Last week I saw two different male teenagers with lower back pain complaints. Both patients were 15 years of age with very similar symptoms. As regular readers of this blog will know, I have a special interest in lower back pain since I manage it on a daily basis myself and find the science of pain fascinating. As with all pain, the factors contributing to it are vast and can widely vary from patient to patient. What works for one patient may be very unlikely to work with another especially when it comes to persistent back pain.
In the case of teenagers and back pain, it is very important to identify red flags relevant to the presentation. The fact that a 15 year walks into your clinic in pain is a red flag in itself so my suspicions are already heightened from the get go. Both patients had no neurological symptoms (absence of pins and needles, numbness, tingling, etc.), pain was insidious, intermittent and activity related in both, sleep was not disturbed, no unexplained weight loss, etc. My suspicions on both were relaxed as the treatment progressed. To set the scene here, whilst anyone visiting a clinic under the age of 20 heightens my suspicion of sinister activity, it is important to bear in mind that almost 80% of teenagers presenting with lower back pain will not involve anything sinister (disease, disc herniation, cancer, etc.). As a physiotherapist my job is to ensure the following
It didn’t take long to ensure that both of these guys fell into the 80% range but both were very interesting patients that taught me different lessons. Obviously for patient confidentiality, I am referring to them as “John” and “Paul”. These are not their real names. There is nothing clinically rare about these patients but both are examples of what physiotherapists see very regularly.
John came in accompanied by his parent. His pain had been ongoing since early in the year (approx. 10 months) and largely came about playing a field team sport involving quite a lot of trunk rotation. His pain would ease when not playing sport and flare up after training or competition. As mentioned, following an examination, nothing untoward jumped out. We were unable to recreate the pain in the clinic but the patient reported that it wouldn’t take long to recreate it in a game.
The patient had been avoiding certain movements in his sport for fear of pain. This meant that his body no longer tolerated certain patterns and reminded him of such regularly during games. The patient had been to physios in the past who gave him trunk stability/core exercises which he routinely did but felt no relief. I explained that my suspicion was that a weak core has little to do with this movement intolerance and that we simply need to get him moving in a non-fearful way on the playing field. The patient got lots of reassurance and we got moving into movement patterns that will begin to allow his body to tolerate rotational movement during sport.
It was in the subjective however that resonated most. John’s mother, quite understandably, was anxious to get a scan done to see what was causing the pain. It was interesting that the patient himself did not feel that the scan was warranted and thought it a bad idea. I explained to the mother that, although very understandable, getting a scan will not give us any more information than we already know considering his symptoms. Thankfully the hospital refused giving a scan a few months previous as they also felt it unnecessary.
“Nobody is asking you if you have a headache due to your grey hair”
There are a lot of lessons to take away for both patients and clinicians reading this:
Once again, a very similar presentation with this young man. Paul is a very active, young athlete with persistent intermittent back pain especially prevalent when playing sport. His sport involves trunk rotation and flexion which is where he would get pain. Again, red flags were discounted. Patient surprisingly had lots of mobility at his hips and was able to do a standing toe touch to the floor without any pain. Standing extension wasn’t an issue either. Supine Straight Leg Raise did however recreate his pain but not at the same intensity as when he would play sport. He had been experiencing pain but did not allow it to limit his involvement in sport or activity. He recently joined a gym to build some more muscle to help him on the field. In general, this guy’s attitude was flawless. Lots of confidence, lots of willingness to get better, he was definitely on the right track already.
What jumped out at me from this patient was a visit he had to a general practitioner last year when he was 14 years old. What the patient understood from this GP was that in order to fix this issue he would have to avoid sport for the rest of his life. Granted this is a 14 year old boy at the time hearing advice from an adult so it may have been misinterpreted but nonetheless that is what he heard. The patient left the GP clinic in tears thinking he was destined to live a life watching his friends play sport while he sat on the sidelines.
I reassured the patient that this pain can be managed with appropriate movement and load monitoring in the sport he was playing. He was coming to the end of a long season and we agreed that he would put a big effort into getting to the gym and working on an introductory strength program I helped him create. We also worked on some stretches to encourage movement tolerance of hip flexion without flaring up pain.
“Always ask your patient to tell you what they will tell their mother/wife/husband/friend when they leave the clinic regarding what is causing their pain”
Paul reinforced the following for me:
I would be lying if I said every patient interaction teaches me something. There are a lot of these opportunities to learn however and these two very similar teenagers provide lessons for not just clinicians but other guys their age and maybe some parents out there reading.