|Year : 2015 | Volume
| Issue : 1 | Page : 9-12
Low back pain in the young athlete
Department of Orthopaedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||19-Jan-2015|
Department of Orthopaedics, College of Medicine, King Saud University, Riyadh
Low back pain (LBP) is a common occurrence among young athletes. Although most back pain is managed non-operatively, a careful assessment is required as some serious pathologies can masquerade as LBP. Both acute and chronic LBP occur in the athlete. Avulsion injuries to the posterior elements and apophysial ring fractures are top on the list of causes of acute LBP. Spondylolysis and spondylolisthesis are common diagnoses which are more frequently implicated as causes of chronic LBP. Extra-spinal causes of LBP should always be ruled out as delayed treatment may result in unacceptable outcomes.
ألم أسفل الظهر هو أمر شائع بين الرياضيين الشباب. على الرغم من أن معظم آلام الظهر
يتم علاجها بطرق غير جراحية، لا بد من تقييم دقيق لكل حالة حيث أن بعض الأمراض الخطيرة يمكن
أن تكون المتسببة بهذا العارض. آلام الظهرالحادة والمزمنة كلاهما يصيب الشاب الرياضي. الإصابات العظمية القلعية للعناصر الخلفية للفقرات وكسور حلقة الناتئ هي أحد أهم أسباب آلام الظهرالحادة. انحلال الفقار والانزلاق الفقاري هي أكثر التشخيصات شيوعاً كسبب لآلام الظهر المزمنة. ينبغي دائما أن يتم البحث عن أسباب خارج العمود الفقري مسببة لآلام الظهر لأن تأخير العلاج قد يؤدي إلى نتائج غير مقبولة.
Keywords: Athlete, low back pain, sports injuries
|How to cite this article:|
Alsaleh K. Low back pain in the young athlete. Saudi J Sports Med 2015;15:9-12
| Introduction|| |
Low back pain (LBP) occurs in 1-30% of young athletes. ,,, True incidence varies by age, gender and the kind of sport participated in. ,, It occurs more commonly in athletes above age 12, and incidence in activities such as gymnastics is up to 85%.  Every effort should be done by the treating physician to identify the cause of the persistent LBP in the athlete, including extra-spinal causes. Those pathologies include urinary tract infections and pelvic inflammatory disease. In general, LBP in the athlete can be categorized into acute and chronic. A plethora of diagnosis-including overuse syndromes-may be responsible. The tendency to manage back pain in this population in a way similar to the adult population undermines the fact that in the young, a specific cause is often responsible and that cause should be identified and treated. As such a diagnosis of muscle strain should only be a diagnosis of exclusion.  To provide the latest evidence for this topic, a thorough search of all available literature from 1966 to June 2014 was performed electronically on Medline® and Healthstar® and relevant clinical trials and reviews were obtained, read carefully and their summary is presented-after careful scrutiny-in this review article.
| History and physical examination|| |
The first step in management of LBP in the athlete is a careful, thorough history and physical examination. Obtaining details of the pain can give the treating physician insight into the possible causes. Onset, duration, location and character of the pain can make the distinction between acute injuries and chronic overuse syndromes. Associated symptoms-such as sciatica-should always be inquired about. No history of LBP in complete without inquiring about "red flags".  They include weight loss, fever, and night pain. These red flags help to point out causes of LBP that might require urgent treatment-such as spinal infection or malignant process. Family history and social history completes the history taking process. A family history of inflammatory joint disease-for example-is useful in guiding the treating physician to rule it out as a cause of LBP in this individual. Social history might indicate that the athlete might even be using the LBP to escape the pressures of participating in sport.
Physical examination should always start with a general look at the patient. The patient should be adequately disrobed and then be observed from the front, back and side. The athlete's posture and gait provide the first hints. Abnormalities in posture include scoliosis, kyphosis, and lumbar hyperlordosis. The shoulders and pelvis should be even. Skin changes-such as hairy patches or café-au-lait spots-could indicate spinal dysraphism and neurofibromatosis respectively. Palpation should include the spinous processes and the sacro-iliac (SI) joints. Range of motion can now be examined, and any limitation noted. Special tests include the straight leg raising test, the flexion-abduction-external rotation (FABER) test-for SI joint pathology-and the single-legged hyperextension test for spondylolysis. Finally, neurologic examination is performed, and any abnormalities are noted.
Routine imaging is not indicated in the management of LBP in the athlete. The treating physician must decide when to investigate the patient depending on the findings of the history and physical examination. If-for example-the provisional diagnosis after careful history and physical exam was that of spinal fracture then imaging is definitely indicated. Furthermore, if the symptoms persisted for more than 6 weeks and there were findings suggestive of-for example-spondylolysis, then imaging is required. Postero-anterior and lateral views are requested first. Oblique views may be of value-the classis "scotty dog" but their routine application to the young athlete with LBP will result in un-necessary radiation exposure. If these radiographs are negative yet the clinical suspicion is still high, technetium 99 bone scan is indicated as it will show the acute pars interarticularis fracture.  Single-photon emission computed tomography (CT) is even more useful than routine bone scan. In combining bone scan with CT, it aids in diagnosing stress fractures of the posterior elements and an acute spondylolysis  [Figure 1]. Computed tomography is indicated in cases where detailed depiction of the bony anatomy of the lumbosacral spine is needed; for example in fractures, chronic spondylolysis and certain bone tumors.  Magnetic resonance imaging (MRI)-often requested for LBP patients has little value in the diagnosis of bone lesions such as spondylolysis. It is indicated in cases of scoliosis associated with pain or subtle neurologic deficit. This is a rare occurrence however as scoliosis is commonly painless. MRI is the study of choice in cases of lumbar disc herniation. Abnormal MRI findings should be interpreted with caution, as 20% of asymptomatic individuals in this age group will demonstrate disc abnormalities on MRI. 
|Figure 1: Single-photon emission computed tomography/computed tomography scan of bilateral spondylolysis|
Click here to view
Specific causes of low back pain in athletes
The repetitive action of lumbar hyper-extension common in sports such as wrestling and gymnastics has long been implicated as a cause of acute disruption of the posterior elements of the spine.  The most common of these disruptions is an acute fracture or stress fracture of the pars interarticularis referred to as "spondylolysis". It is a common finding in young athletes with prevalence up to 47% of athletes with LBP while its prevalence in the general population is up to 6% only.  It is commonly seen at the level of L5-S1. With bilateral par interarticularis defects, subluxation of one vertebra over the other (commonly the L5 over S1) the diagnosis becomes spondylolisthesis. Spondylolisthesis is graded according to the Myerding classification in four grades depending on the amount of subluxation present. The mainstay of treatment of spondylolysis is non-operative treatment focusing on the rest, non-steroidal anti-inflammatory drugs (NSAID) and avoidance of hyper-extension exercises to allow for a stress fracture to heal.  Bracing has not shown to be effective, and its use is controversial.  As for spondylolisthesis, Grade I and II can be managed well non-operatively and rarely progress after skeletal maturity. Higher grades (Grades III and IV) are treated surgically as they tend to progress and don't respond well to conservative treatment. The majority of patients can return back to sport 6 months after diagnosis, unless surgical treatment was done.
Posterior element overuse syndrome
Injury to the muscle-tendon units, ligament and facet joint capsules is referred to as "posterior element overuse syndrome" or "hyper-lordotic LBP". ,, It is a common cause of LBP in young athletes, second only to spondylolysis.  These patients often present with extension LBP and weak core musculature. Investigations are negative for spondylolysis. Management includes core muscle strengthening, activity modification and hamstring stretching.
Sacro-iliac joint pathology
Motion at the SI joint is quite limited. Joint pathologies such as infection or spondyloarthopathy can affect the SI joint and present itself as back pain in this patient population. Changes in the mechanics of the lumbar spine increase stresses on the SI joint.  In addition to that, stress fracture of the sacrum may present the same way. Pain is usually in extension with tenderness on the SI joints posteriorly and a positive FABER test.  Plain radiographs may show changes at the SI joint. For most cases, bone scan or MRI is needed for proper diagnosis. Management of SI joint pain in the athlete is management of the primary pathology. In most cases, activity restriction, bracing and NSAIDs are part of the treatment protocol.
Apophysial ring fracture
In the skeletally immature athlete, the vertebral body and ring apophysis have not united and are-as such prone to injury. A disc herniation can cause an avulsion of the ring apophysis from the vertebral body  [Figure 2]. These injuries are caused by repetitive flexion and extension. The apophysial ring and intervertebral disc displaces posteriorly into the spinal canal.  The presentation is similar to a patient with a central disc herniation. The athlete typically presents with flexion pain, but characteristically no neurologic deficit. On examination, range of motion of the lumbar spine is quite limited in all directions, and there is significant para-spinal muscle spasm. Neurological examination is usually unremarkable. Although plain radiographs may show the fracture, CT can show the fractured and displaced ring apophysis better. Management is non-operative in most cases with rest and NSAIDs. In cases of neurologic deficit, surgical treatment-removal of the fractured fragment to decompress the neurologic elements-may be indicated. 
|Figure 2: Axial computed tomography image of an apophysial ring fracture|
Click here to view
Disc derangements and herniation
Discogenic LBP accounts for 10% of persistent back pain in the young athlete.  The pathology varies from the internal disc derangements-such as annular tears-to frank herniation of the nucleus pulpous. Disc herniations are twice as common in athletes as non-athletes in this age group.  The direction of the herniation also varies in this age group, as the nucleus may herniate vertically-through the vertebral endplate into the vertebral body. , These happen typically at the thoraco-lumbar junction. More commonly, the direction of the herniation is posterior towards the spinal canal. This produces the central disc herniation typical of this age group. Central disc herniations-specially in this age group-usually don't impinge on the spinal nerve roots.  Pain is worse with lumbar flexion, and is aggravated by coughing or sneezing. Physical examination findings are similar to the apophysial ring fracture described above. Magnetic resonance imaging is usually helpful in diagnosis and management is typically conservative with excellent outcomes and no long term implications. Very few young athletes less then 1% will require surgery for the management of lumbar disc herniation. 
Muscle strain is one of the most commonly diagnosed causes of LBP in the athlete. Up to 20% of LBP in the young athlete is attributed to it.  It is caused by disruption of the paraspinal muscle fibers. Acute pain is typical, lasting for 24 to 48 h. Physical examination will show only muscle spasm. Chronic strains are described, but it should only be a diagnosis of exclusion after full assessment and investigation. Inclusion of stretching and conditioning programs into sports will help reduce the incidence of muscle strains significantly. 
| Conclusion|| |
Back pain is common in the young athlete. Most cases of LBP in this population are self-limiting. Serious pathologies-such as infection or malignancy must be ruled out. A plethora of diagnosis can be responsible, but it is mostly commonly due to a disruption in the posterior elements of the lumbo-sacral junction as disc pathology is not common in this age group. Appropriate utilization of investigations will aid the treating physician reach a diagnosis and manage the case properly. Return to sports depends on an accurate diagnosis and management of the individual pathology responsible. Although most treatment methods are non-operative, surgery has a role in a small minority of the cases. Allowing the young athlete a safe return into their sport of choice should be the end result of all efforts pertaining to management of such cases.
| References|| |
d′Hemecourt PA, Gerbino PG 2 nd
, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000;19:663-9.
Taimela S, Kujala UM, Salminen JJ, Viljanen T. The prevalence of low back pain among children and adolescents. A nationwide, cohort-based questionnaire survey in Finland. Spine (Phila Pa 1976) 1997;22:1132-6.
Duggleby T, Kumar S. Epidemiology of juvenile low back pain: A review. Disabil Rehabil 1997;19:505-12.
Kim HJ, Green DW. Adolescent back pain. Curr Opin Pediatr 2008;20:37-45.
Swärd L, Hellstrom M, Jacobsson B, Pëterson L. Back pain and radiologic changes in the thoraco-lumbar spine of athletes. Spine (Phila Pa 1976) 1990;15:124-9.
Lundin O, Hellström M, Nilsson I, Swärd L. Back pain and radiological changes in the thoraco-lumbar spine of athletes. A long-term follow-up. Scand J Med Sci Sports 2001;11:103-9.
Keene JS, Albert MJ, Springer SL, Drummond DS, Clancy WG Jr. Back injuries in college athletes. J Spinal Disord 1989;2:190-5.
Hutchinson MR. Low back pain in elite rhythmic gymnasts. Med Sci Sports Exerc 1999;31:1686-8.
Purcell L, Micheli L. Low back pain in young athletes. Sports Health 2009;1:212-22.
Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, et al.
Red flags to screen for malignancy and fracture in patients with low back pain: Systematic review. BMJ 2013;347:f7095.
Sanpera I Jr, Beguiristain-Gurpide JL. Bone scan as a screening tool in children and adolescents with back pain. J Pediatr Orthop 2006;26:221-5.
Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: A prospective study. J Pediatr Orthop 2008;28:230-3.
Rodriguez DP, Poussaint TY. Imaging of back pain in children. AJNR Am J Neuroradiol 2010;31:787-802.
Boden SD, Davis DO, DinaTS, Patronas NJ, Wiesel SW. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg 1990;72:403-408
Watkins RG. Lumbar disc injury in the athlete. Clin Sports Med 2002;21:147-65.
Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine (Phila Pa 1976) 1999;24:2640-8.
Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: The diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil 2007;88:537-40.
Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995;149:15-8.
Simon LM, Jih W, Buller JC. Back pain and injuries. In: Birrer RB, Griesemer BA, Cataletto MB, editors. Ped Sports Med for Primary Care. Philadelphia: Lippincott Williams and Wilkins; 2002. p. 306-25.
Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. 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.
Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin North Am 2002;49:643-53.
Sassmannshausen G, Smith BG. Back pain in the young athlete. Clin Sports Med 2002;21:121-32.
Keene JS. Low back pain in the athlete. From spondylogenic injury during recreation or competition. Postgrad Med 1983;74:209-12, 213, 217.
Bennett DL, Nassar L, DeLano MC. Lumbar spine MRI in the elite-level female gymnast with low back pain. Skeletal Radiol 2006;35:503-9.
Elliott B, Khangure M. Disk degeneration and fast bowling in cricket: An intervention study. Med Sci Sports Exerc 2002;34:1714-8.
Baker RJ, Patel D. Lower back pain in the athlete: Common conditions and treatment. Prim Care 2005;32:201-29.
Keene JS, Drummond DS. Mechanical back pain in the athlete. Compr Ther 1985;11:7-14.
Dreisinger TE, Nelson B. Management of back pain in athletes. Sports Med 1996;21:313-20.
[Figure 1], [Figure 2]