Conducting the physical exam

Examination of a patient with back pain begins the moment he enters the exam room with observation of gait and posture. With the patient fully undressed, examine him for muscle and pelvic asymmetry, signs of splinting, midline defects, tufts of hair, and hemangiomas. Evaluate spinal contour with the patient both standing and in forward flexion, looking for increased lumbar lordosis, thoracic kyphosis, and scoliosis. (See "A guide to early detection of scoliosis" in the September 2001 issue.)

Figure 1. Forward bending

Palpate the back for tenderness and other findings. Include the vertebrae, spinous processes, vertebral spaces, interspinal ligaments, lumbosacral junction, shoulders and scapulae, and paraspinal muscles. Check for leg-length discrepancy if you observe gait disturbance. (See "A practical approach to the child who limps " February 2002.)

Figure 2. Lateral rotation

A deficit in range of motion of the spine usually locates to the lumbar area. Note any limitation to motion in forward bending (Figure 1), lateral rotation (Figure 2), lateral bending (Figure 3), and extension maneuvers. Pain on forward flexion may indicate injury to the anterior spine, because this maneuver loads the elements in that region. Exerting resistance against the back of the patient as he returns to an upright position, on the other hand, stresses the posterior spine; elicited pain indicates possible injury to the posterior region.

Figure 3. Lateral bending

The provocative hyperextension test (Figure 4) further loads the posterior spine: Ask the patient to stand on one leg as you gently hyperextend the back from behind, stressing the pars interarticularis on the weight-bearing side. A positive test (elicited pain) indicates possible spondylolysis or spondylolisthesis.

Figure 4. Provocative hyperextension test

Continue the examination by observing for quadriceps and hamstring symmetry. With the patient supine, perform a straight leg-raise: grasp the ankle and, while holding the knee in extension, flex the hip to assess range of motion, hamstring flexibility, and any elicited pain. Repeat the maneuver, placing the foot in dorsiflexion as the painful angle is neared. Radiating pain in the back indicates sciatic nerve irritation and a herniated disc. Sacroiliac joint pain can be elicited through the Patrick test (also known as the FABER test: Flexion, ABduction, and External Rotation of the leg at the hip).

Last, perform a complete neurologic examination, including sensory and strength assessment and deep-tendon reflexes.

Because structural problems are a significant cause of low back pain in adolescent athletes, imaging is an integral component of diagnosis. Depending on the history and findings on the physical examination, evaluative tests may include plain radiographs, bone scan, single photon emission computerized tomography (SPECT) scan, and magnetic resonance imaging (MRI). If the history reveals systemic symptoms, laboratory studies should include a complete blood count, erythrocyte sedimentation rate, blood culture, human leukocyte antigen (HLA-B27), rheumatoid factor, and antinuclear antibody.

Differential diagnoses for an athlete with back pain

The imaging and laboratory tests indicated for specific diagnoses are noted in the discussion that follows. That discussion provides an overview of some of the conditions that cause back pain in the young athlete. The table lists conditions included in the broad differential diagnosis.

Contusions and strains

Contusions are common in the active pediatric population and usually present with ecchymosis and tenderness. Flank injuries warrant urinalysis to rule out microscopic hematuria and renal injury. Radiographs can be used to rule out more severe pathology, including fractures, and are indicated when pain is out of proportion to the nature of the injury or lasts longer than three weeks.¹⁰ Treatment is primarily symptomatic and includes rest, ice, and, if possible, compression.

Back muscle strain is a diagnosis of exclusion. Only 6% of all cases of back pain in adolescent athletes arise from a muscle strain, as such, so a thorough evaluation should reveal no other pathology before you entertain a diagnosis of muscle strain.⁶ Your evaluation should include an extensive history with review of any constitutional symptoms and appropriate exam. If indicated by history and exam, radiographs can be used to rule out fracture, and a SPECT scan or MRI can be used to rule out stress fracture or more serious injury. Treatment includes relative rest and ice, and mild stretching, biking, or swimming as tolerated.

Compression and avulsion fractures

Collision sports, such as football, ice hockey, and rugby, are responsible for most compression fractures among adolescents. These fractures usually occur following axial loading with the back in a flexed or upright position. In football, for example, a cervical spine fracture may result from axial loading that occurs when the athlete falls on his head or rams his opponent with his head in a flexed position (chin to chest). Presentation usually includes point tenderness to the involved spinous processes and pain on flexion or extension, or both. Evaluation should include anterior-posterior (AP) and lateral radiographs, as well as computed tomography (CT) to evaluate the stability of the fracture.

Treatment of fractures consists of physical therapy as tolerated and immobilization in a thoracolumbosacral spinal orthosis. Immobilization lasts four to six weeks with a stable lumbar fracture, and six to 12 weeks with a stable thoracic fracture. The athlete can return to full competition when he demonstrates full range of motion and strength and is symptom free.⁷

Avulsion fracture of the spinous process is caused by traction on the spinous process apophysis and is usually the result of a sudden, violent muscle contraction (flexion or extension). Athletes may complain of pain on the avulsed spinous process, and a bone scan will show increased uptake. Treatment includes rest, a nonsteroidal anti-inflammatory drug (NSAID), physical therapy, and limitation of painful activities.¹¹

Stress fracture (spondylolysis)

Spondylolysis and spondylolisthesis are the most common causes of back pain in children older than 10 years.⁶ Spondylolysis is a stress fracture of the pars interarticularis associated with sports that involve repetitive flexion and extension or persistent lumbar hyperextension, such as dance, gymnastics, figure skating, football (especially line positions), tennis, and weight training.

It has been estimated that 60% to 80% of ballet and modern dancers have some history of back pain from chronic hyperlordotic posturing,¹² and frequent hyperlordotic posturing puts them at risk of spondylolysis. Female gymnasts appear to have an increased risk of spondylolysis (11%) compared to the general female population (2.3%).¹³

It is important to fully evaluate the nutritional status of female athletes, especially those participating in sports such as figure skating, dance, and gymnastics, where body image, increased levels of competition, and younger age of onset predispose to the female athlete triad (disordered eating, menstrual cycle disturbance, and osteoporosis). This combination leads to an increased rate of stress fractures and spondylolysis.

Athletes with spondylolysis usually visit complaining of low back pain of insidious onset that becomes worse with activity—especially back hyperextension and twisting. As symptoms progress, patients may complain of tight hamstrings, buttock pain, or pain with daily activities that resolves with rest or supine positioning. Hamstring tightness may be the only presenting symptom and, especially in normally flexible athletes, must be compared to the unaffected side or the athlete's former degree of flexibility.¹¹

Palpation of the back may reveal paraspinal tenderness but not bony tenderness. Pain may be elicited by having the patient return from forward flexion to an upright position against resistance, but the most sensitive test for a pars stress fracture is the one-legged hyperextension test (the provocative hyperextension test), with pain elicited on the side of the injury. A positive hyperextension test warrants further testing for a pars defect.

Within the sports medicine community, controversy exists as to the form and timing of imaging with suspected spondylolysis. If the history and physical exam are consistent with spondylolysis, radiographic evaluation usually begins with an AP and lateral radiograph. Until recently, bilateral oblique views, in addition to AP and lateral, were considered standard in the work-up. However, Congeni, in reviewing the records of 40 patients who were given a diagnosis of spondylolysis but who had normal radiographs (AP, lateral, and oblique) and a positive bone scan, determined that 85% had fractures on CT imaging.¹⁴ Saifuddin confirmed that radiographs may not be helpful by demonstrating that only 32% of defects were oriented within 15 of the 45 lateral oblique plane.¹⁵ Because of the increased amount of radiation necessary with an oblique radiograph, AP and lateral films should be the initial radiographic investigation, followed by CT. In the acute setting (emergency department, walk-in clinic), however, oblique films can be useful, in addition to AP and lateral, when spondylolysis is suspected and follow-up is unreliable.

According to d'Hemecourt and colleagues, if radiographs are negative for fracture, the next imaging modality should be a SPECT scan with a limited CT performed at the isolated level of uptake using 3-mm cuts to classify the fracture (early, progressive, terminal).⁷ It is, however, also considered acceptable to initially obtain a SPECT scan if there is a high index of suspicion for spondylolysis. Depending on your practice, an MRI may be as easy to obtain as a SPECT (in cases in which radiographs are negative) and is often easier to explain to parents concerned about radiation exposure and trauma of an injection. Again, there is no official consensus on initial investigative studies.

The goal of treatment of a stress fracture or stress reaction is healing of the injury and prevention of progression to nonunion (i.e., spondylolytic defect) of the pars.¹⁶ There are many schools of thought, however, as to how to accomplish that goal. The most common approach is a derivative of Micheli's brace protocol:⁷ A Boston overlap brace (thoracolumbosacral orthosis) is fitted at 0 extension. Physical therapy is initiated involving peripelvic flexibility, antilordotic strengthening, biking, and swimming.

Four to six weeks later, if the patient denies pain with activity or lumbar hyperextension, spinal stabilization—in the form of physical therapy, anti-lordotic strengthening, and core strengthening—with lumbar extension to neutral is initiated. Three to four months later, a limited CT is repeated, looking for bone-to-bone healing or fibrous union if the injury is more than a year old. Healing is judged by CT scan documentation of trabecular bridging of the pars and improvement of symptoms. Return to play from a stress injury is permitted when the athlete has painless spinal mobility and has advanced to unrestricted activities without pain.¹⁶

Treatment of a young athlete with back pain and a well-documented spondylolytic defect of the pars is not directed at healing the defect but at alleviating symptoms, with bracing used to relieve pain. Clinical examination at six-month intervals is recommended to check for progression to spondylolisthesis, with imaging performed as necessary when the patient experiences a change in pain or functioning.¹⁶ If the defect is healed, the patient is weaned from the brace. Return to play is allowed after there is demonstrated bony or fibrous union and the athlete is pain free and has full range of motion.⁷ If the defect is only partially healed (fibrous union) and the patient is symptomatic, he should not be medically cleared to play.

Other methods of treatment include use of a so-called warm-n-form orthosis or corset, which is significantly less expensive than the Boston brace, although few studies have shown these products to be as effective.

Spondylolisthesis

Spondylolisthesis is forward slippage of one vertebra onto another, usually L5 onto S1. The defect is graded by percentage of slip: With each 25% increase in slippage over the sacral endplate, the grade is increased by one (0% to 25% is grade I, 25% to 50% is grade II, etc.). Examination and management of grades I and II are similar to that of spondylolysis although, occasionally, examination reveals a palpable step-off in the lower lumbar region.

Significant slippage of the spondylolisthesis may require surgery, whereas spondylolysis rarely requires surgical repair. Surgical stabilization is indicated when slip progression exceeds 50% or when conservative treatment fails. In a 1997 study, only 33 of 86 athletes with documented spondylolisthesis had any progression of the slip (an average 10.5% progression) after intensive daily training. The authors concluded that adolescents with limited spondylolytic spondylolisthesis should be cleared for competitive sports after rehabilitation.¹⁷ Criteria for successful rehabilitation are similar to spondylolysis (painless spinal mobility and return to activities without pain).^16,17

Lordotic low back pain

Symptomatic lordotic low back pain is usually a direct consequence of rapid growth during adolescence, resulting in a tight thoracolumbar fascia. As with all mechanical or muscular low back pain during adolescence, lordotic low back pain should be declared the diagnosis only after other structural problems are ruled out. The pain is usually activity-related, and there are no ominous signs, such as numbness, tingling, night pain, or fever. On exam, there may be hyperlordosis (inward arching of the low back); hamstrings are usually tight. If symptoms suggest a pars stress injury or fracture, evaluation should follow the protocol for spondylolysis.

Sassmannshausen and Smith recommend that patients with lordotic back pain cease activity for a minimum of five to seven days, before gradually returning to activity under the guidance of a physical therapist.¹⁸ Treatment focuses on a program of trunk stabilization and stretching; return to play is determined by pain and sport-specific functioning—the ability of the athlete to perform activities associated with his particular sport without pain or restriction of motion (i.e., a soccer player kicks the ball without pain).

In general, athletes with simple low back pain without evidence of more serious injury should continue to participate in all activities as tolerated, with short rests and physical therapy as needed for minor flare-up. If pain persists despite control measures, investigate other possible causes, including psychological factors.

Transitional vertebrae

A transitional vertebrae is a congenital, incomplete segmentation of the lower lumbar and upper sacral vertebrae. One study estimated the prevalence of transitional vertebrae to be 30% in men.¹⁹ Athletes performing rapid flexion and extension can cause inflammation of the joint, mimicking spondylolysis. A bone or SPECT scan looking for a spondylolytic injury will be negative for a pars defect but may show an area of increased uptake between the involved vertebrae (pseudoathrosis).

Treatment focuses on decreasing inflammation by wearing a rigid lumbosacral orthosis and on stretching and stabilizing the spine with physical therapy. The latter provides sport-specific training (e.g., lower back strengthening for a gymnast, upper back and shoulder strengthening for a tennis player) to avoid a pattern of injury.⁷

Sacroiliac joint pain

Patients who have sacroiliac (SI) joint pain complain of pain with hyperextension, similar to those with pars interarticularis injuries. Physical examination usually reveals pain upon hyperextension and tenderness to palpation of the SI joint. The Patrick (FABER) test may reveal pain on the affected side. Often, a SPECT or bone scan is necessary to rule out a pars stress fracture because radiographs are of limited use in making a diagnosis of SI injuries. In a patient with a positive hyperextension test, negative plain films of the lumbar spine, and a negative SPECT scan, SI joint disease must be entertained.

The differential diagnosis of sacroiliac pain includes stress fracture, ankylosing spondylitis, spondyloarthropathy, psoriatic arthritis, Reiter syndrome, and hematogenously spread infections. Treatment involves activity modification for four to six weeks, with an extensive rehabilitation program focused on specific training related to the cause of the pain. Occasionally a warm-n-form custom orthosis or SI belt can help ease the pain.

Other diagnoses to consider

The differential diagnoses discussed so far tend to be extension injuries. Flexion injuries are part of the differential as well. Possibilities include Scheuermann disease, excessive thoracic kyphosis involving three or more consecutive vertebral bodies wedged at least 5 (adolescent water-ski jumpers are at increased risk); disc injury, including herniation (athletes at higher risk include weight lifters and those participating in a collision sport¹⁸), and vertebral endplate fracture, a rare cause of discogenic pain in adolescents, who usually have a history of heavy lifting.¹¹

Other conditions to consider in the athlete presenting with back pain include:

Discitis and vertebral osteomyelitis . These conditions have a preponderance of onset at a younger age (2 years and 7 years, respectively), as the unique pattern of blood supply in the spine of the immature patient predisposes it to hematogenous seeding of bacteria. Consider discitis in a child, with or without fever, who complains of back pain and maintains his spine in a straight, stiff, or splinted position, refusing to flex it. Vertebral osteomyelitis, believed to be part of the same disease process as osteomyelitis but further along the spectrum, is usually associated with fever, leukocytosis, and bone destruction.

Rheumatologic disease . Ankylosing spondylitis is a spondyloarthropathy involving SI joints and the lumbar spine. It occurs most often in older boys, adolescents, and young adults. Most affected people are HLA B27-positive. The patient may experience transient arthritis of the large hips, followed by low back pain later during the course of the disease. Spinal involvement begins in the SI joints and ascends progressively to involve the rest of the spine. In contrast to ankylosing spondylitis, juvenile rheumatoid arthritis (JRA) affects the cervical spine but spares the lumbar spine.

Diagnosis of ankylosing spondylitis should be suspected in an older child, particularly a boy, who presents with oligoarthritis and enthesitis (inflammation of the sites of attachment of ligaments, tendons, fascias, and capsules to bone) and low back pain. Chronic pain, especially without an inciting event or trauma, should also make the clinician suspect rheumatologic disease. Ankylosing spondylitis is confirmed by radiographic evidence of sacroilitis. JRA is confirmed with blood tests and presence of the appropriate clinical scenario (joint pains, swelling). The diagnosis should be made in conjunction with a pediatric rheumatologist.

These rheumatologic diseases usually respond well to NSAIDs and physical therapy and should be referred to a pediatric rheumatologist.

Tumor of the spine must be considered in the differential diagnosis of a young athlete with back pain, although primary neoplasms of the thoracic and lumbar spine are uncommon. Among the most common benign tumors are osteoid osteoma, osteoblastoma, and aneurysmal bone cyst; the most common (albeit rare) malignant neoplasms are osteosarcoma and Ewing sarcoma.²⁰ The most common malignancy with spinal metastasis is neuroblastoma, although it usually occurs in children younger than 10 years and has a predilection for the thoracic spine.²¹

The presentation of a patient who has a neoplasm comprises back pain upon both activity and rest, occasional constitutional symptoms, and an atraumatic basis. Night pain, especially when it is relieved by a salicylate or NSAID, is highly suspicious for an osteoid osteoma. Occasionally, neurologic symptoms may be present, and the patient or family may notice an abnormality in the child's gait or asymmetry.¹⁸

Examination is usually minimally revealing and may include a nonstructural scoliosis, paraspinal muscle spasm, or posterior mass. Focal neurologic deficits are rare.¹⁸ Plain radiographs must be included in the evaluation of a patient suspected of having a neoplasm. Treatment for benign primary spinal lesions includes rest, bracing, and resection. Malignant lesions should prompt referral to an orthopedic oncologist.

Reflex sympathetic dystrophy (RSD) is characterized by severe pain associated with autonomic dysfunction (swelling, edema, skin color changes, mottling), usually after a trauma, fall, or collision. The precipitating injury may be a simple sprain or disc injury, but the pain continues out of proportion to what is expected for the type of injury. Treatment includes aggressive physical therapy, including tactile desensitization with different textures and range of motion exercises. Pain medication, psychotherapy, and biofeedback are sometimes useful.

Fibromyalgia is usually defined as chronic musculoskeletal pain lasting longer than six months and associated with multiple tender points. The patient often complains of disturbed sleep, headache, irritable bowel syndrome, weakness, swelling, or stiffness in the morning. Many of the tender points are located in the upper or lower back and may mimic more significant back pain. Treatment focuses on preserving activity, usually with physical therapy. NSAIDs are helpful for pain, and a mild soporific agent, such as cyclobenzaprine, may regulate the sleep cycle.

Referral should include "the physical therapy prescription"

Consultation with a specialist is contingent on your level of comfort and experience in dealing with musculoskeletal injury and pain. In general, referral is indicated for congenital lesions of the spine, lesions with neurologic involvement, and any trauma with significant fracture or dislocation.²² You should refer for spondylolysis and spondylolisthesis only if you are uncomfortable making the diagnosis or managing the condition. Refer the patient to a mental health professional if a diagnosis of psychiatric illness is evident.

Physical therapy is an important component of the primary care management of the athlete with a back injury. Even when the complaint is deemed to be psychiatric in nature and you have referred the patient to a mental health professional, it is usually appropriate to recommend referral to physical therapy, or initiation or continuation of exercise or sports participation, because physical activity has been shown to reduce the incidence and intensity of many psychiatric problems.²³

Flexion (disc, slipped apophysis) and extension (spondylolysis, spondylolisthesis) injuries require different treatment protocols. The flexion injury prescription should always include a basic cardiovascular warm-up (exercise bike, elliptical), range of motion, hamstring flexibility, and postural exercises. Patients should avoid flexion activities initially. Extension injury prescriptions should also include a cardiovascular warm-up, lumbar stabilization, abdominal strengthening, and hamstring flexibility. Patients should avoid lordotic (extension) exercises.

An active population needs monitoring

The diagnosis and management of back pain in a young athlete differs significantly from the diagnosis and treatment of back pain in an adult. Spinal pathology is much more common in children and adolescents, and a thorough diagnostic work-up should be initiated sooner than it would be in an adult. The trend toward specialized training of young athletes has yielded a growing number of overuse injuries; among such injuries, spondylolysis is one of the most common. Failure to recognize common overuse injuries can lead to diminished performance and potential debilitation.

Regardless of the initial diagnosis, adequate follow-up is essential to monitor progress, observe for new symptoms, and evaluate for return-to-play. It is your responsibility as the primary care physician to recognize and provide adequate attention to such injuries in the young athletic population.

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