Pri-Med Southwest: Diagnosing and Treating Aches and Pains in the Adolescent Athlete

Developmental and anatomical factors can make diagnosing and treating injuries in adolescent athletes a challenge.

During her presentation at Pri-Med Southwest 2011, Joanne Borg-Stein, MD, an assistant professor of physical medicine and rehabilitation at Harvard Medical School, discussed lumbar back pain in the adolescent athlete. Borg-Stein explained that adolescent athletes face challenges related to development. Skeletal growth often outpaces soft tissue growth. This can lead to, among other things, excessive tightening in the lumbosacral fascia and hamstrings, hyperlordosis, and increased posterior element stress. Furthermore, the skeletal endplates of adolescents are immature. Sports-related stress can result in tissue failure, apophysitis (with tensile forces), herniated nucleus pulposus into the vertebral body (with compression forces), pars defects, and spinal deformity (with repetitive asymmetric forces). Additionally, overtraining and improper technique contribute to injury.

Lumbar spine injuries

Etiology of lower back pain in young athletes differs significantly from adults. Structural problems are common in adolescent athletes and pain is usually not a result of simple “back strain.” The lower back is the most frequent site of injury among participants of gymnastics, football, weightlifting, wrestling, dance, rowing, swimming, amateur golf, and ballet. Lumbar spine pain is a significant source of disability in: general dance, skating, tennis, baseball, jogging, cycling, and basketball. In patients with injuries to posterior elements of the spine, pain is worse with extension. Any young athlete (especially those involved in gymnastics, figure skating, and dance) who presents with extension pain in the lumbar region requires further thorough evaluation.

Causes of lumbar spine pain in the adolescent athlete

The spine is the core from which our movements originate. Athletic performance is dependent upon a stable spine with well-coordinated neuromuscular patterns of movement. Three subsystems maintain a stable spine: the spinal column, neural elements, and the spinal muscles and ligaments. Causes of pain include:

• Spondylolysis and spondylolisthesis
• Lumbar disc herniation
• Iliac crest apophysitis
• Atypical Scheurmann’s disease
• Vertebral body apophyseal avulsion
• Intravertebral disc herniation, Schmorl’s node
• Seronegative spondyloarthropathy
• Discitis/osteomyelitis
• Tumor

Clinical evaluation

• Diagnosing the cause of lumbar back pain requires a thorough history, physical examination, and investigation of risk factors
• Overuse injuries
• Growth process
• Anthromorphic factors -- malalignment, hypermobility
• Gender
• Sports-specific injuries

Physical examination

• Overall impression of posture, facial expression, position
• Observation of gait, transitional movements, active tasks
• Inspection of curves, alignment, atrophy, and symmetry
• Determination of range of motion: flexion, extension, side-bend, and rotation
• Palpation of bony processes (eg, spinous process, transverse process, ribs, trochanter, sacroiliac joint, iliac crest, and discs) and muscle (eg, erector spinae, thoracolumbar fascia, quadratus, glutei, and hip flexors)
• Exploration of neurologic involvement
• Testing of dynamic “athletic” function, looking at quality of movements and how patient manages his/her pelvis and core: one-legged standing lumbar extension, lunge, squat, step ups, clock, lunges, step-ups, unilateral hop

Management and return to play guidelines

For most injuries, proper training and avoidance of aggravating activities may enable participation while pain resolves. Treatment is complicated by psychosocial factors such as the athlete’s competitiveness and desire to return to the precipitating activity. Management should include pain control, activity modification, an exercise program, physical therapy, and, possibly, bracing for pain control and earlier return to play. Very few overuse injuries of the lumbar spine and sacrum require complete rest. Disc herniation, however, does require full pain-free range of motion with normal strength. Athletes must progress through the following stages: pain control; restoration of flexibility, strength, endurance, and balance; and finally, sport-specific training. Management of sacroilieal and iliac crest injuries should be guided by symptoms.

Guidelines for posterior element injuries

• Continue modified, pain-free sports participation
• Curtail extension, torsion, and impact activities
• Consider bracing for earlier return to play
• 3-6 weeks for post element syndrome
• 3 months or longer for spondylolysis or listhesis