Low back pain in youth: Recognizing red flags
Although low back pain in children and teens is usually benign, recognizing red flags that indicate the need for imaging, referral, bracing, or surgery is critical.
PRACTICE RECOMMENDATIONS
› Be aware that low back pain is rare in children < 7 years but increases in incidence as children near adolescence. A
› Consider imaging in the setting of bony tenderness, pain that awakens the patient from sleep, or in the presence of other “red flag” symptoms. A
› Consider spondylolysis and spondylolisthesis in adolescent athletes with low back pain lasting longer than 3 to 6 weeks. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Increased thoracic kyphosis that is not reversible is concerning for Scheuermann disease.9,17,18 A significant elevation in one shoulder or side of the pelvis can be indicative of scoliosis. Increased lumbar lordosis may predispose a patient to spondylolysis.
In patients with spondylolysis, lumbar extension will usually reproduce pain, which is often unilateral. Hyperextension in a single-leg stance, commonly known as the Stork test, is positive for unilateral spondylolysis when it reproduces pain on the ipsilateral side. The sensitivity of the Stork test for unilateral spondylolysis is approximately 50%.32 (For more information on the Stork test, see www.physio-pedia.com/Stork_test.)
Pain reproduced with lumbar flexion is less concerning for bony pathology and is most often related to soft-tissue strain. Lumbar flexion with concomitant radicular pain is associated with disc pathology.8 Pain with a straight-leg raise is also associated with disk pathology, especially if raising the contralateral leg increases pain.8
Using a scoliometer. Evaluate the flexed spine for the presence of asymmetry, which can indicate scoliosis.33 If asymmetry is present, use a scoliometer to determine the degree of asymmetry. Zero to 5° is considered clinically insignificant; monitor and reevaluate these patients at subsequent visits.34,35 Ten degrees or more of asymmetry with a scoliometer should prompt you to order radiographs.35,36 A smartphone-based scoliometer for iPhones was evaluated in 1 study and was shown to have reasonable reliability and validity for clinical use.37
Deformity of the lower extremities. Because low back pain may be caused by biomechanical or structural deformity of the lower extremities, examine the flexibility of the hip flexors, gluteal musculature, hamstrings, and the iliotibial band.38 In addition, evaluate for leg-length discrepancy and lower-extremity malalignment, such as femoral anteversion, tibial torsion, or pes planus.
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