Back Pain In A Junior Olympian - Running

Abstract

HISTORY: 15 year old female member of the Uruguay Youth Olympic National Track Team with 1 year of back pain and 8 months of constant, worsening pain. Pain was located in the low lumbar region and worsened when she ran. Running hills and weighted exercises increased the intensity. Also worsened with prolonged sitting or standing. Improved with walking, stretching, and lying supine with knees in flexion. Outside MRI reported signs of degenerative disc pathology at L4-5 and Schmorl nodule of L5. MRI otherwise normal. After the PanAm games she stopped running completely to try to allow for healing; however, pain remained. Gained no benefit from physical therapy at home. Grew 7 cm in the last year. Questionably regular menses. Resting pain a 6/10. PHYSICAL EXAMINATION: Slender young female. Normal alignment of the pelvis. Tender from L3 to the sacrum in the midline and paraspinal region. Tenderness both SI joints. Pain with flexion and extension. Flexion slightly limited with a Schober’s of 20 cm. Extension -1. Lateral bend normal bilaterally without pain. Hip ROM normal. Straight leg raise negative. Popliteal angle of 70 degrees on the right, 40 degrees on the left. Strength and reflexes of upper and lower extremities are normal. DIFFERENTIAL DIAGNOSIS: 1. Sacroiliitis 2. Pars fracture/spondylolisthesis 3. Quadratus lumborum strain 4. Referred pain from hamstring strain 5. Pelvic/sacral stress fracture in the setting of possible female athlete triad 6. Discogenic low back pain 7. Facetogenic back pain TEST AND RESULTS: Sed Rate - 3 CRP - <3 MRI pelvis - Superior margins of both SI joints show significant subchondral marrow edema on both the sacral and iliac sides. Left greater than right subchondral fatty change. Mild disc degeneration at the L4-5 level. Normal gluteal and hamstring tendons. FINAL WORKING DIAGNOSIS: Bilateral acute on chronic sacroiliitis - likely autoimmune. TREATMENT AND OUTCOMES: 1. Core strengthening program. Encouraged to remain as active as possible. 2. Running evaluation. 3. Gradual return to run. 4. Decided not to get HLA-B27 because diagnosis already made. 5. Started on indomethacin 75mg BID. Consideration for TNF blockers in the future. 6. Rheumatology follow-up recommended. Expected to develop characteristic findings of spondyloarthropathy as she gets older. 7. Consider nutrition evaluation.