Scoliosis: Postural Deformity
Scoliosis is one of the more common spinal curvature deviations affecting posture.
In a healthy spine, the vertebrae are stacked one on top of other beginning at the base of the skull with the cervical spine and proceeding down through the thoracic spine to the lumbar spine, sacrum, and coccyx.
While each vertebra is carefully positioned to align with the above and below vertebra through the intervertebral disc and complex system of ligaments, there are times when the vertebra may begin to shift away from its normal alignment.
While there are a number of postural abnormalities including kyphosis (excessive curvature of the thoracic spine) and lordosis (excessive curvature of the lumbar spine), scoliosis (lateral curvature of the thoracic and/or lumbar spine) is one condition that can be corrected if diagnosed early.
Posture is an area that is often overlooked in athletes, but is one that should be regularly assessed through athletic physical exams or annual exams by a physician trained in the assessment of posture. The deformities seen in posture tend to follow a “slippery slope”.
While postural spinal deformities may originally start as small variations, over time, muscle tightness and muscle imbalances may increase the deformities to the point of significant functional disabilities. However, awareness of how to develop and maintain good posture can help maintain a healthy and dynamic spine for a lifetime.
What is scoliosis?
Although scoliosis is often thought of as a lateral or sideways curvature of the spine, oftentimes scoliosis also has a rotational deformity as well. This means that the curvature may change from anterior to posterior as well as side to side.
Because the curvatures of the spine affect adjacent articulations as well, the shoulders and hips of the athlete may also seem off line. Standing behind the athlete, one shoulder may be lower than the other and may also be rotated forward. This deviation may also affect the levels of the scapula as well as the arm position of the athlete.
The ribs may also be affected by an abnormal curvature in the thoracic spine. One rib cage may be shifted more anterior than the other side.
Moving down the spine, the level of the hips and pelvis can be affected by a lateral curvature of the spine, but may also be the result of a leg length discrepancy (one leg longer than the other).
Classifications of scoliosis
Scoliosis can be classified as structural or nonstructural. Nonstructural scoliosis curves are flexible and can be corrected with lateral bending whereas structural scoliosis is an inflexible curvature that is not ameliorated with lateral bending.
Scoliosis can also be classified as mild, moderate, and severe. Mild scoliosis is diagnosed if the curvature is less than 20 degrees and if the patients are asymptomatic (do not have pain) during daily activities.
Athletes with a curvature of 20 degrees to 45 degrees and who are still growing are diagnosed with moderate scoliosis. If the scoliosis is moderate and progressing, the physician may recommend that the athlete be fitted for a brace.
Severe scoliosis is diagnosed when the individual has extreme lateral deviation and rotation. In these cases, surgery may be recommended to fuse specific vertebra to reduce the deformity and enhance the individual’s spinal stability and functional ability.
Diagnosis for scoliosis
Scoliosis can be diagnosed through a good medical history and thorough clinical evaluation. Inspection and observation of the spine is a necessary part of the evaluation to determine if the spine is deviated or in alignment. This can be accomplished by observing the individual from behind.
While the individual is standing comfortably with his/her hands down at his/her sides, the physician observes the positions of the spinous processes of the thoracic and lumbar vertebrae along with specific boney landmarks including several points on the scapula and the landmarks of the posterior superior iliac spines.
A trained eye can easily spot abnormal variations in the spine. However, visual observation is not enough. Clinical tests can be administered also.
One easy test for scoliosis is to have the athlete begin in a standing position facing away from the sports medicine professional. The athlete gradually bends forward sliding his/her hands down the front of the legs. Scoliosis that is present while the individual is standing and remains after the individual has moved into a position of flexion, he/she would be considered to have structural scoliosis.
Spinal abnormalities tend to be more pronounced as the athlete bends forward at the waist. As the athlete bends forward, the test administrator can palpate each spinous process to determine if there are any abnormalities in vertebra alignment.
If scoliosis is suspected, x-rays may be ordered to document the specific amount of degrees of variation between each vertebra. These x-rays would be important over time to document if the condition is worsening.
Who gets scoliosis?
Scoliosis does not discriminate by sport. Although 80% of those with scoliosis have no known cause, of that 80%, a majority of these cases are diagnosed between the ages of 10 and 13 (Anderson, M.K., Hall, S.J. & Martin, M., 2005).
It is also known that scoliosis is more commonly diagnosed in females as compared to males. The answer to this is unknown.
Mild scoliosis can be developed with long-term unilateral sports activities as can be seen in the sport of tennis. In tennis, the muscles on the dominant side of the body can be developed more than the opposite side. This can lead to overdeveloped muscles on one side and weaker muscles on the opposite side of the spine.
Muscles that are not equally balanced on either side of the spine can cause a variation in the spine. Stronger muscles can pull the vertebra to one side because the same muscles on the opposite side of the vertebrae are not strong enough to maintain the vertebral position in the middle of the body.
Adding to the muscle imbalance is muscle tightness. Unless the athlete continuously works at stretching muscles that are being developed, these developing muscles can become tight and may pull on existing anatomical structures potentially causing an unhealthy shift in the spine.
Causes of scoliosis
The challenge with understanding and trying to prevent scoliosis is that so many cases are idiopathic meaning that there is no known cause. As noted above, 80% of patients with scoliosis have no known cause with some references listing the percentage as high as 90% (Anderson, M.K., Hall, S.J. & Martin, M., 2005).
The following possible causes of scoliosis are documented in the literature:
• Congenital deformities of the spine
• Leg-length differences
• Long-term unilateral activities
• Certain cancers
Prevention for scoliosis
Because the cause of so many cases of scoliosis is unknown, it is difficult to design a preventative program. However, it is known that mild cases of scoliosis can be caused by unilateral repetitive motions in sport. With this in mind, it is important that muscle length and strength be balanced on both the right and left sides of the body.
Ideally, athletes should have good alignment of their bodies when sitting, standing, and when in motion. To check your posture when standing, an invisible line should be able to drop straight through the following structures:
• Anterior view: nose, mouth, center of sternum, umbilicus, and pubic bones while the following structures are level: earlobes, shoulders, fingertip ends, nipples, iliac crests, patella, and medial malleoli (inside ankle bone).
• Posterior view: head, spinous processes from cervical through lumbar spine while the following structures are level: earlobes, shoulders, scapulae, hips, posterior knee creases, and medial malleoli (inside ankle bone).
• Side view: earlobe, bodies of cervical vertebra, center of shoulder joint, and greater trochanter
If alignment looks asymmetrical, consult with a sports medicine professional to determine if there may be a muscle imbalance or something more significant like a structural abnormality.
Treatment for scoliosis
Most individuals with mild to moderate scoliosis can safely participate in sports. Individuals who are asymptomatic with mild scoliosis can participate in sports but should have regular follow-up evaluations with his/her physician.
Athletes with moderate scoliosis are routinely placed in a brace by his/her physician. The purpose of the brace is to apply constant pressure on either side of the spine to mechanically realign the spine.
Some physicians may allow their patients to participate in sports without the brace depending on the number of hours the athlete is required to wear the brace each day.
Physicians may recommend that an athlete wear the brace from only at nighttime to up to 23 hours a day depending on the severity of the abnormality. These athletes also require follow-up care from their physician to monitor the curve progression until the athlete is done growing.
Athletes with severe cases may require surgical intervention to realign the vertebra and return the individual to better function. The type of surgery will be determined based on the sport that the athlete is involved in because some procedures may limit the flexibility of the spine and may have a significant impact on athletes in the sports of dance and gymnastics.
In general, athletes undergoing surgical intervention for scoliosis should not return to collision sports. It is also important to understand that when several vertebra are fused together, additional stress may be placed on adjacent vertebra to absorb the forces during movement of the spine.
The athlete may be permitted to begin swimming at 6 to 12 weeks post-surgery and biking at three months (Sullivan, J.A., & Anderson, S.J., 2000). As with all surgical procedures, the physician should guide all return to sports decisions.
Getting a Second Opinion
A second opinion should be considered when deciding on a high-risk procedure like surgery or you want another opinion on your treatment options. It will also provide you with peace of mind. Multiple studies make a case for getting additional medical opinions.
In 2017, a Mayo Clinic study showed that 21% of patients who sought a second opinion left with a completely new diagnosis, and 66% were deemed partly correct, but refined or redefined by the second doctor.
You can ask your primary care doctor for another doctor to consider for a second opinion or ask your family and friends for suggestions. Another option is to use a Telemedicine Second Opinion service from a local health center or a Virtual Care Service.
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- Anderson, M.K., Hall, S.J., & Martin, M. (2005). Foundations of Athletic Training: Prevention, Assessment, and Management. (3rd Ed.). Lippincott Williams & Wilkins: Philadelphia, PA.
- Houglum, P. (2005). Therapeutic Exercise for Musculoskeletal Injuries (2nd Ed.). Human Kinetics: Champaign, IL.
- Starkey, C. & Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries. (2nd Ed.). F.A. Davis: Philadelphia, PA.
- Sullivan, J.A., & Anderson, S.J. (2000). Care of the Young Athlete. American Academy of Pediatrics: Oklahoma City, OK.