Chapter 6 199

Spine

History 200
Examination 202
Special tests 206
Diagnosis 208
Acute spinal injury 211
Acute injuries of the back in sports 212
Management of musculoligamentous injuries of the back 213
Disc disease 214
Pars interarticularis and spondylolysis 218
Spondylolisthesis 220
Scheuermann’s disease 223
Sacroiliac joint 224
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 200 CHAPTER 6 Spine

History
Most episodes of back pain in sports are gradual in onset because of
repeated stresses, although pain may present as a specific event. Understand
the demands of sport, exercise, and occupation.
Pain
• Chief complaint: back pain vs. lower extremity pain
• Character
• Location and radiation with pattern of radiation
• Relationship to exercise or activity
• Exacerbating and alleviating factors
Neurological symptoms
• Numbness, tingling, pins and needles
• Weakness
• Bowel or bladder complaints
Past history
• Spinal problems
• Orthopedic problems
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Family history
• Spinal problems
Be sure to note any medical or rheumatological symptoms (insidious and
persistent, morning pain or stiffness), mechanical abnormalities (intermit-
tent and associated with activity), disc herniation and nerve impingement
(radiates to lower leg or foot), or tumor (night pain). Also note if there is
relief with aspirin (osteoid osteoma).
Problems that show familial predisposition include disc disease, ankylos-
ing spondylitis, Reiter’s syndrome, and other spondylolarthropathies.
Red flags in history of a patient with back pain
• Less than 10 years of age
• First episode of back pain and over 60 years old
• Unexplained weight loss
• Chronic cough
• Night pain
• Intermenstrual bleeding
• Altered bowel function
• Altered bladder control
• Visual disturbance, balance problems, upper-limb dysesthesias
• Past history of cancer or corticosteroid use
• Bilateral weakness of lower extremities

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 202 CHAPTER 6 Spine

Examination
Inspection
With patient standing:
• From behind: check level of shoulders, lateral curvature or scoliosis,
lumbar list, lengths of lower limbs (level of posterior superior iliac
spines), or hair tufts over spine
• From side: check increased kyphosis, decreased lordosis
Lumbar list (painful scoliosis) may be due to unilateral muscle spasm, or
nerve root irritation may be due to disc herniation.
Palpation
Palpate each spinous process for possible step-off, posterior superior iliac
crest (PSIS)/sacroiliac region, facet joints for tenderness and paraspinal
muscles for tenderness or spasm, and gluteal muscle/sciatic notch for ten-
derness. See Figures 6.1, 6.2, and 6.3.
Active and passive movement
Restriction of spinal movement may be due to muscle spasm as a result
of pathology in one or more functional unit. Note pain during any of the
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movements tested.
Lumbar flexion (normal is 40–60°) occurs by reversing the lordosis.
During re-extension the lumbar lordosis is regained in the final 45°.
Toe touching with straight legs is influenced by hip mobility, and ham-
string tightness so is not useful for assessment. However, lumbar flexion
may be assessed by measuring the increased distance between marked
points over the spinous processes with flexion (Schober’s test). Inability
to touch the toes because of hamstring tightness is a classic finding in
spondylolisthesis.
Lumbar extension (normal is 20–30°) is painful with facet joint or pars
interarticularis pathology; this is called “posterior element pain.” It can be
due to posterior disc pathology or closing of the foramen on nerve roots.
Lumbar lateral flexion (normal is 20°) is painful with ipsilateral facet joint
pathology or lateral disc protrusion (radicular pain), but is often a non-
specific sign.
Lumbar rotation occurs with thoracic rotation (normal is 90°) and is
assessed with pelvis and hips fixed (held by examiner or sitting).
Neurological examination
• Sensory: light touch over back and abdomen, legs, perianal sensation
• Lower limb reflexes (L4 knee, S1 ankle), superficial anal reflex: touching
perianal skin causes contraction of sphincter and external anal muscles
(S2, S3, and S4)
• Motor: squat and return to standing, walk on heels (weak ankle
dorsiflexors—L4) and then toes (weak gastrocsoleus—S1); muscle
strength testing for nerve root assessment (L1—hip flexion, L2—hip
flexion, L3—knee extension, L4—foot dorsiflexion, L5—great toe
extension, foot inversion, S1—knee flexion and foot plantar flexion and
eversion); sphincter tone and contractility
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 EXAMINATION 203

L1
T12

L1 S3/4 S4 S3 S2 L2

Anterior
axial line
L2

Posterior
axial line
L3 L3

L3

L5
L4
L4 L5
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S1
S1
L5
L4
Figure 6.1 Dermatomes of lower limb; note the axial lines. Reproduced with
permission from Mackinnon P, Morris J (2005). Oxford Textbook of Functional Anatomy,
Vol. 1. Oxford, UK: Oxford University Press. ©2005.

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 204 CHAPTER 6 Spine

Trapezius (upper fibers) Levator scapulae

ecternal occipital transverse
protruberance processes of
cervical
vertebrae 1–4
superior nuchal line supero-medial
spines of cervical vertebrae angle of scapula

Rhomboid minor
Outer third of clavicle and major
spines of upper
Inner border thoracis vertebrae
of acromion vertebral border
of scapula
Spine of
scapula
Trapezius
(lower fibers)
medial end
of spine of
scapula
Spines of
thoracis
vertebrae
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Iatissimus dorsi
intertubercular groove Serratus anterior
of humerous upper 8 ribs
Spines of lower 6 near angle
thoracic vertebrea costal aspect of
vertebral border
Lumbar fascia attached to of scapula
spines of lumbar and sacral
vertebrae

Posterior third of iliac crest

Figure 6.2 Superficial muscles of the shoulder girdle and back. Reproduced
with permission from MacKinnon P, Morris J (2005). Oxford Textbook of Functional
Anatomy, Vol. 1. Oxford, UK: Oxford University Press. ©2005.

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 EXAMINATION 205

(a) (b) Odontoid process

Atlas
Axis
Cervical
Spinous
processes
C7 Neural arches

1st rib T3

Thoracic
Thoracis
T7
Transverse
6th rib
processes
Intervertebral
foramena
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12th rib Laminae

Lumbar Lumbar
Intercristal plane

Vertebral bodies

Sacrum
Site for lumbar
Coccyx
puncture

Figure 6.3 Vertebral column. (a) Lateral view; (b) posterior view. Reproduced
with permission from MacKinnon P, Morris J (2005). Oxford Textbook of Functional
Anatomy, Vol. 1. Oxford, UK: Oxford University Press. ©2005.

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 206 CHAPTER 6 Spine

Special tests
Sciatic and femoral nerve tension tests
The principle test is stretching the dura and nerve root to produce leg
pain. A positive test will reproduce the patient’s radicular symptoms.
Sciatic nerve tests
• Straight-leg raise (Fig. 6.4a)
• Contralateral straight-leg raise: reproduction of radiating lower
extremity pain with straight-leg raise of the contralateral limb;
extremely sensitive and specific for herniated nucleus pulposus
• Leseaque test: patient supine with hips flexed to 90°; knee slowly
extended
• Bowstring sign: examiner presses in popliteal fossa and causes increased
pain in leg
• Slump test: patient sits “slumped”; progressive increase in tension by
flexing neck, extending knee, and dorsiflexing foot
Ankle dorsiflexion and neck flexion should aggravate radicular pain or
decrease the angle of straight-leg raise.
A false-positive result is pain with <30° or >70°of straight-leg raise,
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production of back pain with no leg pain.

Femoral nerve test (Fig. 6.4b)
For lateral decubitus, extend the hip then flex the knee to 90°. A positive
test is recorded if there is pain in the thigh with this maneuver. Repeat on
the opposite side.

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 SPECIAL TESTS 207

(a)

(b)
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Figure 6.4 (a) Straight-leg raise test and (b) femoral nerve stretch text.

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 208 CHAPTER 6 Spine

Diagnosis
Diagnosis is indicated when history and physical examination raise sus-
picion of serious pathology, when treatment options may change on the
basis of imaging findings, and when symptoms fail to respond to standard
treatment. Imaging findings must be correlated with the patient’s signs and
symptoms, as degenerative changes appear in asymptomatic persons from
early age, and identification of potential pain generators from imaging find-
ings is nonspecific.
X-rays
Obtain routine anteroposterior (AP) and lateral views (Fig. 6.5).
• Advantages: cheap, low radiation dose, define bones
• Disadvantage: do not define soft tissues
On AP view, check spinous process and two transverse processes, two
pedicles, two laminae, and two facet joints (vertical in lumbar spine) at
each level; assess alignment.
On lateral view, assess bodies of the vertebrae and disc spacing increas-
ing from L1 to L4. Lumbar intervertebral foraminae alignment will give
a smooth curve of posterior aspects of the bodies forming the lumbar
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lordosis.
On oblique view, check for facet joints and pars interarticularis if there
is a high index of suspicion.
Look for the “Scottie dog”—the neck is pars, nose is transverse process,
eye is pedicle, ear is superior articular process, and front legs are inferior
articular process. If a “collar” is seen, this indicates spondylolysis.
Bone scan
Technetium-labeled injection is taken up in areas of increased osteoblastic
activity, demonstrating increased metabolic activity in bone. This can be
detected by a gamma camera. A bone scan reveals stress fractures (i.e.,
spondylolysis) but also epiphyses and metaphyseal bone plates of the
young.
• Advantage: high sensitivity
• Disadvantage: low specificity, radiation dose
Single photon emission computed tomography (SPECT)
SPECT gives a more precise anatomical localization of a “hot spot” than
bone scan. It is the imaging modality of choice to identify spondylolysis.
Computed tomography (CT)
CT is the imaging modality of choice for visualization of bone and bony
abnormalities.
• Advantage: good to detect fractures and impingement of spinal canal,
evaluate spinal tumors
• Disadvantages: radiation dose, slices may miss pathology

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 DIAGNOSIS 209

Figure 6.5 Anteroposterior and lateral X-ray and normal lumbar spine.
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Myelography
Injecting radio-opaque dye into the spinal canal outlines the spinal cord
and nerve roots on subsequent plain X-rays. This can reveal nerve root
compression, though not its cause (i.e., prolapsed disc, osteophyte, or
tumor).
CT myelography
Myelography is combined with CT technology for even greater detail.
Magnetic resonance imaging (MRI)
MRI provides excellent visualization of soft tissues, including discs (see
Fig. 6.6). It can be used to assess impingement of nerve roots and may
indicate hemorrhage from ligamentous injury. MRI can be used to detect
atrophy in paraspinal muscles and changes in the spinal cord, such as syrin-
gomyelia. In most cases it has superseded myelography.
• Advantage: no radiation
• Disadvantage: cost, metallic artifact
Discography
This involves injection of radio-opaque dye into the disc space under pres-
sure, while monitoring for leakage of intradiscal fluid and annular disten-
sion and assessing pain response. Reproduction of the patient’s typical low
back pain suggests a positive test. The reliability of this procedure in iden-
tifying the specific source of pain is debated. The use of this procedure in
the young athlete has not been studied and is not routinely recommended
in this population.

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 210 CHAPTER 6 Spine

(a) (b)
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Figure 6.6 (a) Normal lumbar spine T1MRI saggital view. (b) Normal lumbar spine
T2MRI sagittal view.

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 ACUTE SPINAL INJURY 211

Acute spinal injury

History and examination
Awareness of possible catastrophic injury is most important when an ath-
lete goes down on the field. Question the athlete and witnesses of the
injury.
Primary survey on the field in acute injury should include evaluation of
unconsciousness, airway, breathing, and circulation to identify life-threaten-
ing injuries. Neurological screening can then be done to assess associated
head trauma and injuries that could produce instability of the spine and
threaten neurological structures.
Cervical spine injury and potential instability should be presumed in any-
one who is unconscious after head injury.
When to immobilize?
• An unconscious athlete
• Pain in the spine secondary to high-velocity injury
• Any neurological signs or complaint of numbness, weakness, or
paralysis
Transportation should be on a spinal board by trained personnel to ensure
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immobilization in the position in which the athlete was found. In general,

equipment such as helmets should not be removed unless airway access
is required.
The cervical spine will need assessment by cervical spine X-ray and
clearance by appropriate professionals on the basis of signs, symptoms,
and clinical condition.

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 212 CHAPTER 6 Spine

Acute injuries of the back in sports

• Muscular strain and ligament sprain
• Degenerative disc disease
• Isthmic spondylolysis
• Isthmic spondylolisthesis
• Compression or stress fractures of the vertebral bodies, unless trauma
was extreme, are usually pathological (osteoporosis in elderly athletes
or the young female with the female athletic triad of disordered eating,
amenorrhea, and osteoporosis)
• Fracture dislocations: high-energy injuries (e.g., diving, car racing) with a
high risk of spinal cord injury
Low back pain is a symptom, not a diagnosis. It is often not associated with
any identifiable anatomical abnormality. Back pain episodes are common
in the general nonathletic population, and athletes may or may not be at
higher risk according to their sport of preference.
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 MANAGEMENT OF MUSCULOLIGAMENTOUS INJURIES OF THE BACK 213

Management of musculoligamentous
injuries of the back
• Sprains and strains of the back are thought to be common and self-
limited. Radiological imaging is not indicated unless clinical findings
suggest other causes. Offending activities should be avoided early on.
Ice can be applied in 20-minute sessions and muscle spasm may also be
controlled by anti-spasmodic medication.
Rehabilitation programs aim to restore normal core muscle strength and
muscle firing patterns. Return to sport can be initiated when the athlete is
pain-free with nearly normal mobility, strength, and endurance.
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 214 CHAPTER 6 Spine

Disc disease
Disc disease is a continuum from degeneration to herniation. Sports par-
ticipation may be a risk factor for development of disc degeneration but
not necessarily back pain.
As the disc loses water content with age, more stress is transferred to
the annulus fibrosis, which may develop radial tears. These tears may cause
local back pain, but have the potential to allow herniation of the nucleus
through annulus and consequent nerve root pain.
Diagnosis
Loss of disc space height on plain radiographs and disc dessication (loss of
water content) on MRI indicate degenerative disc changes. These findings,
which are consistent with normal aging, have been variably associated with
the likelihood of back pain in athletes, but the high rate of these findings in
asymptomatic individuals limits a cause-and-effect connection.
Treatment
Treatment of presumed acute discogenic back pain involves adequate
analgesia and antispasmodics if needed and then rehabilitation to improve
core muscle strength and firing pattern to decrease the load on the disc.
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Treatment then focuses progressively on sport-specific postures and

activities.
Disc herniation
Disc herniation is most common in the fifth decade of life, although up to
2% of cases occur in those under 18 years. In disc herniation, the nucleus
pulposus extrudes through a tear in the annulus fibrosis (Fig. 6.7). The her-
niation may press on the nerve root, causing leg pain, numbness, and weak-
ness. Chemical mediators may also cause a component of radicular pain.
Classically, the history may suggest symptoms of disc degeneration prior
to more acute intense back pain, after which, over the next 48 hours,
buttock and leg pain develops. If bilateral leg numbness or weakness is
present, consider the possibility of “cauda equina syndrome” and ask about
loss of visceral function (e.g., bladder and bowel, fecal or urinary inconti-
nence or retention) and saddle anesthesia.
Appropriate treatment of cauda equina is urgent spinal decompression.
Examination
With acute disc herniation, the patient may stand with a list away from the
side of the leg pain and flex asymmetrically away from that side as well.
Muscle weakness, sensory loss, and reflex changes in the lower limbs may
give an indication of the level of the herniation. Sciatic or femoral nerve
tension signs may be positive.
In cauda equina syndrome, perianal and scrotal sensation and sphinc-
ter tone may be lost. MRI is the diagnosis of choice but is not necessary
acutely unless cauda equina syndrome is suspected.

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 DISC DISEASE 215
Figure 6.7 (a) Lumbar herniated nucleus pulposus (HNP) sagittal view. (b) Lumbar HNP axial view.
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(b)
(a)
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 216 CHAPTER 6 Spine

Treatment
Treatment of disc herniation involves analgesia and antispasmodics and lim-
ited bed rest if there is severe pain on movement. However, activity should
be encouraged as soon as the patient can cope with it. Back extension
exercises may be useful. An epidural injection may be effective in reducing
pain, but may not improve neurological deficit.
In persistent cases (e.g., 6 weeks with no response) microdiscectomy
may be performed, although studies suggest the long-term results after
2 years are no better than with continued conservative management.
Rehabilitation to maximize core strength and optimize spinal flexibility may
allow progressive return to sport.
Cauda equina syndrome requires emergent surgical decompression.
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 218 CHAPTER 6 Spine

Pars interarticularis and spondylolysis

Definition
Pars interarticularis is the narrowest section of the lamina, bridge of bone
between the inferior and superior articular process of the vertebra (also
called “isthmus”).
Spondylolysis is fracture of the pars interarticularis.
Asymptomatic spondylolysis is present in about 5% of the skeletally mature
general population. It is not present in the newborn, but has been seen in
6-year-olds.
The pars interarticularis is vulnerable to stress fracture in those engag-
ing in repeated hyperextension of the spine. This occurs in many sports
but particularly in gymnasts and offensive linemen because of the nature
of their sports.
Some children may also have a genetic weakness in the pars interar-
ticularis that predisposes them to this condition. These cases occur most
commonly at L5 (85%–95%) and L4 (5%–15%) but occasionally they occur
at a higher level and can be unilateral or bilateral.
Imaging with bone scan and CT reveals a continuum of mild stress reac-
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tion to complete fracture with potential for nonunion. The lower three
lumbar vertebrae are most at risk.
The term spondylolysis covers defects in the pars interarticularis, but
defects have also been described in the pedicle and other posterior ele-
ments of the spine from sporting activities.
Posterior-element pain is generally characterized by pain on extension
and particularly a positive one-legged hyperextension test (stork test). Pain
usually occurs when the foot of the ipsilateral side to the pars lesion is on
the ground. Adding rotation toward the affected side is more sensitive for
a stress lesion (Fitch test). The reliability and specificity of these tests is
questionable.
Diagnosis
Plain X-ray with oblique view (Fig. 6.8), which may show a “collar” on the
Scottie dog, is the recommended initial imaging modality. However, pain
radiography lacks sensitivity. Therefore, if there is high clinical suspicion,
triple-phase bone scanning with SPECT is the optimal next study. “Hot
spots” in the posterior elements indicate possible sites of spondylolysis,
which can then be identified with a CT scan.
Unfortunately, MRI, which does not pose radiation risks to the patient,
poorly delineates bony structures and may only be positive acutely with
bone stress presenting as edema.
Treatment
Increased uptake on bone scan or SPECT indicates bone stress. Treatment
should include rest from pain-provoking activities, which usually is sport. A
lumbosacral orthosis molded in 10–15° of flexion may be used to prevent
hyperextension.
For those with early bone stress reaction, 6 weeks’ rest may be suf-
ficient, but 12 weeks may be required to allow healing of established stress
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 PARS INTERARTICULARIS AND SPONDYLOLYSIS 219

fractures. When patients are pain free, thorough rehabilitation of the spi-
nal and abdominal musculature is necessary. Return to sports should be
gradual and depend on symptoms. Imaging is not useful in predicting the
time to return to sports.
Established spondylolysis with wide sclerotic bone margins and negative
bone scan is unlikely to heal, even with rest and bracing. Management is
designed to allow pain to settle. Then rehabilitation is started to provide
dynamic stability though exercises and an earlier (less cautious) attempt
to return to sports.
Persistent pain despite activity modification and rehabilitation may
respond to a period of bracing. Pain preventing successful return to sports
could be treated by surgical stabilization, by either pars bone grafting or
fusion, although patients must be counseled that outcomes are not always
favorable. A local anesthetic “lysis” block may give useful information
regarding the potential benefit of treating the lysis surgically.
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Figure 6.8 Pars defect oblique view.

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 220 CHAPTER 6 Spine

Spondylolisthesis
Definition
Spondylolisthesis: anterior displacement of one vertebral body on another
Classification of spondylolisthesis (Wiltse, 1976)
• Dysplastic
• Isthmic (lytic or elongated)
• Degenerative
• Traumatic (fractures)
• Pathological
Grading of spondylolisthesis (Meyerding, 1932)
Grading is based on displacement of the vertebral body relative to the
lower vertebral body anteroposterior diameter.
• Grade 1 = 0%–25%
• Grade 2 = 26%–50%
• Grade 3 = 51%–75%
• Grade 4 = 76%–100%
• Grade 5 >100% (spondyloptosis)
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Spondylolisthesis in the young athlete

• If there are bilateral pars defects, spondylolisthesis can occur.
• Progression of spondylolisthesis is uncommon but is most likely to
occur during the time of peak height velocity.
Examination may reveal the step-off in the spine and hamstrings are often
tight, requiring clinical differentiation from sciatic nerve tension. Lateral
plain X-rays will demonstrate nearly all spondylolistheses, but MRI may
be useful to assess nerve root foramina and disc quality, which may be
compromised in spondylolisthesis.
Spondylolisthesis may progress in the skeletally immature. However,
sporting involvement does not appear to be a risk factor; thus there is no
evidence to exclude an athlete from participation. Nevertheless, it may be
wise to avoid gymnastics and weight lifting if the patient is at stage 2 or 3.
Surgery may be considered for those at stage 3 or those with nerve root
entrapment.
History and examination
• May be asymptomatic. Do not assume that back pain is due to a
radiologically proven spondylolysis or spondylolisthesis unless the
clinical picture is consistent.
• Symptomatic pars stress fractures present with an insidious onset of
unilateral or bilateral pain in the lumbar region (most commonly at the
level of the belt), which may then radiate to the buttocks and leg.
• Pain often is worse with activities requiring lumbar extension.
• Clinical findings: may have increased lumbar lordosis and tenderness
around the facet joint region at the affected level.

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 SPONDYLOLISTHESIS 221

• Pain is reproduced by lumbar extension, which is often worse when

standing on the leg of the affected side.
• There are no neurological signs in the lower limbs.
Diagnosis
• X-ray including oblique view. This gives the classic “Scottie dog”
appearance when a pars defect is present.
• Lateral view is also useful to determine whether a spondylolisthesis
exists and its severity (Fig. 6.9).
• Spondylolisthesis is graded 1–4 according to the degree of slip: grade 1:
25%, grade 2: 25%–50%, grade 3: 50%–75%, grade 4 >75%
• With recent symptom onset the X-ray is often normal.
• A bone scan including SPECT views is very sensitive for recent stress
fractures. A hot spot at the site of the defect suggests that the fracture
is recent and active. If no hot spot (i.e., no osteoblastic reaction) is
seen, active remodeling is not occurring.
• Bone-scan changes often remain positive for many months and are not
useful as a means of timing return to sports.
• CT scanning is useful for staging fractures.
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Figure 6.9 Lumbar spondylolisthesis.

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 222 CHAPTER 6 Spine

Treatment
• Avoid lumbar extension activities.
• Some clinicians recommend the use of a brace to prevent lumbar
extension (e.g., modified Boston brace), especially if the athlete has
pain with activities of daily living.
• Use of a brace has not been shown to increase the rate of fracture
healing.
• Physiotherapy should include an abdominal strengthening program and
postural retraining to address excessive lumbar lordosis and anterior
pelvic tilt.
• A flexibility program to improve hamstring and gluteal flexibility should
also be included.
• Return to sports, which usually occurs within 3–6 months, should be
based on symptom resolution, absence of clinical signs, and good core
trunk strength.
• Monitor for slip progression during the growing years, as progression
may (rarely) require surgical stabilization.
• If there is persistent pain despite appropriate rehabilitation and in
those with a grade 3 or 4 spondylolisthesis (>50% slip) or when the
slip is progressing, referral to a specialist is indicated. These children
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should avoid sports requiring lumbar extension and contact.

Prognosis
• Fractures treated in the early phase appear to have a good prognosis,
especially if they are unilateral.
• Early- and progressive-stage fractures have a 40–80% chance of fracture
healing.
• Terminal-stage fractures rarely unite.
• Excellent clinical outcomes can be achieved in the absence of fracture
healing.
• Bone stimulator use has not been shown to change the rate of healing.

Further reading
Morita T, et al. (1995) Lumbar spondylolysis in children and adolescents. J Bone Joint Surg (Br) 77B:
620–625.
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 SCHEUERMANN’S DISEASE 223

Scheuermann’s disease
Scheuermann’s kyphosis is manifested by vertebral body wedging, verte-
bral end plate irregularities, diminished anterior vertebral growth, and pre-
mature disc degeneration. Compressive forces cause wedging deformity of
the vertebral bodies, resulting in a thoracic kyphosis.
The etiology is unknown but it is considered an osteochondrosis affect-
ing growth plates (ring epiphysis) of vertebral bodies. It affects the thoracic
spine predominantly but can occur in the lumbar spine or at the thoraco-
lumbar junction.
It occurs in adolescents with onset just before puberty and is the most
common cause of hyperkyphosis in adolescence. Incidence is between 1%
and 8% of the general population. There appears to be an increased familial
incidence of the condition. Scheuermann’s kyphosis may be a coincidental
radiographic diagnosis and may or may not be a cause of nonspecific low
back pain in the adolescent or young adult.
History and examination
• Commonly presents in the active adolescent
• May have mid-thoracic pain with activity
• May present as a painless thoracic kyphosis in the late teenage years or
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20s with concerns about “poor posture”

• Tightness of hamstrings and thoracolumbar fascia is common
• Excessive lumbar lordosis often present
Diagnosis
• Wedging of >5° in three or more consecutive vertebrae on lateral
X-ray is diagnostic.
• Disc degeneration on MRI has been shown in 50% of patients
compared to 10% of asymptomatic controls, but it is unclear if this is
primary or due to abnormal mechanical loading of the kyphotic spine.
• Schmorl’s nodes (irregularities in the cartilage end plate causing
irregular ossification) are commonly present.
Treatment
• Persistent pain and/or progression of kyphosis is not inevitable.
• Aim to resolve pain and stop progression of deformity.
• Avoid offending activities until symptoms resolve.
• Hamstrings and thoracolumbar fascia stretches
• Abdominal core-muscle strengthening program
• If kyphosis is >50° at presentation, an extension brace (e.g., a
Milwaukee or DuPont brace) should be used in addition to exercises.
• Rarely, if kyphosis is >70° and bracing and exercises have failed or pain
is severe despite treatment, surgery may be warranted.
Prognosis
• Exercises will reduce symptoms but will not correct the existing deformity.
• Use of a brace before skeletal maturity may improve kyphosis.
• Pain is usually self-limiting and resolves with skeletal maturity unless
kyphosis is severe.

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 224 CHAPTER 6 Spine

Sacroiliac joint
Sacroiliac joint motion is small, not more than 2–3° in the transverse or
longitudinal plane. No muscles directly cross the joint. Pain may come
from trauma or perhaps overuse-type injuries. Sacroiliac joint pain may be
greater in sports requiring unilateral loading such as kicking and throwing
but has been reported in cross country skiers and rowers.
Sacroillitis is an early manifestation of seronegative arthrititides, such as
ankylosing spondylitis or Reiter’s syndrome.
Factors predisposing to overuse injury of sacroiliac joint
• Ligamentous laxity due to hormonal changes of pregnancy
• Leg-length discrepancy
• Gait abnormality
• Prolonged vigorous exercise
• Scoliosis
• Running on uneven terrain or a cambered road
History and examination
History or physical examination findings do not identify the sacroiliac joint
as the pain generator. Pain in the low back, sacrum, pelvis, gluteal region,
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and groin has been ascribed to an origin in the sacroiliac joint.

Unilateral pain is more common than bilateral by a 4:1 ratio. The presen-
tation most consistent with sacroiliac joint pain is unilateral pain localized
below the L5 spinous process.
Clinical findings
• Local pain over joint line (posterior inferior iliac spine)
• Pain on compression or distraction of the iliac crests
• Pain on FABER leverage test (flexion abduction external rotation)
Diagnosis
Imaging may help rule out other sources of pain but is generally helpful in
evaluating sacroiliac joint pain.
Plain radiographs, a bone scan, and MRI may be helpful in identifying
sacral fractures, tumors, sacroiliitis, and ankylosing spondylitis.
HLAB27 may be positive in those with ankylosing spondylitis.
Treatment
Address biomechanical factors, such as pelvic mobility, leg-length dis-
crepancy, hip rotation, footwear, and training factors. Treat with analgesia,
NSAIDs, and ice and consider use of a sacroiliac belt.
Second-line treatment might include corticosteroid injections into the
localized painful area or intra-articularly as a diagnostic and therapeutic
approach.

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