Lower Back Bone Stress Injuries in adolescents and preadolescents
Our spinal column is comprised of 24 vertebrae, 5 of which reside in the lumbar region (lower back). These 5 vertebrae are prone to certain types of injuries due to the force and load they are placed under.
What is the typical clinical presentation?
We go back to think about out childhood and adolescent lives and remember that if we had a fall or an injury, more times than not we would just get up and dust ourselves off with a little bit of compassion from our parents, that would be that. In our younger years, our bodies just have an amazing way of healing quickly (part of it is because there isn’t a requirement to sit behind a desk for 12 hours in a poor ergonomic set up or repetitively lay about 5000 bricks in day!)
Having said this, preadolescent and adolescents are prone to certain types of injuries more than adults are. The most common cause of ongoing lower back pain in these population groups are bone stress injuries, constituting 50% of these cases.
These injuries occur in 5-6% of the population of which only 15% are symptomatic.
- Spondylolysis is a stress injury which occurs gradually over time due to chronic (long term) stress. A part of the vertebra known as the pars interarticularis is typically most affected.
- Spondylolisthesis is a spondylolytic injury that has progressed and resulted in the ‘forward slippage’ of the vertebral body above with respect to the one below.
In the younger population it most commonly affects L5 in ~90% of cases and L4 in ~10% of cases, however can be higher up the lumbar spine if lots of rotation is occurring e.g. cricket and fast bowlers
What are the causes of these bone stress injuries?
Unfortunately the cause of these conditions is unknown, thought to be due to mixed causes e.g. genetics and high risk sports which include cricket, gymnastics, dancing, throwing sports, diving, weight lifting, rowing, wrestling and hockey which all repetitively load up the elements of the spine which cause these injuries.
What are the risk factors associated with bone stress injuries?
- High loads in the past 3 months e.g. increased training for competitions or auditions or just doing too much too soon
- Previous injury in same season
- Anybody under the age of 22 has a 4 x increased risk of developing a lumbar bone stress injury, part of the reason is the body is not fully developed
What is the typical clinical presentation?
- Lower back pain, buttock and or posterior thigh pain
- Sudden or gradual onset
- Often history of overload e.g. competition training or sports camp
- Aggravated by lengthy periods of weight bearing, running, jumping, bowling, kicking and bending backwards
- Eased by rest
- Often blamed on just not stretching enough and ‘growing’ pains
How are these conditions diagnosed?
Unfortunately, bone stress injuries are commonly misdiagnosed in clinical practice as early signs are mild, the patient may do some sports and irritate it and then rest and it goes away and then it becomes a vicious cycle. Often we hear parents blaming ‘growing pains’ as the reason their children experience ongoing pain.
Picking these conditions up early on in the peace is instrumental to slow down the bony changes i.e. the forward slippage of the bone which will negatively impact overall clinical outcome and in some cases can be career-ending in elite athletes. We would typically take a detailed history followed by and comprehensive examination which aims to reproduce the exact pain experienced.
We are taught at university to limit the use of radiographs such as X-Ray, CT and MRI on this population of people, with stress reactions and fractures being an exception to this rule.
What must be considered is that in the early stages of injury it may take up to 3 weeks for these injuries to appear on radiographs and to throw a spanner in the works, 15% of cases will show no obvious signs of bony reaction or fractures on imaging.
As it stands in NSW, anyone under the age of 16 can get a bulk billed MRI of the lower back if a significant injury is suspected but must have had an x-ray taken first.
How are these injuries treated?
The general recommendation is that the adolescent or preadolescent should cease the aggravating sport or activity for a short period of time to allow for the body to rest and heal. In some cases, basic day to day activities can be quite painful let alone 3-4 sessions of gymnastics per week to compound the stress through the body.
We would typically utilise some form of hands on treatment during this ‘rest’ period which would include some soft tissue work, light mobilisations as well as a customised stretching and strengthening program to optimise recovery and minimise deconditioning of muscles.
Although the adolescent and preadolescent populations are at increased risk of developing these bone stress injuries, they are also very responsive to loading which will improve bone mass and strength, but it has to be managed carefully and properly.
Bracing can be used in certain scenarios to limit movement and support healing; however there is still some controversy regarding the use of braces as there is insufficient evidence showing its overall clinical impact.
Certain taping methods may be utilised to help with bodily awareness and in order to limit certain movements (usually bending backwards) for a short period of time to aid healing.
We would also recommend an ergonomic school bag check and consulting with our G.P about the use of natural anti-inflammatory supplements to aid with recovery.
Disclaimer: If your child is in significant physical distress, please take them to the hospital. The information and advice provided in this blog is for educational purposes only and shouldn’t replace the advice or recommendations of your Doctor or Specialist.
Written by Aret Aboulian
References
Gottschlich LM, Young CC. Spine injuries in dancers. Curr Sports Med Rep. 2011 Jan-Feb;10(1):40-4
Masci et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. 2016. BJ Sports Med 40:940-946
Syrmou et al. Spondylosis: A review and reappraisal. 2010. Hippokratia 14, 1:17-21
Back Pain in Children, Orthokids, accessed 1 June 2022, < https://orthokids.org/conditions/back-pain-in-children/ >