» Always Pay Attention to Back Pain in Children
Always Pay Attention to Back Pain in Children

Physical Therapy in Grapevine for Pediatric

Back pain in adults is so common, eight out of 10 people will experience it at least once (and often more than once) in their lifetime. Most of the time, no one even knows what's causing it -- the condition is said to be idiopathic. It's nothing serious and treatment isn't even needed. The patient is told to stay as active as possible. Recovery occurs in seven to 10 days. But back pain in children is something else altogether.

Idiopathic back pain in children and especially in young athletes is much less common. There is usually a very specific reason for the pain. It could be an infection, tumor, or inflammatory condition. More often, it's an injury from a traumatic event or from repetitive motion causing microtrauma. Telling the child to remain active is the wrong advice.

In this article, physicians who treat children review the types of sports activities that lead to back pain most often. The most common injuries are presented along with risk factors and typical history. Identifying the underlying cause of the problem is very important. Treatment without delay is often needed to prevent a minor back injury from becoming a major problem.

As might be expected, high-energy, contact sports such as football, rugby, and soccer increase the risk of an acute traumatic event. But noncontact activities such as gymnastics and figure skating require repetitive bending, extending, and twisting or rotating the spine. Overuse injuries are more common in these groups of athletes.

Most people think kids are made like rubber -- they can bend every which way with no difficulty. But the fact is, that soft tissues (e.g., muscles, ligaments, tendons) can't always stretch and elongate to keep up with growing bone. Muscles get tight or may be off balance at certain times of rapid growth. This is a major risk factor for injury.

Doctors know that girls tend to mature faster than boys. Full bone growth may be completed in some girls by the time they reach puberty. Boys are more likely to reach maximum height and growth several years after girls. Hormones are shifting rapidly during growth phases, too.

Intense training during any of these periods of growth and change can lead to injuries. In fact, overuse injuries can be very unpredictable. A training schedule that worked one month may not be tolerated by the body the next month resulting in an unexpected injury. Since every child's growth rate and maturation is different and their size and strength also vary, it's impossible to come up with a training program that is one-size-fits-all.

Doctors must go back to the patient history and conduct a thorough physical exam in order to make an accurate diagnosis. Prevention of back pain in this age group would be even better. A review of risk factors combined with a physical exam and knowledge of the most common specific injuries would alert the physician of the need to intervene as soon as possible.

The authors help doctors out by providing a list of things to look for and tests to conduct to assess the spine. For example, posture, spinal range-of-motion, nerve tension tests, and muscle strength are all evaluated carefully. Specific tests such as the FABER test, Adam's forward bend test, Gaenslen sign, straight-leg raise, and the single-legged hyperextension are described. Photos of each test are also included.

Each test is looking for a specific problem. Understanding what kind of spinal disorders can occur in athletes helps the examiner recognize the significance of test results. Spondylolysis, a stress fracture in the vertebra is the most common cause of back pain in teenagers. Almost half of all back pain episodes in children are caused by spondylolysis. The second most common cause of low back pain in teens is posterior element overuse syndrome.

With posterior element overuse syndrome, too much spinal extension and rotation cause damage to the area where the muscles and tendons connect. The ligaments, spinal joints, and joint capsules at the level of the repetitive trauma are damaged. The child/teen ends up with too much extension, called hyperlordosis. Less common are disc herniation, Scheuermann's disease, osteomyelitis (bone infection), and bone tumors.

Scheuermann's disease (also called Scheuermann's kyphosis) is a condition that starts in childhood. It affects less than one percent of the population and occurs mostly in children by the age of 11. It affects boys and girls equally. Those who do not get proper treatment for the condition during childhood often experience back pain as adults.

With enough repetitive spinal flexion and extension, the ring apophysis can get damaged along with disc herniation. The apophyseal ring is located along the front of the vertebral body where the disc is attached between the two vertebral bones.

With enough force, this cartilaginous structure can break and become displaced (moved). It pushes the disc back until both structures end up in the spinal canal along the back of the vertebra. This is called a vertebral body apophyseal avulsion fracture. The athletes affected most often are involved in gymnastics, wrestling, volleyball, and weight-lifting.

X-rays and other more advanced imaging such as CT scans, MRIs, or bone scans may be needed to identify the specific vertebral level, location (right or left side), and severity of damage. If the physician suspects an inflammatory or infectious process, blood tests may also be ordered.

Once the diagnosis has been made, conservative (nonoperative) care is tried first. Physical Therapy is helpful to restore more neutral posture and muscle balance. Core training of the trunk and abdomen along with temporary bracing can be helpful for many of these conditions. Each problem is handled slightly differently depending on the underlying damage. Activity modification and reduced activity referred to as relative rest aid the healing process and help prevent re-injury and repeat microtrauma.

For pain and disability that does not respond to conservative care, surgery is an option. With or without surgery, the athletes must retrain and rehab before returning to their full sports activity. Full pain free range-of-motion and strength are required. Sport-specific training under the supervision of a Physical Therapist is advised.

The authors conclude by saying all of this information is well and good, but it would still be better to reduce the risk of injuries and prevent injuries. What can be done? Coaches, trainers, and sports therapists can conduct preseason screening. A past history of injury, muscle weakness, or sign of muscle tightness should be examined closely before allowing the athlete to engage in sports activities.

Athletes' height and weight should be measured and recorded. It may be necessary to change the training intensity during obvious periods of growth. Monitoring frequency, intensity, and duration of training sessions may help improve safety and reduce injuries in adolescent athletes. Limiting the number of times certain movements are made is another good idea. For example, extreme spine extension used by gymnasts and figure skaters should be limited if there is pain or evidence of a growth spurt.

The bottom line is: back pain in children and teens is never normal. This is the body's way to signal that there is a problem. Young athletes should be coached not to hide their pain but to report it. Early diagnosis and intervention can help prevent significant injury and long delays getting back to the game or sport.

Reference: Laura Purcell, MD, and Lyle Micheli, MD. Low Back Pain in Young Athletes. In Sports Health. May/June 2009. Vol. 1. No. 3. Pp. 212-222.