Pediatr Clin N Am 49 (2002) 643 – 653

Low back pain in the adolescent athlete

Daniel E. Kraft, MD
Department of Pediatrics, Indiana University School of Medicine, Methodist Sports Medicine Center,
1815 North Capitol Avenue, Suite 500, Indianapolis, IN 46202, USA

Low back pain in adolescent athletes is a common problem seen in both

sports medicine and general pediatricians’ offices [1]. Whereas low back pain
in adults has often been believed to be a work-related issue, low back pain
in young athletes should be taken seriously as a possible significant problem
until fully evaluated. Various studies have shown up to 38% of athletes who
present with low back pain have plain film evidence of pars defects [2,3]. Other
athletes with low back pain may have normal plain films and show structural
problems on either a bone scan or MR image. Because structural problems
appear to be quite common in adolescent athletes, more timely and thorough
evaluation of these patients is indicated when compared to adult patients with
low back pain.

History
As with other medical problems, obtaining a complete history from the patient
will lead physicians toward the correct diagnosis when evaluating low back pain.
It is important to know the sport and the level of competition of the athlete. For
example, athletes in some sports such as gymnastics, soccer, or ballet have higher
incidences of pars stress fractures. Information about the pain including the length
of symptoms, severity of pain, location of pain, and whether the athlete has
missed any games or practices secondary to pain helps physicians better
understand the patient. Most adolescent athletes present to physicians with back
pain when it affects their ability to participate in practice and games. An
adolescent athlete with significant pain for at least 3 weeks should be seen by a
physician and receive a radiologic evaluation, which may include plain films,
bone scan, SPECT scan, CT scan or MR imaging [4].

E-mail address: [email protected] (D.E. Kraft).

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Physical examination
The physical examination of the adolescent athlete with low back pain should at
least include examination of the lower back, sacroiliac (SI) joints, and hips, and a
neurologic examination. Examination of the lower back starts with palpation of
lumbar sacral spine and evaluation for paraspinous muscle spasms. Range of
motion in forward flexion, side bending, and extension should be quantitated and
checked for symptoms of pain. In the athlete with normal plain films, the single leg
hyperextension test (Fig. 1) has been shown to be quite sensitive for pars stress
fracture but only approximately 50% specific [5]. Thus, if the athlete does have a
positive single-leg hyperextension test on examination, further testing for a pars
stress fracture is needed. Athletes who have a negative single-leg hyperextension
test do not necessarily need further evaluation for a pars stress fracture. The straight
leg raising test is used for the detection of lumbar disc disease, as it is in adults. The
SI joints are evaluated both by palpation of the SI joints and the FABER test. A

Fig. 1. Single-leg hyperextension test.

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positive FABER test (Fig. 2) is indicated by reproducing pain at the SI joint during
the test. The hip examination should evaluate the patient’s range of motion in
internal and external rotation, the patient’s gait, and palpation of anatomic land-
marks around the hip. The neurologic examination checks for muscle strength,
deep tendon reflexes, and sensation in the lower extremities. Refer to Fig. 3 for an
algorithm for evaluating adolescent athletes with low back pain.

Radiologic diagnosis
With structural problems being the most common cause of low back pain in
adolescent athletes, radiologic evaluation is an important component in diagnosis.
Athletes with at least 3 weeks of pain should have a complete radiologic
evaluation, starting with plain films and including anteroposterior (AP), lateral,
and oblique views [4]. If the plain films are normal and the athlete has a positive
single leg hyperextension test, further evaluation with a bone scan and SPECT
scan to evaluate for a pars stress fracture is needed. Studies have shown the
SPECT scan adds sensitivity both in detecting pars stress fractures and localizing
the uptake in the posterior elements of the vertebrae when evaluating for pars
stress fractures [6]. If the plain films are positive for a pars defect, then further
testing with a bone scan and SPECT scan may not be needed because the lesion is
chronic in nature and has a low chance of healing; however, I have begun to order
bone/SPECT scans more aggressively in these patients after finding a few bone/

Fig. 2. FABER test.

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Fig. 3. Evaluation of low back pain in the adolescent athlete.

SPECT scans to be hot at a different lumbar level than the pars defect seen on plain
film. CT scans provide excellent information about the fracture site and help
determine if any healing has occurred with treatment. I currently obtain limited
reverse angle CT scans of the lumbar spine at the initiation of treatment and again
after 3 months of treatment to determine if any bony healing has occurred. These
two CT scans are then compared to evaluate for evidence of either complete
healing, partial healing, or no healing. In this respect, I can have an end point for
brace treatment, and patients know if their stress fracture has had bony healing or
is a nonunion. MR imaging is still used most commonly for disc disease and spinal
cord pathology. It is still not widely used for pars stress fractures, as it is difficult to
determine by MR if any biologic activity is occurring at the fracture site.

Pars interarticularis problems

The most common cause of low back pain in adolescent athletes seen in many
sports medicine practices involves problems of the pars interarticularis. The
problems are pars stress fractures, spondylolysis, and spondylolisthesis. I view
athletes with these three diagnoses as separate patient populations. These three
problems are part of the same spectrum of injury but can be separated chronologi-
cally. I view pars stress fractures as being more acute because we diagnose this
entity with normal plain films and a hot bone/SPECT scan. Spondylolysis is a
chronic pars defect because it shows up on plain films and is cold on bone/SPECT
scan. Pars stress fractures that heal as a cartilage nonunion fall into this category of
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spondylolysis [7]. Spondylolisthesis is the forward slippage of one vertebra and is

commonly considered a possible sequela of spondylolysis.

Pars stress fracture

As noted previously pars stress fractures are more acute injuries to the pars
interarticularis. In my practice, this problem is diagnosed with normal plain films
and a positive bone/SPECT scan. Athletes typically present with a few weeks to
months of low back pain during sports activity. As with other stress fractures, their
symptoms increase with more extensive activity in their sport. Athletes from
almost every sport have been diagnosed with pars stress fractures, but some sports
such as gymnastics [8], soccer [9], and ballet have been noted to have higher
percentages of affected athletes.
The physical examination in athletes with pars stress fractures typically does
not reveal any bony tenderness to palpation. Pain is noted most significantly with
extension of the lumbar spine when compared to forward flexion and bilateral side
bending. The single leg hyperextension test is the most sensitive physical
examination tool to detect pars stress fractures. These patients also have normal
straight leg raising tests, normal hip examinations, and normal SI joint evalua-
tions. Their neurologic examinations typically are normal. As noted previously,
patients with a positive single leg hyperextension test and normal plain films need
further evaluation with a bone/SPECT scan to evaluate for a pars stress fracture.
Once the diagnosis of pars stress fracture has occurred, no ‘‘gold standard’’
currently exists for the treatment of this problem. Because athletes with pars stress
fractures have hot bone scans, the biologic activity at the fracture site gives these
athletes some chance of bony healing. My treatment is therefore aimed at giving
the athlete the best possible chance at healing the stress fracture.
Throughout the nation, the three most common treatments for pars stress
fractures are the Boston Brace, the warm-n-form orthosis or lumbar corset, and no
bracing with activity modification [10]. I currently offer all three options to
athletes. The activity modification treatment requires at least 3 months of no sports
activity, requiring the high school athlete to miss at least one full sports season.
With the Boston Brace or warm-n-form orthosis treatment, patients are able to
return to their sport after 3 weeks of brace treatment or when they become
asymptomatic with activities of daily living, whichever comes last. The athletes
return to all sports activities in their respective brace and are instructed to wear the
brace 23 hours per day. Athletes are routinely treated for a minimum of 3 months
in the brace. Because my patients are usually in season and want rapid return to
their sport, I rarely have patients choose the activity modification without bracing
option. Patients in either brace treatment are started on a rehabilitation program at
the 3-week mark of treatment, if pain-free. The rehabilitation program emphasizes
a vigorous trunk stabilization program and gentle hamstring flexibility. The athlete
is started with basic posterior pelvic tilts and should be progressed through the
levels of a trunk stabilization program during their brace treatment [4].
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I currently use reverse angle CT scans to evaluate for evidence of healing and to
help determine an end point for brace treatment. A reverse angle CT scan done after
3 months of treatment is compared to a baseline CT scan to evaluate for healing.
With evidence of a healed stress fracture, brace treatment is stopped at 3 months. If
the CT scan shows no evidence of any change at the pars, then brace treatment is
also stopped because the stress fracture does not appear to be healing. Partial
healing seen on CT scan is treated with another 6 to 12 weeks of brace treatment.
Our patient data correspond to published data, which shows that a limited
number of these patients actually achieve bony healing, whereas the majority form
nonunions [11]. Most of our patients are able to return to full sports activities
without significant problems. Athletes with unhealed pars stress fractures,
however, are counseled that intermittent episodes of low back pain will probably
occur. These episodes can be treated effectively with a short duration in their
respective brace and activity limitation until pain free. This short duration of brace
treatment is usually in the range of 3 to 10 days. Athletes are not restricted from
any sports activity, but I do recommend against some specific weight lifts such as
squats, cleans, and dead lifts. I also suggest athletes use their brace as a weight belt
for their weight-lifting activities.

Spondylolysis
Whereas pars stress fractures are acute problems, spondylolysis is considered a
more chronic problem. Diagnosis is made by a pars defect seen on plain film and a
cold bone/SPECT scan. Spondylolysis athletes present with similar histories to
pars stress fracture patients. They develop low back pain that increases with sports
activity. Their pain symptoms may be present for weeks to months. These patients
are involved in a wide spectrum of sports as with the pars stress fracture athletes.
The physical examination is often identical to that seen with pars stress fracture.
The athlete has pain with extension and a positive single leg hyperextension test.
With no biologic activity at the fracture site, little chance of bony healing exists.
Therefore, treatment is not aimed at healing the fracture but treating the problem
symptomatically so the athlete can return to sports quickly and without pain. In a
small number of athletes with symptoms of a single leg hyperextension test and a
pars defect seen on plain film, bone/SPECT scans have shown increased uptake at
the pars interarticularis at another lumbar level that did not show up as a pars
defect on plain film. I treat these patients as though they have pars stress fractures.
The athletes with a defect seen on plain film and a cold bone/SPECT scan are
treated in the warm-n-form orthosis. I do not offer these athletes the Boston Brace
option because we are really treating them only symptomatically, and my athletes
have become pain free in the warm-n-form orthosis just as quickly as with the
Boston Brace. The warm-n-form orthosis is significantly less expensive than the
Boston Brace.
Symptomatic spondylolysis patients are placed in the warm-n-form orthosis
23 hours per day and can return to play in 2 to 3 weeks if they are asymptomatic.
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The athletes return to play in the brace and are then slowly weaned out of
the brace over the next few months if they continue to remain asymptomatic.
The patients, like the pars stress fracture patients, are started on a rehabilitation
program. The program again emphasizes trunk stabilization and gentle hamstring
flexibility and should be advanced through the levels of trunk stabilization
during treatment [4].

Spondylosisthesis
Spondylolisthesis is the forward slippage of one vertebra in relation to the
vertebrae below it. Spondylolisthesis is thought to be a progression of spondy-
lolysis and thus also a chronic problem. In my practice, athletes with spondylolis-
thesis are much less common than those with either pars stress fractures or
spondylolysis. Rarely do these patients have spondylolisthesis greater than grade
I. The athletes’ history at presentation varies little from those of other pars
interarticularis problems. They have pain with extension and a positive single leg
hyperextension test. Athletes with significant grade II or more spondylolisthesis
are referred to pediatric orthopedists.
Because the problem is chronic like spondylolysis, these athletes with low-
grade spondylolisthesis are also treated with a warm-n-form orthosis for symp-
toms of pain. The athletes are held out of sports 2 to 3 weeks or until
asymptomatic. They are then returned to play in their brace and are allowed to
play as long as they remain pain-free. The same rehabilitation program based on
the trunk stabilization program is used. These athletes can then be weaned out of
their warm-n-form orthosis if they remain pain-free in sports for 1 to 2 months.
Follow-up plain films until the age of 19 are needed for spondylolisthesis patients
as well as pars stress fracture and spondylolysis patients to check for any
progression of the vertebral slippage.

Lumbar disc herniation

Lumbar disc herniation is a common cause of low back pain in adults but much
less common in adolescents. The disc herniation in younger athletes tends to
contain much proteoglycan or nuclear jelly, whereas adult herniations are more
collagenous in nature [12]. Another difference in young athletes is that their
history and physical examination findings are much less predictable than adults
who present with lumbar disc herniation. Adolescents do not always complain of
the classic radicular pain pattern seen in adults. They may simply have continued
low back and buttock/hip pain or complain of a chronic hamstring injury that will
not heal but did not have any specific injury normally seen with hamstring strains.
Some young athletes, on the other hand, present with classic radicular pain. The
classic physical examination findings of a positive straight left raising test is less
common in young athletes than adults.
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Because pars interarticularis problems are much more common than lumbar
disc herniations, we typically initially use the bone/SPECT scanning for radiologic
evaluation after plain films. If the patient has a normal bone/SPECT scan and does
not respond to a course of rehabilitation and conservative treatment, then we
evaluate further with MR imaging looking for disc or spinal cord pathology. We
also use MR imaging when patents have positive straight leg findings on physical
examination and do not respond to conservative treatment with rehabilitation.
Once the probable diagnosis of lumbar disc herniation is made in a young
athlete, we use a combination of rehabilitation and anti-inflammatory medication
for treatment. The rehabilitation program is built around the lumbar extension

Fig. 4. Functional progression for returning an athlete to a field sport. Once the athlete has completed
the appropriate phases of rehabilitation it is possible to begin a functional progression. The functional
progression is an ordered sequence of activities that enable the athlete to return to athletic endeavors.
The athlete should begin with step one. Once this can be done without pain or limping, the athlete may
proceed to the next step. It is important to perform each exercise correctly, without apprehension.
When the athlete has successfully completed each step of the functional progression, a return to sport
may be attempted. (Data from # Methodist Sports Medicine Center, 2000.)
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program. I limit the athletes’ sports activities until their symptoms of pain have
greatly resolved. They can return to athletics once they can pass a specific
functional progression program for their sport (Fig. 4). I do not let them participate
in any weight-lifting activities until their symptoms have completely resolved for
at least 2 to 3 months. The athletes with lumbar disc herniation seem to have more
symptoms during the school year, as they are sitting in class for many hours per
day. Many times their symptoms significantly improve after the school year ends.
In my practice, I have rarely needed surgical intervention to treat our young
athletes with lumbar disc herniation.

SI joint pain
SI joint pain is another structural problem in young athletes that presents as low
back pain. Clinically, athletes with SI joint pain present much like athletes with
pars interarticularis problems. They complain of pain with hyperextension. Their
symptoms have usually been present for at least a few weeks. Again, as with other
low back problems, these athletes typically present to their physician only when
their symptoms of pain start affecting their sports participation.
On physical examination they often have tenderness to palpation over the
affected SI joint and no other bony tenderness. The athlete usually notes more pain
with lumbar extension than with forward flexion or side bending. The single leg
hyperextension test may be positive. The FABER test typically reproduces pain at
the affected SI joint. The straight leg-raising test is also normal, as is the hip
examination. Plain films of the lumbar spine should be obtained. In patients with
SI joint pain, the films are normal. I have not found much clinical use in obtaining
plain films of the SI joint in most cases. Because these patients with SI joint pain
typically have pain with lumbar extension and may have a positive single leg
hyperextension test, I often evaluate further with a bone/SPECT scan to rule out
pars stress fractures. SI joint pain must be considered in patients with a positive
single leg hyperextension test, negative plain films of lumbar sacral spine, and a
cold bone/SPECT scan.
Treatment for SI joint pain in my practice involves an extensive rehabilitation
program aimed at controlling the patient’s pain symptoms. As with other low back
problems, a physical therapist with experience treating athletes with SI joint pain
is of great value to the physician. The therapy program often must evaluate and
work on mobilization of the affected SI joint while also working on a trunk
stabilization program. If a 3 to 4 week course of rehabilitation treatment does not
make significant progress, we have found that a warm-n-form orthosis can be used
to help ease symptoms of pain. I have had limited success with SI belts in my
athletes and tend to use the warm-n-form orthosis instead. Again, the athlete can
return to his or her sport once the symptoms of pain have resolved and he or she is
able to pass a sport specific functional progression program. If athletes do not
respond to conservative treatment, other treatments such as SI joint injection may
be needed.
652 D.E. Kraft / Pediatr Clin N Am 49 (2002) 643–653

Mechanical/muscular low back pain

Because a large number of adolescent athletes with low back pain have
structural abnormalities, muscular type low back pain should be diagnosed only
after other structural problems have been ruled out. Adolescent athletes with low
back pain should not be assumed to have muscular type pain.
Athletes with muscular low back pain present to physicians with similar
histories of pain with sports, as seen with previously discussed low back problems.
The physical examination usually does not reveal any bony tenderness but may
show increased paraspinal muscle spasm in the lumbar region. The athlete may
indicate pain with all ranges of motion including extension. Evaluation of the hips
and SI joints are normal. Both the straight leg raising test and neurologic
examination are also normal. As with other low back pain, plain films are obtained
if the patient has had 3 weeks of symptoms. If the patient has pain with extension
and a positive single leg hyperextension test, then further evaluation with a bone/
SPECT scan is obtained to rule out pars stress fracture. If the single leg hyper-
extension test is negative, a trial of physical therapy is started focusing on the trunk
strengthening/stabilization program. The basic idea of the trunk stabilization
program is to find a neutral pain free position for the lumbar spine and then
retrain muscles to support this spine position during the use of arms and legs [4].
The program is started with basic exercises and progresses through levels of trunk
strengthening in a controlled manner. Athletes are able to use pain as their guide
when returning to activities but must pass a sport specific functional progression
program to return to their sport.

Summary
There are several other entities such as infection, tumors, and fractures that I
have not covered in this article. These entities are not common in adolescent
athletes but must always be considered when athletes do no respond to typical
treatment protocols for the problems I have discussed. The most important theme
to take from this article is that low back pain in adolescent athletes is a problem
that should not be ignored but instead fully evaluated because structural problems
are quite common in this patient population.

References
[1] Weiker GG. Evaluation and treatment of common spine and trunk problems [review]. Clin Sports
Med 1989;8:399 – 417.
[2] Micheli LJ. Back injuries in gymnastics. Clin Sports Med 1985;4:85 – 93.
[3] Papanicolaou N, Wilkinson RH, Emans JB, et al. Bone scintigraphy and radiography in young
athletes with low back pain. AJR Am J Roentgenol 1985;145:1039 – 44.
[4] Watkins RG, Dillin WH. Lumbar spine injury in the athlete [review]. Clin Sports Med 1990;9:
419 – 48.
[5] Kraft DE. Physical examination findings in pars stress fractures in athletes. Presented at the Annual
Meeting of the American Medical Society for Sports Medicine. Hilton Head, SC, April 1999.
 D.E. Kraft / Pediatr Clin N Am 49 (2002) 643–653 653

[6] Bellah RD, Summerville DA, Treves ST, et al. Low-back pain in adolescent athletes: detection of
stress injury to the pars interarticularis with SPECT. Radiology 1991;180:509 – 12.
[7] Wiltse LL, Widell Jr. EH, Jackson DW. Fatigue fracture: the basic lesion is isthmic spondylolis-
thesis. J Bone Joint Surg Am 1975;57A:17 – 22.
[8] Ciullo JV, Jackson DW. Pars interarticularis stress reaction, spondylolysis, and spondylolisthesis
in gymnasts. Clin Sports Med 1985;4:95 – 110.
[9] Kraft DE, McCarroll JR. Spondylolysis in soccer players. Presented at the Annual Meeting of the
American Medical Society for Sports Medicine, Sun Valley, ID, June 1993.
[10] Kraft DE. Treatment of spondylolysis and spondylolisthesis. Presented at the Annual Meeting of
the American Medical Society for Sports Medicine. Hilton Head, SC, April 1994.
[11] Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis: a study of natural progression in
athletes. Am J Sports Med 1997;25:248 – 53.
[12] McCulloch JA. Ruptured lumbar discs (herniated nucleus pulposus). In: Torg JS, Shephard RJ,
editors. Current therapy in sports medicine. 3rd edition. St. Louis: Mosby; 1995. p. 97 – 100.