Low Back Pain and Young Athletes

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Introduction

Young athlete definition.

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 (7). 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 (8).

7) Policy - Getting more people playing sport gov.uk
8) Taking Part 2013/14 Annual Child Report

Low back pain (LBP) occurs in approximately 10% to 15% of young athletes (d’Hemecourt, Gerbino and Micheli, 2000). Schmidt et al 2014 found that competitive adolescent athletes compared to aged matched individuals have increased prevalence of back pain

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 (Purcell and Micheli, 2009). Evidence has shown LBP occurs is as much as 27% of college football players and between 50% and 86% of gymnasts (Semon 1981; Kolt 1999). Overuse injury can be as a result of repeated flexion, extension and torsion which is performed frequently in gymnastics, ice skating and dancing (Purcell and Micheli, 2009).

Assessment

Subjective assessment

There is usually poorly localized 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.

The clinical history of a patient should include an in depth description of:

Table:

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 have a foot drop?
Previous treatments Has the patient had previous treatment for the same or similar condition?
Was the treatment successful?
Lifestyle 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 with immunosuppressive agents? Has the patient had any previous injury or surgery?
Family History Is there any of family history of orthopaedic, rheumatic s or neurologic conditions? Psoriasis? Inflammatory bowel disease? Ankylosing spondylitis?

Objective assessment

Observation

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)

Range of movement

To test active movements of the thoracolumbar spine patients need to be in a standing position with their pelvis stabilised. Here some examples how to measure the range movement in the thoracolumbar spine

- Flexion – 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).
- Extension – Ask the patient to bend as far backward as possible with knees straight, whilst supporting their lumbar spine (measure the degrees of movement).
- Lateral flexion – Ask the patient to bend as far to the side as possible (the patient should be able to touch their fibular head).
- Lateral rotation – As well as stabilising the pelvis, place a hand on the opposite shoulder to prevent compensatory movements. Ask the patient to rotate their trunk as far as possible (measure the degrees of movement).

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.

Special tests

Scoliosis test (Adams Forward Bend Test)

Patient standing and instructed to forward flex with the
feet together and knees straight. The curve of structural
scoliosis is more apparent when bending over and the
examiner may observe an imbalanced rib cage, with one
side being higher than the other.

Modified Schober’s test

for lumbosacral spine mobility
Patient standing and measurements made 10 cm above
and 5 cm below the lumbosacral junction (dimples of
Venus). Repeat measurement with patient in full forward
flexion. In general, the measure should increase by
at least 6 cm to 21 cm[10]. An increase of less than 6
cm suggests decreased lumbar spinal mobility, which
may be seen in spodyloarthropathies. (Figure 1)

Straight leg raise

Patient supine and the examiner lifts the leg keeping the
knee straight, while supporting the calcaneus. Normal
range is 80 degrees. If the patient has tight hamstrings,
they may localize pain to the hamstring area. If the
patient has sciatic pain, the patient may experience pain
extending down the back of the leg or in the back. Lowering
the leg 15 degrees and dorsiflexing the foot to
stretch the sciatic nerve should reproduce sciatic pain. If
pain persists it is sciatica, if not it is likely tight
hamstrings

FABER or Patrick test

Patient lying supine and leg passively brought into Flexion,
ABduction, External Rotation with foot resting on
opposite knee. Press down gently but firmly on the
flexed knee and the opposite anterior superior iliac
crest. Pain may be felt in the groin with intraarticular
hip pathology or SI joint region with SI pathology.

Trendelenburg Test

Positive when patient stands on one leg and the contralateral
hip drops, indicative of gluteals/hip abductor
weakness. There are many conditions that may weaken
the hip abductors including musculoskeletal and neurologic
problems.

Flexibility

The back and hips should be moved through active and passive range of motion.
Hamstring flexibility is determined by measuring the popliteal angle. The hips and knees are flexed to 90 degrees and then the examiner extends the knee until there is firm
resistance. An angle greater than 45 degrees or asymmetry is common with tight hamstrings and low back pain.

Strength

Lower extremity strength and core strength should be
examined.

Peripheral joint exam

Examination of the hips, abdomen and pelvis is important to rule out referred pain.
Range of motion. Further detailed exam as appropriate.

Neurological exam

A complete neurological exam should include trunk and extremity strength, pain, proprioception and deep tendon reflexes.
Deep tendon reflex tests [Patellar (L2, 3, 4), Achilles
(S1)].
Superficial reflexes [Abdominal reflex (T7-T10 and
T10 -L1for upper and lower muscles)]
Upper motor neuron reflexes [Cremasteric reflex
(T12), Anal wink (S 2, 3, 4)]
Pathologic reflexes [Babinski test]
Sensation of the lower leg in major dermatomes.
Pain and proprioception.

Abdominal and pelvic exam
[abdomen and pelvis pathology may refer pain to the back]

Investigations

Laboratory tests are necessary in evaluating patients with back pain and a high suspicion of infection or systemic disease. CBC, ESR or CRP, blood and joint cultures should be done if infection is suspected. Arthritis is a clinical diagnosis; ANA, rheumatoid factor and
HLA-B27 are helpful in classification and treatment but not diagnosis. CBC, peripheral smear should be done if hematological malignancy is suspected.

Imaging

Radiographs
Standard thoracolumbar views include the standing
anteroposterior (AP) and lateral projections.
Technetium bone scan
Bone scan identifies areas of increased osteoblastic activity
and can help localize subtle areas of bone injury that
may not be visible on radiographs. SPECT (singlephoton
emission computed tomography) is recommended
for imaging the spine in patients who have
negative radiographs and no neurological findings.
SPECT is especially useful in identifying stress fractures
and spondylolysis [8].

Computed (CT)

CT provides additional bony and cartilage detail. CT is
useful in further characterizing lesions identified on
bone scan, including fractures, spondylolysis and tumors
[11].

Magnetic resonance imaging (MRI)

MRI provides increased soft tissue contrast allowing
evaluation of the spinal cord and paraspinal structures.
MRI is useful in the diagnosis of back pain with neurologic
findings but anatomic localization on clinical exam
is necessary to increase the specificity of imaging.

Specific Conditions

Spondylolysis and Spondylolisthesis

Links to relevant Physiopedia pages:

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

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

Scheuermann's Kyphosis

Link to relevant physiopedia page:

http://www.physio-pedia.com/Scheuermann's_Kyphosis