Management of Chronic Neck and Back Pain in Adolescent Athletes
The recommended management for chronic neck and back pain in adolescent athletes should focus on conservative approaches including physical therapy, exercise programs, and activity modification, avoiding interventional procedures which are strongly discouraged for chronic spine pain.1
Initial Assessment
- Radiographs of the symptomatic region are recommended as the first-line imaging modality for adolescent athletes with persistent back pain (>4 weeks) or concerning clinical findings 1
- MRI is appropriate as a next step if radiographs are negative or if there are concerning clinical findings such as neurologic deficits 1
- CT may be useful for detecting spondylolysis when radiographs are negative but clinical suspicion is high 1
- Sport-specific assessment is important as different sports create varying biomechanical stresses (e.g., soccer athletes are more prone to multilevel spondylolysis due to compressive stress injuries, while baseball players experience injuries from rotational and torsional forces) 1
Conservative Management Approaches
Physical Therapy and Exercise
- Physical or restorative therapy is strongly recommended as part of a multimodal strategy for patients with low back pain 1
- Early strengthening exercises should include both flexion and extension exercises, tailored to the specific diagnosis 2
- Address muscle imbalances, particularly focusing on:
Activity Modification
- Avoid prolonged bed rest as muscle atrophy may occur rapidly 2
- Implement a gradual return to sport once pain has resolved and the athlete has regained full strength 4
- Consider sport-specific technique modifications to reduce spinal stress 2
Pain Management
- For acute exacerbations, consider:
- Strong analgesics should generally be avoided except for sleep, as they may mask pain and allow overvigorous activity 2
Interventional Procedures to Avoid
- The BMJ clinical practice guideline (2025) strongly recommends against the following interventional procedures for chronic spine pain (≥3 months) 1:
- Joint radiofrequency ablation with or without joint targeted injection
- Epidural injections of local anesthetic, steroids, or their combination
- Joint-targeted injections of local anesthetic, steroids, or their combination
- Intramuscular injections of local anesthetic with or without steroids
Special Considerations for Different Diagnoses
- Athletes with spondylolysis, spondylolisthesis, and facet joint irritation should initially be limited to flexion exercises 2
- Athletes with acute disc herniation should initially perform only extension exercises 2
- For athletes with multiple concussions or prolonged symptoms, consider evaluation for potential cervical involvement 5
Prevention Strategies
- Address factors predisposing young athletes to back injury 2:
- Growth spurt monitoring
- Gradual increases in training intensity or frequency
- Proper technique instruction
- Suitable sports equipment
- Evaluation for leg-length inequality
Return to Sport Protocol
- Athletes should follow a gradual return to sport process once pain has resolved 4
- Ensure full strength and flexibility have been restored before resuming full athletic participation 4
- Coordinate return plans between clinicians, patients, parents/guardians, coaches, therapists, and athletic trainers 4
Common Pitfalls to Avoid
- Prolonged bed rest which can lead to muscle atrophy 2
- Premature return to sport before adequate healing and rehabilitation 4
- Overreliance on imaging findings without correlation to clinical symptoms 1, 6
- Failure to address underlying biomechanical issues that may predispose to recurrence 2, 4
- Using interventional procedures which are strongly discouraged for chronic spine pain 1