Low back pain in young athletes

Abstract

Context: Low back pain in young athletes is a common complaint and should be taken seriously. It frequently results from a structural injury that requires a high degree of suspicion to diagnose and treat appropriately.

Evidence acquisition: A Medline search was conducted from 1996 to May 2008 using the search terms "low back pain in children" and "low back pain in athletes." Known texts on injuries in young athletes were also reviewed. References in retrieved articles were additionally searched for relevant articles. Sources were included if they contained information regarding diagnosis and treatment of causes of low back pain in children.

Results: Low back pain is associated with sports involving repetitive extension, flexion, and rotation, such as gymnastics, dance, and soccer. Both acute and overuse injuries occur, although overuse injuries are more common. Young athletes who present with low back pain have a high incidence of structural injuries such as spondylolysis and other injuries to the posterior elements of the spine. Disc-related pathology is much less common. Simple muscle strains are much less likely in this population and should be a diagnosis of exclusion only.

Conclusion: Young athletes who present with low back pain are more likely to have structural injuries and therefore should be investigated fully. Muscle strain should be a diagnosis of exclusion. Treatment should address flexibility and muscle imbalances. Injuries can be prevented by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength.

Keywords: adolescents; low back pain; pediatric athletes.

Figure 1.

A figure skater hyperextending her spine duringa spin.

Figure 2.

Anatomy of the lumbar spine.

Figure 3.

Observation of the back (A). From the side, there should be a gentle lumbar lordosis (B).

Figure 4.

Adams forward-bending test. The patient leans forward with the arms hanging down. The examiner stands behind the patient, observing for spinal abnormalities.

Figure 5.

Adolescents should be able to come close to touching their toes with forward flexion of the spine.

Figure 6.

A single-legged hyperextension test, looking for pain in the posterior elements of the spine, is performed by having the patient stand on 1 leg and extend through the spine. A positive test provokes pain on the ipsilateral side to the standing leg.

Figure 7.

The FABER (flexion-abduction–external rotation) test. The patient lies in the supine position on the examining table, with the hip flexed, abducted, and externally rotated and the foot on the opposite knee. The examiner then presses the flexed hip into the table while stabilizing the opposite hip. Pain in the back on the ipsilateral side as the hip is flexed is a positive test for sacroiliac joint pathology.

Figure 8.

Gaenslen sign. The patient lies supine on the examining table with 1 leg maximally flexed. The opposite leg is extended over the edge of the table. The examiner applies downward pressure on the hanging leg. Pain in the back elicited by this maneuver is a positive test for sacroiliac joint pathology.

Figure 9.

Spondylolisthesis of L5-S1.

Figure 10.

Anteroposterior radiograph (A) of lumbar spine. Arrows indicate sclerosis and fracture line of bilateral spondylolysis. Oblique radiograph (B) of lumbar spine. Arrow indicates sclerosis of the “neck of the Scotty dog.”

Figure 11.

Spina bifida occulta can be associated with spondylolysis.

Figure 12.

Bone scan indicating an area of increased uptake consistent with spondylolysis.

Figure 13.

Computed tomography scan of lumbar vertebrae indicating a spondylolytic defect on the right and reactive sclerosis on the left.

Figure 14.

Diagnostic algorithm for investigation of spondylolysis.

Figure 15.

A lateral radiograph of the spine in a patient with Scheuermann kyphosis. The arrow indicates end-plate irregularities.

Figure 16.

Vertebral body apophyseal avulsion fracture.

Figure 17.

An MRI scan of the lumbar spine. There is a disc herniation at L5-S1.

Figure 18.

Core-strengthening exercises are part of rehabilitation for back injuries but can also be incorporated into conditioning programs to prevent injuries. Examples include: (A) using a stability ball, the athlete lies prone on the ball and extends the opposite hand and leg and holds this position for as long possible; (B) in the plank, the athlete rests on elbows and toes and holds back straight as long as possible. Hamstring stretches are also important in both conditioning and rehabilitation of back injuries. One way to stretch the hamstrings is to stand next to a table with 1 leg extended on the table. The athlete bends forward from the waist until a stretch is felt in the hamstrings of the extended leg (C).