducing infection to the site and from a steroid itself about a hundred percent of people can get something called a steroid flare where their symptoms can get a little bit worse before they get better and some patients can get pain at the time of injection which can last for a few days after and some patients don’t get any relief whatsoever and so they go through the process they go through the anxiety of getting the injection then they don’t get any relief, but by and large are they are the main the mean side effects steroid can also give you some minor side effects such as facial flushing which might last 24 to 48 hours it can also disturb your sleep for 24 to 48 hours and it can also have an impact on your blood sugar so if you have diabetes we always recommend that after a steroid injection you keep an eye on your blood sugars for a few days.
A woman had an x-ray which showed a fractured disc, had physio just physio for that but 10 months later she’s still in a lot of pain she goes for walks but it’s very painful when sitting any suggestions where she should go next?
It’s difficult from the amount of information available yeah it’s difficult to sign posts, I mean if she feels that she’s not getting much benefit or she’s had almost a roadblock with a physiotherapist then perhaps it’s time to see a sports medicine physician you know another assessment a second opinion have a look at you know what information is there today and what investigations have been done and then decide on whether any further investigations need to be done and what other treatment options are available to the patient.