HISTORY - A 21 year old college soccer player presented with a three week history of low back pain. During warm-up, he reported doing abdominal strengtheming exercises with his hips flexed and lower extremities elevated. As part of the exercise, his teammate pushed his legs to the right. He immediately felt a sharp pain that resolved within a few minutes. A week later, during an intra-squad scrimmage, he twisted his back. After several days, his back pain radiated down his left lower extremity and alternated intermittently to his right lower extremity with associated numbness and tingling. The symptoms worsened after activity and the pain persisted despite Aleve, rest, stretching, and back exercises. There was no history of back pain, trauma, or prior injuries. PHYSICAL EXAMINATION - General examination revealed normal stance and gait. Examination of the lumbar spine revealed mild scoliosis. Tenderness of the right lower paraspinals were present. Range of motion of his back was 75% of full flexion, lateral bending, and lateral rotation. Full extension was present. He had pain with back flexion and improvement of pain with back extension. Pain was also elicited with hip flexion, extension, and abduction. Popliteal angles bilaterally were 10 degrees. Ely's test was 7 inches bilaterally and caused anterior pelvic tilting with increased lumbar lordosis. Valsalva maneuver and straight leg raise test were negative bilaterally. There was full strength of lower extremities with intact sensation to pinprick. The reflexes were 1 + and symmetrical at the patellas, medial hamstrings, and ankles. DIFFERENTIAL DIAGNOSIS: Lumbar radiculopathy Discogenic low back pain Lumbar strain/sprain TEST AND RESULTS: Lumbar spine plain film: AP/Lateral/Oblique: -normal lumbosacral spine MRI of lumbar spine: partially lumbarized S1 rudimentary disc at the S1/S2 level stress fractures of the pedicles of L4-fracture extend through the inferior cortex and approach the superior cortex no lumbar disc herniation or nerve root impingement FINAL/WORKING DIAGNOSIS: Bilateral pedicle fracture of L4 TREATMENT: Back brace NSAIDs Physical therapy with stretching, strengthening, lumbopelvic stabilization and balance exercises Hold from contact sports