Back Pain
Back pain in a child or adolescent must be taken seriously.
Frequent back extension (heading a soccer ball, gymnastics, line play in football) places axial loads that stress the posterior elements of the lumbar column, often leading to stress injury of the pars interarticularis, most often at L5. Optimally, athletes should take at least one week off between seasons. Many do not heed this recommendation.
The spectrum of lumbar region injury runs from a pre-stress reaction (lumbar pain without true fracture) to frank unilateral or bilateral spondylolysis (true stress fracture of the pars), culminating in spondylolisthesis (anterior motion of a lumbar segment relative to the next distal segment).
Spondylolysis often presents as midline lower lumbar pain of insidious onset with gradual worsening. Extension or rotation of the lumbar region often exacerbates the pain. Radiation of pain to the lower extremities or other neurologic symptoms suggests alternate diagnoses.
Radiologic imaging and subsequent management of suspected spondylolysis are controversial. Additional imaging studies, such as single-photon-emission computerized tomography (SPECT) scans or CT scans, may be indicated to determine acuity and delineate fracture pattern, respectively. Therefore, referral to spine specialists is highly recommended. Rehabilitation strategies include bracing to limit lumbar extension, abdominal strengthening, and hamstring flexibility (see the discussion of knee pain in the following section). Often, athletes must refrain from at-risk activity for at least three to six months.
