Back injuries in the young athlete

The imaging and management of nonconsecutive pars interarticularis defects: a case report and review of literature

BACKGROUND CONTEXT

Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Multiple-level spondylolysis involving consecutive lower lumbar segments are rare. Several authors have reported failure of conservative treatment in the management of multiple-level pars fractures.

STUDY DESIGN

A case report and review of previous literature is presented.

OBJECTIVE

The objectives of this case report were to present a rare case of pars fracture involving nonconsecutive segments and discuss image findings and treatment.

METHODS

The patent's history, clinical examination, computed tomography (CT), magnetic resonance imaging (MRI) findings, and treatment are reported. We also discuss the pathogenesis, various treatment options, and review the literature.

RESULTS

We present the fourth case of bilateral pars fractures involving nonconsecutive lower lumbar spine segments of L3 and L5, in a 16-year-old young adolescent footballer who presented with 4-month history of constant low back pain. After 1 year of conservative management, the more acute fractures at L3 showed complete bony union, symptomatic pain relief, and return to full sporting activity.

CONCLUSION

We report a rare case of bilateral pars fractures involving nonconsecutive segments. Multiplane reconstruction of CT images and MRI are very useful in planning treatment and follow-up. Conservative management may be used to treat multilevel nonconsecutive pars fractures.

Back pain in adolescent athletes

Back pain in the young athlete is a common complaint and often perceived as a challenging problem. A well-directed approach will usually provide the practitioner with a higher comfort zone. The etiology of back pain in the pediatric and adolescent population is different from that of the adult population due to the presence of open physes and increased linear growth velocity. In addition, the frequency and intensity of sports participation in children continues to increase, leading to more overuse injuries. This review article will discuss the anatomy and physiology of the spine and pelvis, as well as focus on the chronic and overuse causes of back pain in the young athlete.

Treatment options for low back pain in athletes

CONTEXT

Low back pain is one of the most common medical presentations in the general population. It is a common source of pain in athletes, leading to significant time missed and disability. The general categories of treatment for low back pain are medications and therapies.

EVIDENCE ACQUISITION

Relevant studies were identified through a literature search of MEDLINE and the Cochrane Database from 1990 to 2010. A manual review of reference lists of identified sources was also performed.

RESULTS

It is not clear whether athletes experience low back pain more often than the general public. Because of a aucity of trials with athlete-specific populations, recommendations on treatments must be made from reviews of treatments for the general population. Several large systemic reviews and Cochrane reviews have compiled evidence on different modalities for low back pain. Superficial heat, spinal manipulation, nonsteroidal anti-inflammatory medications, and skeletal muscle relaxants have the strongest evidence of benefit.

CONCLUSIONS

Despite the high prevalence of low back pain and the significant burden to the athletes, there are few clearly superior treatment modalities. Superficial heat and spinal manipulation therapy are the most strongly supported evidence-based therapies. Nonsteroidal anti-inflammatory medications and skeletal muscle relaxants have benefit in the initial management of low back pain; however, both have considerable side effects that must be considered. Athletes can return to play once they have recovered full range of motion and have the strength to prevent further injury.

Practical approach to the child presenting with back pain

Back pain may be the presenting symptom of many children attending to pediatric health care settings. As such, awareness to the common etiologies of back pain in this subgroup of patients remains essential as it guides appropriate diagnosis. Although several clues may be derived from the child's history and physical examination, imaging techniques may be required to confirm the underlying diagnosis. This review summarizes the most commonly encountered causes of back pain in children and highlights diagnostic approaches that will ensure early diagnosis and intervention for a more favorable outcome.

Associations between disordered eating, menstrual dysfunction, and musculoskeletal injury among high school athletes

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the prevalence of, and association between, disordered eating (DE), menstrual dysfunction (MD), and musculoskeletal injury (MI) among high school female athletes.

BACKGROUND

Female athlete triad (Triad) syndrome is the interrelatedness of DE, MD, and low bone mass. Few studies have examined 2 or more Triad components simultaneously, or their relationship to injury, among female high school athletes.

METHODS

The subject sample consisted of 311 female high school athletes competing on 33 interscholastic high school teams during the 2006-2007 school year. Athletes completed the Eating Disorder Examination Questionnaire (EDE-Q) and Healthy Wisconsin High School Female Athletes Survey (HWHSFAS). Athletes were classified by sport type as aesthetic (AES), endurance (END), or team/anaerobic (T/A).

RESULTS

Of those surveyed, 35.4% reported DE, 18.8% reported MD, and 65.6% reported sustaining a sports-related musculoskeletal injury during the current sports season. Athletes reporting DE were twice as likely to be injured compared to those reporting normal eating behaviors (odds ratio [OR], 2.3; 95% confidence interval [CI]: 1.4, 4.0). Multivariate logistic regression analyses revealed that athletes who reported a history of DE (OR, 2.1; 95% CI: 1.1, 3.9) or prior injury (OR, 5.1; 95% CI: 2.9, 8.9) were more likely to be injured during the sports season.

CONCLUSION

A high prevalence of DE and MD exists among high school female athletes. Additionally, athletes with DE were over 2 times more likely to sustain a sports-related injury during a sports season. Screening and intervention programs designed to identify and decrease the prevalence of DE should be implemented with high school females.

LEVEL OF EVIDENCE

Prognosis, level 2b.

Imaging of back pain in children

While back pain presents less frequently in children than in adults, it still poses a significant clinical challenge with respect to making a firm diagnosis and developing an effective treatment plan. When children have back pain and medical attention is sought, an underlying pathology is usually suspected. Pediatric patients are evaluated, first, with a complete clinical history and examination and, second, by an imaging work-up that is based on initial findings, including the child's age and size, signs and symptoms, and suspected etiology. This article describes 1) the epidemiology of back pain in children, 2) the imaging work-up used, and 3) the correlation of imaging findings with disease entities that may cause back pain in the pediatric patient. The list of diseases giving rise to back pain is not meant to be exhaustive but rather reflective of the most commonly identified pathologies and disorders among young children and adolescents, from athletic injuries to lethal cancers.

Axial back pain in the athlete: pathophysiology and approach to rehabilitation

Back pain in athletes is common. Proper management of an athlete with back pain who is trying to return to competition must take into account the probable biomechanical contributors and incorporate these into a comprehensive rehabilitation program that moves steadily forward towards defined goals. This study will attempt to discuss pathological commonalities of low-back pain in athletes and how these can be applied to an evidence-based rehabilitation approach.

Current concepts in the diagnosis and treatment of spondylolysis in young athletes

Spondylolysis is common among young athletes and should be suspected in any young athlete presenting with low back pain that persists for more than a few weeks. Diagnostic evaluation typically includes plain radiographs followed by more sensitive modalities, including single-photon emission CT, CT, or MRI. There is no consensus on the most appropriate protocol for diagnostic evaluation. Treatment usually consists of rest and/or bracing to allow healing to occur, followed by rehabilitation that includes core strengthening. More large-scale controlled studies need to be done in order to clarify the most effective diagnostic and therapeutic protocols.

Back pain in athletes

The athlete with back pain presents a clinical challenge. Self-limited symptoms must be distinguished from persistent or recurrent symptoms associated with identifiable pathology. Athletes involved in impact sports appear to have risk factors for specific spinal pathologies that correlate with the loading and repetition demands of specific activities. For example, elite athletes who participate in longer and more intense training have higher incidence rates of degenerative disk disease and spondylolysis than athletes who do not. However, data suggest that the recreational athlete may be protected from lumbar injury with physical conditioning. Treatment of athletes with acute or chronic back pain usually is nonsurgical, and symptoms generally are self-limited. However, a systematic approach to the athlete with back pain, involving a thorough history and physical examination, pertinent imaging, and treatment algorithms designed for specific diagnoses, can facilitate symptomatic improvement and return to play. There are no reliable studies examining the long-term consequences of athletic activity on the lumbar spine.

Lumbar spine injuries in athletes

✓Lumbar spine injuries in athletes are not uncommon and usually take the form of a mild muscle strain or sprain. More severe injuries sustained by athletes include disc herniations, spondylolistheses, and various types of fracture. The recognition and management of these injuries in athletes involve the additional consideration that to return to play, the lumbar spine must be able to withstand forces similar to those that were injurious. The authors consider common lumbar spine injuries in athletes and discuss management principles for neurosurgeons that are relevant to this population.

Stress fractures in the spine and sacrum

Stress fractures of the pars, pedicle, and sacrum are important considerations in the differential diagnosis of lower back pain in the child or adolescent athlete. A thorough history and physical examination as well as a high index of suspicion are essential when assessing a patient with lower back pain. Diagnostic imaging, including radiographs, bone scans, CT scans, and other imaging modalities are important for further narrowing the diagnosis. The early identification and proper management of stress fractures of the pars, pedicle, and sacrum are integral in the prevention of stress fractures in the adolescent athlete population. This article reviews current concepts in the assessment and management of stress fractures of the lumbosacral spine, particularly of the pars (spondylolysis), pedicles, and sacrum.

Nonspondylolytic Etiologies of Lumbar Pain in the Young Athlete

Approximately 50% of adolescent athletes with persistent lumbar pain can be diagnosed with spondylolysis or spondylolisthesis. The remaining 50% will have suffered injury of the vertebral body, intervertebral disc, ring apophysis, pelvis, articular processes, spinous processes, interspinous ligament, or other soft tissues of the lumbar spine. The adolescent spine is prone to these injuries as a consequence of the growth spurt and skeletal immaturity. Accurate diagnosis is mandatory in order to achieve successful treatment. History, physical examination, imaging modalities, and precision spinal injections can be employed to accurately diagnose the source of the symptoms. Appropriate treatment measures can then be prescribed to optimally treat the adolescent spine injury.

Common musculoskeletal disorders in women

Women are prone to certain orthopedic conditions and may present to their primary care physician for treatment. An appreciation of the physiological and anatomical differences between women and men and the musculoskeletal conditions that commonly affect active women can aid the physician in diagnosis and treatment. We discuss common musculoskeletal conditions of active women including those affecting the low back, knee, shoulder, and foot. We also discuss common stress fractures seen in women. Various treatment and prevention strategies are reviewed and include physical therapy, bracing, medications, and surgery.

Differential diagnosis of spondylolysis in a patient with chronic low back pain

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 26-year-old male sought physical therapy services via direct access secondary to a flare-up of a chronic low back pain condition. The patient complained of recent onset of lumbosacral joint pain, including (1) constant right-sided deep-bruise sensation, (2) intermittent right-sided sharp stabbing pain, and (3) constant bilateral aching. The patient's past medical history included a hyperextension low back injury while playing football at age 17. Physical examination revealed (1) deep pain with palpation over the right lumbosacral joint region, (2) sharp right lumbosacral joint pain with 1 repetition of active trunk backward bending, and (3) a marked increase in pain and joint hypomobility with right unilateral joint assessment at the L4 and L5 spinal levels.

DIAGNOSIS

The examining therapist referred the patient for radiographic evaluation due to strong suspicions of a pars interarticularis bony defect. Lumbar plain films, oblique views, revealed an L5 bilateral pars defect, leading to a diagnosis of a longstanding bilateral L5 spondylolysis.

DISCUSSION

Patients with low back pain often seek physical therapy services. Identification of pathology requiring examination by other health care providers, leading to patient referral to other health care practitioners, is a potential important outcome of the therapist's examination. This resident's case problem illustrates the importance of a systematic examination scheme, including a thorough medical screening component that led to a patient referral for radiographic evaluation. The resultant diagnosis, although not representing serious pathology, did impact the therapist's patient plan of care.

Epidemiology of athletic head and neck injuries

In this article, we review the available data on sporting injuries to the head and neck and discuss sport-specific injury risk and prevention strategies, as well as the costs of head and neck injuries.

Spondylolysis: returning the athlete to sports participation with brace treatment

Between 1988 and 1995, 73 adolescent athletes treated with the Boston Overlap Brace for spondylolysis were reviewed to evaluate improvement in pain score and activity level. A favorable clinical outcome was achieved in 80%. Girls and boys who participated in high-risk sports were five times more likely to have an unfavorable clinical outcome than those who participated in low-risk sports (odds ratio = 5, 95% confidence interval = 2.4-7.5, P = .003). In addition, acute onset of pain and hamstring tightness were associated with a worse outcome. Athletes with symptomatic spondylolysis treated with an antilordotic brace can expect improvement in their clinical course and return to sports participation in 4-6 weeks.

Back pain in the young athlete

Back pain in the pediatric athlete is rare compared to the adult population. However, the diagnosis should be accurate as most have specific etiologies and treatment. Nearly 50% of the time, the cause of the pain is an injury to the pars interarticularis. A thorough history and careful physical examination should guide the physician to a working differential diagnosis. Based on this, appropriate laboratory and imaging work-up is pursued to arrive at a timely diagnosis and subsequent treatment regimen.

Common athletic injuries in adolescent girls

Teenaged girls constitute the fastest growing segment of children and adolescents participating in organized athletics. Adolescent girls appear to have similar injury rates as boys in comparable activities but different injury patterns. To properly diagnose and manage athletic injuries in adolescent girls, pediatric health care providers must be aware of these differences, especially as the literature and their knowledge base may be skewed to the traditional predominance of males in sport. This review identifies athletic injuries that are unique to or especially common in adolescent girls, including apophyseal injuries; breast and pelvic injuries; scoliosis and spondylolysis; multidirectional shoulder instability and "gymnast's wrist"; anterior cruciate ligament injuries and patellofemoral pain syndrome; chronic exertional lower-leg compartment syndrome, ankle sprains, and reflex sympathetic dystrophy; and stress fractures. It also briefly discusses possible risk factors for these injuries, emphasizing the female athlete triad.