Disc degeneration in young gymnasts. A magnetic resonance imaging study

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

Association of Lumbar Spondylolytic Spondylolisthesis With the Incidence and Prognosis of Anterior Ring Apophyseal Abnormalities of the Vertebrae in Young Gymnasts

Background

Although anterior apophyseal abnormalities of the vertebrae and spondylolytic spondylolisthesis (SS) are prevalent in gymnasts during growth spurts, no studies have examined the relationship between apophyseal abnormalities and SS.

Hypothesis

A significant relationship will exist between anterior apophyseal abnormalities and SS in young gymnasts.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 306 gymnasts (123 male, 183 female; age range, 6-28 years) with >2 weeks of back pain were enrolled in this study. Apophyseal abnormalities were evaluated using radiography. In the primary analysis, multiple logistic regression analysis was performed to assess the odds ratio (OR) for multivariate factors (age, body mass index, sex, skeletal maturity, competitive level, and presence of spondylolysis or SS) influencing the incidence of apophyseal abnormalities. In the secondary analysis, 90 of the 306 gymnasts were followed up radiographically for a minimum of 2 years, and factors contributing to the worsening of apophyseal abnormalities were identified.

Results

In the primary analysis, the chi-square test revealed a relationship between anterior ring apophyseal abnormalities and SS at the L5-S1 segment (OR, 7.6). Multiple logistic regression analysis demonstrated that the presence of SS at L5-S1 (OR, 9.5) and competitive level (international: OR, 6.7; national: OR, 4.5) correlated with the incidence of apophyseal abnormalities. The secondary analysis identified the presence of SS at L5-S1 (OR, 5.9) as a significant factor contributing to the worsening of apophyseal abnormalities.

Conclusion

The presence of SS was a factor affecting the incidence and prognosis of anterior apophyseal abnormalities.

Magnetic Resonance Imaging Findings in High School Football Players: Brain and Cervical Spine

Football exposes its players to traumatic brain, neck, and spinal injury. It is unknown whether the adolescent football player develops imaging abnormalities of the brain and spine that are detectable on magnetic resonance imaging (MRI). The objective of this observational study was to identify potential MRI signatures of early brain and cervical spine (c-spine) injury in high school football players. Eighteen football players (mean age, 17.0 ± 1.5 years; mean career length, 6.3 ± 4.0 years) had a baseline brain MRI, and 7 had a follow-up scan 9–42 months later. C-spine MRIs were performed on 11 of the 18 subjects, and 5 had a follow-up scan. C-spine MRIs from 12 age-matched hospital controls were also retrospectively retrieved. Brain MRIs were reviewed by a neuroradiologist, and no cerebral microbleeds were detected. Three readers (a neuroradiologist, a neurosurgeon, and an orthopedic spine surgeon) studied the cervical intervertebral discs at six different cervical levels and graded degeneration using an established five-grade scoring system. We observed no statistically significant difference in disc degeneration or any trend toward increased disc degeneration in the c-spine of football players as compared with age-matched controls. Further research is needed to validate our findings and better understand the true impact of contact sports on young athletes.

The Prevalence of Abnormalities in the Pediatric Spine on MRI: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to provide an overview of the prevalence of reported musculoskeletal abnormalities on magnetic resonance imaging (MRI) of the pediatric spine.

SUMMARY OF BACKGROUND DATA

Back pain is a common complaint and significant health issue, already in children. Several studies have investigated musculoskeletal abnormalities of the pediatric spine as possible cause of low back pain (LBP). However, it is not clear which abnormalities are the most prevalent among children.

METHODS

A systematic literature search on the prevalence of musculoskeletal spinal abnormalities on MRI in children was conducted in the Embase, Medline Ovid, and Cochrane CENTRAL databases. Risk of bias (RoB) was assessed using a checklist based on the Downs and Black checklist. General information on study and patient characteristics and the prevalence of spinal abnormalities were extracted from the studies. Prevalence data were presented in three subgroups: nonathletes without LBP, participants with LBP, and athletes. Prevalence data of the most reported abnormalities were pooled using random-effects proportion meta-analysis. The study protocol was prospectively registered in PROSPERO (CRD42017080543).

RESULTS

The search resulted in 16,783 articles, of which 31 articles (2373 participants) were included in this systematic review. Two-thirds of the studies had a low RoB. The pooled prevalence in nonathletes without LBP, participants with LBP, and athletes without LBP was respectively 22%, 44%, and 22% for disc degeneration, 1%, 38%, and 13% for herniated discs, 5%, 22%, and 11% for endplate changes, and 0%, 30%, and 6% for pars fractures.

CONCLUSION

Disc degeneration, herniated discs, endplate changes, and spondylolysis are the most reported spinal abnormalities on MRI in children in literature. Spinal abnormalities seen in adults are already prevalent in children with LBP, with the highest prevalence for disc degeneration and herniated discs.

LEVEL OF EVIDENCE

2.

Is There a Relationship Between Workload and Occurrence of Back Pain and Back Injuries in Athletes?

The back is subjected to a great deal of strain in many sports. Up to 20% of all sports injuries involve an injury to the lower back or neck. Repetitive or high impact loads (e.g., running, gymnastics, skiing) and weight loading (e.g., weightlifting) affect the lower back. Rotation of the torso (e.g., golf, tennis) causes damage to both, the lumbar and thoracic spine. The cervical spine is most commonly injured in contact sports (e.g., boxing, football). One of the factors that increases the odds of injuries in athletes is excessive and rapid increases in training loads. In spite of currently emerging evidence on this issue, little is known about the balance between physiological loading on the spine and athletic performance, versus overloading and back pain and/or injury in athletes. This scoping review aims (i) to map the literature that addresses the association between the training load and the occurrence of back pain and/or injury, especially between the Acute:Chronic Workload Ratio (ACWR) and back problems in athletes of individual and team sports, and (ii) to identify gaps in existing literature and propose future research on this topic. A literature search of six electronic databases (i.e., MEDLINE, PubMed, Web of Science, SCOPUS, SportDiscus, and CINAHL) was conducted. A total of 48 research articles met the inclusion criteria. Findings identified that fatigue of the trunk muscles induced by excessive loading of the spine is one of the sources of back problems in athletes. In particular, high training volume and repetitive motions are responsible for the high prevalence rates. The most influential are biomechanical and physiological variations underlying the spine, though stress-related psychological factors should also be considered. However, limited evidence exists on the relationship between the ACWR and back pain or non-contact back injuries in athletes from individual and team sports. This may be due to insufficiently specified the acute and chronic time window that varies according to sport-specific schedule of competition and training. More research is therefore warranted to elucidate whether ACWR, among other factors, is able to identify workloads that could increase the risk of back problems in athletes.

Perceptions of low back pain in elite gymnastics: A multi-disciplinary qualitative focus group study

OBJECTIVES

To explore the multidisciplinary team experience of Low Back Pain (LBP) in elite gymnastics.

DESIGN

A qualitative focus group.

SETTING

British Gymnastics.

PARTICIPANTS

Ten coaching, sports science and medicine multidisciplinary team members working with British gymnasts.

MAIN OUTCOME MEASURES

A topic guide informed by literature/expert opinion enabled discussion that was recorded/transcribed verbatim. Initial inductive analytic process developed theoretical insights. Manual coding using constant comparative methods categorised meaningful themes and sub-themes.

RESULTS

Two key aspects were identified. Emerging themes for LBP presentation included: early identification LBP and influence of multidisciplinary team members on outcomes; factors influencing LBP reporting e.g. coach-athlete relationship; frequent presentations of LBP and accepted norms; athlete history and physical examination e.g. training load. Emerging themes for causation of LBP included: intrinsic risk factors e.g. growth and maturation; extrinsic risk factors e.g. equipment.

CONCLUSIONS

Individual responses of a gymnast to experiencing LBP were important across all themes. Some LBP was perceived as normal. The coach-athlete relationship and support team are crucial decision-makers around training load and adaptation. Early detection will help minimise time loss from training/performance to expedite healing.

The association between occupational loading and spine degeneration on imaging - a systematic review and meta-analysis

Background

There are inconsistencies in findings regarding the relationship of occupational loading with spinal degeneration or structural damage. Thus, a systematic review was conducted to determine the current state of knowledge on the association of occupational loading and spine degeneration on imaging.

Methods

We performed electronic searches on MEDLINE, CINAHL and EMBASE. We included cross-sectional, case control and cohort studies evaluating occupational loading as the exposure and lumbar spine structural findings on imaging as the outcomes. When possible, results were pooled.

Results

Seventeen studies were included in the review. Ten studies evaluated the association of occupational loading with disc degeneration (signal intensity), four of which were pooled into a meta-analysis. Of the 10 studies, only two did not identify a relationship between occupation loading and disc degeneration. A meta-analysis including four of the studies demonstrated an association between higher loading and degeneration for all spinal levels, with odds ratios between 1.6 and 3.3. Seven studies evaluated disc height narrowing and seven evaluate disc bulge, with six and five identifying an association of loading and with imaging findings respectively. Three studies evaluated modic changes and one identified and association with occupational load.

Conclusions

There was moderate evidence suggesting a modest association between occupational loading and disc degeneration (signal intensity), and low-quality evidence of an association between occupational loading and disc narrowing and bulging.

Disc degeneration on MRI is more prevalent in young elite skiers compared to controls

PURPOSE

Evidence-based facts regarding spine abnormalities and back pain are needed in order to develop rehabilitation programs and prevent spine injuries in young skiers. The aim therefore is to identify MRI changes in the thoraco-lumbar spine and the lifetime prevalence of back pain, as well as the association between them, in young skiers compared to non-athletes.

METHODS

Seventy-five young elite alpine and mogul skiers, age range 16-20 years, were compared with 27 non-athletic controls. All subjects underwent spinal MRI and answered back pain questionnaires.

RESULTS

Fifty-six percent of skiers had at least one disc Pfirrmann grade ≥3 compared to 30% of controls (p = 0.027). Schmorl's nodes (46%) and disc height reduction (37%) were significantly more prevalent in skiers compared to controls (0%) (p < 0.001). When all parameters were combined together, skiers had significantly higher rate of radiological changes than controls, 82% compared to 54% (p = 0.007). The mean number of discs with Pfirrmann grade ≥3 was 1.1 per individual in skiers (median 1, range 0-6) versus 0.6 in controls (median 0, range 0-3). There was no significant difference in lifetime prevalence of back pain between skiers (50%) and controls (44%) (n.s.). MRI abnormalities in skiers did not correlate with lifetime prevalence of back pain. Skiers had a better health perception than controls (p = 0.026).

CONCLUSION

Alpine skiers have more degenerative disc changes compared to non-athletes, but these changes do not correlate with the lifetime prevalence of back pain. Lifetime prevalence of back pain is not significantly different between the groups; however, skiers report more severe pain on VAS score.

LEVEL OF EVIDENCE

II.

The effect of repetitive flexion and extension fatigue loading on the young porcine lumbar spine, a feasibility study of MRI and histological analyses

BACKGROUND

The biomechanical mechanisms of failure of FSUs have been studied but the correlation of repetitive flexion and extension loadings to the initial phase of fatigue in young FSUs are still not known. The purpose of the study was to examine the fatigue results of low magnitude repetitive flexion and extension loading on porcine lumbar Functional Spinal Units (FSUs) with Magnetic Resonance Imaging (MRI) and histology.

METHODS

Eight FSUs were subject to repetitive pivot flexion and eight to extension loading by a protocol of 20 000 cycles at 1 Hz with a load of 700 N. All loaded FSUs (N = 16) were examined with MRI and histology post loading. Three FSUs were examined with MRI as controls. Further three FSUs were non loaded histology controls.

RESULTS

Fifteen (94%) of the loaded FSUs have decreased MRI signal in the growth zone of the superior vertebra and 12 (75%) in the inferior vertebrae. Fourteen (88%) FSUs have increased signal in the superior vertebral body. Fourteen (88%) FSUs have a reduced signal in all or any endplate. The histology morphometry displayed that the unstained parts of the epiphyseal growth zone were larger among the loaded FSUs (mean 29% vs 4%) and that the chondrocytes in the endplate and growth zones had abnormal structure and deformed extracellular matrix.

CONCLUSION

Repetitive loading of young porcine FSUs in both extension and flexion causes concurrent MRI and histological changes in the growth zones and endplates, which could be a first sign of fatigue and an explanation for the disc, apophyseal and growth zone injuries seen among adolescent athletes.

Stretching the Spines of Gymnasts: A Review

Gymnastics is noted for involving highly specialized strength, power, agility and flexibility. Flexibility is perhaps the single greatest discriminator of gymnastics from other sports. The extreme ranges of motion achieved by gymnasts require long periods of training, often occupying more than a decade. Gymnasts also start training at an early age (particularly female gymnasts), and the effect of gymnastics training on these young athletes is poorly understood. One of the concerns of many gymnastics professionals is the training of the spine in hyperextension-the ubiquitous 'arch' seen in many gymnastics positions and movements. Training in spine hyperextension usually begins in early childhood through performance of a skill known as a back-bend. Does practising a back-bend and other hyperextension exercises harm young gymnasts? Current information on spine stretching among gymnasts indicates that, within reason, spine stretching does not appear to be an unusual threat to gymnasts' health. However, the paucity of information demands that further study be undertaken.

Back pain and MRI changes in the thoraco-lumbar spine of young elite Mogul skiers

Athletes have a higher prevalence of LBP and spinal abnormalities on Magnetic Resonance Imaging (MRI) compared to non-athletes. The objective of this study was to investigate the amount of spinal MRI abnormalities and the lifetime prevalence of low back pain (LBP) in 16 young elite Mogul skiers compared to 28 non-athletes in the corresponding age in a cross-sectional design. LBP was assessed by a questionnaire consisting of a part regarding previous or present back pain, the Oswestry disability index, and the EuroQol questionnaire. MRI examinations from Th5 to sacrum were conducted to evaluate spinal pathologies. The Mogul skiers had significantly more MRI abnormalities (like disc degeneration) in mean (7.25 vs 3.78, P < 0.023) compared to the controls. No significant difference was seen regarding the lifetime LBP prevalence between the groups (50% vs 42%, P = 0.555). No correlation could be found between disc degeneration and back pain in this study. Young elite Mogul skiers, compared to an age-matched control group of non-athletes, have an increased risk of developing spinal abnormalities potentially due to the different high loads that they are subjected to in their sport. Future relationship between the MRI abnormalities and LBP cannot be verified by this study design.

Influence of Physiological Loading on the Lumbar Spine of National Level Athletes in Different Sports

The lumbar spine is subjected to considerable stress during many athletic efforts. The purpose of this study was to assess the effects of physiological loading on the lumbar spine in national male players of different games, which may be predictive of the future development of low back pain and injury symptoms. Thirty-four national players (12 cricket players, 12 field hockey players, and 10 basketball players) underwent magnetic resonance imaging, and selected geometric variables including intervertebral disc angles, the Farfan ratio, the lumbar body index, the compression deformity ratio, the biconcave deformity ratio and the anterior wedge deformity ratio were measured using KINOVEA-0.8.15 software and syngo fast view software and calculated using specific formulas. The results indicated a significant difference in the intervertebral disc angle between the three groups at the L2/3, L3/4 and L4/5 levels. In relation to the lumbar vertebral body shape and size, significant differences were found in the lumbar index at the L2 level, in the biconcave deformity at the L1 and L2 levels and in relation to the anterior wedge deformity at L2 between the three selected groups. Our data suggest that the different physiological loadings in the selected sports play an important role in the development of degenerative changes of the lumbar spine, which may be considered a risk factor for future injury and/or low back pain in each specific sport because of the unique demands of each discipline.

Incidental findings on magnetic resonance imaging of the spine in the asymptomatic pediatric population: a systematic review

Study Design Systematic review.

Clinical Question What is the prevalence of incidental magnetic resonance imaging (MRI) findings of the spine in asymptomatic pediatric patients?

Methods Electronic databases and reference lists of key articles were searched up to December 15, 2013, to identify studies reporting the incidence or prevalence of incidental findings on MRI in asymptomatic pediatric patients. Athletes or children with a known history of trauma, infection, or congenital abnormalities were excluded.

Results Seven publications, one prospective cohort, and six cross-sectional studies met the inclusion criteria. The most commonly reported findings on MRI were disc-related and included degenerative disc disease (seven studies, prevalence 19.6%), disc herniation/protrusion (four studies, 2.9%), disc height/narrowed disc space (two studies, 33.7%), and endplate changes (two studies, 5.3%). Other disc-related findings, reported by one study each, included bulging disc, abnormal nucleus shape, annular tear, high intensity zone, and nerve root compression, with prevalences ranging from 4.5 to 51.6%. Spondylolisthesis and spondylolysis were reported by one study each with a prevalence of 2.3 and 0%, respectively. Other findings reported included tumors and infections (one study, 0% for both) and Scheuermann-type changes (one study, 7.7%).

Conclusions The prevalence of positive MRI findings in the asymptomatic pediatric population is higher than previously assumed, particularly in regard to disc morphology, highlighting the importance of correlating the history and physical examination to the MRI findings to avoid misdiagnosis or over-treatment in the pediatric population.

Anterior Limbus Vertebra and Intervertebral Disk Degeneration in Japanese Collegiate Gymnasts

Background:

Magnetic resonance imaging (MRI) studies have shown that gymnasts have a high prevalence of radiological abnormalities, such as intervertebral disk degeneration (IDD) and anterior limbus vertebra (ALV). These 2 abnormalities may coexist at the same spinal level. However, the relationship between IDD and ALV remains unclear.

Hypothesis:

A significant relationship exists between IDD and ALV in Japanese collegiate gymnasts.

Study Design:

Case-control study.

Methods:

A total of 104 Japanese collegiate gymnasts (70 men and 34 women; age, 19.7 ± 1.0 years) with 11.8 ± 3.6 years of sporting experience participated. T1- and T2-weighted MRIs were used to evaluate ALV and IDD.

Results:

The prevalence among the gymnasts of IDD and ALV was 40.4% (42/104) and 20.2% (21/104), respectively. The prevalence of IDD was significantly higher in gymnasts with ALV than those without ALV, as determined using the chi-square test. Logistic regression analysis demonstrated a significant association between IDD and ALV (adjusted odds ratio [OR], 6.60; 95% confidence interval [CI], 2.14-20.35). IDD was further grouped by whether it was present in the upper lumbar region (L1-2, L2-3, and L3-4 disks) or in the lower lumbar region (L4-5 and L5-S1 disks). Upper IDD had a greater association with ALV (adjusted OR, 33.17; 95% CI, 7.09-155.25) than did lower IDD (adjusted OR, 6.71; 95% CI, 1.57-28.73).

Conclusion:

In Japanese collegiate gymnasts, ALV is a predictor of IDD, especially in the upper lumbar region.

Clinical Relevance:

Information regarding ALV is important to prevent IDD in Japanese collegiate gymnasts.

Investigation of Spinal Posture Signatures and Ground Reaction Forces During Landing in Elite Female Gymnasts

The link between static and dynamic landing lumbar postures, when gymnasts are exposed to large ground reaction forces, has not been established. This investigation aimed to (a) determine if a relationship exists between sagittal static and dynamic landing lumbar spine angles at peak ground reaction force (GRF) and (b) quantify how close to end-range postures the gymnasts were at landing peak GRF. Twenty-one female gymnasts’ upper and lower lumbar spine angles were recorded: statically in sitting and standing, during landing of three gymnastic skills, and during active end-range lumbar flexion. Pearson’s correlations were used to investigate relationships between the angles in different postures. Significant correlations (r= .77–.89,p< .01) were found between all the static/dynamic postures in the lower lumbar spine angle, while fewer and less significant upper lumbar spine correlations were reported. Thirty percent of gymnasts landed a backsault with their lower lumbar spine flexed beyond their active end-range while experiencing GRF 6.8–13.3 times their body weight. These results inform low back pain prevention and management strategies in this population and highlight areas for future research.

A treatment-based classification approach to examination and intervention of lumbar disorders

CONTEXT

Low back injuries are a common occurrence in athletes and often result in missed competition and practice time. The examination of athletes with low back pain commonly involves diagnostic imaging, which rarely guides the clinician in selecting the appropriate interventions.

DATA ACQUISITION

All years of PubMed, CINAHL, PEDro, and SPORTDiscus were searched in December 2010. Keywords included treatment based classification and lumbar with the following terms: rehabilitation, treatment, athlete, low back pain, sports, and outcomes.

RESULTS

A treatment-based classification approach is preferred for the management of the athlete with low back pain. The treatment-based classification approach involves 3 steps. First is to screen the patient for potentially serious conditions that are not appropriate for conservative management. Second is staging the athlete (based on current disability ratings and ability to perform functional activities). Finally, treatment interventions are selected on the basis of the athlete's signs and symptoms.

CONCLUSION

The treatment-based classification scheme provides the clinician with a reliable algorithm for matching an athlete's symptom presentation to the optimal intervention, potentially reducing participation loss. Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.

Back pain in the pediatric and adolescent athlete

Clinicians taking care of athletes are likely to see many young patients complaining of back pain. The young athlete places significant repetitive stresses across the growing thoracolumbar spine, which can cause acute and overuse injuries that are unique to this age and patient population. Fortunately, by using a careful and systematic approach, with a sport-specific history, careful physical exam, and proper imaging, most problems can be properly identified. Although it is important to always remember that rare and more serious problems such as a neoplasm or infection maybe a source of pain in the athletic patient, most problems are benign and can be treated conservatively. Accurate diagnosis and management of back pain not only can prevent long-term deformity and disability, but it can also allow young athletes to return to doing what they love to do most: play sports.

Acute injury of an intervertebral disc in an elite tennis player: a case report

STUDY DESIGN

A case report.

OBJECTIVE

To present a previously not described rare case of intradiscal hematoma due to acute trauma in an elite tennis player.

SUMMARY OF BACKGROUND DATA

Several studies have demonstrated a high frequency of radiological changes in the spine of athletes, especially in sports with high loads on the back. Signs of disc degeneration without disc herniation have frequently been found in magnetic resonance imaging (MRI) studies of the spine of athletes. It has also been shown that radiological abnormalities of the spine in young athletes are correlated to back pain.

METHODS

An elite male tennis player experienced pain in the right buttock after a backhand stroke. He was successfully treated for hip problems and started to play competitive tennis, 2 weeks later. After few games, a backhand stroke again resulted in intense pain projected in the os coccyx region. At examination, there were no neurologic disturbances. At palpation over the spinal processes (Springing test) of L1-L2, the patient experienced intense pain projected to the os coccyx region.

RESULTS

MRI examination showed an injured L1-L2 disc with fluid inside the disc with a signal similar to blood. Four additional MRI examinations were performed 2 weeks and 2 years after the injury until disc degeneration is formed. Radiograph examination before and 2 years after the injury is available.

CONCLUSION

In conclusion, trauma in athletes can cause intradiscal hematoma, which probably is a new etiology for disc degeneration. Also that sudden onset of pain in the hip or the gluteal region may be caused by referred pain due to a disc lesion. Intradiscal hematoma can be visualized using MRI.

SPONDYLOLYSIS AND SPONDYLOLISTHESIS IN YOUNG GYMNASTS

OBJECTIVE

To determine the incidence of spondylolysis and spondylolisthesis among female gymnasts, and to correlate these with lumbar pain, history of trauma and training load.

METHOD

Eighteen competitive-level Olympic-style gymnasts aged 8-17 years, with an average age of 11.3 years, were evaluated on a voluntary basis. The gymnasts answered a questionnaire about their sports activities and underwent a clinical examination and lumbar spine radiography.

RESULTS

The radiographs were analyzed by orthopedists specializing in surgery of the vertebral column. The prevalence of spondylolysis was 5.56%, while no cases of spondylolisthesis were found.

CONCLUSION

The incidence of the radiographic abnormalities identified was similar to what has been reported in the literature for non-athletic individuals, and the lumbalgia reported by these athletes did not show any direct relationship with spondylolysis and spondylolisthesis.

Magnetic resonance imaging findings of the lumbar spine in elite horseback riders: correlations with back pain, body mass index, trunk/leg-length coefficient, and riding discipline

BACKGROUND

Most orthopaedic problems experienced by competitive horseback riders are related to pain in the lower back, hip joint, and hamstring muscles. Riders-especially, show jumpers-are frequently hampered in their performance because of lumbar pain. To date, there has been no research into lumbar disk degeneration in elite competitive riders.

HYPOTHESIS

Competitive horseback riding accelerates lumbar disk degeneration.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Fifty-eight elite riders (18 men, 40 women; mean age, 32.4 years) and a control group of 30 nonriding volunteers (17 men, 13 women; mean age, 28.7 years) were evaluated for lumbar disk degeneration, cross-sectional area of paraspinal muscles, spondylolysis, and spondylolisthesis, using magnetic resonance imaging (MRI). The prevalence of disk degeneration between the 2 groups was compared, and the relationship was investigated between low back pain (LBP), riding discipline, body mass index (BMI), trunk/leg-length coefficient, and MRI results.

RESULTS

Eighty-eight percent of elite riders (n = 51) had a history of LBP, versus 33% of the controls (P < .05). There was no statistical difference for the prevalence of LBP among the different riding disciplines. However, there was a high rate of pathologic T2 signal intensity of the lumbar intervertebral disk among riders-specifically, dressage riders-yet no significant increase when compared with controls. History of LBP symptoms, riding discipline, BMI, and trunk/leg-length ratio had no significant effect on the development of lumbar disk degeneration. Occult fractures of the pars interarticularis and manifest spondylolysis were not seen for any rider. Two controls had spondylolisthesis Meyerding grade 1 not associated with back pain.

CONCLUSION

Although riders have a high prevalence of LBP, there is no conclusive MRI evidence to suggest that the cause lies in undue disk degeneration, spondylolysis, spondylolisthesis, or pathologic changes of the paraspinal muscles of the lumbar spine.

Back pain and MRI changes in the thoraco-lumbar spine of top athletes in four different sports: a 15-year follow-up study

A total 71 male athletes (weight lifters, wrestlers, orienteers, and ice-hockey players) and 21 non-athletes were randomly selected, for a baseline MRI study. After 15 years all the participants at baseline were invited to take part in a follow-up examination, including a questionnaire on back pain and a follow-up MRI examination. Thirty-two athletes and all non-athletes had disc height reduction at one or several disc levels. Disc degeneration was found in more than 90% of the athletes and deterioration had occurred in 88% of the athletes, with the highest frequency in weight lifters and ice-hockey players. 78% of the athletes and 38% of the non-athletes reported previous or present history of back pain at baseline and 71 and 75%, respectively at follow-up. There was no statistically significant correlation between back pain and MRI changes. In conclusion, athletes in sports with severe or moderate demands on the back run a high risk of developing disc degeneration and other abnormalities of the spine on MRI and they report high frequency of back pain. The study confirmed our hypothesis, i.e. that most of the spinal abnormalities in athletes seem to occur during the growth spurt, since the majority of the abnormalities demonstrated at follow-up MRI after the sports career were present already at baseline. The abnormalities found at young age deteriorated to a varying degree during the 15-year follow-up, probably due to a combination of continued high load sporting activities and normal ageing. Preventive measures should be considered to avoid the development of these injuries in young athletes.

Magnetic resonance study of lumbar disks in female dancers

BACKGROUND

Previous imaging studies have shown that degenerative disk disease is more common in the competitive female gymnast than in asymptomatic nonathletic people of the same age training to any degree. However, results of exposure-discordant monozygotic and classic twin studies suggest that physical loading specific to occupation and sport has a relatively minor role in disk degeneration, beyond that of upright postures and routine activities of daily living.

HYPOTHESIS

Intensive, regular, and prolonged dancing causes strain on the lumbar spine and can trigger or accelerate the development of degenerative diskopathy.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Forty volunteer female dancers (20 ballet and 20 flamenco) aged between 18 and 31 years (mean = 24.2) underwent magnetic resonance imaging of the lumbar spine. They were compared against a control group of 20 women of the same age. A descriptive analysis was done, and the 2 groups were compared by contingency table analysis using the Pearson chi-square test complemented by an analysis of residuals. Results Nine of the 20 women (45%) in the control group had disk degeneration compared with 13 of the 40 (32.5%) women in the dancer group, with a chi-square of 0.897 (not significant). There were 12 degenerated disks of the 100 explored (12%) in the control group compared with 21 of the 200 explored (10.5%) in the dancer group (chi-square = 0.153; not significant).

CONCLUSION

Dancing cannot be considered a risk factor for lumbar disk degeneration in women.

CLINICAL RELEVANCE

The present study indicates that dancing has no negative effect on the development of degenerative diskopathy.

Magnetic resonance imaging showed no signs of overuse or permanent injury to the lumbar sacral spine during a Special Forces training course

BACKGROUND CONTEXT

Special Forces training is even more demanding than that of elite athletes. The training includes grueling physical activity and periods of sleep deprivation. The soldiers routinely carry heavy loads up to 40% of their body weight on their backs while running and marching for distances up to 90 km.

PURPOSE

Our purpose was to find out if Special Forces recruits are able to complete the preparatory Navy Seals training program without sustaining magnetic resonance imaging (MRI) signs of overuse or irreversible injury to their backs.

STUDY DESIGN/SETTING

Prospective cohort study. We performed MRI scans before and after 14 weeks of Navy Seals preparatory training course.

PATIENT SAMPLE

Ten soldiers underwent MRI of their lumbar sacral spines and right knees before and after the completion of Navy Seals preparatory training.

OUTCOME MEASURES

Physiologic measures. Lumbar sacral spine and knee MRI tests were performed before and after the training to identify changes in the spinal discs, facet joints, pars interarticularis, vertebral bodies, knee articular cartilage, ligaments, knee menisci, and the presence or absence of soft tissue and/or bone edema.

METHODS

We investigated the difference in spine and knee pathology before and after a 14-week Navy Seals preparatory training course by using MRI criteria. The recruits participating in the study were monitored for acute and overuse injuries every 3 to 4 weeks.

RESULTS

Before the training, seven out of ten spine MRI scans were normal. Two showed small L5-S1 disc bulges, one of them with concomitant Scheuermann's disease. Another soldier's MRI showed L1-L4 mild Scheuermann's disease. Follow-up MRI showed no spinal changes. Before the training, one knee had a small lateral femoral condyle cartilage lesion. Nine of ten knees had prepatellar swelling, five had increased joint fluid, and two bone edema. Follow-up magnetic resonance imaging showed improvement in the prepatellar swelling in eight soldiers, no change in one soldier, and increased knee effusion and a new medial femoral condyle bone edema in another. The lateral femoral condyle lesion remained unchanged.

CONCLUSIONS

According to MRI criteria, the soldiers in this study completed the 14-week training, which involved loading of their spines far beyond the levels recommended by the US National Institute for Occupational Safety and Health without sustaining irreversible damage to their spines or knees. Although the subjects' knees showed signs of overuse injury, their backs did not.

Physical activity and low-back pain in schoolchildren

Design of the experiment is to study the cross-sectional sample with retrospective information. The objective is to identify the types of physical activity associated with the decreased occurrence of low-back pain (LBP) in schoolchildren. Physical activity may be hypothesized to possess a potential for LBP prevention. The possible connection between LBP and specific sports activities is however sparsely documented. A total of 546, 15- to 16-year-old schoolchildren filled a questionnaire on current physical activities and LBP occurrence and severity. In multiple logistic regressions, the association of LBP with exposure variables was corrected for body height and weight (data from school health service files) and for anthropometric and school furniture parameters. More than half of the children reported pain or discomfort in the low-back region during the preceding 3 months, and 1/4 experienced a decreased functioning or need of care because of LBP. LBP correlated with physical inactivity, e.g. time spent on homework and hours watching TV or video, and with a series of sports activities, e.g. jogging, handball playing and gymnastics. Among sports activities, only swimming and the number of hours per week participating in soccer were associated with a decreased LBP prevalence. With the exception of swimming and soccer, the types of sport reported by this schoolchild population do not offer themselves for consideration as tools for LBP prevention. Based on the associations found with indicators of physical inactivity, attempts to motivate the children to increase their general physical activity level should be considered for trial.

Low back pain in 15- to 16-year-old children in relation to school furniture and carrying of the school bag

STUDY DESIGN

Cross-sectional sample with longitudinal information.

OBJECTIVE

To estimate the relationship between the occurrence of low back pain (LBP) and various types of school furniture and anthropometric dimensions in schoolchildren, and physical loading by school bag carrying.

SUMMARY OF BACKGROUND DATA

Some types of school furniture may be hypothesized to prevent or cause LBP. Despite strong opinions in the public debate about a possible relationship between use of various types of school furniture and LBP, scientific research on this matter is sparse.

METHODS

Five hundred forty-six schoolchildren aged 14 to 17 years answered a questionnaire about sitting positions during school hours and the presence and severity of LBP. Furthermore, the anthropometric dimensions and the weight of the school bags were measured. The types and dimensions of the school furniture were described and measured. In multivariate analyses was adjusted for physical activity and other possible risk factors.

RESULTS

More than half of the adolescents experienced LBP during the preceding 3 months, and 24.2% reported reduced daily function or care seeking because of LBP. LBP occurrence was not associated with the types or dimensions of the school furniture or body dimensions, but was positively associated with carrying the school bag on 1 shoulder [OR: 2.06 (1.29-3.31)].

CONCLUSION

The present study does not support the hypothesis of different types of school furniture being a causative or preventing factor for LBP. Carrying the school bag in an asymmetric manner may play a role.

Body mass, nonspecific low back pain, and anatomical changes in the lumbar spine in judo athletes

STUDY DESIGN

Cross-sectional study of a specific population.

OBJECTIVES

To investigate the prevalence and coprevalence of nonspecific low back pain (nsLBP) and lumbar radiological abnormalities (LRA) in judo athletes.

BACKGROUND

nsLBP and LRA occur frequently in judo athletes. High body mass has been reported to be associated with both nsLBP and LRA.

METHODS AND MEASURES

The subjects comprised 82 male judo athletes (mean +/- SD age, 20.1 +/- 0.9 years) from 3 weight categories: lightweight (n = 29), middleweight (n= 31), and heavyweight (n = 22). The presence of nsLBP was evaluated using a questionnaire. LRA were examined using plain-film radiographs and magnetic resonance imaging. The prevalence of nsLBP and LRA were compared among weight categories.

RESULTS

The prevalence of nsLBP in the lightweight, middleweight, and heavyweight categories was 34.5%, 32.3%, and 40.9%, respectively. For LRA, prevalence for the 3 weight categories was 65.5%, 90.3%, and 90.9%, respectively (middle-weight and heavyweight greater prevalence than lightweight [P<.05]). The prevalence of LRA in athletes with nsLBP in each category was 50.0%, 100%, and 88.9%, respectively (middleweight greater prevalence than lightweight [P<.05]). The prevalence of LRA in athletes without nsLBP in each category was 73.7%, 85.7%, and 92.3%, respectively.

CONCLUSIONS

The prevalence of LRA was approximately 90% in the middleweight and heavyweight categories, which was greater than for the lightweight category. There was a large coprevalence of nsLBP and LRA. However, many judo athletes without nsLBP had LRA. The presence of LRA may not have a direct association with nsLBP.

Radiographic changes in the lumbar spine in former professional football players: a comparative and matched controlled study

Heavy physical work and activity lead to degenerative changes, especially in the lumbar spine. We aimed to find out the occurence of radiographic changes (vertebral osteophytes, heights of lumbar dicsc, concavity index) and abnormalities of the lumbar spine in former professional football (association football or soccer) players according to their specialization (goalkeeper, defender, midfielder, forward) in their past professional sport life. We included 70 male former professional football players and 59 men as the control group. The football players group consisted of 15 defenders (21%), 29 midfielders (41%), 18 forwards (26%) and 8 goalkeepers (12%). Their mean professional football life was 11.04 years and the mean time period after their retirement was 13.87 years. Radiographs of both groups were taken to measure the disc height, concavity index and to determine osteophytes and abnormalities of the lumbar spine. FFbH-R score was assessed for daily activities. The mean FFbH-R score of football players was lower than that of the control group (P = 0.005). The total number of osteophytes in the player group was higher than in the control group (P = 0.001). The mean disc height of L1-L2 in football players was higher than in the control group (P = 0.045). The mean disc height of T12-L1 in goalkeepers was higher than in forward players (P = 0.019). The mean concavity index of L1 in forward players was lower than in defenders (P = 0.018). The mean disc heights of T12-L1 and L2-L3 were both higher in players whose professional sport life was >10 years than in players with </=10 years (P = 0.018, P = 0.016). The mean disc height of L5-S1 was higher in players who had continued sport activity after retirement (P = 0.025). No statistically significant result was obtained with the rest of the variables. Playing football is heavy work. The decreased height of lumbar discs and the lower value of concavity index of forward players are because the lumbar spine of forward players is loaded more than in the rest of the players.

Lower lumbar spine axial rotation is reduced in end-range sagittal postures when compared to a neutral spine posture

Sports such as rowing, gymnastics, cycling and fast bowling in cricket that combine rotation with spine flexion and extension are known to carry greater risk of low back pain (LBP). Few studies have investigated the capacity of the lumbar spine to rotate in various sagittal positions, and further, these studies have generated disparate conclusions. The purpose of this study was to determine whether the range of lower lumbar axial rotation (L3-S2) is decreased in end-range flexion and extension postures when compared to the neutral spine posture. Eighteen adolescent female rowers (mean age=14.9 years) with no history of LBP were recruited for this study. Lower lumbar axial rotation was measured by an electromagnetic tracking system (3-Space Fastrak) in end-range flexion, extension and neutral postures, in sitting and standing positions. There was a reduction in the range of lower lumbar axial rotation in both end-range extension and flexion (p<0.001) postures when compared to neutral. Further, the range of lower lumbar axial rotation measurements in flexion when sitting was reduced when compared to standing (p=0.013). These findings are likely due to the anatomical limitations of the passive structures in end-range sagittal postures.

Back pain and degenerative abnormalities in the spine of young elite divers: a 5-year follow-up magnetic resonance imaging study

Several studies have been published on disc degeneration among young athletes in sports with great demands on the back, but few on competitive divers; however, there are no long-term follow-up studies. Twenty elite divers between 10 and 21 years of age, with the highest possible national ranking, were selected at random without knowledge of previous or present back injuries or symptoms for an MRI study of the thoraco-lumbar spine in a 5-year longitudinal study. The occurrence of MRI abnormalities and their correlation with back pain were evaluated. Eighty-nine percent of the divers had a history of back pain and the median age at the first episode of back pain was 15 years. Sixty-five percent of the divers had MRI abnormalities in the thoraco-lumbar spine already at baseline. Only one diver without abnormalities at baseline had developed abnormalities at follow-up. Deterioration of any type of abnormality was found in 9 of 17 (53%) divers. Including all disc levels in all divers, the total number of abnormalities increased by 29% at follow-up, as compared to baseline. The most common abnormalities were reduced disc signal, Schmorl's nodes, and disc height reduction. Since almost all divers had previous or present back pain, a differentiated analysis of the relationship between pain and MRI findings was not possible. However, the high frequency of both back pain and MRI changes suggests a causal relationship. In conclusion, elite divers had high frequency of back pain at young ages and they run a high risk of developing degenerative abnormalities of the thoraco-lumbar spine, probably due to injuries to the spine during the growth spurt.

Lumbar spine MRI in the elite-level female gymnast with low back pain

OBJECTIVE

Previous studies have shown increased degenerative disk changes and spine injuries in the competitive female gymnast. However, it has also been shown that many of these findings are found in asymptomatic athletic people of the same age. Previous magnetic resonance imaging (MRI) studies evaluating the gymnastic spine have not made a distinction between symptomatic and asymptomatic athletes. Our hypothesis is that MRI will demonstrate the same types of abnormalities in both the symptomatic and asymptomatic gymnasts.

DESIGN

Olympic-level female gymnasts received prospectively an MRI exam of the lumbar spine. Each of the gymnasts underwent a physical exam by a sports medicine physician just prior to the MRI for documentation of low back pain. Each MRI exam was evaluated for anterior apophyseal ring avulsion injury, compression deformity of the vertebral body, spondylolysis, spondylolisthesis, degenerative disease, focal disk protrusion/extrusion, muscle strain, epidural mass, and bone-marrow edema.

PATIENTS

Nineteen Olympic-level female gymnasts (age 12-20 years) were evaluated prospectively in this study. All of these gymnasts were evaluated while attending a specific training camp.

RESULTS

Anterior ring apophyseal injuries (9/19) and degenerative disk disease (12/19) were common. Spondylolysis (3/19) and spondylolisthesis (3/19) were found. Focal bone-marrow edema was found in both L3 pedicles in one gymnast. History and physical exam revealed four gymnasts with current low back pain at the time of imaging. There were findings confined to those athletes with current low back pain: spondylolisthesis, spondylolysis, bilateral pedicle bone-marrow edema, and muscle strain.

CONCLUSIONS

Our initial hypothesis was not confirmed, in that there were findings that were confined to the symptomatic group of elite-level female gymnasts.

The effect of altered pitch length on performance and technique in junior fast bowlers

The aim of this study was to assess the effect of pitch length (20.12 m [full length], 18 m and 16 m) on the fast bowling performance and technique of junior cricketers. Performance measures included ball release speed and accuracy, while technique variables evaluated were those shown to be related to the aetiology of lower back injury. Thirty-seven fast bowlers from the under-11 (n=14), under-13 (n=11) and under-15 (n=12) age groups were filmed bowling five deliveries at each of the above pitch lengths. Two synchronized NAC video cameras operating at 200 Hz permitted three-dimensional reconstruction of the hip and shoulder alignments, while a standard digital video camera operating at 50 Hz (positioned perpendicular to the bowling action) was used to measure front knee angle and ball release speed. Accuracy scores were taken from a zoned target at the batsman's stumps. A two-way analysis of variance with repeated measures (with age and pitch length as the between- and within-participant variables, respectively) was used to compare each age group at the 0.05 significance level. Results showed that accuracy improved in all age groups at shorter pitch lengths, although ball velocity remained constant throughout all trials. Shoulder counter-rotation increased significantly for the under-13 bowlers when bowling on the full-length pitch in comparison with the two shorter lengths. Counter-rotation also increased on the full-length pitch in the under-11 age group, although this increase was not significant. The under-15 bowlers' techniques did not change as pitch length increased. As under-11 and under-13 bowlers adopted a "safer" bowling action with superior accuracy on the 18?m compared with the full length pitch, it was concluded that these age groups should bowl on an 18?m pitch to reduce the likelihood of lower back injuries and improve accuracy.

Lumbar disc degeneration: epidemiology and genetic influences

STUDY DESIGN

A literature review.

OBJECTIVE

To synthesize the scientific literature on the prevalence of lumbar disc degeneration and factors associated with its occurrence, including genetic influences.

METHODS

A literature review was conducted of the prevalence of disc degeneration. Studies of the etiology of disc degeneration were summarized, with particular attention given to studies of genetic influences.

RESULTS AND CONCLUSIONS

There are extreme variations in the reported prevalence of specific degenerative findings of the lumbar spine among studies, which cannot be explained entirely by age or other identifiable risk factors (e.g., prevalence figures for disc narrowing varied from 3% to 56%). It is likely that these variations are due, in great part, to inconsistencies in case definitions and measurements, which are impeding epidemiologic research on disc degeneration. Research conducted over the past decade has led to a dramatic shift in the understanding of disc degeneration and its etiology. Previously, heavy physical loading was the main suspected risk factor for disc degeneration. However, results of exposure-discordant monozygotic and classic twin studies suggest that physical loading specific to occupation and sport has a relatively minor role in disc degeneration, beyond that of upright postures and routine activities of daily living. Recent research indicates that heredity has a dominant role in disc degeneration, explaining 74% of the variance in adult populations studied to date. Since 1998, genetic influences have been confirmed by the identification of several gene forms associated with disc degeneration.

Radiographic changes in the lumbar spine in former elite athletes

STUDY DESIGN

The authors conducted a retrospective cohort study.

OBJECTIVE

The objective of this study was to clarify the occurrence of radiographic changes (vertebral osteophytes, heights of lumbar discs, concavity index) of the lumbar spine in former elite athletes of different track and field disciplines.

SUMMARY OF BACKGROUND DATA

The influence of physical activity on occurrence of radiographic changes in the lumbar spine is not well known and seems to be contradictory. The loadings in the different track and field disciplines seem to play an important role in the development of radiographic changes.

METHODS

One hundred fifty-nine former male elite track and field athletes were selected for a radiologic study. The heights of lumbar discs, the concavity index, the presence of anterior vertebral osteophytes, a radiographic evaluation according to Kellgren and Lawrence, and the FFbH-R score for the assessment of functional limitations in activities of daily living (ADLs) were determined. The influence of age, body mass index, current physical activity, and training history was also examined.

RESULTS

In high jumpers and throwers, the absolute heights of lumbar discs increased from level T12/L1 to a maximum at L4/L5 and decreased again from level L4/L5-L5/S1. In endurance athletes and other jumpers, the absolute heights increased linearly from level T12/L1 to a maximum at L5/S1. The concavity index did not yield any significant differences between athlete categories. Shot putters, discus throwers, and high jumpers showed a significantly higher prevalence of osteophytes after adjustment for possible confounders. According to Kellgren and Lawrence, the highest prevalence of radiographic changes in the lumbar spine is seen in javelin throwers. Significant differences in the assessment of functional limitations in ADLs are not found between the disciplines.

CONCLUSION

In throwing disciplines, the lumbar spine is more highly loaded than in jumpers and runners. Despite the observation of evident degenerative changes in some former athletes, there were only minor changes seen in ADLs. Even if body constitution is taken as a preselection factor, athletes in throwing disciplines as well as high jumpers have a higher risk of developing vertebral osteophytes of the lumbar spine.

Injury prevention in women's gymnastics

The most serious problem faced by contemporary gymnasts is injury. Given that prevention is superior to treatment, can the gymnastics community and the scientific and medical community do a better job at injury prevention? Most research in gymnastics has been descriptive in nature. Injury prevention ultimately requires that one can predict the outcome of certain activities and their injurious nature. Making such predictions requires a knowledge of the scientific and medical aspects of injury, but more than that, one must have an intimate knowledge of the sport. Injury prevention efforts must be firmly grounded in science and medicine while making pragmatic linkages to gymnastics as it exists and is practiced. This article attempts to bridge the gap between the scientific and medical community and what actually happens in gymnastics.

Back injuries in the young athlete

The diagnosis of back pain in the young athlete should be specific and not attributed to nonspecific, mechanical causes. Risk factor identification and intervention are required. Treatment is then initiated in a specific pattern, addressing flexibility and muscular imbalances. Bracing is often used to allow healing of growth tissue. The lumbosacral orthosis may be molded in a lordotic posture to unload the disc or antilordotic posture to relieve the posterior column; however, customizing the lordosis to the individual biomechanics may be required. Spinal stabilization is initiated with therapy for strengthening isolated weaknesses and progressing to coactivation and proprioceptive techniques, such as the balance ball. Returning to competition is preceded with sport-specific training.

Low-back pain in adolescent athletes

In this 3-yr longitudinal study we investigated the occurrence of low-back pain and anatomic changes in the low back in relation to loading and injuries among 98 adolescents: 33 nonathletes (16 boys, 17 girls), 34 boy athletes (17 ice hockey, 17 soccer players), and 31 girl athletes (17 figure skaters, 14 gymnasts). During the 3-yr follow-up, low-back pain lasting longer than 1 wk was reported by 29 (45%; 95% CI, 32%-57%) athletes and by 6 (18%; 95% CI, 7%-35%) nonathletes (P = 0.0099). Acute back injury was reported by 17 of 19 subjects who also reported low-back pain (89%; 95% CI, 67%-99%) and by 2 of 63 of those without prolonged low-back pain (3%; 95% CI, 0%-11%) (P < 0.0001). Among 43 girls participating in baseline and follow-up MRI examinations of the lumbar spine, new MRI abnormalities were found in 6 of 8 reporting acute back injury (75%; 95% CI, 35%-97%) and in 8 of the remaining 35 girls (23%; 95% CI 10% to 40%) (P = 0.018). In conclusion, excessive loading that involves a risk for acute low-back injuries during the growth spurt is harmful to the lower back.

Childhood back pain: diagnostic evaluation of an unusual case

Low back pain is uncommon in children. The case of a 5-year-old boy presenting with back pain that proved to be caused by a metastatic primitive neuroectodermal tumor is presented and the evaluation of such patients is discussed.

Low Back Pain in Athletes

The complaint of persistent low back pain in an athlete is usually related to an identifiable structural disorder. As with all other medical conditions, effective treatment relies on an accurate diagnosis. Certain sporting activities are associated with characteristic acquired lesions; this knowledge, when combined with a thorough history and physical examination, will often dictate when the clinician should refer an athlete for further testing. Most causes of back pain in athletes can be treated nonsurgically if they are identified early and treated appropriately. The common congenital abnormalities, acquired conditions, and overuse syndromes causing low back pain in athletes will be discussed, along with appropriate diagnostic tests and treatment regimens.

Sacral osseous destruction in a female gymnast: unusual manifestation of Scheuermann's disease?

We describe a 14-year-old female gymnast whose complaint was that of chronic low back pain. Radiographs and computed tomograms showed both lumbar manifestations of Scheuermann's disease and an osseous destruction of the S1 vertebral body. We suggest that this is a sacral component of Scheuermann's disease.

Back pain in children and teenagers

Controversial opinions have been published concerning the frequency of LBP among children and adolescents. Studies from orthopaedics or neurosurgical departments have reported low figures for prevalence of specific LBP due to serious disorders. Field surveys, on the contrary, have shown that cumulative life prevalence of non-specific LBP in children and teenagers can be comparable to the prevalence data for adult populations. Some specific diagnoses are more common or characteristic of children complaining of LBP. Age, gender, sports activities and family history of LBP have been found to be significantly associated with an increased prevalence in non-specific LBP among children. Low back pain among children and teenagers is common and should be recognized. This chapter provides guidelines for a clinical approach and differential diagnoses. Most back pain in these age groups is benign and should be treated as such.