Causes and prevention of low back pain in young athletes

Question 1

How common is low back pain in the pediatric athlete?

Answer 1

10-15%

Question 2

What sports have higher incidence of lower back pain?

Answer 2

1. Football
2. Figure skating
3. Gymnastics
4. Soccer

Question 3

What are risk factors for back injuries?

Answer 3

1. Muscle imbalance
2. Inflexibility
3. Structural differences of the spine
4. Improper training
5. Repetitive spine flexion
6. Poor technique
7. Excessive training

Question 4

What is spondylolysis?

Answer 4

Stress fracture of the pars interarticularis causes by repetitive spinal extension and rotation

Question 5

What sports increase the risk of spondylolysis?

Answer 5

1. Dance
2. Figure skating
3. Gymnastics

Question 6

What is the presentation of spondylolysis

Answer 6

1. Insidious onset of extension-related back pain.
2. Reduced hamstring flexibility.
3. Pain w/ impact activities e.g. running, jumping.
4. Hyperlordosis
5. Paraspinal muscle spasm
6. Hamstring tightness

Question 7

What are the imaging findings with spondylolysis?

Answer 7

1. AP and Lat X-ray: anatomical variants and developmental defects
2. Oblique X-ray lumbar spine: stress reaction of pars interarticularis in 1/3 cases
3. CT bone scan: confirms spondylolysis, monitors healing

Question 8

What is the management of spondylolysis?

Answer 8

1. Avoid painful activities i.e. extension
2. Abdominal strengthening
3. Hip flexor and hamstring stretches
4. Anti-lordotic exercises
5. Custom thoracolumbar orthoses or lumbar braces to limit spinal extension (controversial) x 4-8wk until pain free, then gradually increase activity and wean brace, then restrict activity without brace x 3-6m until pain free

Question 9

What is posterior element overuse syndrome?

Answer 9

Aka “hyperlordotic back pain” or “mechanical/muscular back pain”. Constellation of conditions involving the posterior spine, including muscle-tendon units, ligaments and facet joints

Question 10

What is the presentation of posterior element overuse syndrome?

Answer 10

1. Insidious onset of extension-related back pain.
2. Focal tenderness of the lumbar spine
3. Tender paraspinal muscle

Question 11

What are the typical findings on investigation for posterior element overuse syndrome?

Answer 11

Negative

Question 12

What is the management for posterior element overuse syndrome?

Answer 12

1. NSAID
2. Avoidance of extension movements
3. Anti-lordotic exercises
4. Abdominal strengthening
5. Hamstring and thoracolumbar stretches
6. Anti-lordotic bracing untl pain resolves

Question 13

What is the typical prognosis for posterior element overuse syndrome?

Answer 13

Typically resume full activity without pain within 4-8 weeks

Question 14

What is the typical prognosis for spondylolysis?

Answer 14

Typically return to full activities without brace and without pain within 6m

Question 15

What is vertebral body apophyseal avulsion fracture?

Answer 15

Repetitive spinal flexion and extension can injure the ring apophysis resulting in fractures that may posteriorly displace into the spinal canal, along with the intervertebral disc

Question 16

What sports do avulsion fractures commonly occur in?

Answer 16

1. Volleyball
2. Gymnastics
3. Weightlifting

Question 17

What is the typical presentation of a vertebral body apophyseal avulsion fracture?

Answer 17

1. Acute onset flexion related lumbar pain
2. No associated neurological symptoms
3. Spinal flexion and extension limitation
4. Paraspinal muscle spasm

Question 18

What is the typical findings on investigation for vertebral body apophyseal avulsion fracture?

Answer 18

1. Lumbar X-ray: ossified fragment in the canal
2. CT: preferred imaging
3. MRI: may miss injury

Question 19

What is the management of vertebral body apophyseal avulsion fracture?

Answer 19

1. Rest
2. Heat
3. NSAIDs
4. Surgical excision of the fragment if significant neurological findings e.g. significant leg weakness or loss of bowel/bladder control

Question 20

What is the typical prognosis of vertebral body apophyseal avulsion fracture?

Answer 20

Rest for 3-6m for resolution of symptoms

Question 21

How common is disc herniation in young athletes?

Answer 21

11%

Question 22

What is the typical presentation of disc herniation?

Answer 22

1. Acute onset flexion related lumbar pain
2. Back muscle spasms
3. Hamstring tightness
4. Buttock pain sometimes
5. Radicular symptoms (muscle weakness and paresthesias) uncommon
6. Decreased lumbar flexion
7. Positive straight leg raise
8. Decreased reflexes/strength of lower extremities (occasionally)

Question 23

What are the typical findings on investigation for disc herniation?

Answer 23

1. Lumbar X-ray: r/o associated pathological conditions e.g. fractures or tumours
2. MRI: extent of herniation, incld. nerve root impingement, use for porgressive or refractory symptoms

Question 24

What is the management of disc herniation?

Answer 24

1. NSAID
2. Physical therapy
3. Surgery if cauda equina syndrome, progressive neurological deficit or refractory pain

Question 25

What is the typical prognosis of disc herniation?

Answer 25

Usually improve with conservative management in 3-6m

Question 26

What are other causes of low back pain?

Answer 26

1. Inflammation
2. Infection
3. Tumors
4. Visceral pathology

Question 27

What are red flag symptoms for back pain?

Answer 27

1. Fever
2. Night pain
3. Neurological abnormalities
4. Weight loss
5. Malaise

Question 28

What are some low back pain prevention strategies?

Answer 28

1. Reduce training during rapid growth
2. Emphasize proper technique
3. Core-strengthening exercises
4. Hamstring and hip flexor stretches

Question 29

What are return to play guidelines for low back pain?

Answer 29

Return to full play when pain-free ROM and normal strength have been obtained.