Case: The 14-Year-Old Diver

Part 1: The patient is a 14 year old female presenting to outpatient physical therapy with complaints of low back pain of recent onset 2 weeks ago. She denies any mechanism of injury. Her back pain is localized to the lower lumbar spine and hurts with walking, sitting for extended periods of time, bending forward/backwards as well as twisting. She describes her pain as achy at rest and sharp at times with movement. She denies any feelings of weakness, radicular pain, paresthesias or bowl/bladder changes.

Her father adds that she injured her left ankle 2 years ago during a diving incident while attempting to jump from the diving board. He mentions his daughter suffered a type 2 talus fracture requiring surgical fixation and subsequent removal of hardware 6 months later. She attempted to return to diving 8 weeks from the date of her surgery after being cleared by her surgeon. This attempt was unsuccessful due to moderate pain and weakness. She was then treated in physical therapy for approximately 1 year, but chose not return to diving. She does participate in high school cheerleading for the football team as a base and is currently 4 weeks into the season.

She is 5 feet, 2 inches tall and weighs 115 lbs.

F/u Questions for you

1. Are there any red flags? yellow flags? sinister pathology you would like to rule out?
2. Based on the information provided, what additional subjective information would you like to know and why?
3. Could you come up with at least 2 preliminary diagnoses?
4. What subjective outcome measures would you select that may provide useful information from this patient?

Part 1: summary

1. Are there any red flags? yellow flags?
- Red Flags: Any information that help decrease the chances of serious pathology such as a space occupying lesion, infectious disease or Spondyloarthropathy. Some information was provided that would help increase our confidence in there being no red flags such as no bowel/bladder changes. Though for a teenager, the wording of these questions may need to be more specific to get a more accurate response. Additional information that help with the other red flags include: 1) any recent sicknesses 2) feelings of stiffness at any point in the day and 3) pain in other joints.
- Yellow Flags: any recent growth spurts and by how much, changes in weight, changes in coordination that accompanied the most recent growth spurt, a history of scoliosis, hyper-mobility, congenital anomalies (ie., lumbarization, sacralization, can be structural or functional)
- In this case, there were no red or yellow flags

2. Based on the information provided, what additional subjective information would you like to know and why?
- Has she had any imaging performed? Yes, x-rays were negative for significant pathology. Views used were anterior/posterior and lateral. Would you want any additional imaging at this point? If so, what type of imaging and why?
- Has she had a Risser score for stages of growth or told anything about growth? per chart review, she was classified as a grade 3, indicating a slowing of growth. She was told that she is done growing for the most part.
- Why hasn’t she returned to diving? In this case she states she is nervous about returning to the diving board due to the mental imagery surrounding her original injury and that she does not feel she can trust her ankle. Her father felt he was doing the right thing by returning her to diving at 8 weeks once she was cleared by the surgeon, even though she explained she did not feel ready. 
- How did her rehab for the ankle injury go? It was slow, she ended up having quite a bit of pain from the screws before getting them removed. The surgeon also explained she had excessive scar tissue that needed to be removed.  

3. Could you come up with at least 2 preliminary diagnoses?
- spondylolysis
- spondylolisthesis
- lumbar strain
- complex regional pain syndrome (reflex neuro-vascular dystrophy)
- sacroiliac dysfunction
- mechanical causes of low back pain

4. What subjective outcome measures would you most likely provide that may provide useful information for this patient?
- Micheli Functional Scale
- Numeric Rating Scale-11 for pain  or Visual Analog Scale
- Patient Specific Functional Scale

Part 2

After digging deeper with the history, you feel confident that the patient is at a low risk of having any red flags such as neurological symptoms indicative of a spinal tumor. You do note that she has grown 3 inches in the past 6 months and has gained 30 lbs since her ankle injury. She feels she is not as flexible as she was prior to her growth spurt.  She shares with you that she has been a cheerleader for 8 years and has no previous history of back pain. Her pain is described as 2/10 at rest during your evaluation and 7/10 at worst. Her pain with trunk flexion typically occurs at end range when she attempts to return to a standing position. Her pain with trunk extension is described as sharp and sudden at times.

Objective Examination
Static standing posture:
- sway back with increased thoracic kyphosis
- no significant signs of muscle imbalance or scoliosis while in upright position
- hypertrophic erector spinae noted bilaterally

Gait: unremarkable with the exception of decreased arm swing noted bilaterally and a decreased cadence.

Assessment of spinal mobility in the cardinal planes reveals demonstrating full range trunk flexion followed by a curve reversal and onset of pain when returning to an upright position. No signs of scoliosis were noted in a fully trunk flexed position. Lateral trunk flexion is unremarkable for pain and range of motion deficits. Extension is limited early in the movement, painful and described as occurring bilaterally in her lower lumbar region. Upon observation, you also notice her willingness to move into trunk extension is diminished. Over pressure was applied to all cardinal plane movements and reproduction of pain was noted with extension only.

Neurological assessment was unremarkable with regards to strength testing of key muscles , sensation and deep tendon reflexes.

f/u Questions to part 2

1. Are you missing any important objective information? If so, what else would you like to know?
2. If you could only pick to perform 3 additional special tests, which would you choose and why?
3. Did the additional information strengthen or weaken any of your initial hypotheses?