Low back pain in the adolescent athlete

Epigenetic Factors Related to Low Back Pain: A Systematic Review of the Current Literature

Low back pain (LBP) is one of the most common causes of pain and disability. At present, treatment and interventions for acute and chronic low back pain often fail to provide sufficient levels of pain relief, and full functional restoration can be challenging. Considering the significant socio-economic burden and risk-to-benefit ratio of medical and surgical intervention in low back pain patients, the identification of reliable biomarkers such as epigenetic factors associated with low back pain could be useful in clinical practice. The aim of this study was to review the available literature regarding the epigenetic factors associated with low back pain. This review was carried out in accordance with Preferential Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was carried out in October 2022. Only peer-reviewed articles were considered for inclusion. Fourteen studies were included and showed promising results in terms of reliable markers. Epigenetic markers for LBP have the potential to significantly modify disease management. Most recent evidence suggests that epigenetics is a more promising field for the identification of factors associated with LBP, offering a rationale for further investigation in this field with the long-term goal of finding epigenetic biomarkers that could constitute biological targets for disease management and treatment.

Utility of Physical Examination Findings for Predicting Low-Back Pain in Adolescent Patients with Early-Stage Spondylolysis: A Retrospective Comparative Cohort Study

Introduction

This study aimed to elucidate low-back pain (LBP) characteristics, i.e., its qualities, extent, and location, in patients with early-stage spondylolysis (ESS).

Methods

We recruited patients (≤18 years old) who presented with acute LBP lasting up to 1 month. Patients were divided into ESS and nonspecific LBP (NS-LBP) groups based on their magnetic resonance imaging findings; patients showing no pathological findings that might explain the cause of LBP were classified as NS-LBP. All patients were evaluated using the following tests: hyperextension and hyperflexion (pain provocation tests in a standing position), pain quality (sharp/dull), pain extent (fingertip-sized area/palm-sized area), and pain location (left and/or right pain in side [side]/central pain [center]). We have also compared outcomes between the ESS and NS-LBP groups in terms of gender and physical symptoms.

Results

Of 101 patients, 53 were determined to have ESS (ESS group: mean age: 14.3 years old; 43 males/10 females), whereas 48 had no pathological findings explaining the LBP origin [NS-LBP group (mean age, 14.4 years old; 31 males/17 females)]. Chi-squared test has identified gender (male), a negative result on hyperflexion test, pain extent (fingertip-sized area), and pain location (side) to be significantly associated with ESS. Among these, regression analysis revealed that male gender and LBP located on the side were significantly associated with ESS (p<0.05).

Conclusions

Although the hyperextension test is generally considered useful for ESS, we demonstrated that its association is not deemed significant. Our results indicate that male gender, a negative result of the hyperflexion test, fingertip-sized pain area, and LBP on the side may be specific characteristics of ESS. Of these physical signs, male gender and LBP located on the side are characteristic factors suggesting ESS presence.

Immediate functional progression program in adolescent athletes with a spondylolysis

OBJECTIVE

To assess the preliminary evidence for the efficacy and safety of an immediate functional progression program to treat adolescent athletes with an active spondylolysis.

DESIGN

Prospective single-arm trial.

SETTING

Hospital-based sports medicine and physical therapy clinic.

PARTICIPANTS

Twelve adolescent athletes (14.2 ± 2 years, 25% female) with an active spondylolysis.

MAIN OUTCOME MEASURES

Clinical outcomes included time out of sport, Micheli Functional Scale (Function and Pain) and adverse reactions. Clinical outcomes were assessed at baseline, 1 month, 3 months and 6 months. Magnetic resonance imaging was performed at baseline and 3 months to confirm diagnosis and assess healing of lesion.

RESULTS

Eleven participants (92%) fully returned to sport in a median time of 2.5 months (75 days; interquartile range 55 days, 85 days). All participants demonstrated marked improvements in pain and function by the end of the program. One participant (8%) had an adverse reaction during care with a significant recurrence of LBP and had not returned to sport by 6 months. Magnetic resonance imaging demonstrated improvement of the spondylolytic lesion in all but one participant.

CONCLUSION

The immediate functional progression program appears a viable method for treating active spondylolysis and warrants future research.

Predictors of Spondylolysis on Magnetic Resonance Imaging in Adolescent Athletes With Low Back Pain

Background:

Spondylolysis and undiagnosed mechanical low back pain (UMLBP) are the main causes of low back pain (LBP) in adolescent athletes. No studies have evaluated the difference in clinical and radiographic factors between these 2 conditions. Furthermore, it remains unclear which adolescent athletes with LBP should undergo advanced imaging examination for spondylolysis.

Purpose:

To compare the clinical and radiographic factors of adolescent athletes with spondylolysis and UMLBP who did not have neurological symptoms or findings before magnetic resonance imaging (MRI) evaluation and to determine the predictors of spondylolysis findings on MRI.

Study Design:

Cohort study, Level of evidence, 3.

Methods:

The study population included 122 adolescent athletes aged 11 to 18 years who had LBP without neurological symptoms or findings and who underwent MRI. Of these participants, 75 were ultimately diagnosed with spondylolysis, and 47 were diagnosed with UMLBP. Clinical factors and the following radiographic parameters were compared between the 2 groups: spina bifida occulta, lumbar lordosis (LL) angle, and the ratio of the interfacet distance of L1 to that of L5 (L1:L5 ratio, %). A logistic regression analysis was performed to evaluate independent predictors of spondylolysis on MRI scans.

Results:

Significantly more athletes with spondylolysis were male (82.7% vs 48.9%; P < .001), had a greater LL angle (22.8° ± 8.1° vs 19.3° ± 8.5°; P = .02), and had a higher L1:L5 ratio (67.4% ± 6.3% vs 63.4% ± 6.6%; P = .001) versus athletes with UMLBP. A multivariate analysis revealed that male sex (odds ratio [OR], 4.66; P < .001) and an L1:L5 ratio of >65% (OR, 3.48; P = .003) were independent predictors of positive findings of spondylolysis on MRI scans.

Conclusion:

The study findings indicated that sex and the L1:L5 ratio are important indicators for whether to perform MRI as an advanced imaging examination for adolescent athletes with LBP who have no neurological symptoms and findings.

Pediatric Sports Injuries

With increasing pediatric participation in organized sport and the early specialization of children in single sports, the number of injuries seen in the pediatric and adolescent athletic population continues to increase. Children experience acute traumatic injuries during practice and competition as well as chronic overuse injuries secondary to the repetitive stress on their developing bodies. The unique nature of the pediatric patient often requires a different diagnostic, prognostic, and treatment approach to sports injuries compared with their adult counterparts.

A Comparison of the Effect of Kettlebell Swings and Isolated Lumbar Extension Training on Acute Torque Production of the Lumbar Extensors

The aim of this study was to use a fatigue response test to measure the muscular fatigue (defined as a reduction in torque production) sustained by the lumbar extensors after a single set of kettlebell swings (KBS) in comparison with isolated lumbar extensions (ILEX) and a control condition (CON). The purpose of which is to measure the physiological response of KBS against an already established modality. Subsequent data provide insight of the efficacy of kettlebells swings in strengthening the lumbar muscles and lower back pain treatment. Eight physically active males participated in a repeated measures design where participants completed all conditions. There were statistically significant reductions in maximal torque, reported as strength index (SI), after both KBS and ILEX exercise. A statistically significant difference was found for reductions in maximal torque between CON and both KBS (p = 0.005) and ILEX (p = 0.001) and between KBS and ILEX (p = 0.039). Mean reduction and effect sizes were -1824 ± 1127.12 (SI) and -1.62 for KBS and -4775.6 ± 1593.41 (SI) and -3.00 for ILEX. In addition, a statistically significant difference was found between KBS and ILEX for rate of perceived exertion (p = 0.012). Data suggest that both KBS and ILEX were able to fatigue the lumbar extensors. Isolated lumbar extension was able to generate a greater level of fatigue. However, contrary to previous research, the KBS was able to elicit a physiological response, despite the lack of pelvic restraint supporting the potential to strengthen the lumbar extensors.

The effects of set volume during isolated lumbar extension resistance training in recreationally trained males

Background/Aim. Exercise designed to condition the lumbar extensor musculature is often included in resistance training (RT) programs. It is suggested that deconditioning of this musculature may be linked to low back pain. Thus effective means of conditioning these muscles are of interest to pursue. Evidence suggests that isolated lumbar extension (ILEX) RT might be most efficacious, however, the best means of manipulating resistance training variables in this regard is unknown. Set volume is an easily manipulated RT variable and one thought to also interact with training status. As such this study sought to examine the effect of set volume during ILEX RT in trained males. Methods. Trained males previously engaged in exercises designed to condition the lumbar extensors underwent a 6 week intervention and were randomised to either a single set (1ST, n = 9), multiple set (3ST, n = 8) or control group (CON, n = 9). Pre- and post-testing of ILEX strength was conducted. Results. Both 1ST and 3ST significantly increased ILEX strength (p < 0.05) with large effect sizes (d = 0.89 and 0.95 respectively) whereas the CON group produced significant losses (-8.9%) with a moderate effect size (d = - 0.53). There was no statistically significant difference in ILEX strength gains when 1ST and 3ST were directly compared (p = 0.336). Conclusions. The results of this study suggest that significant ILEX strength changes occur in trained males as a result of 6 weeks of ILEX RT and that these changes are unaffected by set volume.

Low back pain in the adolescent athlete

Clinicians must have knowledge of the growth and development of the adolescent spine and the subsequent injury patterns and other spinal conditions common in the adolescent athlete. The management and treatment of spinal injuries in adolescent athletes require a coordinated effort between the clinician, patients, parents/guardians, coaches, therapists, and athletic trainers. Treatment should not only help alleviate the current symptoms but also address flexibility and muscle imbalances to prevent future injuries by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength.

Diagnosis of radiographically occult lumbar spondylolysis in young athletes by magnetic resonance imaging

BACKGROUND

The early stages of spondylolysis are extremely difficult to diagnose on plain radiography. Although several studies have examined changes in active spondylolysis on magnetic resonance imaging (MRI), no studies to date have determined the onset frequency of active spondylolysis detectable on MRI but occult on plain radiography. Moreover, the clinical features of active spondylolysis described in the literature do not facilitate the differentiation of this condition from other causes of low back pain.

PURPOSE

This study aimed to evaluate the usefulness of MRI in diagnosing active spondylolysis early and in determining the prevalence of active spondylolysis in cases where findings were not detected on plain radiography. In addition, specific clinical features to aid in the early detection of active spondylolysis were evaluated.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were 200 consecutive young athletes (144 boys and 56 girls; mean age, 14.1 ± 1.5 y) with low back pain. All patients were examined by plain radiography (188 with negative findings and 12 with unclear findings of spondylolysis) and MRI. Computed tomography (CT) was performed only for patients with high intensity changes of the pedicle observed on MRI. The presence or absence of low back pain was examined during lumbar spine extension and flexion. The Kemp test on the right and left sides and percussion of the vertebral spinous process were also performed.

RESULTS

Ninety-seven (48.5%) patients showed evidence of active spondylolysis on MRI, findings that had been missed by plain radiography. These pars defects were organized into the following categories based on CT findings: nonlysis stage, 52; very early stage, 37; late early stage, 22; progressive stage, 10; and terminal stage, 0. No significant physical examination factors were identified that could assist in the early detection of active spondylolysis.

CONCLUSION

The MRI results suggest a high rate of active spondylolysis in young athletes with low back pain who test negative for spondylolysis on plain radiography. Magnetic resonance imaging appears to be useful in the early diagnosis of active spondylolysis, especially as we found no significant physical examination factors that could assist in early detection.

Low back pain in young athletes

Context

Low back pain in young athletes is a common complaint and should be taken seriously. It frequently results from a structural injury that requires a high degree of suspicion to diagnose and treat appropriately.

Evidence Acquisition

A Medline search was conducted from 1996 to May 2008 using the search terms “low back pain in children” and “low back pain in athletes.” Known texts on injuries in young athletes were also reviewed. References in retrieved articles were additionally searched for relevant articles. Sources were included if they contained information regarding diagnosis and treatment of causes of low back pain in children.

Results

Low back pain is associated with sports involving repetitive extension, flexion, and rotation, such as gymnastics, dance, and soccer. Both acute and overuse injuries occur, although overuse injuries are more common. Young athletes who present with low back pain have a high incidence of structural injuries such as spondylolysis and other injuries to the posterior elements of the spine. Disc-related pathology is much less common. Simple muscle strains are much less likely in this population and should be a diagnosis of exclusion only.

Conclusion

Young athletes who present with low back pain are more likely to have structural injuries and therefore should be investigated fully. Muscle strain should be a diagnosis of exclusion. Treatment should address flexibility and muscle imbalances. Injuries can be prevented by recognizing and addressing risk factors. Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength.

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.

Intervertebral disc changes after 1 h of running: a study on athletes

The lumbar spines of 25 long-distance runners were examined using an upright magnetic resonance imaging scanner. All volunteer runners were scanned before and after running for 1 h. Scanning was performed with the runners seated upright (neutral), leaning forwards (flexion) and leaning backwards (extension). All measured discs showed a reduction in disc height after 1 h of running. A significant reduction in disc height was observed in all three body positions (neutral, flexion and extension) after 1 h of running. The results showed that, in flexion, extension and neutral positions, intervertebral discs undergo significant strain after 1 h of running. The lowest disc-height reduction was found at the L5 - S1 space in the neutral position; the same space had the highest percentage of disc degeneration.

The role of rehabilitation in juvenile low back disorders

Both children and adolescents are frequently affected by low back pain--mainly when they are involved in sporting activities--but they rarely ask for medical help, because their symptoms are often mild and self-resolving. However, in the young patients who seek orthopaedic evaluation, especially in referral centres, there is a high incidence of organic causes of their back pain. Mechanical, developmental, inflammatory and tumoural or tumour-like disorders are the most frequent aetiologic factors. A diagnosis of psychosomatic back pain should be made only when all the other possible organic causes have been excluded. Rehabilitation is part of the treatment of low back disorders in children and adolescents. Postural low back pain is likely to be resolved by physical therapy alone. In other disorders that initially require medical, orthotic or surgical treatment, rehabilitation plays an important role either in combination with them or as a subsequent treatment.

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.

Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis

BACKGROUND

Active spondylolysis is an acquired lesion in the pars interarticularis and is a common cause of low back pain in the young athlete.

OBJECTIVES

To evaluate whether the one-legged hyperextension test can assist in the clinical detection of active spondylolysis and to determine whether magnetic resonance imaging (MRI) is equivalent to the clinical gold standard of bone scintigraphy and computed tomography in the radiological diagnosis of this condition.

METHODS

A prospective cohort design was used. Young active subjects with low back pain were recruited. Outcome measures included clinical assessment (one-legged hyperextension test) and radiological investigations including bone scintigraphy (with single photon emission computed tomography (SPECT)) and MRI. Computed tomography was performed if bone scintigraphy was positive.

RESULTS

Seventy one subjects were recruited. Fifty pars interarticulares in 39 subjects (55%) had evidence of active spondylolysis as defined by bone scintigraphy (with SPECT). Of these, 19 pars interarticulares in 14 subjects showed a fracture on computed tomography. The one-legged hyperextension test was neither sensitive nor specific for the detection of active spondylolysis. MRI revealed bone stress in 40 of the 50 pars interarticulares in which it was detected by bone scintigraphy (with SPECT), indicating reduced sensitivity in detecting bone stress compared with bone scintigraphy (p = 0.001). Conversely, MRI revealed 18 of the 19 pars interarticularis fractures detected by computed tomography, indicating concordance between imaging modalities (p = 0.345). There was a significant difference between MRI and the combination of bone scintigraphy (with SPECT)/computed tomography in the radiological visualisation of active spondylolysis (p = 0.002).

CONCLUSIONS

These results suggest that there is a high rate of active spondylolysis in active athletes with low back pain. The one-legged hyperextension test is not useful in detecting active spondylolysis and should not be relied on to exclude the diagnosis. MRI is inferior to bone scintigraphy (with SPECT)/computed tomography. Bone scintigraphy (with SPECT) should remain the first-line investigation of active athletes with low back pain followed by limited computed tomography if bone scintigraphy is positive.

Fatigue fracture of the sacrum in an adolescent

There are relatively few reports of sacral stress fractures in children. In adolescents, sacral stress fractures have been reported in patients involved in vigorous athletic activity. Recognition of these fractures is important to avoid unnecessary biopsy if the findings are confused with tumor or infection. We report a sacral fatigue fracture in a 15-year-old without a history of athletic participation or trauma.