Sports Medicine Update:
Back Pain in Young Athletes
Kevin G. Shea, M.D.Ron Pfeiffer, Ed.D., ATC
Back pain is a common complaint in young athletes, especially in the adolescent age group. In most cases, this represents an overuse/over-training injury, but other diagnoses should be considered. The differential includes spondylolysis and/or spondylolisthesis, diskitis, osteomyelitis, spinal cord or osseous tumor, inflammatory arthropathy, disk herniation, and scoliosis.
Young athletes that present with back pain should have a thorough history and physical, including a complete neurological examination. A history of continuous back pain including pain at night, headaches, neurological symptoms (weakness, gait changes, abnormal bowel or bladder function), fever or other signs of systemic illness may indicate a serious illness, and appropriate workup is necessary.
Significant findings on the physical exam, such as abnormal finding on the neurologic exam (gait, balance or coordination disturbance, asymmetric reflexes or sensation of the extremities or abdomen), lower extremity length or size discrepancy, spinal asymmetry (scoliosis, pelvic obliquity, shoulder imbalance), or abnormal skin findings (birthmarks, hair patches or skin dimpling over the spinous processes) may require a detailed evaluation, including advanced imaging studies (bone scan, MRI or CAT scan). Although rare, young patients with a history of back pain have a higher incidence of significant pathology (tumors, infections, inflammatory disease, etc.), compared to adults with a history of low back pain. Because of this difference, the initial evaluation of back pain in young patients is frequently more extensive than the evaluation of back pain in adults.
Spondylolysis and spondylolisthesis are two of the most common sources of persistent back pain in pediatric and adolescent athletes, and this article will focus upon the presentation and evaluation of these related conditions. Spondylolysis is a stress reaction or fracture in the posterior elements of the vertebra. In young athletes, this is typically seen in the L5 region, although it can occur in other regions as well. Some cases of spondylolysis become bilateral, and this can lead to spondylolisthesis. Spondylolisthesis refers to a translation of the vertebral body, in which a superior vertebra will begin to migrate anteriorly on an inferior vertebra. In some cases, the translation can be significant enough to require a spinal fusion to prevent further progression of the spinal deformity. Athletes that perform back hyperextension maneuvers are more prone to develop spondylolysis or stress fractures of their lumbar spine. Hyperextension maneuvers place a high concentration of stress on the pars region in the posterior spine. This can lead to a stress reaction or stress fracture in the spine. These conditions are usually associated with low back pain, which is aggravated by activities. The symptoms are usually worse during and after activities, although the pain may become chronic in some cases. Sports with high risk for this injury include gymnastics, football, wrestling, diving, and figure skating. Many female gymnasts will develop spondylolysis or spondylolisthes by the age of 9 or 10 years, although other athletes usually develop these conditions as adolescents or young adults.
Most young athletes that present with back pain will have a normal history and physical examination. In patients with spondylolysis or spondylolisthesis, mild hamstring spasm may be the only notable physical finding. Hamstring tightness can be assessed by a straight leg raise, or asking the athlete to bend forward with the knees straight, and touch the floor. Most young athletes should be able to touch the floor, or come within 3-6 inches of doing so. The posture of the lumbar spine should also be examined. In some athletes with spondylolisthesis, the normal lumbar lordosis is not present, and the lumbar posture will appear kyphotic. For the evaluation of routine back pain in adults, plain radiographs are not always indicated in the initial evaluation. Most young patients with back pain should be evaluated with radiographs. The incidence of diseases that can be identified with plain radiographs is much higher in younger patients. In patients at risk for spondylolisthesis and spondylolysis, the radiographs should focus upon the lumbo-sacral spine. In addition to standard antero-posterior and lateral radiographs, oblique lumbar images may be necessary to demonstrate a spondylolysis. In some cases, bone scan, CAT scan, or even an MRI may be necessary to confirm the diagnosis. Posterior element bone tumors can present in manner similar to spondylolisthesis, and should be considered in the differential diagnosis. For patients with spondylolysis without spondylolisthesis, activity modifications are usually effective. In cases that do not respond to activity modifications, a TLSO brace may be necessary for several months. The braces are effective at reducing symptoms, and in some cases, the stress fracture(s) may heal. In many cases, spondylolysis is asymptomatic. In some cases, spondylolysis will progress to spondylolisthesis, and can be associated with significant chronic back pain. In patients with spondylolisthesis, the risk of progression to more advanced displacement exists. Younger patients require close follow-up, as the risk of progression is significant. Counseling in regards to continued participation in high-risk sports is appropriate. If progression of the spinal deformity is significant, surgery may be required to prevent worsening of the deformity.