So now I would like to introduce Doctor Rhonda Watkins. She's a pediatric primary care, sports medicine physician here at U CS F in the pediatric orthopedics department. She completed her pediatrics residency at University of California, San Francisco Fresno, followed by sports medicine fellowship at Boston Children's Hospital. Doctor Watkins is a former track and field Olympian who completed, who competed in the 2008 Summer Olympics in Beijing and a former NCAA champion in the long jump. Her interest includes sport, injury prevention and return to sport after injury. She draws on her personal experiences with athletic training and injuries to shape the care she provides to her patients. Thank you so much for being here and I will hand it over to you now. Thank you. Thanks for that introduction. Welcome everyone. Good morning. I know it's early. I'm excited to share with you today on um back injuries and pediatric athletes. Uh This is my passion. I love taking care of young athletes. I know you may not share that uh excitement, but I hope you leave feeling at least equipped to take care of these young athletes that you might encounter in your practices. I have no disclosure. Is it? So these are my objectives for today. I'm going to help you list common causes of back pain in Children. I hope you'll be able to identify some indications for diagnostic imaging and therapeutic interventions for Children with back pain and describe sport specific considerations for back pain as well as help you provide some return to sport guidance for athletes with overuse related back pain. So to get started, it's important to recognize that back pain in young athletes is not the same as it is in adults. About a third of Children will complain of back pain. You know this because you see them in your clinics and and they complain of back pain and an identifiable cause uh is present in about 30%. Only 30% of them will be able to identify a cause of their back pain, which uh compared to only 10% in adults with back pain. And what about in in athletes, young athletes in particular? Well, lower back pain is estimated to occur in about 10 to almost 50% even more in some sports of pediatric, adolescent and adolescent athletes. We know that it, it occurs up to two times or twice as high a prevalence in in this young athlete population compared to non athletes in the same age group. We see back pain and pediatric athletes most commonly in the lumber region. And it tends to be mostly because of overuse injuries rather than acute injury. And that overuse uh pattern that we're seeing is largely due to this new culture of sport specialization that we see in the US today. Over the past 20 years, there's been a shift in the emphasis from youth driven child free play in a variety of sports to more parent and coach driven skills development with an emphasis on achieving a high level of accomplishment in a single sport. So this has led to a culture where very young kids are quitting all other sports to focus on just one sport and participating in in a long amount or high number of hours in that sport per week, which lends itself to overuse injuries. So we know that the prevalence of back pain is higher or back injuries are higher in in certain sports. So I've listed some here, football, basketball, cheerleading, dance, weight lifting, rugby, ice hockey, some of the racket sports, wrestling and the highest prevalence in the literature seems to be around gymnasts and, and football players. So when you're evaluating an athlete with back pain, it's important that you know, their sport, you consider their sport position, the frequency of which they play this sport, their conditioning level and and also their level of play. Is it just recreational? Are they super competitive? And this is because certain sports involve specific atter risk motions which can place the back at risk for injuries. So when we think about sports that require repetitive hyperextension like gymnastics, football, figure skating, tennis and dance. We know that that movement causes both direct uh trauma uh to the posterior spine or the posterior spine element. And it also narrows both the canal and the neural parameter, which can be painful. Sports that require repetitive rotational forces like uh baseball, bowling or swimming, uh can put you at risk for disc injury. Similarly, sports that require axial loading and flexion like weight lifting, rowing, snowboarding and other collision sports can put you at risk for herniated discs as well as fractures of the spine. So, what are some of the causes of lower back pain in young athletes? Well, as you might imagine, there are a number of them, I've listed some here. So Sarel chest injuries, Boulis lumber muscle strains, which aren't that common in kids. Uh Sherman's csis lumbar disc disease, si joint dysfunction. Uh So we're only gonna discuss some of these and this list by no means is comprehensive. But in the interest of time, we'll, we'll go over a few and the ones that you will more commonly see in the young athlete population. So any examination for the back should involve an assessment of posture. We know that paw posture uh is, is linked to to back pain and there are a number of different maladaptive postures that your patient might present with. So some of them are pictured here. They might have this sway back pattern where they the knees are flexed and they, they lean backwards. Um This might be in, in obese kids that carry a lot of their weight in the abdomen. Um and that in itself can put uh excessive pressure on, on the lower back. Uh They may have an exaggeration of the normal lumber, low doses uh seen in the lumbar spine, which also loads and and puts unnecessary undue force on the lumbar spine. They may have a humpback or thoracic KPHO pictured here, um which can cause both upper and lower back pain. They may have this forward head position. We're all looking at our phones and, and uh at screens and, and that can be associated with neck pain and upper back pain. Uh Most the neck pain in, in kids will be postural related and, and it's not really anything structural or, or need for you to, to worry. Um an exam for the back should also include a full neurologic exam. You wanna think about the mod R exam as well. Uh If you are concerned that there might be some myopathy, some C N S E theology of balance assessment can be helpful. Uh When you look at their gate, it should include heal and toe walking, uh to assess the L four L five nerve roots in the case of hill walking and uh test S one nerve roots in the case of toe walking. Some clinical tests that you should perform on Children with back pain or pitch. Here. The first is the atoms for Ben test where the examiner stands behind and has the patient flex forward. You're looking really for any thoracic or rib prominence or curvature of the spine. And that can be indicative of uh scoliosis. Um The other one pitch, it here is the straight leg raise test where the patient is, is laying supine and the examiner raises the, the leg uh while it's extended and reproduction of pain, while it's being lifted is a positive test and might be indicative of lumbar ridiculing or lumbar disc disease. The favor or a figure four test is pictured here in the lower right. And that test uh is done where the knee is crossed over the leg and a figure four pattern like this. And then you apply some pressure to the bent knee and reproduction of pain at the si joint is a positive test. So this test uh tends to be done to uh evaluate for si joint path pathology. The one picture here is a superficial abdominal reflex and this is elicited by stroking each quadrant of the abdomen, looking for contraction of those muscle muscles. Usually the the um the belly button or the umbilicus will move in the direction of the stroke. And, and that is a normal reflex. If it's absent or abnormal movement, it might suggest some thoracic abnormality like a thoracic uh spinal lesion, for example. So you wanna um go through all of these clinical tests. In your assessment, you should also assess for hamstring tightness. Uh hamstring tightness can be both a sign and a cause of back pain. As you see here, the hamstring really tethers the pelvis. So if it's tight, the spine has to move more to compensate for any movement, which can lead to overuse and pain. The hamstrings are loose that tends to reduce strain on the lumbar spine. So you can assess hamstring tightness. As pictured here with the patient laying supine and the knee is flexed to uh the hip is flexed up and the knee is flexed about 90. And then you want to try to extend the knee. So someone that has great flexibility like a dancer or a gymnast, you'll be able to straighten that knee all the way uh to get a 1 80 degree angle be between the heel and the bed, for example. And then someone with tight hamstrings, you won't be able to extend the knee uh once it gets into that flex per position. Very much. So, what about red flags? So we talk about this a lot. Now, a abnormal exam findings are important to pay attention to. So we talked about some exam findings previously, uh particularly abnormal neurological exam findings uh is a red flag and should be noted uh severe back pain that lasts uh for a long time. So, in general, if a kid has back pain and it's going on for months. That's not concerning. Right. You know, that nothing has changed with their, uh, outlook or their, their exam, they just have continued to complain of chronic pain. But if that pain is, is really intense and it sort of persisted, we have the benefit in primary care, being able to bring patients back for evaluation. You notice that the intensity hasn't really changed even though you might have tried some stretches, some rest. That that's a red flag. If they are waking up, uh, from pain or from sleep at night due to pain, that's a red flag. If they have associated signs and symptoms. So sudden or unexplained weight loss issues with bowel or bladder control. Usually incontinence what they'll experience, um, if they are having difficulty walking or limping, limping is really hard to fake in, in a child. Uh, it from an athlete perspective, if they have quit their sport because of this pain, you should sit up and take notice because a lot of times these kids will want to continue playing and they will do so at any cost if they are physically unable to, that's when they will stop. And if they've stopped their sport, what they love doing the most because of this, um, it should be considered a red flag as well. So when should you refer for, for uh specialty care in its simplest form? It's really, if you find that there is any abnormal exam finding So a neurological deficit, a neuro change some deformity, you know, uh curvature, et cetera or if they have abnormal imaging and imaging, you can obtain if they've had uh back pain for three or more weeks. Um And, and we'll talk a little more about, you know, what sort of images you can obtain. The one caveat to referring for abnormal imaging I'd say is this incidental finding of spina bifida. Um You can see it pictured here. It's a a defect in a bony defect in the posterior element. Here. It does not impact the soft tissue below it, like some of the more severe forms of spina bifida and it's quite common. So it occurs in about 20% of patients and it's often identified incidentally on routine imaging of the spine and it does not warrant any further evaluation or concern unless there's neurologic or structural um exam findings or skin issues at that site. And in itself spina bifida cul does not cause back pain. So now we're gonna move on to some common diagnoses uh that we'll see in pediatric athletes. The first of these are uh spondylolysis, spons is a stress fracture in the lumbar spine. It is the most common identifiable cause of lower back pain in adolescent athletes, but we can see it in the general population as well in about 5% of the general population even. So we think in the athletic population, it's uh due to overuse. So you uh in sports that require excessive hyperextension and rotation. What happens is you compress the posterior elements. The weak point of the posterior elements are the pars is the pars interarticularis, this area in between the superior and inferior articular facets. And as you do that repetitive loading, hyperextension, you compress that area, stress builds up there and eventually it can fracture, causing uh a stress fracture. So the these kids will have pain with hyperextension. That's the, the main thing I want you to take away and their pain is extension based. So you can ask them, is your pain worse when you bend forward or backwards, let's say it's worse with extension. They usually don't have an injury history and the pain would have been going on for some time, three weeks or more before they present. And um the one test that you can do in the clinical setting to uh reproduce this pain or evaluate for lysis is the ST test or one legged hyperextension test pictured here where the patient stands on one leg and you bend them back and twist them. A positive test is reproduction of pain on the side that they're standing on. They may also have evidence of posterior chain tightness, uh A K A tight hamstrings, um and when you look at their posture, they may have this anterior uh pelvic tilt as a result. And we talked about how that can load the lumbar spine as well. So when we think about imaging for diagnosing spondylolysis uh in the past or traditionally, we've been taught to get a p lateral and oblique views, particularly to look for the Scotty dog sign, which is the shape of the dog is, is in the vertebrae. Here, if the dog has a collar that is representative of a fracture in the pars or a spondilytis, ok. Now, we know now that that oblique view is not necessary and that's been born out of studies like this one from Milan at all in 2013, which found that there was no difference in the sensitivity between obtaining only A P and lateral views versus the additional oblique views. So the new standard of care is to get a P and lateral views only. And that's a great place for you to start when you obtain x-ray for a kid with backing A P and lateral views of the lumbar spine. When diagnosing spondylolysis, you know that it's uh difficult often to see on x-rays. So MRI really is the gold standard. Sometimes you will see it on, on an x-ray, particularly if it's bilateral, if they have bilateral defects, but even still you're getting MRI. So MRI really is the gold standard to diagnose it. Uh it is it sensitive for it and it also has the benefit of no radiation as you know, and it can detect early stress. So we talked about how uh stress fractures start as stress that builds up in the pars area and you may not necessarily have transitioned to the fracture just yet, but an MRI would pick up edema in that area even before the fracture occurs. And that, and that can help you prevent the patient from developing uh a true stress fracture. C T is definitive. You know, it has great bony detail, but it has radiation explosion, it cannot detect early stress. So it's usually used now only to establish chronicity. So if kids don't respond as we expect, we check to see if there's been um any changes on imaging, uh we can also use it for surgical planning if they need to have surgery to repair their spinal lysis. Now, management is typically conservative for a minimum of three months. Uh It can take longer in some people and it involves activity modification at some period of rest usually and bracing as well as physical therapy. I use bracing with the Boston overlap brace. That's how I was trained um out of Boston. And, but that's controversial. Not everybody will use that brace. That brace is an anti lodo brace that's custom made. Uh but others will use uh A L S O and, and, and it can be effective as well. Uh Most of these kids will do well with conservative management. Uh over 80% of them will have successful outcomes after a year. Some of them however, will fail conservative treatment and may even progress to thesis, particularly in the pubertal growth uh period. If those things occur, then they can have surgery to repair this. So, what is this modulo thesis? So we talked about the pars and how it can be loaded with overuse from sports that, that demand a lot of hyperextension and twisting as that stress builds up. You can have a fracture, which is the spondylolysis. If that happens on both sides. As you can imagine, there's nothing tethering the vertebrae, so it can slip forward on the vertebra, be below it. And that's when you get a spon list. Um For this, you want to be getting x-rays to diagnose uh a lateral x-ray of the lumbar spine is usually able to identify it. So you can see, I hear how that slipped forward over this vertebrae and looks like there's a pars defect as well. And you need to be aware of the, the kid that's less than 10 that's coming in with. They are at high risk for progression uh to high grade slips or higher grade ESIs because we know more than anything that growth can cause this to progress, not necessarily any particular sport participation. So these kids are managed with bracing and physical therapy and they are able to return to sport after resolution of their symptoms. If they're symptomatic, uh again, if they are less than 10, they should be getting yearly x-rays to evaluate for progression of the slip. And if they do end up having a high grade slip, they will need surgery or if they develop neurologic symptoms or evidence of uh spinal stenosis as a result of the slip, they will have to have surgery. So this is a case of a 14 year old female gymnast that I took care of with lysis. She came to me for a left sided lower back pain. Uh, for four weeks, she's a level 10 gymnast. She trains about 31 hours a week. So a lot, a lot of uh hours in sport per week and she noted that her back pain was worse with her back bend overs and in practice. So she initially got x-rays and, and you were able to see a defect in the pars here. Uh And soon after she got uh MRI to confirm, then you could see there's some active inflammation around the site of her pars defect as well. So in my goal to fulfill my objective of helping you um coach or counsel kids as they go back from injury to play, I want to share with you how I um helped her or guided her through her return to play. So initially, she was managed with bracing with the Boston overlap brace for six weeks. She wore it uh all the time except when showering and she also started physical therapy right away, but there are limitations with the physical therapy, no impact, no extension based exercises. Um And in that period. She was on complete rest from gymnastics. I use the Boston overlap brace because I feel like it helps people become pain free faster and help. It also helps them be able to get back to sports sooner. That's my practice. Some people don't brace. Some people will have them brace for a much longer period. At the six week mark. I, she came back to see me. She was doing well. She had no pain with the ST test. So I allowed her to go back to gymnastics, but in the brace, so the brace limits significantly the things she's able to do in gymnastics as you might imagine. And she still had to wear the brace for a long period. But I was able to cut down the hours at about uh 12 weeks, we were able to change our uh change from uh Boston overlap. The more soft lumber o uh lumber support or tosis and which is a, a soft uh lumber back support base. And she cut down her hours and she was able to progress to now some impact things and, and extension based things in both P T and in gymnastics. And then she was not cleared to full extension based things until around a week 18. Um And they eventually was doing the lumber support based for practices only in general. This is the progression that you follow for, for gymnasts with the extension based uh pain or spondilytis or list the uh they start with bars and you go to beams, floor vault and then they can do competition. So a word on other fractures that you might encounter in athletes, these are quite rare um but some are specific to pediatric uh athletic population. So, stress fractures have been reported in runners, players, gymnasts and ballet dancers. So this is a overuse stress injury of the sarum instead of in the cars, you see it in the state room. And it's an uncommon cause of buttock and back pain in athletes, vertebral compression fractures in athletes are also rare but may occur in sports with Axio loading of the spine in either a flexed or upright position. So typically we'll see these in in collision, sports like football and the apophyseal fractures are, are really posterior rim of ulgen fractures of the, the vertebra. They are unique to the pediatric population because it's, it's an apothesil of that bone that has not fused yet and is weaker. Um And in sports that require repetitive hyper flexion of the lumbar spine like weight lifting or diving and gymnastics, you can put traction on that area and and cause a fracture. So this is a case of a 13 year old female dancer with lower back pain that came to me, you know, she said her right, lower back and butt was painful and it had been going on for about four weeks on exam. She had an abnormal gau she was limping. She had tenderness at the right si joint and the glute muscles and her favorite test was positive. Her x-rays were, were negative. So she had an MRI which is featured here that showed uh a stress fracture in, in the sarum on that side. So how did I guide her back to sport? So I want you guys to understand that a lot of times. So there are absolute indications for, you know, keeping someone out of sport, but it is a quite intricate decision and uh sometimes it could be pretty complicated and time intensive guiding someone back the sport. They want specific recommendations on what they can do when and usually this is something that you should be referring for. You're not gonna have the time or interest perhaps on guiding some of these athletes back uh to their specific sport related movements and uh demands. So for, for my dancer with the so called chest fracture, I had a rest completely for four weeks. So the treatment for stress fracture is you have to have some period of rest. Uh How long depends on how severe the fracture is, what location? So she rested for about four weeks. Usually in that time, they can do low impact things if they still want to maintain some conditioning like a stationary bike. As long as that's not painful. At around four weeks, she came back, she still had some pain on palpation, but her gate was improved. She started physical therapy. Uh And then at around week eight, she had no pain with single leg hop test, no tenderness. So she was cleared to start some gradual return to impact activity. And then about um week 12 was cleared for full dancing. So that brings us to lumber dis disease. Uh So you, you'll see these things reported on, on imaging results by radiologists, et cetera. And it's important to understand that a bulging this alone is not that concerning you, we're concerned if there is neural encroachment and for that, you sometimes need to be able to do uh a careful uh neuro exam and uh understand, you know how to interpret some of these images. So if you see these things on on imaging, you know, this disease with neural encroachment, you absolutely should be referring. Uh It's important to understand that that this, that bulge or, or encroach on the nerves as well, do not recover. Um So they will have pain into adulthood or be at risk for pain into adulthood and as such should modify their activities. So I usually will tell my kids with this, that they should not be the ones that sign up to help someone move or get into a job or career that demands heavy lifting. If they do have to bend over to pick up anything, their backpack, heavy books, et cetera, they should be bending at the knees, not at the back. Um And they really depending on how severe it is should avoid grueling actual loading sports because as we've talked about now, uh quite a bit these sports put you at risk for this disease and, and even progression. So, lumber prolapse uh or Hern nations where a portion of the disc extrudes posteriorly and causes some kind of mass effect uh to the adjacent cord or exiting nerves. It is not as common as I in adults. So we see it in only about 11% of adolescents compared to 48% of adults. But you, this is something that you will see. Uh it's important to know that they're, you know, at increased risk in sports that we talked about collision and weightlifting and that these kids may not necessarily present the way you typically read about this prolapse in adults, for example. So they may have minimal back pain and they don't have to have sciatica. Some of them will only have leg pain. I remember I had a, a volleyball player that came in. Our only complaint was leg pain, one sided leg pain and she hadn't had any acute injury or anything to suggest that it would be hamstring or soft tissue injury. And sure enough, it was uh this disease causing that leg pain. So consider that uh in kids that present with isolated leg pain as well. If, if it doesn't sort of fit the acute injury history for some of the other leg pain conditions that we, we usually um talk about. This pain is usually flexion related as opposed to extension base as we see see in, in the stress fractures like spy and they often will have tightness of the dorsal lumber fas and the hamstrings for the reasons we've discussed before, which can limit actually their for reflection and restrict uh straight leg raising. This can be diagnosed clinically, but you do use MRI to confirm the diagnosis and even if I suspected based on positive straight leg rays, which usually is indicative of uh L five S one herniation or a positive femoral stretch, which can indicate this disease at L four or higher. So that's where they're sitting and you have them bend forward and try to touch their, their toes with the leg extended. Um Even if I have high suspicion based on my clinical exam, I'm still getting uh MRI because as we talked about the, these things can progress and it's important for them to know how they may might need to um manage their, their symptoms. So, uh we manage this disease with a period of relative rest with no sports uh followed by P T. Some kids will have a lot of pain from this. Uh They can benefit from epidural uh injection if they have persistent ridiculous symptoms and pain. And this is usually done by I R or the interventional non of spine people. Um if they continue to have pain despite conservative measures, so, unacceptable pain for more than six months, uh, they can be candidates for a dissect toy. This, it's important to not only treats the ridiculing really does not necessarily cure or stop the back pain. Uh, so they usually will still need physical therapy and things of that sort. If they have any weakness or critical loss of sensation as well, they'd be candidates for, for surgery for their disc disease. So this is uh a case of an 18 year old male volleyball player that came into me with back pain. Uh It was a bilateral on both sides and it had been going on for about three or four weeks. He was away at a intensive volleyball camp um at U C L A and, and said he thought maybe something happened while he was lifting, but he wasn't sure. And uh his pain is worse with prolonged sitting and for reflection and jumping. So, uh he got an MRI and it showed that he had a lumbar dys disease, uh pictured here. And how did I have him go back to sport or what was his course back to sport? So initially, he rested for about four weeks before he became um significantly pain free. And during that time, he did also start physical therapy, which uh as you see, there's a trend that, that this is a main save a life of the treatments for sports related injuries. Uh by week six his exam was normal. His pain was improved and he was cleared to start some impact activity with P T. So I usually will have them do that before, especially if they've rested for a long period. So a month out of your sport, you can't just go back to sport like normal. You have to sort of gradually build up to what you were doing before and, and, and P T can be helpful for introducing or reintroducing you to that, that impact in particular. Uh because he, in, in this case, had a pain with impact like jumping. So they would start with just running on the treadmill or the antigravity treadmill, which controls how much force uh you would put on your um your legs and then uh advanced to some stuff outdoors and in the gym, some sport specific stuff. So around week eight, he was cleared for full ball wall. So that brings us to si joint dysfunction, uh which is the si joint in itself is an important joint in athletes. It plays a crucial role in the transfer of forces from the ground to the trunk and the upper extremities. And so it really sort of disperses the forces between the trunk and the lower extremity. And it can be a source of pain in the young athletes because of uh hyper laxity or asymmetric landing that might lead to instability or inflammation even at the si joint. So athletes will present with pain over the si joint that is insidious and onset oftentimes they don't, you know, recall any injury and this pain may or may not radiate into the legs. So there are a couple of tests that you can do to diagnose si joint pain. The first is tenderness over the si joint. So you put your hands on the iliac crest and you're at about L five, you drop down a little and you should be at the, the si joint. So pain when you palpate there, um it is concerning for si joint pathology. Uh the figure four or favor test pictured here, which we talked about before as well. Uh can be done to evaluate for i joint pathology or dysfunction as well. The thigh thrus loads the si joint. So it's pictured here where you apply a force through that bent knee down through the back and, and a positive test is reproduction of pain at the si joint. And so we talked about how asymmetric loading uh of the joint can cause pain. So you're essentially trying to reproduce that hair. A gains test is another special test you can do where uh the patient is on the back or laying on their back and one leg is allowed to fall over the side of the table and the other one is flexed and you will push against both. So push against the, the non tested side or the flex hip as well as on the knee that's falling over the side of the table. A positive test is, is reduction of pain on the the side that's over the table or the leg that's extended over the table. Now, imaging x-ray imaging is usually negative with si joint dysfunction. So you're usually going off of symptoms, location of pain. Some of these clinical tests that we've done in diagnosing i joint dysfunction in young athletes. It's important to consider though that young athletes can have pain from other things, right? Uh As primary care providers, you can't only think about them as things. So they might have inflammatory sais or infectious. So you need to ask about those things on history, fever, any family history, um aon arthropathies, if you are concerned about that or you think maybe it was as simple as I joint dysfunction and they're not responding as they as you might expect you, you would want to get more imaging um with MRI to look further and you might even need to get some lab work. Screening lab works like C R P S R CBC and H L A B 27 to evaluate further. These kids are managed with activity modification. Uh They don't necessarily have to stop everything completely. Uh They can just avoid the exercises or activities that cause pain. They need physical therapy as well for pelvic stabilization, uh hip and abdominal strengthening and then I nsaids can be helpful to alleviate pain and any inflammation that might be causing pain as well. So this is a case of a 15 year old male fencer who came to me with right sided lower back pain. So, if you think about fencing, he, he lunges and he actually lunges with his right leg. So he's unilaterally loading that si joint on that side, right, similar to the special test of the thy thrust that we're doing. So, every time he does that lunch to fence, he's having pain. Uh, his pain was going on for about three weeks. He fences a lot. He has no injury that he can remember and he does fence in for about 20 hours a week. So these x-rays were normal, but the exam is very specific, localized pain to the si joint, positive pain with thy thrust and, and when you think about sort of the mechanics of his sport and, and his complaint made sense that he was having some si joint dysfunction. So for his return or his Eva evaluation, uh I had him rest for two weeks, complete rest, uh, from fencing. And I also had him taken an anti-inflammatory scheduled for about a week and then at, at week, two or two weeks after this rest, he was feeling better. Uh, he was able to go back to some fencing, but with modification to trying to avoid uh repetitive lunging things that cause pain. And, and at about four weeks, he had done that, he had no return of his pain. He was progressing in, in physical therapy and he was cleared to return to sport. So now we're gonna move on to Bertil Syndrome, which is, is something you may be unfamiliar with. But you might have seen uh it's common for people to have a lumber sa girl transitional vertebra. So you might have seen that on an x-ray. So that's where there is an anomalous enlargement of one or both of the transverse processes of the L five vertebrae, which can actually articulate with either the sacrum or the ilium. And as you might imagine, if you have some sort of or use pattern or even acute injury at that site, it might cause some pain. So, Birla syndrome is the symptomatic combination of having that anomaly and back pain. Some people, a lot of people, more people will have the anomaly without having back pain. So it's something that, that you might have seen or you will see and the incidence of bertolotti is about 15% in patients with lower back pain uh below 30. So these patients will present with pain at rest, particularly when sitting or standing. And the pain is exacerbated by extension and uh stair climbing and on radiographs, usually you're able to identify the presence of the lumber or lumber transitional uh vertebrae and uh MRI if they have pain, MRI can be helpful to look at the quality of the disc and the nerve roots at that area, it might show indentation or swelling of the L five nerve roots and an MRI would be preferred over C T. Uh In this case, for some of the reasons we've talked about before, when you think about playing radiographs, going back to that uh Ferguson A P view uh is a true A P view of the lumber Sarel junction uh can be helpful to diagnose or get a better picture of that area and help you identify the transitional vertebrae a little better. So you can think about adding that into your work up as well. Uh So how are these kids managed? Initially? They're managed conservatively with like N A P T, some form of rest. Uh If they respond to that grade, if they do not, they can benefit from a therapeutic and sometimes diagnostic steroid injection into that articulation between the transitional vertebrae and the sarum or the ilium. Uh If that's not helpful um or they have significant articulation, we're sure it's, it's really only from this articulation surgical resection of the enlarge trans process articulation or fusion of the normal articulation is really the definitive way to treat it. So, I uh had a, a kid, a 13 year old soccer player who came in with lower back pain and she said it started after, while playing soccer, she was in a soccer game where she tripped into a fence and caused her back to hyperextend. And then she started having pain from that and it had been going on for about a month when I examined her. She had pain over all um L L one through elf five along the spine and then her pain, she had pain with both flexion and extension, but it was definitely worse with uh flexion. And she also interestingly had a straight leg race test. So the this is her imaging and you can see the abnormal um transfer process here and some edema at the articulation with the, the sacrum. And um this was what her like this at that level looked like. So how is she managed? So her, her management is actually still ongoing. But initially, I had had her rest for about two weeks. I had her take naproxen for her pain scheduled and then she came back and she wanted to try to go back to sport. She felt good. Um And at that time, I had her start physical therapy as well. She went back and she tried to play but the pain came back, same intensity, same quality right away to we had her shut it down. And that was the point when we got the MRI imaging and it confirmed that she had this syndrome and um she was instructed to just rest and continue with P T and I referred her to our spine surgeon for further management. Oops, sorry. So in that time, she did a period of absolute rest. Um and then had some failed attempts of um getting back to sport. So eventually she was referred for an I I R guided steroid injection, which uh was immediately helpful for her. And then she was placed and embrace uh with no activity for six weeks and then six weeks post the injection, she restarted physical therapy and it's been doing ok, but it's not yet back to sport. So now that you have an idea of some of the common um pediatric back injuries in, in athletes, um I want you to understand also that most of the back pain that you'll see in kids, it's not really serious and it will go away with very little treatment. Uh A lot of what you see is stuff that you can't identify a diagnosis for. Uh and it's very nonspecific in nature and for, for these kids, um some complementary and alternative medical therapies might be helpful. Um There is not a lot of great literature about the effectiveness of some of these for, for kids, the, the literature and the cam therapies for vaccine is really uh in adults. There, there is some literature on acupuncture and kids suggests that it, it helps, you know, other things that kids can try and see benefit from or massage, pupping, uh chiropractor, work, yoga. I'm a big proponent of yoga. People can do it at home. There's yoga for athletes, uh elite athletes, collegiate athletes do yoga to compliment uh whatever sport in. So I'm a big, big proponent uh of it. Uh a word on activity modification here, essentially, it, sometimes these kids just have because they're doing too much. They're in multiple travel leagues, they're training for excessive hours a week and they might need to quit that third or second travel team so that they're not uh stressing their body uh as much. And again, these are difficult conversations to have with them and, and we're happy to see them and, and, and help them navigate that thought process and, and come to that realization of how important or equally important rest is uh to training um C BT. So a lot of kids will have chronic pain or, or somatic, even manifestations of back pain and, and they may not know how to understand or deal or process that. And C BT can be helpful for that. We have a great pain management department here that, that uh offers a lot of these modalities um that can help your your young athletes with, with back pain. So to summarize pediatric back pain is not the same as adult back pain. Even still most do not have an identifiable cause. Um but remember the ones that we talked about that are quite common in pediatric athletes, particularly spondilytis. The most commonly identifiable cause of lower back pain in young athletes. Remember to consider their age, their sport occurrence of a recent growth spirit, for example, that can be associated with increased hamstring tightness, increased risk for stress fractures like as well. And remember your red flags and diagnosis, specific exam findings uh when evaluating these kids. So these are some of my references and I wanna thank you. Um This is a picture of me competing at the World juniors in the long jump in Beijing in oh six. And um I I love, love, love taking care of young athletes. I this is what I went to med school to do and I'm happy to see your referrals or answer your questions or help you navigate how to get them back to sport, uh and, and teach them how to prevent injury as well. That's equally important. So with that, I want to thank you. Thank you so much, Doctor Watkins. Amazing. Um We do have a, a question and a comment and thank you for this talk. Could you comment on when a PC P should order imaging plain films versus MRI versus just refer to P T first and, or um Ortho or sports medicine and, and let them decide and it sounds like from what I've learned in, in this talk and also with rotating with you as a resident, is that the history and the exam and the exam are really critical for that. Is that right? Yeah. So um we talked about some exams, specific things if, if they have a neurologic findings use or changes or associated signs and symptoms, uh you should be imaging and you always start with, with XXY first, you're not gonna get an MRI approved unless you do that. So a p later of, of the lumbar spine usually can be helpful. Uh if they have no acute injury and the pain has been going on. Uh for a short period, you can watch that you can bring them back before you x-ray. If the pain is really intense, even if it's been going on for a short time, you, you should x-ray um if they have positive special tests. So we talked about a couple of diagnoses and some special tests to evaluate those, then you should be referring, if you find abnormal imaging or findings on these x-rays, you should be referring a question of or so versus sports kind of depends on where you practice. Um Here at U CS F, we're combined in one piece Ortho Pete sports. Um So they're gonna be taken care of if it's uh a bony thing, I, I would say I would send to, to Ortho um if they need guidance with the return to sports, I think sports, but either way you can start with sports and we can get them to Ortho if they need to be seen. Uh I think it's often easier for us to get advanced imaging, we know how to navigate that and, and, and make it happen faster. So, so I would just start with plain imaging and refer if you're concerned. Thank you. There's also a question um, about, you spoke to sports specialization in younger and younger kids in our culture and there's a question about shouldn't coaches for high risk sports recommend yoga and other preventive strategies across the board and what sort of advocacy is being done there? Yeah. So there's a lot of work on, uh, sport specialization and counseling on, on when that's appropriate. Um, I don't think all coaches are aware of it. Uh I think there's a role for providers including primary care providers to give some anticipatory guidance on that. On the list of all the things that you have to give anticipatory guidance in port, I would say you see a healthy kid, you know, they, they're active in sports, great. They have no other problems. That's your opportunity. You know, we we, we think sport specialization is ok, certain sports that demand specialization at a young age. So like dancing gymnasts, it's really hard to talk them out of specializing anyway. So you instead teach them how to know their body, how to report pain, what pain is bad pain that they can't work through. But for the other sports, um we know that participation in multiple sports is helpful, it's beneficial, it helps you use your body in different ways, it reduces injury, particularly overuse injury. So we want them to participate in multiple um sports and that can, should happen at least through puberty. Um I know a lot of my teammates in college even were people that were participating in multiple sports all throughout high school and even at the collegiate level, they were participating in, in multiple sports. So, so we, we really should be encouraging kids to be active in multiple sports and not specialize in one. Um They should try to limit their hours in sports to their age or less per week. That's like a good guideline. They should have at least one rest day. And then I'm a big proponent of a day where they do cross training. So yoga is a great cross training activity. Um It's basically a way to use your body in a different way from whatever sports you're doing, it promotes great flexibility. So I think there's still a lot to be done in terms of getting this across the board to coaches as a way to reduce injury in young athletes. But, but we have a role as providers too. So being aware of sort of those general guidelines can be helpful. Thank you. And for those Children who are obese or not necessarily athletes, does that change um their management for the conditions that you spoke to or increased risk? Um So I I will say that back pain thrives in inactivity. So I think it, depending on where you practice, you may see more back pain in, in inactive kids, even though we know that athletes tend to have more back back pain than, than inactive kids. And, and the management is the same if they happen to have. We talked about how you can see spon ISIS in the general population as well. Not just in athletes, you would manage them the same. But I think the key is, is one acknowledging how their weight might be impacting their posture and that and all that can lead to back pain as well. We talked about some of these things and, and continuing to guide them on how and why weight loss is important. Um and then um encouraging them to be active. So I, you know, a lot of these kids that you can't find an ideology for it's not specific, specific or you might think it's muscular um activity can help them. So, encouraging activity, all the things you always talk about um for 00 obese kids, it's not necessarily any, any different um particularly if, if you can find a diagnosis and it's even more important to harp on activity if you cannot find a diagnosis. Thank you. And another question, um Can you speak to the role of mental health when you recommend prolonged breaks from sports? This person seen kids become deeply anxious and depressed when they're told they have to miss out on big chunks of the season. And do you have preferred referrals and resources that you offer for that? Yeah. So um as we, as you know, mental health services are, are really hard to access. Um, and it's no different for athletes. There are, you know, a few private places that will, are tailored to athletes. Um, a mindset dot I O is one that's local to, to Oakland. Um, and yeah, mental health goes hand in hand with, um, improvement recovery from injury. Um, and I think the way I approach, helping them understand why it's important to rest. It's not that we're saying you can't do your sport forever one, you could still work on certain elements of your sport or you can participate in another sport, but it's helping them realize how ineffective it is to be doing one thing year round and usually they're in your office because they're injured. Um, I often will use myself as an example, even as a collegiate athlete, we practiced four days a week, we had Wednesdays off or it was a day where we did cross training, swimming in the pool and that kind of thing and that's at the collegiate level. So it's no different. Um, for them, you know, coming up, they should start, um, treating their bodies well, uh, with respect, that's sleeping well, resting when you should. And if you're struggling with accepting that or recovering from injuries, yes, certainly tapping into a mental health coach, um, support groups, et cetera. Thank you another question. I think that this might be the last one that we have time for as an athletic trainer at a high school. Do you have an opinion or advice on when athletic trainers should be referring to a physician. Obviously red flags or worsening symptoms require a referral but unsure about how long I should try to manage low grade pain without major improvement. Yeah, I think if you're not seeing improvement, they need to be evaluated. Right. You don't have the benefit of imaging, um, and you, you need to tap into that a lot of times And even if it's just to rule out other things, like you may know exactly what it is and what you're treating. But if they're not um progressing, like you would expect, I'd say I would give it like max two weeks modified activity, it's not changing. Uh I would have them come in uh to be evaluated and then uh certainly knowing, you know, what your athlete's sport puts them at risk for, right. And so you can narrow your differential that way and a lot of the things you need imaging um to diagnose um and it doesn't hurt for them to get an evaluation and everything be ok and then they continue working with you. But I, I think um because of the lack of access to imaging and things like that, it's, it's safer to send them in sooner rather than later, if only to rule out other pathologies as an athletic trainer. Thank you so much. This has been a really high yield grand rounds today and I wish everyone a good week. Thank you, Doctor Watkins. We appreciate you. Thank you.