Injury and the Young Athlete
Patients often look to their DCs as a primary source of healthcare as they bring their children into a chiropractic practice — often for sports-related injuries. Dr. James R. Brandt, Executive Director and past President of the Academy of Chiropractic Orthopedists, now the International Academy of Neuromusculoskeletal Medicine (IANM) shares a case study and offers his insights on the issue.
Posted in Risk Management on Tuesday, April 10, 2018
Following is a brief case study of a young patient Dr. Brandt saw with a serious football injury.
History
A 15-year-old male came into my office after experiencing enduring low back pain. His pain began when he was playing freshman football nine months prior to admission at my office.
His injury began when he was hit waist high from the side and landed on his opposite side. He had immediate low back pain and was taken to the after-hours clinic at his primary care provider. He was examined and plain film X-rays were taken, which were found to be unremarkable.
The young man continued to have intermittent lower back discomfort until two months before entering my office when the pain became sharp. During this time, he had begun a course of structured weightlifting and started wrestling. By the time I saw him, he could no longer lift weights or participate in wrestling due to the pain.
Examination
The patient’s pain severity scale was “8 to 9” out of “10” with an Oswestry back index of 26 percent. Vital signs were unremarkable. The patient’s LROM was slightly reduced on flexion and reduced 50 percent on extension.
Kemp’s was localized bilaterally in the mid-line and just above the beltline. Trendelenburg, Triad of Dejerine and MSR’s were all negative.
There was only mild spasm in the lower lumbar paraspinals to palpation. The Stork test was positive. SLR bilaterally was to 65 degrees with mid-line low back pain. When asked to do the Milgram’s test, the patient was unable to lift his legs at all. He said this was the most intense pain he felt during the examination.
The abdomen was supple and normal bowel sounds were present. No lymphadenopathy was detected.
Imaging Study
Lumbar AP and lateral films were ordered. There was a subtle lucency across the L3 pars region on both the lateral and AP views, consistent with bilateral spondylolysis without spondylolisthesis. MRI with STIR images were recommended due to the patient’s history and plain film findings.
The MRI results confirmed the spondylolysis, but also indicated that the patient had an acute bilateral pars fracture.
Treatment Recommendations
I counseled the patient’s mother that her son should not participate in sports or activities that would stress his low back. I made an appointment for an orthopedic consult and sent records and images along with a letter of introduction. The patient was placed in a lumbo-sacral orthotic for six weeks, and his condition resolved favorably. The young man is now doing fine and has decided not to wrestle next year; however, he may begin weightlifting for football this summer.
What the Literature Says
Spondylolysis in the lumbar spine is defined as a unilateral or bilateral stress fracture of the narrow bridge between the upper and lower pars interarticularis. It’s a common cause of low back pain in adolescent athletes. Athletes participating in sports that involve repetitive spinal motion, especially flexion and extension are vulnerable.1
Approximately 85 percent of spondylolysis occur at L5, but it could occur as high as L2.2 Spondylolysis is associated with spondylolisthesis in approximately 25 percent of cases, and the tendency or progression of spondylolisthesis is correlated with the pubescent growth spurt.3
There is a hereditary predisposition to the defect and a strong association with spina bifida occulta,4 and there is a very high coincidence5 of spina bifida occulta in more than 60 percent of lumbar spondylolysis.
A very important article stated the prevalence of low back pain in children ages 11-17 has been reported to be as high as 30.4 percent among adolescents participating in sports.6 Lumbar spondylolysis must be considered in the differential diagnosis of low back pain in this population.
- Common sports or sporting activity that have a high incidence of spondylolysis include:
- Gymnastics
- Diving
- Weightlifting
- Dance
- Wrestling
- Rowing
- Figure skating
- Volleyball
- Football
- Soccer
- Tennis
- Track and field (pole vault and high jump)
One of the most important takeaways in providing chiropractic care to young people is that if the low back has been injured in a teenage athlete, there is a high probability of injury to the pars. Mechanism of onset will be important, and the examination of these athletes should include the Stork test and imaging.
1Malanga et al in eMedicine/medscape, Dec 2009
2 Litao and Munyak in eMedicine Specialties— Sports Medicine—Spine, Jan 2009
3Saraste in Pediatric Orthopedics, Nov 1987
4Fredrickson in JBJS vol 66 1984
5Sairya in Spinal Cord, Nov 2005
6Olsen et al in American Journal of Public Health, April 1992