What is the workup for a 13-year-old male (M) with sports-related back pain?

From the Guidelines

For a 13-year-old male with sports-related back pain, I recommend starting with a thorough history and physical examination to determine the cause and severity. Initial management should include relative rest from aggravating activities, ice for acute pain (15-20 minutes several times daily), and over-the-counter pain medications such as acetaminophen (10-15 mg/kg/dose every 4-6 hours, maximum 3,000 mg/day) or ibuprofen (10 mg/kg/dose every 6-8 hours with food, maximum 600 mg/dose) 1. Physical therapy focusing on core strengthening and proper body mechanics should be initiated early. Some key points to consider in the workup include:

• The presence of red flags such as fever, weight loss, night pain, neurological symptoms, or pain that wakes the child from sleep, which would prompt further imaging 1
• The duration of symptoms, with persistent back pain lasting for 4 weeks or more constituting a clinical red flag that should prompt further imaging 1
• The importance of ruling out spondylolysis, a stress fracture of the pars interarticularis common in sports involving repetitive hyperextension, in adolescent athletes 1 If symptoms persist beyond 2-3 weeks or if there are red flags, further imaging is warranted, starting with plain radiographs. For adolescent athletes, particular attention should be paid to ruling out spondylolysis, a stress fracture of the pars interarticularis common in sports involving repetitive hyperextension. If spondylolysis is suspected, advanced imaging such as MRI or CT scan may be necessary 1. Most adolescent sports-related back pain is mechanical in nature and responds well to conservative management, but proper diagnosis is essential to rule out more serious conditions and prevent chronic pain or recurrence through appropriate rehabilitation and activity modification. It is also important to note that early, routine imaging and other tests usually cannot identify a precise cause, do not improve patient outcomes, and incur additional expenses 1. Therefore, a thorough history and physical examination, along with a period of conservative management, should be the initial approach for a 13-year-old male with sports-related back pain.

From the Research

Evaluation of Back Pain in a 13-Year-Old Male Athlete

The evaluation of back pain in a 13-year-old male athlete involves a careful and systematic approach, including a sport-specific history, physical exam, and proper imaging 2. The most common causes of back pain in young athletes include:

• Muscle strain or spasm
• Spinal deformities (e.g., Scheuermann kyphosis, adolescent idiopathic scoliosis)
• Spondylolysis
• Bulging or herniated intervertebral disks
• Apophysitis of the iliac crest
• Functional pain syndromes such as fibromyalgia 3

Risk Factors for Back Pain in Young Athletes

Several risk factors have been identified for back pain in young athletes, including:

• Participation in athletic activity alone
• Increased body mass index
• Varsity status
• Nationally/internationally competitive status
• Certain sports, such as weightlifting, gymnastics, football, and combat sports 4
• Increased lumbar lordosis, abdominal muscle weakness, hip flexor tightness, hamstring tightness, thoracolumbar fascia tightness, femoral anteversion, genu recurvatum, and thoracic kyphosis 4

Diagnosis and Management

The diagnosis of back pain in young athletes can usually be made on the basis of history and physical examination 5. Imaging studies, such as radiography, magnetic resonance imaging, computed tomography, or a bone scan, may be needed for further evaluation if underlying pathology is suspected 3. The management of back pain in young athletes typically involves:

• Relative rest
• Home-based exercises
• Physical therapy
• Limited use of nonsteroidal anti-inflammatory drugs 3
• Perturbation-based exercise interventions to reduce the incidence of back pain 4

Red Flags for Immediate Evaluation

Certain factors warrant immediate evaluation, including:

• Patient age younger than five years
• Symptoms persisting beyond four weeks
• Systemic symptoms
• Nighttime pain
• Bowel incontinence/urinary retention
• Other neurologic symptoms 3