Bertolotti Syndrome as a Potential Cause of Low Back Pain in Golfers

Abstract

Bertolotti syndrome, defined as the association of back pain with lumbosacral transitional vertebrae (LSTV), was first described in 1917 by Mario Bertolotti [1]. LSTV, which are caused by congenital factors, are estimated to be present in 12.3% of the general population [2]. The actual relationship between the presence of LSTV and low back pain is highly debated, with several studies that claim little or no significant correlation [3-5], and other studies that conclude that transitional vertebrae result in a predisposition to low back pain [6-9]. The latter of these studies hypothesize that the transitional vertebrae at the L5-S1 level cause hypermobility and abnormal torque at the adjacent vertebral segment that leads to increased disk and/or zygapophyseal joint (z-joint) degeneration. Low back pain is clearly exhibited among golfers, with 22%-36% of male golfers and 22%-27% of female golfers reporting back pain [10]. Investigators in several studies assert that the general shift from the “classic swing” to the “modern swing,” which places more rotational stress and hyperextension on the lumbar spine, is behind the increased occurrence of back pain in golfers [10-12]. The biomechanics of the “modern swing” expose the spine to increased spinal loading, which may elevate the risk for myofascial, diskogenic, spondylolitic, and/or z-joint injuries, and the subsequent development of low back pain [11,12]. Our review of the literature regarding Bertolotti syndrome in athletes revealed only one article, which briefly describes the condition in a 20-year-old baseball player [13]. The present article reports the cases of 2 golfers with chronic low back pain, whose source of pain was identified to be the LSTV through diagnostic imaging and fluoroscopic injections. These cases highlight how, in many sports, and golf in particular, the lumbar spine is placed under significant repetitive loads that could potentially lead to the uncommon expression of Bertolotti syndrome from LSTV, which normally exists as asymptomatic anatomic anomalies. As a result, physicians should consider Bertolotti syndrome in their differential diagnosis when examining athletes who present with idiopathic low back pain.