Lower Back Pain in the Young Athlete

Youth athletic back pain is common, with a reported incidence of 21% and a prevalence that ranges from 37-66% (1). The most common source of low back in this population is lumbar bone stress injury (LBSI) or spondylolysis, while only 6% of the adult population will suffer such conditions (2). 

It is suggested in the literature that adolescents are at a greater risk of back pain due to the changes that occur in the spinal column during puberty, periods of rapid growth and their immature skeletal system (3). The lumbar vertebrae do not fully fuse until around the age of 23, making it more susceptible to injury such as LBSI or spondylolysis (2). Lower back pain in young athletes occurs as a result of either an acute traumatic event (e.g. a high-force tackle during a contact sport) or repetitive trauma (overuse injury). Lower back pain is most prevalent in young athletes competing in football, rugby, ice skating and dancing (4). 

Types of Low Back Pain Seen in Youth Athletes

Acute soft tissue sprains, strains, and muscle contusions

Soft tissue injuries in the lumbar region can occur and are usually the result of a blow to the twisted spine, direct contact, and forced hyperextension of the lumbar spine (5,6). 

Spondylolysis

Spondylolysis is a non-displaced fracture of the pars interarticularis (1). Sports that expose the athlete to repetitive flexion, extension and torsion (twisting) of the lumbar spine may have an increased risk of spondylolysis. The most common vertebra involved in athletes presenting with this condition is the L5 vertebrae, which is involved in greater than 90% of incidences (7). 

Spondylolisthesis

Spondylolisthesis typically results from undiagnosed spondylosis and refers to the slipping of the vertebrae either anteriorly or posteriorly (forwards or backwards) relative to the vertebral body below. The most common segment involved is L5/S1 and the diagnosis is classified based on the severity (see Figure 1). 


Figure 1: Spondylolisthesis Stages 

Stress Fractures

Stress fractures are fractures caused by either repetitive loading of normal bone (fatigue fractures) or repetitive loading of abnormal bone (insufficiency fractures). Risk factors for bone stress Injuries can be biomechanical or biological, as outlined in Figure 2. Repetitive back hyperextension and rotation are common injury mechanisms resulting in stress fractures in young athletes (1). 

Figure 2: Biomechanical and Biological Risk Factors for Bone Stress Injury 

The Most Common Cause of Low Back Pain in Young Athletes

As stated before, the most common cause of low back pain in young athletes is lumbar bone stress injury (LBSI) or spondylolysis; however, this may not always be the source of back pain in all cases. Some common subjective markers that aid in effectively identifying suspected LBSI in athletes under the age of 23 include: 

1. Unilateral lower back pain
2. Aggravated by extension-related activity and eases with rest 
3. Progressively gets easier to provoke symptoms 

The only accurate way to diagnose a LBSI is through imagining. In adult low back pain presentations, there is typically a poor correlation between structural changes found on imagining and the symptoms the patient may be experiencing and therefore, it is not recommended that these adult patients undergo imagining. However, in adolescent athletes, the percentage of presentations that have a definitive pathology is as high as 73%, compared to 5-15% in the adult population (2). MR imagining is used over both CT scans and X-rays due to its high sensitivity and specificity for diagnosing LBSI. In particular, MRI with VIBE sequence has been reported in one study to have a sensitivity of 98% and a specificity of 92% compared to a CT (2). In cases where an MRI scan is not available, and a LBSI is suspected,  it is best practice to assume a LBSI is present and commence a period of offloading and activity modification with a graded and gradual return to activity. 

Treatment and Management

There is strong evidence that supports the efficacy of physical therapy in the management of low back pain in young athletes (1). In cases where LBSI is suspected, a multi-disciplinary approach may be most beneficial to ensure all risk factors are accounted for. This may include: 

• Physical therapy for pain management, offloading and activity modification protocol and graded return to activity 
• Dietitian & Nutritionist to guide adequate energy intake, nutrient availability and effective meal timing for training, competition and rest days. 
• The Coach to help monitor athletes during training and game days and assist in appropriate rest and return to graded activity. 
• Parents & Family to provide close support to the patient and assist in attending appropriate appointments, scans, etc. 

Typical time frames for return to play for spondylolysis and spondylolisthesis are 6-8 weeks after injury and 4-6 months after diagnosis, respectively. For bone stress injuries, the severity will dictate the expected time frames. Typically, 4–8 weeks of relative rest is recommended for non-complicated stress fractures, followed by a gradual return to activity. Most stress fractures heal with simple conservative management, avoiding the need for surgery.

At Pogo Physio, our team of Physiotherapists, Nutrition & Dieticians, Podiatrists and Exercise Physiologists are all trained in the management of bone stress injuries and management of lower back pain across the lifespan. Book in today for a comprehensive assessment and management plan for back pain, or any other condition that is preventing you from being at your physical best!

Sarah Ellis  B. Exercise Science (APAM)

POGO Physiotherapist
Doctor of Physiotherapy

Book an Appointment with Sarah here

References

1. Vij, N., Naron, I., Tolson, H., Rezayev, A., Kaye, A. D., Viswanath, O., & Urits, I. (2022). Back pain in adolescent athletes: a narrative review. Orthopedic Reviews, 14(3). https://doi.org/10.52965/001c.37097
2. Jackson, A. (2024, April 15). Is imaging a priority in adolescent athlete low back pain? Angela Jackson Physiotherapy. https://angelajacksonphysio.com/2024/04/15/is-imaging-a-priority-in-adolescent-athlete-low-back-pain/
3. Sjolie, A. N. (2004). Low-back pain in adolescents is associated with poor hip mobility and high body mass index. Scandinavian Journal of Medicine and Science in Sports, 14(3), 168–175. https://doi.org/10.1111/j.1600-0838.2003.00334.x
4. Purcell, L., & Micheli, L. (2009). Low Back Pain in Young Athletes. Sports Health: A Multidisciplinary Approach, 1(3), 212–222. https://doi.org/10.1177/1941738109334212 
5. Huang, P., Anissipour, A., McGee, W., & Lemak, L. (2015). Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries. Sports Health: A Multidisciplinary Approach, 8(1), 19–25. https://doi.org/10.1177/1941738115610753 
6. Patel, D. R., & Kinsella, E. (2017). Evaluation and management of lower back pain in young athletes. Translational Pediatrics, 6(3), 225–235. https://doi.org/10.21037/tp.2017.06.01
7. Zukotynski, K., Curtis, C., Grant, F. D., Micheli, L., & Treves, S. T. (2010). The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain. Journal of Orthopaedic Surgery and Research, 5(1), 13. https://doi.org/10.1186/1749-799x-5-13

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