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Today's focus on intense, specialized sports training at younger ages means that children are increasingly susceptible to back injury. The authors provide an overview of the diagnosis and treatment of back pain in child and adolescent athletes, including conditions to consider in the differential.
DR. KRONBERG is clinical instructor of pediatrics, State University of New York at Stony Brook School of Medicine.
DR. SMALL is assistant clinical professor pediatrics, orthopedics, and rehabilitation medicine, Mount Sinai School of Medicine, New York, N.Y., and director, Family Sports Medicine and Nutrition, Mount Kisco, N.Y.
The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.
Today's focus on intense, specialized sports training at younger ages makes young athletes increasingly susceptible to back injuries, especially those caused by overuse (repetitive microtrauma). The incidence of back injury among young athletes has been estimated to be between 10% and 15%,3,4 with the risk varying by sport. Among athletes participating in wrestling, gymnastics, soccer, or tennis, 50% to 85% have had back pain.5
The predominant causes of back pain in children and adolescents are different from those in adults. A study that compared 100 adolescent athletes who had back pain to 100 adults who had back pain found that 47% of the adolescents suffered from spondylolysis (stress fracture of the pars interarticularis), whereas 48% of the adults suffered from discogenic pain. In addition, 10% of the adults studied suffered from spinal stenosis and osteoarthritis, but not one of the adolescents suffered from those conditions.6
Pediatric patients with back pain have a higher percentage of pathologic diagnoses than do adults, necessitating a high index of suspicion and a quicker initiation of a thorough diagnostic evaluation. In a case of adolescent back pain unaccompanied by fever, weight loss, or night pain, most experts agree that no more than three weeks should go by before studies are initiated-and even less time should pass before studies are started in children.7
Questions for the history
Ask about onset of pain (acute vs gradual); inciting injury; duration of symptoms; frequency, intensity, and radiation of the pain; and factors that alleviate or accentuate it. Inquire about a history of previous injury. Investigate the level of sports participation, including increases in intensity of activity (number of hours a week); initiation of any new sports or techniques; amount of activity since pain started; and any associated cross-training. Pain that interferes with activities of daily living or sports participation usually warrants a thorough evaluation.
Of primary importance in the initial history-taking is determining the need for immediate intervention. Systemic symptoms, such as fever, weight loss, night pain, and pain at rest (without a history suggesting an acute or overuse injury), are suspicious for a malignancy or infection and should be evaluated immediately. Timing of pain is also important (pain during sleep, pain at rest). Any patient awakened and kept awake by back pain should be evaluated for tumor, infection, or an inflammatory condition. Night pain relieved by ibuprofen, naproxen, or a salicylate is suspicious for an osteoid osteoma. Morning stiffness can be a symptom of a rheumatologic condition. Difficulty moving side to side in bed may suggest a disk problem or lumbar sprain. A history of ankle or foot weakness, change in bowel or bladder function, or altered gait suggests neurologic impairment.
Find out what medications, if any, the patient has taken and any therapies he has tried, such as chiropractic, acupuncture, physical therapy, and individual exercise programs. Also ask parents about the load their child carries daily in his (or her) school backpack. A backpack that weighs more than 15% to 20% of a child's weight may be associated with back pain,8 as well as with a decrease in lung volume and respiratory mechanics.9 Backpacks should weigh no more than 10% of a child's weight, be worn for a limited time, and be properly fitted with a waistband so that weight is transferred from the back to the pelvis and legs.9
Bear in mind the possibility of psychosomatic back pain, especially when the history and physical examination are inconsistent with an athletic injury or serious medical issue. A complaint of back pain, like headache or stomach pain, may signal a psychiatric disorder.