When one thinks of overuse injuries in the young athlete, the first few problems that come to mind are things such as shin splints, tendonitis and chronic knee or shoulder problems. Most people do not even realize that after knee and ankle problems, lower back injuries are the third most common injuries seen among young athletes, as was recently presented at the latest American Academy of Pediatrics Conference by Dr. Jayanthi, a primary care sports medicine physician. In fact, the notion of back injuries among children and adolescents in general seems to come as a big surprise to many because both parents and coaches are so used to seeing kids zipping around, effortlessly twisting and bending like elastic bands.
The reality of the matter is that young athlete’s are now are often times stretched very thin in terms of their practices, skill sessions, games, and tournaments. It seems as if every child-athlete has a schedule that involves a great deal of sacrifice with respect to both time and rigor on one’s body. In a previous article, I discussed the dangers of sport specialization at a young age and the overuse injuries and burnout seen among these young athletes, but the data presented at this recent conference made me realize that back injuries in the young athlete should not only be brought to light, but should be described so that parents and coaches can work together to try to prevent such injuries from occurring by picking up on warning signs.
It is most important to first examine some of the more common overuse injuries to the spine. These injuries are oftentimes missed, but may occur due to repetitive microtrauma secondary to cyclic loading of the vertebrae or repetitive shear, tensile, or compressive forces that can be seen as a result of some of the physical movements required to be successful in some sports. The following will be a discussion of three of the more common overuse injuries that athletes sustain in their spines.
Isthmic spondylosis is a very common cause of lower back pain among athletes. In fact, one study found that 47% of athletes complaining of low back pain were examined and found to have spondylosis in their lumbar region. Essentially, this condition involves a stress fracture of the pars interarticularis of the lumbar vertebrae. It’s a painful condition that is secondary to repetitive forces and cyclic loading of the spine.
There is some debate over whether or not this is a congenital (inherited) or acquired condition. There seems to be genetic risk factors that may predispose an athlete to developing this condition, but often times in the non-athlete this condition is asymptomatic which has lead many to believe that it may be both acquired and congenital.
These patients commonly describe a slow onset of pain that seems to worsen with any hyperextension of their back or during practices and games in which the repetitive movements and/or sheer volume of training may result in aggravation of their symptoms.
Figure skating, competitive dancing, soccer, and football lineman are often sports that require repetitive hyperextension of the spine and can be seen to be associated spondylosis as well as injuries to the back or posterior aspect of the spine.
When an athlete comes in complaining of these symptoms imaging is usually performed after a positive physical to confirm the diagnosis and then the treatment involves the cessation or limitation of the athlete’s participation in athletics for 3-6 months and the application of a brace depending on the severity and where the injury has occurred. Surgery is not a first line treatment, but is an option that is reserved for the younger athletes who have pain that does not go away after the aforementioned treatment and truly impinges upon their daily activities.
More commonly referred to as a slipped disk, this injury involves the herniation of a portion of the soft, jelly like disks (nucleus pulposis) that sit between each vertebra. Though it is much more common in adult patients due to the changes that occur in the composition of the intervertebral disks as we age, these injuries may also occur as the result of overuse or end-plate fractures in the immature skeleton.
Sports that would be considered higher risk activities for sustaining this injury include gymnastics, weight lifting, rowing, football, and bowling in which the body must undergo repetitive flexion of the spine as well as rotation of the spine that we call axial rotation and compression.
These patients report pain upon flexion of the spine as well as possible radicular pain or pain that may be experienced more distal (further away from the spine) due to nerve roots being compressed by the disk.
After a physical exam, an MRI usually is helpful in revealing where the herniation is located. Typically treatment involves the use of NSAIDs for pain relief as well as rest, cross-training and physical therapy with a proper assessment of range of motion and flexibility. For those who do not experience relief with more conservative treatment, the possibility of a procedure to shrink or remove a disk may be considered, though the majority of patients do not require more invasive treatment.
Though not nearly as common as the previous two overuse injuries that were discussed, this condition involves inflammation of a joint in the pelvis. It may be associated with asymmetric and repetitive loading of the pelvis in certain sports or in children who have a limb-length discrepancy. The pain is often times hard to treat and in addition to rest and use of NSAIDs, occasional injection of corticosteroids may be helpful in controlling pain.
So why is this a concern? It has been estimated that 50-60% of all injuries seen in pediatric sports medicine clinics may be attributed to overuse injuries and that older children typically are the ones sustaining a greater percentage of such injuries. When we look at sports injuries in general, 10-15% of all athletic injuries involve the spine with this number increasing to as much as 30% depending on the sport. Though a lot of these injuries are self-limiting, they are still debilitating and certainly raise questions about the long-term implications that they may have when sustained by younger athletes.
Risk factors for sustaining such injuries is certainly associated with the more time spent practicing and competing. In fact, training in excess of 15 hours per week is a notable risk factor that may predispose an athlete to these types of spine injuries. Furthermore, there seems do be a gender correlation as well, with a greater incidence of spine injuries observed in the sports that commonly have more female participants such as dancing/ballet and gymnastics.
But what about the young athlete makes them more inclined or at risk for spine injuries? Well, we all are aware that each year younger and younger athletes are competing at more intense levels of play and beginning to train at earlier ages. The major difference between the adult athlete and that of the adolescent or even younger athlete is that the growth cartilage exists in the immature skeleton. This growth cartilage, though essential to bone growth and development, puts younger athletes at a much higher risk for some of the injuries that are especially associated with compression and repetitive movements because it is much weaker than the mature bone that it will eventually develop into.
It is also essential to recognize that depending on the child’s age group, certain injuries may be more or less common. For example, a recent retrospective chart study that was performed by researchers at the Children’s Hospital in Boston, MA, examined the types of injuries seen among two age groups: 5-12 and 13-17 years old. What they found was that soft tissue injuries such as ACL tears accounted for a higher proportion of the injuries among the older 13-17 year-old group as compared to the younger group.
When specifically considering spine injuries among young athletes, this study also looked at the five most common injuries to a particular body area and compared these lists between both the younger group and the older group. What they found was that in the 15-12 year old group, spondylosis comprised 36.4% of the spine injuries followed by pain (24.2%), fracture (6.1%), strain (6.1%) and stress reactions (sacroiliac inflammation, disk lesions, pars stress reaction.). In the 13-17 year old group the top five spine injuries were: Spondylosis (40.7%), pain (23.7%), fracture (6.2%), disk lesion (6.2%) and sacroiliac joint inflammation (3.4%).
It is clear that children and adolescents today are competing at much higher levels and in more competitive atmospheres than they did in the past. This is not coming without a price. The data are clearly showing increases in all types of sport-related injuries among both younger athletes and adolescents. Though it is essential for a competitive athlete at any level to train hard and practice often, coaches, parents and school officials should be cognoscente of the reality that overuse injuries are plaguing youth sports.
As a sports enthusiast, I respect and love dedication, hard work, and drive, but we must work together to ensure that training is age and skill level appropriate and that we do not take the fun out of the game/activity. One’s long-term health and ability far outweigh several big tournaments or meets, especially with a young athlete who has a promising career ahead of him/herself. It is my hope that by distributing this information, we can all work together to ensure that our young athletes stay healthy while enjoying the sports and activities they are passionate about.
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