Why does my back hurt?

Back pain in the young athlete is very common. It has been reported that up to 75% of adolescents will experience back pain by the time they reach 18 years of age.  As more youth sporting activities are performed year-round, there is a greater risk of sports-specific repetitive activities over-loading the athletes back.  Too much activity applied too quickly to the back can cause pain.  In athletes less than 10 years of age, back pain is uncommon, for many reasons. However, as the athletes grow, add more muscle mass, generate more force and speed and training more (frequency, intensity and duration) the risk of back pain increases. In general, a gradual change in sporting activities and training will minimize the risk of developing back pain. The good news is >90% of back pain in adolescence is muscle-based and due to overloading the muscles.

Like many orthopaedic injuries the commonly recommended treatment is the "RICE" treatment, which partially applies here. Rest, ice, compression (hard to do for back injuries) and elevation (also hard to do) is recommended for the first 4-6 weeks after back pain develops. This is especially true when the athlete can relate the onset of back pain to an event in their sports. Over-the-counter pain medications (acetaminophen, ibuprofen or naproxen) can be helpful for pain control. Pain which came on without a known injury or activity, fevers, numbness in legs, bowel or bladder difficulties or other neurological symptoms is more concerning and should be evaluated by a physician early.  Depending on the amount of pain, the athletes level of participation and upcoming events a course of physical therapy can be helpful.  A course of paraspinal muscle strengthening, core strengthening and stretching can speed up recovery.  Back braces are not recommended, in general, because they can cause the back muscles to become too weak.  Similarly, narcotics and muscle relaxers are not recommended, except in extreme situations.

An evaluation for back pain is appropriate if the back pain has been present for longer than 6 weeks, there is lower extremity numbness or weakness, or bowel or bladder problems develop.

What is Spondylolysis or a Pars Fracture?

If you break the word spondylolysis down to its Latin roots and then translate to English you get spondylo- which means "vertebra" and lysis which means "crack or break".  So spondylolysis is when there is a crack in the posterior, or back part, of the bony arch of a vertebra at the pars region (see figure).  This area has a relatively thin area of bone, with a poor blood supply.  Hence it has a lower-capacity to heal when it is stressed.  The most concerning repetitive motion is back hyperextension, with or without rotation. This typically occurs in the low back (or lumbar spine) in the lowest vertebra (L5 or L4), where there is maximal back motion.

The cause of this crack is likely a stress fracture due to repetitive back motion (hyperextension).  It is most common in athletes who do repetitive hyperextension of their back, such as in American football linemen and gymnasts. Why some individuals get this problem and others don't is unknown, but it is likely some individuals have a predisposition to developing a stress fracture. Interestingly there is a higher frequency of this occurring in Inuit Eskimos, hence some populations appear more at risk. Evaluation of this problem starts with plain radiographs but can include CT, MRI, and bone scans. Treatment is dependent on the previous treatments and how long the problem has been symptomatic. In general the first level of treatment is nonsurgical with rest, limitation of activities and bracing (possible).  In situations with longstanding pain, a surgical repair may be the best option. The surgical repair is aimed to simply getting the crack in the vertebra to heal, without a fusion between vertebra, so no back motion will be lost. If a spondylolysis occurs in a younger patient, <12 years of age it is important to get intermittent radiographs of the low back to watch for any potential slippage of the vertebra forward.

 

This post has been previously posted in the Young Athlete Blog

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