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Breaking down adolescent low back pain with Angela Jackson

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In this episode with Angela Jackson, we delve into the realm of adolescent low back pain, uncovering its various facets and management strategies. From identifying common causes to understanding the progression of bone stress injuries, we navigate through the complexities of this prevalent issue. Tune in as we explore the age groups most at risk, examine gender differences in presentation, and unravel effective management approaches tailored to this specific population.

Want to learn more about adolescent low back pain? Angela recently did a brilliant Masterclass with us called “Assessment and Rehabilitation of Low Back Pain in Youth Athletes” where she goes into further depth on this topic.

👉🏻 You can watch her class now with our 7-day free trial:
https://physio.network/masterclass-jackson

Angela Jackson is a Chartered Physiotherapist, who over the last 35 years has dedicated her career to understanding youth athlete injuries. She owned a highly successful physiotherapy clinic for 30 years and has become an expert in youth injury risk factors, helping hundreds of children reach their athletic potential.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio

SPEAKER_02:

Intermittent low back pain settles with rest and worse with overhead and extension based activities, then what we'd see is on an MR scan is symphonia edema. And these might be quantified as either what we call a early or a very early spondylolisis, bone stress injury. And the good news is that if we catch them at that point, then they will turn around very quickly and the probability is we'll get 100% rate of healing.

SPEAKER_01:

Today we are talking to Angela Jackson on the topic of low back pain in adolescence. In this episode, we look at the common causes of lower back pain in adolescents, how we can spot some of the more serious differential diagnoses that we could easily miss, and how we can best manage adolescents who present to us with lower back pain in clinic. Angie is a chartered physiotherapist who has spent over 35 years seeking to understand why some young athletes get injured, yet others don't. As a youngster herself, Angela excelled in tennis and hockey before developing a series of knee injuries that halted her sporting dreams. Her determination to Thank you very much. lower back pain in adolescence, where you can dive so much deeper into this area than we were able to go into in today's episode. Click the link in the show notes to watch Andy's masterclass for free with our seven-day trial. You are going to love this episode. I'm James Armstrong, and this is Physio Explained. Andy, thank you so much for coming on to the Physio Explained podcast today. How are you?

SPEAKER_02:

I'm really well, thank you. How are you?

SPEAKER_01:

Very well indeed. It's brilliant to have you on. And today we are going to be talking about the topic that you've covered for a masterclass with us, which is looking at lower back pain in adolescence and all the things around it. And we're going to be picking out a specific topic today from the masterclass. And we're going to dive straight in because this is quite a big topic that we've said off air we need to get into this short period of time that we've got. So we're going to go straight into it, if that's all right. And we're going to start with the common causes of lower back pain in adolescence.

SPEAKER_02:

Great, so there's been lots of studies out really that have highlighted the most common cause of low back pain in adolescence and it's got so many different names but in the literature is usually regarded as a lumbar spondylolisis. What that means in English is potentially a spectrum of bone stress injuries that goes from a sort of bone bruise almost at the one extreme where you've got some bony edema but no fracture right through to a stress fracture at the other end and the potential for that to go on and become a spondylolisthesis. And I'm happy to just sort of expand on that a little bit as to what the different levels are. What we know is that these children all presented to an A&E department in the States and around 40 to 50% of children with low back pain for just two weeks were diagnosed on an MRI scan with a spondylolisis that had fractured. So we know that a good chunk of these kids that we're seeing with acute onset low back pain, but critically, they were all athletes. So this is something that is in the sporting population, very different from the non-specific low back pain that we see in adults, where perhaps potentially they're worse when they do prolonged sitting, they're worse in bending. And This particular subset are all effectively active kids who are running around, kicking, throwing, overhead activities. And what they present with is, in the very early stages, let's take somebody who plays tennis or cricket. Let's imagine they're right-handed. They would present with contralateral, so left-sided, low back pain. And in those very early phases, what we see a little bit like a bone stress injury and maybe the tibia that lots of people are familiar with, is that you'd get pain on activity. And initially it'd be just transitory where when you're doing the activity, it hurts, but it settles down very quickly. And then just like we would see in a sort of bone stress injury in the tibia, if we persist in doing that activity, then we start to get more persistent symptoms. So they become a little bit more constant. Now at this phase, if we get our intervention right and these children are made aware that playing sport with low back pain is not normal, then what will happen is given a couple of weeks rest, just like we know the bone will adapt to the stresses applied to it and it will reinforce itself and the symptoms will go away. So if we were to classify those at this point, intermittent low back pain settles with rest and worse with overhead and extension-based activities, then what we'd see is on an MR scan is some bony edema. And these might be quantified as either what we call a early or a very early spondylolisis, bone stress injury. And the good news is that if we catch them at that point, then they will turn around very quickly. And the probability is we'll get 100% rate of healing. The problems occur is, How many people know about this injury? So we're not taught it at undergraduate level. And I guess it'd be interesting to know your experiences as to when you came across it as to if it's not on our list of differential diagnosis as a clinician, then we're not going to be diagnosing it. So we're going to send these away as potential muscle spasm, as a muscle strain, and we'll be blissfully unaware. that this condition exists because once the bone fuses at the age of about 23, 24, then this condition is only really seen in a very small subset of elite cricketers and certain other population groups, but it's not seen in the generalized low back pain groups. So it'd be interesting for you to reflect and think about maybe when you came across it and when it came onto your radar. Yeah,

SPEAKER_01:

probably quite late on. And I actually can pinpoint it. It was actually when you and I have previously spoken before. That's when it really came to my light as a sort of relatively newly graduated physio. So exactly proving your point.

SPEAKER_02:

And that's really what I'm aiming to do is to try and raise awareness. Firstly, working a lot with children and parents and kiddies that are playing lots of sports to say playing with back pain is not normal. And then we've got to work on all the clinicians to say, well, we need to raise your awareness about this area of what we call these injuries occur in the vertebral body at an area called the pars interarticularis. And as I've just alluded to, bones need to not be fully fused in order to allow for longitudinal growth in height. And so this potentially puts weak spots throughout the body. And one of those areas is at this pars or even the pedicle within the vertebral ring. So lots of extension based activities are going to put repeated compressions and torsions on this immature bone and cause a bone stress injury. So initially that bruising and what we can then see is if these kiddies aren't powered down and they're not removed from the pain provoking activity is that they will go on to get an incomplete or a complete lumbar stress fracture. And our terminology has had to change because we were going to freak out the entire population of children with low back pain if they thought that everything that they did with regard to pain was a fracture. And so we've tried to move away to this bone stress injury terminology, but these children can still fracture and that's the important part. And if they're missed, so let's imagine that the early phases, they didn't know about it. Their parents just thought it was muscle spasm. Worse still, they went to a clinician. who didn't have that pediatric knowledge or sports knowledge, and they were told to just carry on or maybe rest for a few days and then go back. The potential is that if we miss this window of opportunity, they go from being just a single-sided low back pain to being bilateral. And at that point, the probability for healing drops enormously. If they go on to fracture, a complete fracture, and particularly if they're not picked up for a few months, they'll enter what we call the terminal type of diagnosis. And those have very, very little initiative for healing. And what you get is a fibrous union, but you'll never get a bony ossification. So we've got a massive moral responsibility. That's why I'm running around the country trying to raise awareness. And thank you to you for that opportunity to just share with people that children don't get back pain in a sporting situation. And if they do, it's more than likely going to be some part of the spectrum of a bone stress injury.

SPEAKER_00:

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SPEAKER_01:

And in terms of age ranges, Angie, are we looking at a particular age range that tend to be more at risk of this?

SPEAKER_02:

Yeah, absolutely. They don't probably do enough repetitive extension-based activity and they've probably not got enough forces going through the body until potentially around the age of seven or eight. So the youngest ones we're seeing are almost always the gymnastic population. If they're that young, the dance population who are doing a lot of backbends and things like that. And so one of the things that we face is that the culture there is that a little Johnny or little Jenny has got low back pain, but all gymnasts get low back pain. So the coaches assume it's normal. So they carry on and they carry on. And so by the time this little cohort see us, they've often got not just a complete fracture, but also a spondylolisthesis. And what happens there is that the bilateral fracture then allows one vertebrae to slip forward on the other. And at which point you've got an actual sort of step-like deformity that you can see on a lateral x-ray view.

SPEAKER_01:

And what about in terms of looking at sort of difference between male and female? Do we start to see any differences in age presentation?

SPEAKER_02:

Good point. And I think the jury's out. The research is all based around boys and girls. Interestingly, the majority of these, the bone fuses around the age of 23. We have to account for the fact that some kids are sort of three years behind, three years ahead of each other. So just bear in mind whether this person is an early maturation child or a late one. So that window can fluctuate a little bit. But so far to date, if you think that they occur lots in cricketers, we have lots of them in soccer. To date, those types of baseball were all being played predominantly by boys. So the research at the moment is the cohorts are predominantly male, involved in extension-based sporting activities, either kicking a ball with the lower limb or throwing one or bowling or hitting with the upper limb. Big butt. I think what will happen and what I've seen this season with the explosion of girls in cricket, girls in football, is a huge influx of ex-gymnasts, ex-dancers suddenly taking up football and cricket. And the presentations are really different. They are definitely moving in a different way than the boys that present. They are often presenting bilaterally already because I think they've got this almost like dominant motor patterns that they've got from those extension-based activities in gymnastics. So a little bit different, but the research isn't there yet. The volume isn't coming through, but in clinical practice, for sure.

SPEAKER_01:

So obviously in the masterclass, you're going to go into a hell of a lot more detail in terms of what we're about to talk about next in terms of differential diagnosis and other things relating to this. This is just a very small snapshot of what's going to be a fantastic masterclass. Talk us through some of the common differential diagnosis that might present similarly, but obviously slightly different.

SPEAKER_02:

Yeah, so in the gymnast, we sometimes see that instead of the injury, the hyperextension injury occurring through the pars, then what can happen is you can actually get almost like an impingement or an impact injury in the spinous process. So you can get this sort of almost like bone stress at the tip of the spinous process where the vertebrae come together. So that's one of the differential diagnoses. So being very specific about whether they're feeling it slightly lateral to the spine or central. We can't rule out, just because these are sporty kids, sadly, they still get all sorts of other weird and wonderfuls. So if you've got somebody with low back pain, but it's less related to maybe activity, but it's certainly stiff in the morning, we've got to consider the juvenile arthropathy group. We've got to consider that if the pain is constant, that we could have the risk of either a discitis, an infection within the disc, infection in adjacent tissues. But also you can get juvenile discs. So very rarely do these bone stress injuries cause referred pain. That's not to say they don't. And particularly with a spondylolisthesis, they most definitely will do. But on the whole, we're talking about if you've got referred symptoms, I'd pretty much sort of say I want this child scanned because that's very unusual. and therefore would start to point me towards, is there a juvenile disc? Is there any malignancy? Is there a slip? A spondylolisthesis needs imaging in order to know how big the slip is and how safe it is to ignore it. So we don't need to image every bone stress injury, but we do need to image those that have definitely got referred symptoms or just aren't responding to a period of two to three weeks rest.

SPEAKER_01:

And that rest is quite key. That's what you said earlier on as well. Using that as almost a bit of a diagnostic tool to say, is it improving quite quickly with rest? And then using that offload.

SPEAKER_02:

Absolutely. And so what we've got to remember, though, is that I power any child that walks into my clinic. I will power them down for around two weeks. No extension based activity. The only thing they can do is cycle. And so static bike in a flex position isn't going to stress the bones. So perfectly safe to do. And so I usually sort of power them down for at least two weeks. If the pain hasn't settled, I would assume at that point that either they've not listened to my recommendations, often the case, but if they have, then you would basically probably be going, this is a bone stress injury now, this is more likely to be a fracture. And We need to follow the protocol to get them back to sport or you need to image them to understand what's going on. But with the majority of them, the problem we've got is if they are pain-free at two weeks, no bone is going to be fully healed or resolved at that point. And it's what do you do with this child who's pain-free and itching to get back to sport? And so it becomes really, really important to give them a good explanation of the healing process because what we know is it's probably going to take a minimum of six weeks to get them back to sport. We've got to look at not sending them back doing what they did. Tons of education. And that's what the masterclass will go into is what sort of factors do we need to look at in terms of sleep and nutrition? Do we need to look at how they're moving? Are they strong enough so that we can really address all the risk factors and not just send them back doing what got them into trouble in the first place?

SPEAKER_01:

Brilliant. I think we've done it. And we've actually got through everything in the time allotted. And there's an awful lot of information just there. And as I said before, this is just a snapshot of what we're covering in the masterclass. And for those who are listening who want to find out more about this topic, which I'm sure you do, do check out the show notes because there's going to be a free seven-day trial for the masterclass. So you can check this out, which is going to be brilliant. Angie, thank you so much for your time yet again. What's the best platform that people can follow you on?

SPEAKER_02:

I'm better on Twitter. So Angie J Physio, A-N-G-I-E J Physio. But at Angie J Physio, I'm also on Instagram. I try to be better on there. And I pop some slightly longer posts on LinkedIn. So any of those formats, people can reach out to me. We've introduced the kidsbacktosport.com website now where practitioners can go and get resources. my advice booklet for parents and children who've got a bone stress injury is there as a free download practitioners are welcome to go to the site download it and share it with their parent patients and parents

SPEAKER_01:

wonderful andy thank you so much again and i'm sure we'll have you on the podcast because there's lots and lots of topics that i want to pick your brains up about and i know that the listeners will be really interested to hear as well so have a lovely evening and thank you very much for your time

SPEAKER_02:

and thanks for inviting me i love being on the show

SPEAKER_01:

Take care.