Spinal Injuries in Adolescent Athletes

Because of their age and involvement in vigorous activities and sports, adolescents risk injury to the spine (back bone). Certain types of sport activities increase the risk of injury, especially to the lower back. However, these athletes can take steps to prevent many types of spinal injuries.

Anatomy and skeletal development
The spine is made up of vertebrae (bones), intervertebral disks (shock absorbers between vertebrae), and the spinal cord and other nerves (Figs. 1A and 1B). The vertebrae and intervertebral disks protect the spinal cord, and they enable the torso to move in many directions.

Physes (growth plates) are areas on the ends of a child's bones where the bone grows. As the skeleton matures, the physes harden, and bones stop growing. Girls reach skeletal maturity at about 16 1/2 years of age; boys, at about 17 1/2 or 18.

Causes
Trauma and repetitive stress can cause back injury in adolescent athletes. Repetitive bending and twisting put athletes at risk for spinal injuries. During long training days, athletes are at increased risk of injury because their fatigued bodies cannot give full protection to the back. Using improper sport technique and having weak abdominal and tight leg muscles also can lead to injury.

The lumbar vertebrae (bones of the lower back) are more prone to injury in the growing adolescent, especially during sports participation. Ligaments and muscles that support the spine may not grow as fast as bone, and, therefore, they may become tight, putting increased stress on the spine.

Difficult maneuvers involving "flight" account for most spinal injuries. During these activities, the athlete is airborne and lands on a hard surface, such as the floor in gymnastics, or the water, such as in diving maneuvers. Other activities associated with spinal injuries include blocking in football, takedowns in wrestling, and use of heavy weights and attempts at complex free-weight lifts in weight training.

Specific injuries
Spondylolysis and spondylolisthesis. Putting repetitive stress on the vertebrae can cause a thin area of bone, called the pars interarticularis, to fracture (break). Spondylolysis refers to a fracture on one side of the pars interarticularis (Fig. 2A). In spondylolisthesis, the fracture has occurred on both sides of this area and the fractured vertebra has slipped forward against its neighboring vertebra (Fig. 2B). Repetitive hyperextension of the lower back, such as excessive back bends by gymnasts or by football linebackers, can lead to these conditions.

Disk herniation. Intervertebral disks are made up of firm, gristle-like fibers that encompass a soft, fluid-like center. Disk material can bulge into the spinal canal and push on the spinal cord or another nerve.

In adolescents, disk herniation most commonly results from repetitive trauma to the back. In adolescents, a vertebral growth plate and its adjacent disk can become displaced into the spinal canal and push on the spinal cord. This condition is called slipped vertebral apophysis. It usually results from heavy lifting or from participation in sports that require very strenuous training, such as gymnastics.

Fractures. Blows to the back can cause fractures to certain parts of the vertebrae. Likewise, the physes and sacrum (tail bone) also can be fractured. Activities in which the athlete can get hit in the back or can fall from a great height can lead to spinal fractures.

Scheuermann's disease. This condition results in an exaggerated curve (hump) of the upper back involving at least two abnormally wedge-shaped vertebrae. The cause is not known.

Symptoms
Pain often accompanies back injuries. In many cases, activity makes the pain worse. To determine the seriousness of your adolescent's back problem, pay attention to whether he or she has back pain at night, limited movement of the lower back, or pain that goes down the leg. If your adolescent has these symptoms, he or she needs to seek treatment from a doctor.

Treatment
To treat a back injury, the adolescent athlete must stop playing the sport and participating in weight training, and he or she must see a doctor. The primary care doctor examines the athlete's back and, if necessary, refers the adolescent to an orthopaedic doctor. The doctor may prescribe a pain medication. Some adolescents need to wear a back brace as part of the treatment. A physical therapist instructs the athlete in appropriate conditioning, stretching, and strengthening exercises to rehabilitate the back and to enable him or her to return to sports participation.

After treatment, the doctor decides when the adolescent athlete can return to sports participation. Sometimes, the athlete has to decrease the intensity of practice or change the way he or she performs a particular activity.

Parents should be aware that the problem can reoccur. If it does, the adolescent will have to receive treatment again.

Prevention
Adults can help adolescent athletes prevent spinal injury. For example, coaches can institute shorter practices. Properly trained coaches, athletic trainers, parents, or other adults can supervise training sessions. They also can teach proper technique for weight training and various exercises.

Low back injury in adolescents is a serious problem. However, if diagnosed and treated properly, the athlete usually can return to vigorous activities.

Galasko CSB. Back pain in children. In: Jayson MIV (editor). The Lumbar Spine and Back Pain. 4th edition. Edinburgh: Churchill Livingstone, 1992; 603-617.

Lawrence D. Powell, M.D.
Atlanta, Georgia