Low Back Pain and Young Athletes

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Introduction

In the United Kingdom there are a large number of children and adolescents who are participating in sport. The government is currently spending over £450 million on improving the quality of the Physical Education and sport activities that pupils are offered [1]. Leading to high numbers of participants in sport, not only inside of school but outside as well, 96.7% of children aged 11-16 and 84.1% of children aged 5-10 participated in sport outside of school [2].
The young person with athletic potential is likely to have enhanced physiological and physical attributes compared to their peers [3] and can therefore be defined as a young athlete.

Low back pain (LBP) occurs in approximately 10% to 15% of young athletes[4] . Schmidt et al (2014) found that competitive adolescent athletes compared to aged matched individuals have increased prevalence of back pain[5].
LBP  is defined as pain localised between the 12th rib and inferior gluteal folds, occuring with or without leg pain [6].

There are significant differences between the nature of LBP in adults and young athletes [7]. The most common causes of LBP in young athletes are spondylolysis, spondylolisthesis, hyperlordosis syndrome (posterior element overuse syndrome) and discogenic pain[7].
The growing spine introduces certain variables that predisposes the back of the young to specific injuries such as pars interarticularis injury; reported to occur in up to 47% of young athletes [7].
It is of great importance for an athlete with persisting symptoms to undergo a thorough assessment [8].

The impact of the structural problems is considered alongside other aspects such as psychological, social and cultural issues [9]. This approach facilitates compliance with the rehabilitation process and promotes recovery [9], as there is evidence showing athletes with a prior back injury are 3 times more likely to develop LBP [10].

Epidemiology

According to the literature low back pain occurs in 10-15% of young athletes[9]. However studies exhibit great variability in prevalence rates, with estimates ranging from 1.1%[11] - 66%[5], the variability in the studies may be due to:
• Age of the sample
• Sample size
• The authors definition of low back pain
• The low back pain recall period
• Strategy of extracting data and methodology used

The prevalence of low back pain varies between sports and, in some cases, the speciality of the position[5].
In young athletes the prevalence of low back pain increases with age and females are more likely to suffer from low back pain compared to males of the same age group[11]. The literature suggests that the physical changes that occur during puberty could increase the prevalence for low back pain[12]

Injuries encountered to the lower back in young athletes occur from either an acute traumatic event or repetitive trauma (overuse injury) and are commonly seen in individuals participating in sports such as football, rugby, gymnastics, ice skating and dancing[9]. Evidence has shown LBP occurs is as much as 27% of college football players and between 50% and 86% of gymnasts[13]. Overuse injury can be as a result of repeated flexion, extension and torsion which is performed frequently in gymnastics, ice skating and dancing[9].

Table showing the causes of low back pain from 100 adolescent athletes with a chief complaint of low back pain and 100 adults presenting with acute back pain[14].
Specific Condition Adolescent Athletes (aged 12-18) Adults (aged 21-77)
Hyperlordotic mechanical back pain 26 0
Spondylolysis/Spondylolisthesis 47 5

Discogenic

11

48
Herniated 9 24
Degenerated 1 22
Both 1 2
Lumbosacral strain 6 27
Scoliosis
8 7
Spinal Stenosis 0 6
Osteoarthritis
0 4
Hamstring Strain 1 0
Neoplasm 0 2
Trochanteric bursitis 1 0
Ankylosing Spondylosis 0 1


Growth and Development of the Spine

The vertebrae undergo gradual growth and development over the childhood and adolescence. This causes distinct structural differences of the spine from the adult spine, which affects the nature of injury in young athletes.

Development of the vertebrae

Ossification of the vertebrae

Development of the vertebral column occurs in three stages: mesenchymal, chondrification, and ossification.

There are two ossification stages:

  • Primary - begins during ninth to tenth weeks in utero[15]
  • Secondary - begins after puberty and ends at about age 25[16]


Primary ossification:

Lumbar spine primary ossification centres.png

Figure 2 - An illustration of a transverse section of a cartilaginous lumbar vertebra


The vertebrae typically have three primary ossification centres [17]:

  • The oval centrum
  • One in each half of the cartilaginous neural arch


The three parts are united by hyaline cartilage. A cartilaginous ring develops around the anterior and lateral periphery of the centrum-disc interface, which firmly anchors the annulus to the centrum. The two halves of the arch ossify posteriorly by appositional growth [17]. The centrum joins the arch during 3-6 years old [16].


Secondary ossification: 

Lumar spine secondary ossification centres.gif

Figure 3 - Secondary ossification centres of lumbar vertebra[18]


At puberty (age 13-16), five secondary ossification centres appear [17][19]:

  • One at the tip of the spinous process
  • One at the tip of each transverse process (two in total)
  • Cartilaginous mammillary processes (two in total)


Around the age of 25, union of secondary ossification centres with the rest of the vertebra is completed [16].
Adolescent spines are more prone to pars defects/fractures due to the incomplete bony maturation present in the neural arch [7]. Biomechanical studies have indicated that the bone strength of the vertebrae especially the neural arch, can increase into the fourth or fifth decade of life [20].


Ossification stages in the lumbar spine.png

Figure - A summary of ossification states in lumbar spine at different ages[16][15]

Growth of vertebral body

The physes associated with the vertebral end plates facilitate the growth of the vertebral body
Vertebral endplate are comprised of 2 parts[13]:

  • Hyaline cartilage (adjacent to the nucleus pulposus)
  • Physeal cartilage (adjacent to the vertebral body)


Physeal cartilage are comprised of:

Ring apophysis
  • Surrounds periphery of the vertebral body
  • Facilitated the horizontal growth of the vertebral body
  • Begins to ossify at age 7 or 8 [8] 
End-plate physis
(Growth plate)
  • Causes longitudinal growth of the vertebral body throughout childhood and adolescence [15]
  • Begins fusing with the vertebral body at about age 14-15
  • Final closure occurring around age 21-25 [8] [21]

The physes may be vulnerable during development. Fusion between ring apophysis and the adjacent vertebral body does not complete fully prior to the age of 25 years. This increases the risk of apophyseal ring fractures in adolescents[8].

Stages of the growth of vertebral bodies.png

Figure - Stages of the growth of the vertebral bodies[15]

A. The vertebral bodies, discs and growth plates (GP) of a 1-year old infant.

B. The same structures in a pre-pubertal child.

C. The appearance of the ring apophyses (RA) in adolescence.

D. Ossification of the ring apophyses and the formation of the vertebral endplates (VEP) in adulthood.


Lumbar vertebra.jpg

Figure - Anatomy of an adult lumbar vertebra, disc and spine.[22]

Development of the intervertebral disc

Compared with the adult spine, the nucleus pulposus in the spine of children has a relatively greater hydrophilic nature, allowing more effective force absorption and central distribution of force transfer to the adjacent vertebrae. Due to the combination of central distribution of force, via the nucleus pulposus, and a weaker vertebral endplate, Schmorl nodes occur more frequently in children and adolescents compared to adults. Schmorl nodes are vertebral end-plate herniations of disc material [23] . It was demonstrated that the vertebral end plate often fails before the disc in young spines, allowing herniation of the nucleus into the vertebral body creating Schmorl nodes rather than herniating into the spinal canal as in adults[24]. The relative strength of the intervertebral disc compared with that of the adjacent bone may also account for the relative reduction in rates of discogenic injuries seen in adolescents compared with adults [8][21].

The composition of the nucleus pulposus begins to change at 7-8 years old, resulting in a more peripheral force distribution of the disc[8].

Schmorl node MRI.jpg

Figure - An MRI scan of acute Schmorl node [25]


Summary - Significance of developmental pattern of spine to injury

In summary, there are several aspects of the developmental pattern that are important in understanding injury to the young spine:

  • The incomplete bony maturation present in the neural arch contributes to the occurrence of pars fractures in adolescents.
  • The physes may be vulnerable during development, increasing risk of apophyseal ring fractures in adolescents.
  • The more central distribution of force by way of the nucleus pulposus combined with a relatively weak vertebral end plate may account for the relatively high frequency of end plate herniations of disc material (Schmorl nodes) that occur in children and adolescents.
  • The relative strength of the intervertebral disc compared with that of the adjacent bone may also account for the relative reduction in rates of discogenic injuries seen in adolescents compared with adults.

Risk Factors 

Intrinsic and extrinsic risk factors

Risk factors can be divided into two groups; intrinsic (i.e. age) or extrinsic (i.e. weather) [26]. The intrinsic factors such as age and gender act as predisposing factors to injuries, extrinsic factors act from the outside which could influence injury risk.It is the combined effect of both of these categories that can make the individual vulnerable to injury [27].
The effect of intrinsic and extrinsic factors in sporting injuries is illustrated in a model shown in figure 1 [27]. It is the 'susceptible phase' of the model where the risks add together [27].


Figure 1- showing the model of risk factors in sporting injuries [27]

Model of Risk Factors.jpg

Structural aspects of the growing spine

During adolescence injuries of the low back are prevalent due to the spinal column changing in structure and flexibility, the changes take place in the vertebral bodies and neural arch [28]  which are known as the growth ossification centres, one in the vertebral body and two in the vertebral arch [29].

Epiphyseal growth plates surround either end of the vertebral body and ring apophyses attach to the outer anulus fibrosis. There are risks of injury associated with these structures including herniation of the intervertebral disc through the ring apophyses caused by repetitive flexion. Furthermore, injuries occurring to the ring apophyses can cause avulsion fractures [9].

The vertebral arch consists of the facet joints, spinous process and pars interarticularis [9]. Failure in the fusion of these structures can lead to development problems, such as spina bifida occulta, which if present at the lumbosacral junction can increase the risk of spondylolysis[9]. The lack of fusion can also lead to pars interarticularis fractures, which has been found to occur in 47% of young athletes [7]. During periods of growth muscles struggle to lengthen as fast as bones grow. This can cause inflexibility and muscle imbalances predisposing them to injury[30][31].

Variances in the adolescent spine development

Growth and maturation rates can differ in children of the same age, resulting in differences in size, strength and skeletal maturity [9].
The varied differences in size alongside other factors such as playing ability in young athletes can influence the impact of overload or excessive stress placed on spinal structures [32].

Training

Young athletes participate in intense training programmes with repetitive practice which increases the likelihood of injury [33] for example a gymnastic training programme can consist of up to 40 hours of training per week for elite gymnasts [3]. This can cause overuse injuries and other musculoskeletal injuries [26].
As part of training, a warm up is typically completed to reduce the risk of injury Lumbar flexibility is of importance for the lower back [27][34].

Modifiable and non-modifiable risk factors

Risk factors can be further categorised into modifiable and non modifiable factors, modifiable factors are of importance as there is the possibility of being able to change them, for example training to improve flexibility and strength[35]. Non-modifiable factors are unchangeable but do influence the modifiable risk factors and therefore potential injury [26].

Table 2 summarises the most common factors for injury during sport: categorised according into intrinsic factors (modifiable and non-modifiable) and extrinsic factors (modifiable and non-modifiable)[30][31].

Table - The potential risk factors for injury in sport[30][31]

 

Modifiable Non-modifiable
Intrinsic

• Fitness level

• Sport specific training/warm-up

• Muscle strength

• Flexibility

• Joint stability

• Biomechanical factors

• Balance/proprioception

• Psychological factors




• Gender

 • Age

• Maturity level

• Previous injury







Extrinsic

 • Rules and regulations

• Coaching education/training

• Playing time

• Playing surface

• Equipment


• Type of sport

• Sport context

• Weather conditions

• Level of play

• Time of season

• Playing position


Additional risk factors

The relationship between lower limb function and LBP has been investigated in college athletes and it showed athletes with reported LBP presented with a 5.8% greater difference between left and right extensor strength in the lower extremity compared with athletes without LBP[36]. The study concluded that it is clinically relevant in terms of screening athletes as part of preparation for participating in sport to minimise the occurrence of LBP and lower extremity injuries[36].


Assessment

Subjective assessment

There is usually poorly localised lumbar pain without any associated neurologic symptoms.
Specific area of pain and neurologic symptoms are more likely to show an underlying pathology.
Knowing the onset of symptoms can help distinguish between acute or chronic overuse injury, and postural and developmental abnormalities.[37]

The clinical history of a patient should include an in depth description in order to hypothesize what could be causing the back pain. Red flags should be screened before carrying on with further assessment. An assessment for low back pain in young athletes is very similar to an assessment of low back pain in any individual.

Subjective Assessment
Investigating Specific questions
Pain


Location
Type
Aggravating and easing factors
Onset
Duration
Any night pain

Trauma Repetitive/overuse microtrauma
Acute macrotrauma
Specific movement of trauma
Body positioning in trauma
Mechanical symptoms Is the pain worse on movement?
What specific movement?
Does the pain cease during rest?
Inflammatory symptoms Is there any morning stiffness?
Does it get better with movement?
Neurological symptoms Radiculopathy
Pins and needles
Bowel or bladder dysfunction
Weakness
Systemic symptoms Does the patient have a fever, night sweats or recent weight loss?
Gait Does the patient suffer from foot drop
Previous Treatments Has the patient had previous treatment for the same or similar condition?
Was the treatment successful?
Lifestyle What sport they play?

What position they play in?

What time in the season is it?

Does the pain have any effect on their psychosocial well-being? Does it interfere with school or interests?

Past Medical History Does the patient suffer from any medical conditions such neurological disorders, scoliosis, malignancy, osteoporosis, chronic inflammatory joint disease or has any treatment of immunosuppressive agents?

Has the patient had any previous injury or surgery?

(Female) Have they had any problems with their menstrual history?

Family History

Is there any of family history of orthopaedic, rheumatic or neurologic conditions?
Psoriasis?
Inflammatory bowel disease?
Ankylosing spondylitis?





Objective assessment

Observation

Observation begins as soon as you see the patient. The examiner should observe the patients gait and posture as they walk in and note down any abnormalities. To observe the patients posture in more detail it is best appreciated if the examiner is able to see specific bony land marks and areas on the patients back.[37]

Standing Posture
Anterior/Posterior view

  • Both shoulders should be level
  • Both anterior superior iliac spines (ASIS) and posterior superior iliac spines should be level
  • Symmetry of soft tissue and bony landmarks either side of the midline


Lateral view

  • Foot arch cavus/planus?
  • There should be a gentle cervical lordosis, thoracic kyphosis and lumbar lordosis (excess lumbar lordosis may be caused by weak abdominal muscles or a hip flexion contracture)

Palpation

It is best appreciated palpating the posterior spine with the patient in a standing position. Any point of severe tenderness should be related with the underlying soft tissue anatomy or bone. Useful places to palpate over, are the facet joints, spinous processes, paraspinal muscles, sacroiliac joints, posterior iliac crest, PSIS, gluteals, greater trochanters and ischial tuberosities.

Range of movement

To test active movements of the thoracolumbar spine patients need to be in a standing position with their pelvis stabilised. The examiner should note down the measure of range of movement, and any symptoms that are brought about. Here are some examples of how to measure the range movement in the thoracolumbar spine:

Flexion

The examiner will ask the patient to bend forward and try to touch their toes with their knees straight (measure the distance from their fingertips to the floor).

IMG 4666.JPG

Extension

The examiner will ask the patient to bend as far backward as possible with knees straight, whilst supporting their lumbar spine (measure the degrees of movement).

Lumbar Extension.JPG

Lateral flexion

The examiner will ask the patient to bend as far to the side as possible, both left and right sides. (the patient should be able to touch their fibular head).

Lumbar Side Flexion.JPG

Rotation

As well as stabilising the pelvis, the examiner will place a hand on the opposite shoulder to prevent compensatory movements. They will ask the patient to rotate their trunk as far as possible (measure the degrees of movement).

IMG 4674.JPG


Hamstring length

Tight hamstrings or asymmetry between hamstring lengths is common in patients complaining of low back pain.

To examine a patients' hamstring flexibility the examiner will measure their popliteal angle. This is done with the patient in supine with their hips and knees flexed to 90 degrees. The examiner will then extend the patients' knee until there is a large resistance. The angle is measured between the femur and tibia at the joint line of the knee. An angle larger than 45 degrees may be a factor to having low back pain. The patients' back and hip range of movement should be measured passively and actively. By measuring the patients' popliteal angle it determines their hamstring flexibility.

Popliteal angle.PNG


Strength

The patients core and lower limb strength should be examined. Lower limb strength can be measured using the MRC scale.

MRC Scale:

0: No contraction

1: Flicker of Contraction

2: Active Movement (can't resist gravity)

3: Active movement against gravity

4: Active movement against resistance

5: Normal strength

Neurological exam

A neurological exam should include trunk and lower limb sensationstrength, and deep tendon reflexes to investigate whether there is any neural involvement in the low back pain.

Dermatomes

Dermatomes drawing.JPG

Myotomes

L2 Hip Flexion
L3 Knee Extension
L4 Ankle Dorsiflexion
L5 Great toe extension
S1 Ankle Plantar Flexion
S2 Knee Flexion

[38]

Deep tendon reflex tests

Patellar- L3-L4

Achilles- S1-S2[38]

Special tests


Abdominal, pelvic and hip exam

Back pain can be referred from abdomen, pelvic or hip pathologies and injuries, so it is important to rule out all of these before carrying on with any treatment.

Further investigations

Laboratory tests


It is necessary to perform laboratory tests to investigate patients with back pain and high suspicion of systemic disease or infection. If an infection is suspected CBC, ESR or CRP, blood and joint cultures should be screened.[37]

If arthritis is suspected rheumatoid factor, HLA-B27 and ANA can be investigated to help classification and decide treatment, but these results may not help diagnosis.[37]

If a hematological malignancy is suspected a peripheral blood smear (CBC) should be investigated.[37]

Imaging

Radiographs

Radiographs can be used to detect fractured vertebrae and herniated discs.

Technetium bone scan

A bone scan detects regions of increased osteoblastic activity and can help locate specific areas of bone injury that may not be visible on radiographs.

SPECT (singlephoton emission computed tomography) is useful in identifying stress fractures and spondylolysis[40].

Computed (CT)

CTs provide a detailed image of bone and cartilage. A CT scan is useful for further investigation into lesions that are identified on a bone scan, including spondylolysis, fractures and tumors[41].

Magnetic resonance imaging (MRI)

MRI provides an detailed image of contrasts of soft tissue which allows evaluation of paraspinal structures and the spinal cord. MRI is useful for neurologic findings but it is necessary to compare and agree with clinical examination results to increase the specificity of imaging


Specific Conditions

Spondylolysis and Spondylolisthesis

Spondylolysis is a defect of the pars interarticularis at the posterior neural arch. It is thought to be a developmental or acquired stress fracture secondary to chronic low-grade trauma[42] .
Sponlylolysis is more frequently encountered by adolescents. There is a higher incidence particularly in those participating in certain sports or activities involving repetitive spinal extension and rotation e.g. dance, figure skating, gymnastics, and rowing [43][44][8]
Among young athletes presenting with low back pain, spondylolysis is the most frequent diagnosis, occurring in up to 47%, and are postulated to be caused by incomplete bony maturation present in the neural arch [7].
It involves mostly the lower lumbar region, which the incidence of lumbar spondylolysis in sports-engaged population has reached 63%.

Bilateral spondylolysis at the same vertebral level can result in spondylolisthesis. Spondylolisthesis refers to the anterior displacement of a vertebral body compared with its alignment with the adjacent vertebral body[8] .
It was reported that about 80% of patients with spondylolyis demonstrated spondylolisthesis[45]. During growth, the growth plate is the weakest link to anterior shear forces thus it is more prevalent to develop sponlylolisthesis [46]. It is supported that there is not any increased risk of progression of spondylolisthesis with sports participation. When there is an increase in the anterior translation of one vertebral body on the other, it is usually correlated with growth spurt, and typically symptomless[47].

Management should focus on avoidance of painful activities (extension movements), with the essential element of care being relative rest. However the ideal length of time resting from sport is unclear[8]. An exercise programme should be initiated which focuses on strengthening the core muscles with the aim that this will stabilize the lower back and pelvis [48].
Some practitioners recommend custom thoracolumbar orthoses or lumbar braces to limit spinal extension. Others advise restriction of activities without bracing. There is evidence for[49][50][51][52][53][54] and against[49][55] bracing in the management of spondylolyis therefore bracing a controversial issue among clinicians[8].


Brace - the athlete wears the brace for four to eight weeks until he or she is pain-free. Activity is gradually increased until the athlete is participating fully in activities in the brace with no pain. Then the brace is weaned over the next couple of months.

No Brace - athlete is usually restricted from activity for three to six months or until he or she is pain-free, and then activity is gradually increased until full activity is restored.

The main effect of bracing, according to biomechanical studies, is for the brace to restrict gross movement as opposed to restricting intersegmental mobility[56]. Camels and Fayolle-Minon[57] compared brace vs no brace and concluded that there is no positive use of a brace in terms of bony union. Another study[58] investigated the management of spondylolyis in young footballers and found that best results were obtained from a period of rest from sport for three months regardless of bracing.

The best initial treatment is rest and ideally rest should include avoidance of any physical activity and sports[29]. However the literature does not suggest specific duration of activity restriction, the consensus is based on the individual athlete’s clinical response and appearance of pars lesion on CT[13]. Bracing is not uniformly supported by the literature. Spondylolysis rehabilitation can be started early and progressed depending on symptoms[13].

Surgical intervention is rarely required, although a young athlete with a slip of 50% or greater surgical treatment is considered the best option[13].
Other potential indicators for surgical intervention:
• Progressive slip
• Intractable pain
• Development of neurological defects
• Segmental instability with pain

An athlete who has resumed full pain-free activities without a brace is considered to be clinically healed. Most athletes with spondylolysis return to full activities without a brace and without pain within six months[13]

Meyerding Grading System is commonly adopted to catagorise the degrees of spondylolithesis, based on the percentage of anterior translation of vertebral body:

Grading Criterion
Grade I 0-25%
Grade II 26-50%
Grade III 51-75%
Grade IV 76-100%
Grade V (spondyloptosis) >100%







Lumbar spondylolisthesis grades.jpg






Figure - Grade of spondylolisthesis based on Meyerding Grading System


Links to relevant Physiopedia pages:

http://www.physio-pedia.com/Lumbosacral_spondylolysis 


Posterior Element Overuse Syndrome (Hyperlordotic Back Pain)

Posterior element overuse syndrome, also known as spondylogenic back pain, hyperlordotic back pain, mechanical low back pain and lumbar facet syndrome [9]. It is a constellation of conditions involving the posterior spine, including muscle-tendon units, ligaments and facet joints [7]. Posterior element overuse syndrome is the most common cause after spondylolysis of low back pain in adolescents [59].


Signs and Symptoms

  • Pain with extension and sometimes rotation
  • Paraspinal muscle tenderness
  • Focal tenderness over lower lumbar spine

Management

  • Pain relief and anti-inflammatory - Ice and non steroidal anti-inflammatory drugs (NSAIDs)
  • Allow pain-free activities but avoid extension of the spine.
  • Physiotherapy - An exercise program involving abdominal strengthening, anti-lordotic exercises, hamstring and thoracolumbar stretches
  • Use of anti-lordotic brace for short time support and protection.[44]

Vertebral Body Apophyseal Avulsion Fracture

Repetitive spinal flexion and extension can injure the ring apophysis, resulting in fractures of the cartilaginous ring apophysis displacing posteriorly into the spinal canal, along with the intervertebral disc. Avulsion fractures occur in sports such as volleyball, gymnastics, wrestling and weightlifting [21].


Signs and Symptoms

  • Lumbar pain on flexion (usually without neurological symptoms)
  • Limited lumbar flexion and extension
  • Paraspinal muscle spasm

Management of pain relief

  • Rest
  • Heat
  • NSAIDs
  • Massage

Surgery 

Required if significant neurological findings from neural compression. Symptoms such as significant leg weakness or loss of bladder/bowel control are necessitates for surgical excision of the fragment [13]

Disc Herniation

Low back pain secondary to disc disease is uncommon in adolescent athletes. Only 11% of young athletes with low back pain have acute disc herniation of the lumbar spine [7]. Adolescents typically present with acute onset, flexion-related back pain with associated paraspinal muscle spasm, hamstring tightness and gluteal pain [60]. Compared with the adult population, traditional radicular symptoms are not often initially present.


Physical examination
A comprehensive physical and neurological examination is essential for athletes with presuming abnormalities.


• Decreased lumbar range of motion particularly flexion
• Positive neural tension signs e.g. straight leg raise and seated slump test.
• Possible decreased reflexes and strength on the affected side of the correlating myotomes. However, the presentation can be variable, with the patient having only axial low back pain until undergoing the provocative examination.

Management
Nonoperative care is advised as the dominant form of treatment for adolescent athletes who have discogenic pain [13]. Overall, almost 90% of patients improve with conservative management [54].

  • Medication e.g. NSAIDs
  • Physiotherapy - addressing lumbar stability and neuromuscular control
  • Intervention treatment e.g. epidural injection

Disc conditions are an uncommon problem in young athletes; although when they do occur it can be a significant problem. Kumar[61] found that out of 742 patients undergoing surgery for lumbar disc disease only 3.5% of the patients were under the age of 20

Surgical option is reserved for those who have:

  • Severe radicular pain not responding to optimal nonoperative care
  • Cauda equina involvement
  • Progressive neurologic loss

Scheuermann's Kyphosis 

Scheuermann kyphosis is a developmental condition of uncertain cause affecting the thoracic or thoracolumbar spine. Scheuermann first described the thoracic kyphosis with three consecutive anterior vertebral bodies wedged at least 5% each, along with vertebral end plate changes, Schmorl’s nodes and apophyseal ring fractures [62]. Although it generally occurs in the thoracic spine, a less common lumbar variant of Scheuermann kyphosis has been described with end-plate changes, Schmorl nodes, disc space narrowing and vertebral wedging, which occurs less frequently [8]. The lumbar variant is seen more commonly in athletes participating in sports involving rapid flexion and extension or with heavy lifting. It is believed that this process may be a different clinical entity than it just being a variant of thoracic Scheuermann kyphosis [63].

The literature suggests that Scheuermann Kyphosis has an incidence reported to be 0.4% to 8.3% in the general population and may be more frequent in males than females [63][64]. Those diagnosed with Scheuermann Kyphosis tend to have a greater mean height than the overall population[63].

Treatment depends on the extent of the symptoms and the degree of curvature. Patients with a curve of less than 50 to 60 typically respond well using flexibility and postural exercises in combination with relative rest, anti-inflammatory medication, or bracing. For more substantial curves of 50 to 75 in a skeletal immature patient, bracing should be considered. For those with curves greater than 75, bracing may no longer be effective and surgical treatment should be considered[63][64].


Condition Type of Pain Onset Sports with higher occurence
Spondylolysis Extension Insidioius Dance, figure skating, gymnastics, rowing, weight lifting, throwing track and field sports, diving, wrestling, cricket, crew
Posterior Element Overuse Syndrome Extension Insidious
Vertebral Body Apophyseal Avulsion Fracture Flexion Acute Volleyball, gymnastics, wrestling, weight lifting
Disc Herniation Flexion Acute, sometimes chronic Weight lifting, collision sports, bowling

 [44][60][13]


Prevention

Recognising the risk factors is essential to reducing injury in sports, and especially in young athletes[43]. A review published in 2014 stated that having preventative measures could possibly reduce the occurrence of injuries by 50%[30]. Here are some key aspects to consider when aiming to prevent injury:

Pre season

A preseason screening programme can identify risk factors such as inflexibility, muscle weakness and previous injuries that are not fully recovered. These risk factors should be identified and addressed before the start of the season.

Also athletes should start a general strength and fitness training program several weeks before the season begins, increasing the frequency and intensity of training gradually adapting towards the high demands of the sport[65]. The training program, performance standards, and physical and psychological factors should be taken in to account[66].

For a prevention training programme to be more successful in preventing injuries their needs to be detailed understanding of the training content, frequency, duration, recovery and athlete compliance.[31]

Growth spurts

During periods of growth muscles struggle to lengthen as fast as bones grow. This can cause inflexibility and muscle imbalances predisposing them to injury[43][65] . Due to this, young athletes should decrease the amount of training and repetitive movements during growth spurts. Stretching tight hip flexors and hamstrings can help reduce the risk of low back.[67]

Technique and repetition

Specific movements in certain sports, such as walk overs in gymnastics and lay back spins in ice skating, put high amounts of pressure on the posterior spine that may lead to injury. Athletes may need to reduce the amount of repetitions of these movements, especially if their pain is associated with these movements.

Performing the correct techniques should be stressed to all athletes. Correcting posture to reduce excessive lordosis in the lumbar spine is important to help prevent injuries on the lumbar spine. Correct techniques must be used to prevent damage to the back in sports that require lifting, such weight lifting and dancing[43].

Competition

There can be a vast variability of sizes and strengths between players in team sports. Efforts should be made in contact sports to match athletes in strength and size in order to prevent injuries from contact with stronger and larger players[43][65]

Early Intervention

It is important that athletes don’t associate back pain as being a part of their sport. Increasing complaints of pain should be addressed early and taken seriously to avoid significant injury, especially if the pain is interfering with activity[43].


Return to sports

Back pain is associated with time lost playing sports among competitive athletes[34].

It is reported that one fifth of injuries are severe which results in time away from sporting activity for up to 4 weeks and 20% of injuries are recurrences[30].

The duration of the athletes treatment time off can be an indication of the severity of the injury and the sporting time lost can impact upon the sports person in several ways, such as mental well-being, therefore it is important that the athlete returns to sport as soon as possible[3].

Return to sport following an injury is deemed appropriate after a period of rehabilitation for the specific condition which includes education regarding spinal awareness and dynamic postural control [13].
A criterion for return to play consists of normal strength and pain-free range of motion [9].

Table- overview of time scales for return to play for specific conditions common in the young athlete

 Condition Return to play
Spondylolysis 6-8 weeks after injury[13]
Spondylolisthesis 4-6 months after diagnosis [8]
Posterior element overuse syndrome 4-8 weeks [60]
Vertebral body apophyseal avulsion fracture 3-6 months [60]
Disc herniation/Disc disease Once achieved full range of motion, strength and technique for the sport [44]
Scheuermann Kyphosis With a lordotic brace set at 15° lordosis the athlete could return to sport in 1-2 months [44]


 

References

  1. Department for Culture, Media and Sport, Department for Education. Getting more people playing sport, February 2013.
  2. Department for Culture Media and Sport. Taking Part 13/14 Annual Child Report. Statistic Release September 2014.
  3. 3.0 3.1 3.2 Armstrong N, Van Mechelen W. Paediatric Exercise Science and Medicine. Oxford University Press, 2008
  4. d'Hemecourt PA, Gerbino PG, Micheli LJ. Back injuries in the young athlete.Clin Sports Med. 2000 Oct;19(4):663-79.
  5. 5.0 5.1 5.2 Schmidt CP, Zwingenberger S, Walther A, Reuter U, Kasten P, Seifert J, Günther KP, Stiehler M. Prevalence of low back pain in adolescent athletes – an epidemiological investigation. Int J Sports Med. 2014; 35(8):684-9
  6. Krismer M, van Tulder M. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol. 2007; Feb;21(1):77-91.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Micheli LJ, WoodR. Back pain in young adults. Significant differences from adults in causes and patterns. Paediatric and Adolescent Medicine1995;Vol 149
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 Standaert C. Low Back Pain in the Adolescent Athlete.Phys Med RehabilClin N Am.2008; 19(2):287-304
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Purcell L and Micheli L. Low back pain in young athletes. Sports Health. 2009;1(3): 212-222
  10. Greene HS, Cholewicki J, GallowayMT, Nguyen CV, Radebold A. A history of low back injury is a risk factor for recurrent back injuries in varsity athletes. Am J Sports Med.2001;29(6):795-800.
  11. 11.0 11.1 Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013
  12. Sjolie AN. Low-back pain in adolescents is associated with poor hip mobility and high body mass index. Scand J Med Sci Sports. 2004
  13. 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 Luigi AJ. Low Back Pain in the Adolescent Athlete. Phys Med Rehabil Clin N Am 25 (2014) 763–788
  14. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from fckLRadults in causes and patterns. Arch Pediatr Adolesc Med. 1995 Jan;149(1):15-8
  15. 15.0 15.1 15.2 15.3 Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 4th ed. Churchill Livingstone, 2005.
  16. 16.0 16.1 16.2 16.3 Pansky B. Review of Medical Embryology. Macmillan USA, 1982.
  17. 17.0 17.1 17.2 Schafer RC. Clinical Biomechanics: Musculoskeletal Actions and Reactions, 2nd ed. Williams & Wilkins, 1986.
  18. Matt's Training Resources, Anatomy. Ossification centres: http://nothinbutapeanut.com/?page_id=637#Spine (accessed 14 Jan 2015)
  19. Williams PL, Warwick R. Gray’s Anatomy, 36th ed. Churchill Livingstone, Edinburgh, 1980.
  20. Cyron BM, Hutton WC. The fatigue strength of the lumbar neural arch in spondylolysis. J Bone Joint Surg Br 1978;60-B:234–8.
  21. 21.0 21.1 21.2 Clark P, Letts M. Trauma to the thoracic and lumbar spine in the adolescent. Can J Surg 2001;44(5):337–45.
  22. Netter FH. Atlas of Human Anatomy, 2nd ed. Icon Learning Systems, 1989.
  23. Ferguson RL. Thoracic and lumbar spinal trauma of the immature spine. In: 
Herkowitz HN, Garfin SR, Eismont FJ, et al, editors. Rothman-Simeone the spine. 5th edition. Philadelphia: Saunders; 2006. p. 603–12.
  24. Roaf R. A study of the mechanics of spinal injuries. J Bone Joint Surg [Br] 1960;42: 810-23.
  25. Case courtesy of Dr Chris O'Donnell. http://radiopaedia.org/cases/acute-schmorl-node-1
  26. 26.0 26.1 26.2 Emery CA. Risk factors for injury in child and adolescentsport: a systematic review of the literature. Clin J Sport Med.2003;13(4): 256-68.
  27. 27.0 27.1 27.2 27.3 27.4 Meeuwisse WH, Tyreman H, Hagel B, Emery C. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation. Clinical Journal of Sport Medicine2007;17(3), 215-219
  28. Haus BM, Micheli LJ.Back pain in the pediatric and adolescent athlete.Clin Sports Med.2012; 31(3):423-40.
  29. 29.0 29.1 De Luigi AJ. Low Back Pain in the Adolescent Athlete.Phys Med RehabilClin N Am.2014;25(4): 763-788
  30. 30.0 30.1 30.2 30.3 30.4 Theisen D, Malisoux L, Seil R, UrhausenA Injuries in Youth Sports: Epidemiology, Risk Factors and Prevention. Dtsch Z Sportmed2014; 65 248- 252.
  31. 31.0 31.1 31.2 31.3 Frisch A, Croisier JL, Urhausen A, Seil R, TheisenDInjuries, risk factors and prevention initiatives in youth sport. Br Med Bull2009; 92:95-121.
  32. Micheli LJ.Low back pain in the adolescent: differential diagnosis. Am J Sports Med.1979; 7(6):362-4.
  33. Cassas KJ and Cassettari-Wayhs, A. Childhood and Adolescent Sports-Related Overuse Injuries Am Fam Physician.2006; 73(6):1014-1022.
  34. 34.0 34.1 Bono CM. Current Concepts Review. Low Back Pain in Athletes.THE JOURNAL OF BONE AND JOINT SURGERY · JBJS.ORG2004; VOLUME 86-A · NUMBER 2
  35. Bahr R,Holme I. Risk factors for sports injuries--a methodological approach.Br J Sports Med.2003; 37(5):384-92.
  36. 36.0 36.1 Nadler SF, Malanga GA, DePrince M, Stitik TP, Feinberg JH. The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes. Clin J Sport Med. 2000; 10(2): 89-97
  37. 37.0 37.1 37.2 37.3 37.4 Houghton, K. M. Review for the generalist: evaluation of low back pain in children and adolescents. Pediatr Rheumatol. 2010. 8(1), 28.
  38. 38.0 38.1 Kenyon K., Kenyon J. The Physiotherapists Pocket Book. 2nd Edition.China. Churchill Livingston Elsevier. (2009) p.40-41
  39. Majlesi, Javid, Halit Togay, Halil Ünalan, and Sadk Toprak. "The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation." JCR: Journal of Clinical Rheumatology 14, no. 2 (2008): 87-91.
  40. Bhatia N, Chow G, Timon J and Watts G. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. Journal of Pediatric Orthopaedics. 2008. 28(2), 230-233.
  41. Rodriguez P., and Poussaint Y. Imaging of back pain in children. American Journal of Neuroradiology, 2010. 31(5), 787-802.
  42. Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lumbar spondylolysis: a review. 
Skeletal Radiol, 2011;40(6):683-700.
  43. 43.0 43.1 43.2 43.3 43.4 43.5 Zetaruk M. Lumbar spine injuries. In: Micheli LJ, Purcell LK, editors. The adolescent athlete. New York: Springer; 2007. p. 109–40.
  44. 44.0 44.1 44.2 44.3 44.4 d'Hemecourt PA, Gerbino PG II, Micheli LJ. Back injuries in the young athlete.Clin Sports Med; 2000:19:663–79.
  45. Saraste H. Spondylolysis and spondylolisthesis. Acta Orthop Scand (Suppl 251) 1993; 64
  46. Farfan HF, Osteria V, Lamy C. The Mechanical Etiology of Spondylolysis and Spondylolisthesis. Clin Orthop Relat Res. 1976 Jun;(117):40-55.
  47. Muschik M, Hahnel H, Robinson PN, et al. Competitive sports and the progres
sion of spondylolisthesis. J Pediatr Orthop 1996;16:364–9.
  48. George SZ, Delitto A. Management of the athlete with low back pain. ClinfckLRSports Med. 2002 Jan;21(1):105-20. Review
  49. 49.0 49.1 Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin North Am 2002; 49:643–53
  50. d’Hemecourt P, Zurakowski D, Kriemler S, et al. Spondylolysis: returning the athlete to sports participation with brace treatment. Orthopedics 2002;25:653–7
  51. McTimoney CA, Micheli LJ. Current evaluation and management of spondylolysis and spondylolisthesis. Curr Sports Med Rep 2003;2:41–6
  52. Steiner ME, Micheli LJ. Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace. Spine 1985;10:937–43
  53. King HA. Back pain in children. Orthop Clin North Am 1999;30:467–74.
  54. 54.0 54.1 Brown TD, Micheli LJ. Spinal injuries in children’s sports. In: Maffuli N, Chan KM, Macdonald R, et al, editors. Sports medicine for specific ages and abilities. 
London: Churchill Livingstone; 2001. p. 31–44.
  55. Standaert CJ, Herring SA. Spondylolysis: a critical review. Br J Sports Med 2000;34:415–
  56. Axelsson P, Johnsson R, Stromqvist B. Effect of lumbar orthosis on intervertebral mobility. Spine 1992;17:678–81
  57. Calmels P, Fayolle-Minon I. An update on orthotic devices for the lumbar spine based on a review of the literature. Rev Rhum Engl Ed 1996;63:285–91
  58. Rassi GE, Takemitsu M, Woratanarat P, et al. Lumbar spondylolysis in pediatric and adolescent soccer players. Am J Sports Med 2005;33:1688–93.
  59. Masci L, Pike J, Malara F, et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J 
Sports Med 2006;40:940–6.
  60. 60.0 60.1 60.2 60.3 Purcell L. Causes and prevention of low back pain in young athletes. Paediatr Child Health Vol 14 No 8 October 2009
  61. Kumar R, Kumar V, Das NK, Behari S, Mahapatra AK. Adolescent lumbar discfckLRdisease: findings and outcome. Childs Nerv Syst. 2007 Nov;23(11):1295-9. EpubfckLR2007 May 31
  62. Scheuermann HW. Kyphosis dorsalis juvenalis. Ugeskr Laeger 82385, 1920
  63. 63.0 63.1 63.2 63.3 Shah SW, Takemitsu M, Westerlund LE, et al. Pediatric kyphosis: Scheuermann’s disease and congenital deformity. In: Herkowitz HN, Garfin SR, Eismont FJ, et al, editors. Rothman-Simeone the spine. 5th edition. Philadelphia: Saunders; 2006. p. 565–85.
  64. 64.0 64.1 Karol LA. Back pain in children and adolescents. In: Herkowitz HN, Garfin SR, Eismont FJ, et al, editors. Rothman-Simeone the spine. 5th edition. Philadelphia: Saunders; 2006. p. 493–506
  65. 65.0 65.1 65.2 Simon L., Jih W., Buller JC. Back pain and injuries. Pediatric sports medicine for primary care. Philadelphia. Lippincott Williams and Wilkins. (2002) p. 306–25.
  66. Maffulli, Nicola, Umile Giuseppe Longo, Filippo Spiezia, and Vincenzo Denaro. "Sports injuries in young athletes: long-term outcome and prevention strategies." Phys Sportsmed 38, no. 2 (2010): 29-34.
  67. Feldman, Debbie Ehrmann, Ian Shrier, Michel Rossignol, and Lucien Abenhaim. "Risk factors for the development of low back pain in adolescence." American Journal of Epidemiology 154, no. 1 (2001): 30-36.