:dropcap_open:B:dropcap_close:ack injuries in adolescents are not very common, but add participation in athletics and you increase the opportunity of experiencing some form of low back pain. According to Micheli, back injuries of young athletes are a significant phenomenon, estimated to occur in 10 to 15 percent of participants1. The prevalence will vary, based on certain sports. In sports like gymnastics back injuries are 11 percent whereas, in football linemen, it has been recorded as high as 50 percent2.
Back injuries can occur from single episodes of blunt trauma -—like being pushed or hit in the back-— to repetitive microtrauma (overuse) from activities of repetitive lumbar extension from practicing sports like gymnastics and diving. Commonly seen back-related injuries in adolescents can result in fractures, which usually are not associated with the severity of a cervical spine fracture that can lead to catastrophic spinal cord injuries. Acute disc herniation, contusions, sprains, strains, spondylolysis and spondylolisthesis, facet syndromes and lordotic low back pain are common. Injuries associated with flexion can be both Atypical and Typical Scheuermann’s Kyphosis, compression or end plate fractures. All of these mechanisms will result in and contribute to vertebral subluxation complexes.
:dropcap_open:All of these mechanisms will result in and contribute to vertebral subluxation complexes.:quoteleft_close:
I would like to focus on just one of the above-mentioned conditions due to it being commonly missed diagnostically. This is “lordotic low back pain.” As doctors of chiropractic, we commonly see adolescents in our office with low back pain that ranges from many causes, and often the patient or parent cannot give a mechanism of injury. One of the most important consideration factors when treating an adolescent is to first determine if they are going through a growth spurt.
Let us look at Elyse, a 12-year-old female gymnast who enters our office with low back pain. Elyse complains of lower back pain which she describes as being on and off for several weeks in duration. The severity ranges from a 0 to a 10 on a pain scale and can change for no related reason. Today, the pain is at a 10, which is why the appointment was made. History indicates Elyse is an active gymnast who practices four days a week, averaging about two hours per practice. Some days the pain restricts her practice time. She describes that location of the pain varies from along the tops of both hip bones (crest of the ilium) to the middle of her low back. Both mother and Elyse deny any recent fall or trauma in the last six months.
Examination shows a normal 12-year-old in height and weight. She can heel-toe walk normally. Balance and coordination appear normal. Ranges of motion demonstrates full ranges of all extremities, cervical spine, and dorsolumbar spine with exception of pain on dorsolumbar extension and restricted flexion that was less painful. Palpation notes symmetrical tightness of the lumbar musculature with no spasms. Palpation of the iliac crest and especially the lumbar spinous process bring about a response of soreness.
Based on our examination findings, we determine the need for lumbar radiographs. The AP view shows a nice straight spine with no rotation. It also shows normal height and formation of the vertebrae with no wedging. Iliac crest and femoral heads all are equal in comparison. Open growth places are noted along the iliac crest and pelvis. The lateral view also shows normal vertebral heights and disc heights. No evidence of degeneration, fracture or other pathology. With additional viewing of the lateral film, we note a slight hyperlordosis of the lumbar spine with no interruption of George’s line.
I am sure I am not the only DC who has looked at an X-ray and found very little of anything structurally wrong on the films. You then question yourself as to how you are going to explain to the parents and child why they are experiencing such pain. It’s easy when we can reference a scoliosis, or point out disc wedging caused by misaligned vertebrae, rotated spinous processes, and phases of disc degeneration. But what are we going to tell the parents and child now as to why Elyse is having low back pain and why she needs chiropractic care? What are we going to adjust? Yes, chiropractic care should be part of everyone’s health program, but we have a child in pain that is looking for answers to why she hurts.
This is why this condition is commonly misdiagnosed. The key diagnostic signs here are the areas of pain, restricted flexion and extension ranges of motion, and the only radiographic finding is the hyperlordosis of the lumbar spine. Above all, the key sign is her age, because she is going through a growth spurt!
:quoteright_open:This is a time that the spine and its supporting tissues are usually very elastic and pliable.:quoteright_close:
In this case, as the lumbar vertebrae are growing, the thoracolumbar fascia is not stretching at the same rate. This phenomenon is what causes the hyperlordosis of the lumbar spine. The fascia is so strong and isn’t expanding, so the growing lumbar vertebrae have no place to go but forward, causing the increased hyperflexion. Considering the anatomy of the fascia and where it originates from across the iliac crest, the body is actually causing a tractioning on the apophysis. The low back pain can be caused from the lumbar spinous processes being jammed upon each other.
Commonly, when we adjust this patient, the lumbar spine is very tight and you will usually not get any movement of the spine. The patient may tell you it was very painful when the lower back was adjusted. I am sure as we described this episode, many of you were able to recall patients of this age that you encountered with the same scenario, and often we lose this patient because he or she gets discouraged because the episodes of pain are so sporadic. More commonly than not, on the days the pain is worse, they are going through a growth spurt.
This patient is truly a chiropractic patient. We must be able to educate the patient and parents on what is actually happening during the child’s development. This is a time that the spine and its supporting tissues are usually very elastic and pliable. Therefore, monitoring structural alignment during these episodes of growth is essential to maintain good spinal development and prevent possible structural problems from developing in the future. Additional considerations you could recommend to help with pain are stretching and use of an anti-lordotic brace.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.
References:
1. Micheli, LJ. “Back Pain in Young Athletes.” Arch Pediatr Adolesc Med 149:15-18, 1995.
2. Mundy, DJ. “Epidemiologic study of sports and weight lifting as possible risk factors for herniated lumbar and cervical disc.” Am J Sports Med 21:854-860, 1993.