Back Pain in the Child Athlete

An Overview of Back Pain in the Child Athlete

Children generally do not complain of back pain. When this complaint is heard, the initial impulse is to have the child “run it off”. Many times, low back pain in children and back pain in the child athlete may generate from overuse syndrome or a strain within the back; causes of back pain in kids could also be from a sprain of the lower back. Overuse is the temporary internal disruption of the contracting proteins (actin and myosin) in the muscle that creates the “soreness” we all know from performing an activity that we have not participated in for a while. A strain is a small tear of a muscle or tendon and a sprain is a small tear of a ligament. (A ligament is a tough fibrous structure that connects bone to bone like an ACL- anterior cruciate ligament in the knee).

All of these conditions of the spine are generally benign and symptoms will disappear with time and rest and often, back pain exercises (2-4 days for overuse, 3-4 weeks for a strain and 6-8 weeks for a sprain). There are, however, complaints of low back pain in children that do not disappear or only recede if the sporting activity is halted. The return to sports recreates the pain. In addition, if the adolescent is not questioned regarding the presence of pain, some individuals will not report pain for fear of being removed from competition.

Causes of Back Pain in the Child Athlete

There are three conditions that need to be diagnosed if lower back pain is present for some time or if a child demonstrates “favoring behavior” (antalgia) while competing. These are Scheuermann’s disorder, isthmic spondylolysis, and degenerative disc disease with or without a disc herniation within the spine.

We must first describe the anatomy of the lower back for the understanding of these causes of back pain in the child athlete. The lumbar vertebra is shaped with a large body in the front to carry the loads of the chest and head and transfer the load to the disc. The disc is sandwiched in between the two vertebrae and is the shock absorber of the spine. The projections out of the back of the vertebra (the pedicles and lamina) contain the facets, the “doorstops” that hook one vertebra onto its neighbors above and below. These facets act like train tracks to guide the motion of the vertebrae.

In children and adolescents, there are open growth plates on the top and bottom of the body of the vertebra. These growth plates (there are two) are like the tops and bottoms of an Oreo cookie with the main body of the vertebra sandwiched in between these growth plates the crème filling. The growth plates are attached to the bone of the body of the vertebra by cartilage, which is not as strong as bone.

Scheuermann’s Disease

The first disorder we will discuss is Scheuermann’s disease. These spinal disorders in children involves the growth plates; when they are not as strong as normal, they can fragment and fracture under load. These spine fractures in children are painful. The pain tends to be the upper portion of the lower back (six inches above the belt line) and the spine region behind the chest area (thoracic spine). Adolescents that overload these growth plates typically play in sports that significantly compress the spine and can lead to a fracture in the spine. Examples are football, wrestling, weight lifting, bump skiing and gymnastics. Many times, rest and bracing can allow the fractures to heal. There are some special cases where the spine deforms; spinal disorders in children, and deformities, are sometimes due to wedging of the vertebra.

Isthmic Spondylolysis

The second condition which is one of the causes of back pain in kids is isthmic spondylolysis. Unlike Scheuermann’s disorder, this condition normally occurs in the lowest level of the spine at L5-S1 (at the beltline). Isthmic spondylolysis is estimated to be found in one of every twenty adolescents. This disorder occurs with sports that require repeated extension (bending backwards) like gymnastics, football, tennis, diving and wrestling. Repeated backwards bending stresses the area of the spine called the pars interarticularis (Latin for “area between the joints”).

The bone fatigues from too much bending back and forth and does not have time to heal before the next round of activities again stresses the area (which can cause or worsen a fracture(s) in the spine). This is similar to taking a wire coat hanger and bending it up and down until the metal fatigues and breaks. This break may be found only on one side or on both sides. Catching this impending fracture early before the bone actually breaks makes treatment easier and more successful. If the bones fracture on both sides, treatment is more difficult and surgery may be in order. A fracture in the spine can be very painful and an x-ray or an MRI would be necessary to properly diagnose the condition.

(Click to Enlarge Image) This is an illustration of the side view of the vertebrae. You can see the large body of the vertebra in front separated by the disc and the facets in back connected by the pars interarticularis.

(Click to Enlarge Image) This is an illustration of a juvenile spine with open growth plates on the top and bottom of the vertebral body.

(Click to Enlarge Image) Scheuermann’s disease- note irregular endplates (small arrows) and wedged vertebra (large arrow).

(Click to Enlarge Image) Pars fracture of L5 (arrow).

(Click to Enlarge Image) Normal MRI of lumbar segment (axial view or bottom up)- arrow points to spinal canal- black dots are nerve roots floating in white CSF. Disc is normal in front and facets are normal in back.

(Click to Enlarge Image) Herniated Disc- white arrow points to herniation compressing the S1 nerve root. Note the opposite side nerve is uncompressed.

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(Please keep reading below for more information on this condition.)

Disc Injuries

Other spinal disorders in children that are not as commonly discussed, include disc injuries. Most people think of degenerative disc disease as an adult problem. This is where genetics plays a big role. Disc wall tears can strike in this age group. Back pain occurs and is located in the lower back (around the belt line). Diagnosis can lead to treatment that can manage the pain. If the degenerative disc disease progresses, it can lead to a disc herniation.

Disc herniation in an adolescent can occur in two ways, through a standard tear in the disc wall (a herniated disc) or through a fracture of the endplate of the vertebra. Just like in Scheuermann’s disease, the growth plate in the adolescent is still open. As stated before, the area of attachment of the growth plate to the vertebra is somewhat weak and a stress riser. The disc wall may not tear in its substance but may fracture off a piece of its insertion leaving a bony mass in the canal.

Interestingly, children and adolescents with disc herniations that compress nerves normally do not develop leg pain. This has to do with the resilience of the nerves in the adolescent. Pain is typically found in the back but can radiate down to the buttocks and possibly the upper thigh. Early diagnosis is helpful to return the child to sports and back pain exercises are usually recommended to help strengthen the muscles within the back and ease pain.

Please contact Dr. Donald Corenman, spine surgeon and back doctor in the Vail, Aspen, Denver and Grand Junction, Colorado area, for additional information and resources on back pain in the child athlete, spinal disorders in children, and other conditions that may cause low back pain in children.

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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