Low Back Pain in a Collegiate Swimmer

Abstract

HISTORY: 21 year-old female collegiate swimmer with several weeks of left sided low back pain insidious in onset. She reports the symptoms started after running during practice and initially only recurred during land training. Symptoms worsened over time and began to occur with pushing of the wall while swimming and during backstroke. Symptoms were described as sharp aching pain localized to the left side of the lower back with occasional radiation to the left posterior and lateral thigh. She also reported one episode of numbness and tingling down the lateral aspect of her left thigh. A few days of rest, NSAIDS, and PT initially helped to improve her symptoms. She returned to swimming without problems for approximately one week. She then restarted lifting and running and her symptoms returned within a few days. She denied any recent change in menstrual cycle, although she had a history of irregular periods during her junior year. She denied any recent weight loss and in fact reported a recent 10 pound weight gain. She denied any history of stress fracture. She reported a history low back pain as a teenager (she had a history of spondylolysis) and commented that “this feels different”. PHYSICAL EXAMINATION: Gross examination of the back revealed normal contour, no gross deformities, no leg length discrepancy. Range of motion was normal, there was no pain with full active range of motion. There was moderate tenderness with palpation over the left side of the sacrum. No tenderness over the spinous processes. No reproduction of symptoms with FABER. Gaenslen's Test was negative, stork test was negative. Straight leg raise negative. There was reproduction of her symptoms with hopping on the affected side. Lower extremity strength was 5/5 B DTR's 2+ on left, 3+ on right, sensation was intact. DIFFERENTIAL DIAGNOSIS: spondylolisthesis/spondylolysis Inflammatory spondyloarthropathy Piriformis Syndrome Sacroiliitis Sacroiliac Sprain Herniated disc Musculoskeletal pain Stress Fracture TEST AND RESULTS: X-ray L-spine (9/14/2005) – spondylolysis at L4 & L5 MRIL-spine (10/4/2005)- abnormal signal of the left sacrum, pars defect L4&L5 causing minimal spondylolysis, small L4/L5 disk herniation MRI sacrum/pelvis (10/17/2005) – fracture of the left sacral ala with extension into the SI joint posteriosuperiorly with the remainder of its coarse parallel to the SI joint. FINAL WORKING DIAGNOSIS: Sacral Stress Fracture TREATMENT AND OUTCOMES: Activity Modification – no weight bearing exercise Returned to swimming as tolerated Discussion of nutritional factors and offseason training regimen