Ingrid K. Ichesco, MD

A female high school rower, aged 17 years, presents to your clinic for upper back pain. She is preparing for her senior year and would like to row competitively in college. Her back pain has been present for 2 months. Initially pain was only with rowing, but it has been progressively worsening and now she has pain at rest. Reviewing her medical record, you notice that she has lost 33 pounds since her last visit about 9 months ago. Her body mass index (BMI) was 24.3 kg/m

 (75.6% percentile) 9 months ago and today it is 18.6 kg/m

 (11.7%). On review of systems, you learn that she has not had a menstrual period in the last 6 months. Menarche occurred when she was aged 12 years. She endorses feelings of depression, but no suicidal ideation. Academically, she is a straight-A student.

A male cross-country runner with right lower leg pain for 2.5 weeks, aged 15 years, presents to your clinic. He was previously running about 30 miles per week but recently increased his mileage to 60 miles per week. He has a history of shin splints but his current pain feels like it is “in the bone of [his] lower leg.” The pain is focal to his midtibia. Pain is present with weight-bearing and he has a limp with walking due to pain. He stopped running a week prior, but he likes to be physically active and has been cross-training with core and upper-body resistance training. He has a history of a right tibial stress fracture from the past year. On review of systems, you learn that the patient’s BMI has decreased from 19.3 kg/m

 (3%) over the past 2 years. He is a vegetarian. X-ray today demonstrates a stress fracture (Figure 1).

The female athlete triad was first described in 1997 as the interrelationship among amenorrhea, osteoporosis, and disordered eating. In 2007, the triad was revised to better identify athletes at risk, recognizing that presentation can be on a spectrum, ranging from optimal health to subclinical and clinical disease (Figure 2). The 3 components are now called menstrual function, bone mineral density (BMD), and EA,1 with low EA being the root cause of the triad. Acknowledging the existence of a spectrum of disease allows athletes to be identified earlier and to receive earlier intervention. If an athlete has any of the 3 components, a more thorough investigation should be performed to evaluate for the other components, which may have subclinical presentations.

 Due to the spectrum of disease, it can be difficult to accurately estimate the prevalence of the female athlete triad. An athlete may have 1, 2, or all 3 components. It is estimated that all 3 components are present in 1.0% to 1.2% of high school athletes, 2 components in 4% to 18%, and 1 component in up to 54%.

 Any athlete can develop aspects of the triad, but athletes in sports that emphasize endurance, appearance, or weight class are most at risk. Sport specialization at an early age can also increase risk (Table 1). The Female Athlete Triad Coalition Consensus Panel recommends screening during the pre-participation physical exam or if there are concerns that an athlete may have the triad (Table 2).

EA is the amount of dietary energy (calories) remaining for physiologic function after exercise. Low EA is the root cause of the triad as it may affect bone health and lead to hormonal disturbances in the athlete.

Many athletes’ low EA is not intentional and they do not display pathologic eating or weight control behaviors. When this is the case, simply increasing caloric intake will treat the patient. However, restriction of caloric intake can be intentional in athletes who are trying to maintain a weight class or achieve a certain appearance. Disordered eating is estimated to occur in 6% to 45% of female athletes.

 Athletes who have specialized diets (vegan, vegetarian, pescatarian, etc) may also be at increased risk. In cases where the athlete has intentional disordered eating, psychological intervention and treatment may be required.

According to a study of 1000 female athletes by Ackerman et al, those with low EA were more likely to have negative performance effects, including decreases in coordination, concentration, endurance, and training response. In the clinic setting, it may be helpful to discuss with the athlete how decreased EA can negatively affect performance.

A low BMI is a strong predictor of low bone mineral density and stress fractures. An adolescent should be screened carefully if they have a BMI that is less than 17.5 kg/m

. An athlete’s goal weight should be >90% of expected body weight.

 However, it is important to keep in mind that even athletes with a normal BMI may still have low EA.

If you are able to work with a dietitian, you can calculate fat free mass (FFM) for your athlete patient. In order to have normal menstrual function, 30 kcal/kg of FFM/day are needed, but 45 kcal of FFM/day is ideal.

 Because this calculation can be difficult, it is helpful to have the athlete see a sports dietitian and exercise physiologist, if possible.

Even in the absence of amenorrhea, disordered eating can be associated with lower BMD in athletes.

Adolescence is the most crucial time for bone mass accumulation, so the presence of the athlete triad can be particularly harmful during this time. Maximum rate of bone formation usually occurs between the ages of 10 and 14 years, and 90% of peak bone mass is attained by 18 years.

 Diet, weight-bearing activities, and genetic makeup all contribute to an individual’s bone mass accrual. Achieving sufficient bone mass is important to decrease the risk of fracture and to prevent osteoporosis in adulthood. Lower estrogen and lower EA increase bone resorption and suppress bone formation and remodeling.

Stress fractures are often the initial presenting symptom in patients with the triad. Stress fractures usually occur due to chronic, repetitive micro-trauma that cause tiny cracks in the bone. Athletes with menstrual irregularities are more likely to have bone stress injuries. As with the other aspects of the triad, a spectrum of stress injury exists, ranging from stress reaction (intermediate injury; bone marrow edema) to fracture (when enough trauma has occurred to cause a break in the cortex).

A dual-energy radiograph absorptiometry (DXA) can be used to assess bone density and should be considered in athletes with a history of stress fractures, and/or menstrual dysfunction, and/or low EA for at least 6 months. Notably, DXAs are usually ordered on postmenopausal women, and separate standards exist for performing DXAs on children or adolescents. Therefore, DXA should ideally be done at a facility whose staff is familiar with interpreting results based on the patient’s age and gender. In adults, BMD is interpreted using the T-score, which compares the patient’s BMD with the maximum expected BMD achieved aged between 25 and 30 years. Pediatric bone density, however, is assessed using the Z-score, which compares the patient’s BMD with those of others of similar age and race. Further details are available in the guidelines provided by DeSouza et al.

 It may be helpful to discuss these with the performing radiologist.

Athletes who participate in high-impact and resistance activities would be expected to have a BMD that is 10% to 15% higher than those of athletes participating in nonimpact sports. This should be taken into consideration when interpreting DXA scans. Z-scores of less than –1.0 may be abnormal in an athlete, alerting concern for low BMD, but that score may be normal in a nonathlete. An athlete who has a Z-score of less than –1 should undergo further evaluation.

It is not normal for female athletes to have menstrual dysfunction; they should not lose their period during their sport season (a phenomenon most classically seen in cross-country runners). Functional hypothalamic amenorrhea (ie, amenorrhea with the female athlete triad) is a diagnosis of exclusion, so if an athlete is experiencing amenorrhea or oligomenorrhea, it is crucial to rule out other causes (Table 2).

 Primary amenorrhea is absence of menarche by age 15 years. Secondary amenorrhea is defined as absence of menses for 3 months or longer, while oligomenorrhea is defined as cycles lasting longer than 35 days.

 Maintaining normal menstrual function is important for the athlete’s bone health.

 As such, exogenous hormones (ie, birth control pills) may be perceived as beneficial. However, many studies have shown that oral contraception is not an effective way to restore bone health. An athlete with menstrual dysfunction may use oral birth control pills to prevent pregnancy, but it is important to let her know that having a period on birth control does not mean her bone health is improving.

Menstrual dysfunction can also negatively affect cardiovascular health in athletes. The results of some studies in ballet dancers and endurance athletes have shown that athletes with oligomenorrhea and amenorrhea had increased risk for high cholesterol and other vascular findings that correlate with the development of atherosclerotic disease.

It may take up to 1 year or longer to resume menses after EA restoration. Decreased bone density, the result of female athlete triad, may be irreversible, although it can improve with increasing EA. Early intervention is key, so it is crucial to screen for those at risk.

Relative energy deficiency in sport (RED-S)

The term RED-S was introduced in 2014 by the International Olympic Committee to encompass males and to acknowledge that energy deficiency can affect other aspects of an athlete’s health. These may include issues involving the endocrine, metabolic, hematologic, cardiovascular, gastrointestinal, and immunologic systems as well as growth and development. Research done by Ackerman et al demonstrated that athletes with low EA were more likely to have many of the ill effects of RED-S than those with appropriate EA.

The male athlete triad is a term used in males to describe the interrelationship of low EA, impaired bone health, and reproductive suppression. Low EA has been associated with decreased testosterone in male athletes due to a suppressed hypothalamic–pituitary–gonadal axis. True prevalence of low testosterone from hypogonadotropic hypogonadism is unknown.

 Low testosterone can have numerous effects on the male athlete, including decreased physical performance, sleep disturbances, fatigue, decreased motivation, sexual dysfunction, loss of muscle mass, sperm abnormalities, lower BMD, and depression.

Male athletes with recurrent bone stress injuries or with initial injury in a trabecular region (pelvis, sacrum, femoral neck) should be evaluated for nutrition and hormone function, especially if the athlete has other risk factors such as low BMI. Tenforde et al recommend screening for low BMD with DXA, nutritional evaluation (including a 25-hydroxy vitamin D test), and endocrine work-up (including free and total testosterone) in athletes with high-risk stress fracture in areas such as the pelvis or femoral neck, although more evidence-based guidelines are needed.

Restoring EA is the mainstay of treatment of both male and female athlete triad. This can be accomplished if the athlete increases caloric intake and decreases physical activity/energy expenditure. Working with a sports dietitian to increase EA to >45 kcal/kg FFM per day is ideal, but increasing calories by 300 to 600 per day and decreasing exercise by 1 day per week can be a productive starting point. This should be done on an individual basis depending on the athlete’s training regimen and expenditure. The goal is to increase BMI to >18.5 kg/m

 and to restore normal menstrual function. Working with a multidisciplinary team that includes a PCP, dietitian, psychologist, athletic trainer, and sports medicine specialist is helpful.

In the past, oral contraceptive pills were commonly used to restore menses; however, as mentioned above, this may offer a false sense of security and should be avoided unless they are necessary for other indications. Bisphosphonates are also generally not recommended in the pediatric/adolescent population. No evidence exists for their effectiveness and they may be teratogenic if an athlete were to become pregnant.

Calcium and vitamin D are important for bone health. The recommended daily amount of calcium is 1300 mg; if this is not achieved with diet alone, it should be supplemented. The recommendation for vitamin D for patients aged between 1 and 18 years is 600 IU, although higher doses may be considered depending on climate and deficiency. A recent systematic review of military submariners determined that the combination of vitamin D and calcium has a synergistic effect, and that vitamin D levels were most effectively increased with supplementation levels of 2000 IU/day.

 Weight-bearing exercise is also important for enhancing the accrual of bone mass.

Because the consequences of the athlete triad can be irreversible, affecting long-term bone, reproductive, and possibly cardiovascular health, a PCP must have a high index of suspicion for the triad in an athlete presenting with any of the above components. The annual well-child exam or sports physical is an opportunity for the PCP to screen patients for the athlete triad.

ACKNOWLEDGMENTS: We would like to thank Amanda Weiss Kelly, MD, for her mentorship and expertise on this topic.

1. De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. 

2014;48(4):289. doi:10.1136/bjsports-2013-093218

2. Weiss Kelly AK, Hecht S; Council On Sports Medicine and Fitness. The female athlete triad. 

2016;138(2):e20160922. doi:10.1542/peds.2016-0922

3. Bratland-Sanda S, Sundgot-Borgen J. Eating disorders in athletes: overview of prevalence, risk factors and recommendations for prevention and treatment. 

2013;13(5):499-508. doi:10.1080/17461391.2012.740504

4. Ackerman KE, Holtzman B, Cooper KM, et al. Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. 

2019;53(10):628-633. doi:101136/bjsports-2017-098958

5. Hoch AZ, Papanek P, Szabo A, Widlansky ME, Schimke JE, Gutterman DD. Association between the female athlete triad and endothelial dysfunction in dancers. 

2011;21(2):119-125. doi:10.1097/JSM.0b013e3182042a9a

6. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Lindén Hirschberg A. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. 

2005;90(3):1354-1359. doi:10.1210/jc.2004-1286

7. Tenforde AS, Barrack MT, Nattiv A, Fredericson M. Parallels with the female athlete triad in male athletes. 

2016;46(2):171-182. doi:10.1007/s40279-015-0411-y

8. Sivakumar G, Koziarz A, Farrokhyar F. Vitamin D supplementation in military personnel: a systematic review of randomized controlled trials. 

2019;11(5):425-431. doi:10.1177/1941738119857717

Articles

A guide to recognizing the female and male athlete triad in young athletes.

Recognizing the importance of energy availability in the young athlete

Physical exams for shoulder pain in young athletes can be performed in the primary care setting. Here are 6 tests to help diagnose the source of the pain.

Slideshows

How to perform a physical exam of shoulder pain in an athlete

A 12-year-old, right-hand dominant male travel baseball player presents to your clinic complaining of right shoulder pain. He is a pitcher and also plays the catcher position. His pain has been present for 3 weeks and is located “in his shoulder joint.” He has no neck or elbow pain. The patient denies a history of trauma, shoulder dislocation, or shoulder instability. He reports that he is unable to throw as hard or as accurately as he was able to prior to the onset of this pain, and that no specific throw type exacerbates his pain. This athlete has stated that he has multiple upcoming tournaments, that he “is the star pitcher for his team,” and “that he cannot sit out from playing baseball and his team needs him.”

Your exam reveals tenderness on palpation of the right proximal humerus and pain with resisted internal and external rotation of the shoulder. He also has very poor posture with forward-slumped shoulders. You obtain radiographs of his shoulder that demonstrate widening of the proximal humeral physis (Figure 1).

Arm pain is a common complaint in overhead-throwing athletes. In a survey of youth baseball players, only 26% reported that they did not have arm pain while throwing.

 Throwing a baseball applies sheer torsional stress on the proximal humerus and valgus stress on the medial elbow. Shoulder pain is a common presenting complaint in young athletes, particularly with recurrent overhead arm movement, not only in baseball and softball but also commonly in swimming, tennis, and volleyball. Other sport activity where upper body motion is not as repetitive yet with high risk for falls and direct blows to the shoulder include football, hockey, wrestling, and winter sports such as skiing and snowboarding.

The shoulder is a ball-and-socket joint that allows a large range of motion. However, it is relatively unstable. This joint is made up of a large humeral head fitting into the small glenoid fossa of the scapula. The labrum is a fibrocartilaginous cup that helps deepen the socket of the shoulder joint to increase stability. Glenohumeral ligaments and the joint capsule are static stabilizers.

Dynamic stabilizers are muscles that allow movement but are also needed to help keep the joint stable. They consist of the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, teres minor) and scapular stabilizers (trapezius, pectoralis minor, and serratus anterior muscles). Strong scapular stabilizers are essential to help with the motion and function of the rotator cuff (Figures 2A and 2B).

Differential diagnosis for shoulder pain can be helpful to think about in terms of whether there is an event that caused an acute onset of pain or if the pain is chronic. Acute pain could be due to clavicle fracture; acromioclavicular joint sprain; shoulder (glenohumeral) joint dislocation or subluxation; labral tear; proximal humeral fracture; or contusion. Our athlete in this case did not have acute onset of pain, and these injuries are therefore not included in his differential diagnosis.

In contrast, insidious onset of pain in a young athlete typically is due to overuse injury from repetitive stress applied to a tendon, bone, growth plate, or fascia. Differential diagnosis of insidious symptom onset that results in chronic shoulder pain includes impingement, rotator cuff tendinopathy, biceps tendinopathy, labral tear, epiphysiolysis of the humeral head, and multidirectional instability.

Tumors also are possible and may present with pain that has a gradual onset or that may be acute in the instance of a pathologic fracture. Benign tumors include unicameral bone cysts, chondroblastoma, osteochondroma, enchondroma, and periosteal chondroma. Osteosarcoma is the most common malignant tumor of bone in adolescents followed by Ewing sarcoma. Other causes of shoulder pain may be referred pain from cervical, myocardial, or abdominal injury/pain. The Table outlines the differential diagnosis for shoulder pain in a youth athlete.

The patient described in this article has a classic history, physical exam, and radiographic findings of Little League shoulder (proximal humeral epiphysiolysis), an injury to the proximal humeral growth plate and unique to a skeletally immature athlete. Growth plates are 2 to 5 times weaker than bone and their surrounding ligament and tendon attachments, and they are prone to injury. Little League shoulder also may be described as proximal humeral epiphysiolysis, epiphysitis, or Salter-Harris type 1 injury to the proximal humeral physis.

The injury is due to repetitive overhead rotational stress that, as the name suggests, is most often seen in baseball or softball players but that also may occur in swimmers, tennis players, gymnasts, and volleyball players. It is most common in athletes aged between 10 and 14 years. In Little League shoulder, athletes will report insidious onset of pain with throwing or overhead activity. They may also report loss of velocity or accuracy with throwing. The diagnosis is clinical and made when a young athlete has tenderness on exam over the proximal humeral growth plate. Radiographs may or may not demonstrate widening of the growth plate.

Rotator cuff tendinopathy, biceps tendinopathy, or shoulder impingement also would be a consideration in this patient as these diagnoses can be frequently seen in overhead-throwing athletes. However, this patient is skeletally immature and has tenderness on palpation over the proximal humeral physis, which is consistent with the diagnosis of Little League shoulder. He does not have a history of shoulder dislocation or subluxation events making the diagnosis of shoulder instability less likely. Multidirectional instability is a condition in which there is increased laxity in both shoulders and that may be present in any direction. This can be an underlying condition that may predispose an athlete to develop shoulder pain. It is treated with rest and physical therapy to strengthen surrounding muscles. The lack of an osseous mass on imaging or an acute fracture in this case excludes other entities in our differential diagnosis.

The physical exam should include inspection of the patient with the shirt off in boys or in a tank top or gown in girls. Visible deformity, swelling, and ecchymosis can be seen with acute trauma such as clavicular fracture or as sternoclavicular or acromioclavicular dislocation. The examiner should take note of the patient’s posture as it may be poor with forward-slumped shoulders potentially contributing to pain or injury (Figure 3). Asymmetric shoulder height may be due to scoliosis, trapezius spasm, or repetitive shoulder use of the dominant arm causing increased strength of the rotator cuff and depression of the ipsilateral shoulder.

Palpation of the shoulder should include the clavicle, acromioclavicular (AC) joint, proximal biceps tendon, proximal humeral head, scapular, and periscapular musculature. Range of motion (preferably active) should be evaluated and may be performed with the Apley scratch test (Figure 4). This test may be performed superiorly, which evaluates abduction and external rotation, or inferiorly, which evaluates internal rotation and adduction. In sports with repetitive overhead motion, such as baseball in particular, there may be an increase in external rotation and loss of internal rotation in the dominant shoulder.

Strength of the rotator cuff muscles should be evaluated, which includes the supraspinatus (empty can) test (Figure 5); subscapularis testing (Figure 6); and resisted internal and external rotation. There are numerous specialized tests that can be performed on the shoulder, including stability tests (apprehension, relocation; Figure 7) and impingement tests (Hawkins-Kennedy, Figure 8; Neer, Figure 9). More testing may be performed in the sports medicine or orthopedic office but are often not necessary in the primary care setting.

Initial workup of shoulder pain by a primary care provider should begin with 2 views of the shoulder, typically anteroposterior (AP) and Grashey views. Additional views may be considered by a sports medicine physician or orthopedic surgeon including trans-scapular Y lateral and axillary views. Radiographs should be obtained in instances of acute trauma, pain for longer than 1 month, nighttime pain, and history of instability episodes. When Little League shoulder is suspected, shoulder radiographs may demonstrate widening with adjacent sclerosis of the proximal humeral physis, particularly along the lateral aspect. It can be helpful to obtain a contralateral view as a comparison to better identify the abnormality of the growth plate.

Even if radiographs are symmetric, the diagnosis may still be Little League shoulder if the patient has tenderness on palpation over the proximal humeral physis. Magnetic resonance imaging (MRI) is the most sensitive test for detecting subtle physeal injury although MRI typically is not needed in making a diagnosis of Little League shoulder. If an MRI is obtained, it may demonstrate physeal widening on T1-weighted and non–fat-saturated proton density images, and periphyseal edema on T2-weighted sequence.

In cases of glenohumeral dislocation, instability, and suspected labral tears, a magnetic resonance (MR) arthrogram should be obtained to fully evaluate the fibrocartilaginous labrum. An MR arthrogram is performed following the image-guided injection of gadolinium-based contrast material into a joint with specific T1-weighted sequences obtained in the MRI scanner. Downsides to obtaining an MR arthrogram include cost, time, need for gadolinium administration, and the invasive nature of the study (injection into the joint performed by a radiologist). If a pediatrician is considering MRI evaluation for chronic shoulder pain in a young athlete with either positive or negative radiographic findings, it is likely time to consider referral to a sports medicine physician or orthopedic surgeon.

In a study in which shoulder MRI was performed on asymptomatic Little League baseball players, 12 of 23 players had positive MRI findings on the dominant shoulder compared with the nondominant shoulder. Most athletes demonstrated widening or periphyseal edema of the proximal humeral physis, but labral tears and partial-thickness rotator cuff tears also were present in high numbers. Risk factors associated with MRI findings were year-round play and players that only participate in baseball.

 Ultrasound may be of benefit to evaluate soft tissue structures including the rotator cuff tendons and presence of joint effusion but do not adequately evaluate the labrum. Ultrasound is unique in that it may offer the opportunity for dynamic evaluation and does not require sedation or radiation.

One of the most important aspects of treatment of Little League shoulder is rest from throwing and overhead activities to allow the growth plate to heal. Allowing the athlete to participate in batting as long as it does not elicit pain may be considered. In doing so, it will allow the athlete to remain involved with their team, which is important from a psychosocial standpoint.

Physical therapy is important to work on range of motion, posture, and strength. Strengthening of not only the shoulder muscles, including the rotator cuff, but also scapular stabilizers, hip, core, and lower extremity muscles is important. Correction of posture can be helpful to align shoulders to a neutral position and avoid forward slumping with associated pectoralis tightness and scapular muscle weakness.

Once the patient is pain free and has appropriate strength, a gradual return to a throwing program may be initiated. Total course of treatment and return to full play typically takes approximately 3 months but may take longer.

Shoulder overuse injuries in young athletes have been identified as common but largely preventable issues. Risk factors for development of overuse injuries include pitching with arm fatigue, higher volumes of pitching, pitching consecutive days, and pitching through pain.

A study of 9- to 14-year-old male baseball players identified that taller players and those with faster pitching velocities are at a higher risk of development of pain.

Recommendations regarding maximum pitch counts as well as appropriate length of rest depending on age of the pitcher have been established by USA Baseball and should be followed to decrease risk of overuse injuries.

 Avoidance of high-velocity (fastballs) and breaking balls (curveballs or sliders) has been recommended until an athlete is skeletally mature (aged ~14 years). Throwing mechanics should be reviewed by a pitching coach. Resting from overhead sport for at least 4 months of the year is also recommended. Youth athletes and families should be educated to not ignore or try to play through upper extremity pain but instead should rest and be evaluated promptly.

A survey looking at healthy youth baseball players identified that there are psychosocial effects of arm pain that include decreased enjoyment of playing, and that players felt encouraged to keep playing despite arm pain.

1. Makhni EC, Morrow ZS, Luchetti TJ, et al. Arm pain in youth baseball players: a survey of healthy players. 

2. Aoyama JT, Maier P, Servaes S, et al. MR imaging of the shoulder in youth baseball players: anatomy, pathophysiology, and treatment. 

3. Pennock AT, Dwek J, Levy E, et al. Shoulder MRI abnormalities in asymptomatic Little League baseball players. 

4. Greenberg EM, Lawrence JTR, Fernandez-Fernandez A, et al. Physical and functional differences in youth baseball players with and without throwing-related pain. 

5. USA Baseball. Pitch Smart. Available at; 

Arm pain is a common complaint in young athletes but playing though shoulder pain can have serious consequences. Here is guidance for diagnosing shoulder pain and helping these players get their game on.

How to diagnose shoulder injuries in young athletes

A 15-year-old female competitive gymnast presents to the clinic with 3 months’ history of right-sided lumbar back pain. She reports no specific injury but the pain has been worsening over time and has not improved despite 2 weeks of rest. The pain worsens with extension maneuvers such as back walkovers, back flips, and back handsprings. The pain is sharp in quality and does not radiate down her legs. Ice, heat, and anti-inflammatory medications have not helped. She denies neck pain, limping, nighttime pain, and incontinence of bowel or bladder.

A physical exam reveals tenderness on palpation at the midline of the L4-L5 level and pain with lumbar extension. The patient also has a positive 1-legged hyperextension (Stork) test consisting of pain when she lifts up her right leg, flexing at the hip and knee while extending her lumbar spine (Figure 1). She has 5/5 strength in her lower extremities bilaterally and symmetric 2/4 patellar and Achilles deep tendon reflexes.

Possible etiologies of this athlete’s pain include mechanical (muscular) back pain, sacroiliac dysfunction, lumbar disk herniation, spondylolysis, and spondylolisthesis (Table).

 Although mechanical back pain is most likely, pain with extension in a gymnast raises concerns about the possibility of a spondylolysis with or without spondylolisthesis.

otated to evaluate for development of pain at the ipsilateral sacroiliac joint) may help evaluate for sacroiliac joint involvement in addition to palpation and compression of the joint. This gymnast does not have a positive FABER test, which makes sacroiliac joint dysfunction less likely. Disk herniation often causes pain with forward flexion and this athlete’s pain worsens with lumbar extension, making disk herniation less likely and the possibility of spondylolysis more concerning.

Initial diagnostic workup consisting of lumbosacral radiographs (anteroposterior [AP] and lateral views) is normal, which rules out spondylolisthesis. A spondylolysis, however is not always apparent on x-ray. Given a high suspicion for this condition, and this athlete’s desire to continue to participate in her sport, the next step is to proceed with magnetic resonance imaging (MRI), which confirms a spondylolysis of the right L5 vertebra.

The most common identifiable etiology of lumbar back pain in adolescents is spondylolysis. One recent study identified spondylolysis as the cause in 30% of adolescent athletes presenting with lumbar back pain.

 Another study found that 40% of pediatric patients presenting for evaluation for lumbar back pain had a spondylolysis (9% of elementary students, 60% of junior high students, and 32% of high school students had a spondylolysis).

 In this study, all patients who had spondylolysis were athletes. The study was performed in an orthopedic clinic, but general pediatricians should consider this injury in patients presenting for evaluation for low back pain.

A spondylolysis is a stress fracture to the pars interarticularis, which is a portion of the vertebral bone that joins the facet joints in the posterior aspect of the spine (Figure 2). A spondylolysis is usually caused by chronic stress applied to the lumbar spine, most likely due to repetitive lumbar hyperextension and rotation that cause shear and compressive forces on the pars interarticularis. In a small proportion of cases, an acute incident may cause this injury. A spondylolysis may be unilateral or bilateral and is most commonly seen at the L5 level (85% to 95% of the time), followed in frequency at L4. Spondylolysis is possible, but is much less common, at higher lumbar vertebral levels.

Sports such as gymnastics, dance, diving, volleyball, rowing, and football (linemen) have traditionally been thought to present high risk for spondylolysis. However, a recent study of nonelite athletes found that baseball, soccer, and basketball had the highest prevalence in males whereas gymnastics, marching band, and softball had the highest prevalence in females.

 Another recent study in New York found that soccer, basketball, lacrosse, baseball, tennis, and football were sports most associated with spondylolysis.

 It is important to consider the sports common to the surrounding geographic area.

 In general, adolescent athletes with back pain have a higher prevalence of spondylolysis compared with nonathletes.

The adolescent growth spurt is a common factor in development of this injury as increased growth velocity places additional force on the spine during extension activities. Spinal deformities such as kyphosis and spina bifida occulta are also associated with spondylolysis. Tight hamstrings as well as gluteal and lumbar extensor weakness may increase risk of this condition.

Spondylolisthesis is a potential complication of a spondylolysis (Figure 3). This occurs when there is a bilateral spondylolysis with an anterior translation (slip) of 1 vertebra. Spondylolistheses are graded based on the amount of slippage of the width of the vertebral body. A grade 1 spondylolisthesis is the most common and least severe, with the amount of slippage less than 25% of the width of the vertebral body. Grade 2 is 25% to 50%; grade 3 is 50% to 75%; and grade 4 is slippage greater than 75% of the vertebral body width.

Patients with spondylolysis may complain of midline or lateral back pain that typically worsens with extension. It is unusual to have complaints of numbness, tingling, or limping, but these may occur if a spondylolisthesis is present and progresses to impact the spinal cord.

The primary care physician should evaluate for the presence of any “red flags” that might raise concerns for malignancy or other worrisome etiology prompting further workup. Red flags would include symptoms starting at younger than age 4 years; nighttime pain; incontinence of bowel or bladder; fever; weight loss; history of malignancy; or severe and worsening pain.

As long as none of these factors are present, appropriate initial workup consists of AP and lateral radiographs (Figure 4).

 The radiographs may or may not show the presence of a spondylolysis. However, the lateral view evaluates for the presence of spondylolisthesis, which would indicate that there is a bilateral spondylolysis. Previously, oblique view radiographs of the lumbar spine were recommended to look for the “Scottie dog” sign. However, these views are not usually helpful as they may be normal even in the presence of spondylolysis. Given the additional radiation exposure without added value,

 these oblique views are no longer typically obtained.

If radiographs are completely normal, and there is high clinical suspicion for spondylolysis, it is prudent to consider initiating treatment that includes prolonged rest and physical therapy. Many athletes are anxious to return to sport, and finding a definitive diagnosis with advanced imaging can be helpful. There is variation of practice in the choice of advanced diagnostic imaging. Options include MRI, computed tomography (CT), bone scintigraphy, and single-photon emission computed tomography.

Computed tomography is the best way to visualize bone and it has been considered a gold standard for diagnosing spondylolysis. However, MRI is becoming more popular due to the lack of associated radiation.

 Dhouib and colleagues found that an MRI has 81% sensitivity and 99% specificity.

 Although typical MRI protocols usually are geared toward evaluation for disk pathology, which is more common in the adult population, a protocol that includes thin-cut oblique sequences may be helpful for visualizing the pars interarticularis to help assess for the presence of spondylolysis at this location (Figure 5). It may be useful to discuss the most appropriate test for the patient with a local radiologist.

Treatment of spondylolysis is typically very successful with conservative management. The cornerstones of initial treatment are rest, activity modification, physical therapy, and gradual progression back to activity when the athlete is pain free. Physical therapy can address lower extremity inflexibility and core weakness. One approach may be to wait until the athlete’s pain is decreased to initiate physical therapy. However, a recent study demonstrated that early initiation of physical therapy may decrease time to return to sport by an average of 25 days.

Some providers may place athletes in a brace to immobilize the spine to help promote bony healing, but there is concern for further weakening of abdominal and core muscles with prolonged immobilization. The use of bracing in treatment of spondylolysis is debated. However, braces may be used to help reduce pain, allow for bony healing, and make the patient more comfortable with activities such as prolonged sitting in school. Bony healing is not necessary for resolution of symptoms as many athletes may have fibrous healing and still will be successfully able to return to sport pain free.

 Return to sport is typically achieved within 3 to 6 months, after the athlete has gradually added back extension-based activities and is able to participate in his/her sport without back pain.

Complications include development of spondylolisthesis if a patient has a bilateral spondylolysis. There is a small risk of progression that is highest around the adolescent growth spurt, which typically will occur prior to skeletal maturity. Referral to a spine surgeon should be made for spondylolistheses greater than grade 2, for significant change in degree of spondylolisthesis, or persistent symptoms for longer than 6 months despite conservative treatment and compliance (Figure 6). Development of neurologic symptoms such as progressive radiculopathy and cauda equina syndrome warrant urgent referral to a spine surgeon.

When teenaged athletes complain of lumbar back pain that worsens with activity, there should be a high index of suspicion for a spondylolysis. Careful consideration should take into account appropriate further workup with diagnostic imaging and course of treatment, the cornerstones of which are rest, physical therapy, and gradual return to activity.

Most patients do very well with conservative management, particularly in the short term. Of a small group of elite male ice hockey players, 96% were able to return to elite-level play with an average return to play at 8 weeks.

 In another study in which a retrospective review with telephone follow-up found that most patients (67%) are able to return to their previous level or higher of sport, however, 45% of patients reported recurrence of symptoms at long-term follow-up and 34% required medical treatment.

There is no evidence that sports participation increases the chance of progression of spondylolisthesis.

1. Kraft DE. Lumbar and thoracic spine. In: American Academy of Pediatrics Council on Sports Medicine, American Academy of Orthopedic Surgeons; Harris SS, Anderson SJ eds. 

 ed. Elk Grove Village, IL: American Academy of Pediatrics. 2009:331-342.

2. Selhorst M, Fischer A, MacDonald J. Prevalence of spondylolysis in symptomatic adolescent athletes: an assessment of sport risk in nonelite athletes. 

. November 14, 2017. Epub ahead of print.

3. Nitta A, Sakai T, Goda Y, et al. Prevalence of symptomatic lumbar spondylolysis in pediatric patients. 

4. Ladenhauf HN, Fabricant PD, Grossman E, Widmann RF, Green DW. Athletic participation in children with symptomatic spondylolysis in the New York area. 

5. Schroeder GD, LaBella CR, Mendoza M, et al. The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic lower back pain. 

6. Tofte JN, CarlLee TL, Holte AJ, Sitton SE, Weinstein SL. Imaging pediatric spondylolysis: a systemic review. 

7. Beck NA, Miller R, Baldwin K, et al. Do oblique views add value in the diagnosis of spondylolysis in adolescents? 

, et al. Current evidence regarding diagnostic imaging methods for pediatric lumbar spondylolysis: a report from the Scoliosis Research Society Evidence-Based Medicine Committee. 

9. Dhouib A, Tabard-Fougere A, Hanquinet S, Dayer R. Diagnostic accuracy of MR imaging for direct visualization of lumbar pars defect in children and young adults: a systemic review and meta-analysis. 

. September 23, 2017. Epub ahead of print.

10. Selhorst M, Fischer A, Graft K, et al. Long-term clinical outcomes and factors that predict poor prognosis in athletes after a diagnosis of acute spondolysis: a retrospective review with telephone follow-up. 

11. Klein G, Mehlman CT, McCarty M. Nonopertive treatment of spondolylosis  and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. 

12. Donaldson LD. Spondylolysis in elite junior-level ice hockey players. 

When teenaged athletes complain of lumbar back pain that worsens with activity, there should be a high index of suspicion for a spondylolysis.

Ingrid K. Ichesco, MD

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