Low back pain in Adolescent Athletes Claes Göran Sundell Department of Community Medicine and Rehabilitation Umeå 2019 Responsible publischer under Swedish law: The Dean of the Medical Faculty This work is protected by the Swedish Copyright Legislation (Act 1960:729) Dissertation for PhD ISBN: 978-91-7855-024-1 ISSN-0346-6612 New series no: 2014 Copyright © Claes Göran Sundell, 2019 Cover illustration: Stina Norgren, Illustre.se Illustrations: Stina Norgren, Illustre.se, page 1,3,4,12,13,41 Illustration page 2: Permission Encyplopedica Brittanica, page 2 Pictures: 3D4 Medical; www.3D4Medical.com, page 1,3,5,6,7 Article nr .3 "© Georg Thieme Verlag KG." All previously published papers were reproduced with the kind permission of the publishers Electronic version available at: http://umu.diva-portal.org/ Printed by: UmU Print Service, Umeå University Umeå, Sweden, 2019 1 “Listen to the Sound of Silence” Unknown To my family: Doris, Cecilia, David, Johan Contents Abstract .......................................................................................... iv Sammanfattning på svenska ........................................................... vi Preface .......................................................................................... viii Abbreviations ................................................................................. ix Introduction .................................................................................... 1 1.Anatomy ......................................................................................................................... 1 1.1 The skeleton .......................................................................................................... 2 1.2 The Spine ...............................................................................................................3 1.3 The lower back ..................................................................................................... 4 1.4 The Functional Unit of the Spine ........................................................................ 4 1.5 The vertebrae ........................................................................................................ 5 1.6 The Pars interarticularis of the Vertebrae ......................................................... 6 1.7 The Zygapophysial facets of the Vertebrae ......................................................... 7 1.8 Apophysis .............................................................................................................. 7 2. Functional anatomy ...................................................................................................... 7 2.1 Spinal Load .......................................................................................................... 8 3. The historical perspective of Low back Pain .............................................................. 8 3.1 The natural history of LBP .................................................................................. 9 3.2 The history of Spondylolysis .............................................................................. 9 4. Low Back Pain.............................................................................................................. 9 4.1 Non-Specific Low Back Pain (NLBP) ................................................................ 10 4.2 Specific Low back Pain ...................................................................................... 10 4.3 Adolescent Low Back Pain (ALBP).................................................................... 10 4.4 Low Back Pain and Disability ........................................................................... 10 5. Low Back Pain in Adolescent athletes ....................................................................... 11 5.1 Spondylolysis ...................................................................................................... 11 5.2 Spondylolysis-Aetiology .................................................................................... 11 5.3 Spondylolysis-Pathogenesis .............................................................................. 11 5.4 Spondylolysis- Stress reaction .......................................................................... 12 5.5 Spondylolysis- Stressfracture (Incomplete/Complete) .................................... 13 5.6 Spondylolysis/Pseudoarthrosis ......................................................................... 13 5.7 Spondylolisthesis ................................................................................................ 13 5.8 A differential diagnosis ..................................................................................... 14 6. Aims ............................................................................................................................ 14 7. Summary of Papers ..................................................................................................... 15 Paper 1 ...................................................................................................................... 15 Paper 2 ...................................................................................................................... 15 Paper 3 ...................................................................................................................... 16 Paper 4 ...................................................................................................................... 16 Paper 5 ...................................................................................................................... 17 i Methods ......................................................................................... 18 Questionnaries – Study I and II ..................................................................................... 18 Epidemiology/Prevalence study - Study I .............................................................. 18 Retrospective questionnaire study – Study II ........................................................ 19 Physical examination – Study III, IV, V ....................................................................... 20 Physical examination - Study III............................................................................ 20 Functional movement test ....................................................................................... 21 Specific provocation tests ........................................................................................ 21 Physical examination – Study IV ............................................................................ 21 Physical examination – Study V ............................................................................ 22 MRI and CT – study II, III, IV, V .................................................................................. 22 Study II .................................................................................................................... 23 Study III ................................................................................................................... 23 Study IV ................................................................................................................... 24 Study V ..................................................................................................................... 24 Differential diagnosis .................................................................................................... 24 Statistical Methods ........................................................................................................ 24 Statistical analysis .................................................................................................. 24 Etichs ...............................................................................................................................25 Results ........................................................................................... 26 Results – Study I-V ........................................................................................................ 26 Study I ...................................................................................................................... 26 Prevalence ..................................................................................... 26 Duration ........................................................................................ 26 Consequences ................................................................................ 27 Study II Retrospective ................................................................................................... 30 Study III. Clinical study .................................................................................................. 31 Clinical investigation ............................................................................................... 31 Study IV. Subgroup Study III – Classification ...................................................... 33 Study V. Differential diagnostic ..................................................................................... 37 Discussion ..................................................................................... 39 Low back pain ................................................................................................................ 39 Prevalence. ............................................................................................................... 39 Low Back Pain in adolescence ...............................................................................