32 years ago, when just starting in practice, I contacted our local high school football coach and offered my services to his team.  A couple times a week I would work on any players who asked for help.  As great as the job seemed, it was short lived.  As soon as the school physician got wind of my involvement, I was introduced to the politics of sports.  The athletic director informed me I was not to come onto the campus again.

So, my simple goal was to get back onto campus, and through the front door this time, not some side door where no one knew I was there.  Along the way, I’ve learned a lot.   We live with a broken sporstmedicine system, and this age group is all but ignored.

Here’s the deal:

Just about all healthcare decisions are based upon health insurance guidelines. Most high school athlete’s care will depend upon what their insurance covers.  So, they have to be injured before they can do anything.  Anyone in the healthcare delivery industry knows that health insurance coverage is shrinking at a severe rate (increased co-pays and deductibles with decreased coverage) and, unfortunately, the care of high school athletes is jammed underneath this broken healthcare system umbrella.  Athletes, especially middle and high school athletes, have needs that are much different and far greater than the needs of the general population.  These needs are ignored.

All middle and high school athletes receive a physical prior to the season beginning, but the majority of this examination is a medical exam, i.e., eyes, ears, nose and throat.  Yes, these tests are needed, but the biomechanical exam, which checks the muscular, neurological and skeletal systems, is absent.  The examiner will perform a scoliosis screening.  (This is like saying the absence of terminal cancer means you’re healthy).  As in, there’s a lot more to biomechanics than a scoliosis screening.

We live in a reactive healthcare system dictated by economics.  These kids are never looked at until they’re hurt.  Secondly, our front line docs (primaries) are not trained in biomechanics, therefore, are not qualified to accurately diagnose or treat these injuries.  The “System” then kicks into a costly referral system, going from the primary to the orthopedist to the physical therapist or chiropractor, and the treatment goal is to get rid of the pain/injury.  No biomechanics involved.

The New York Giants and Chicago Bulls used a conditioning pyramid, with the base of that pyramid containing 6 categories; aerobic capacity, body composition, joint mobility, strength endurance, core strength and aerobic capacity.  These professional athletes needed to pass tests in all 6 categories before they could enter the weight room.  In almost every high school in this country, kids begin aggressively working out with weights with questionable supervision and absolutely no biomechanical evaluations.  This egregious omission WILL produce devastating long term detrimental effects.

When an athlete becomes injured, the goal is to reduce the symptoms, but never correct the underlying problem.  Fig. 1 shows an example of the biomechanical imbalances that exist in all of us, and it is these imbalances that lead to the majority of injuries in athletes.  These imbalances originate in the feet (our foundation) and if this imbalance is not addressed, we have a limited potential in balancing the rest of the structure.

We’re sitting on a ticking time bomb.  Many of these kids suffer with low level injuries that don’t meet the criteria for taking action.  But, all of these kids have mild to extreme biomechanical faults, and our current sportsmedicine system prefers to perform joint replacements and prescribe a lifetime of pharmaceuticals later rather than address the issues now.

Possible solutions

Chiropractors and Physical Therapists—You’re the biomechanical providers out there, so you need to step up.  The first step is to get to the schools and educate the families and coaches.  Then offer your services for a complete biomechanical exam for all athletes, not just those injured.  This should take place before the season begins.  A biomechanical exam can be found at www.StructuralManagement.com.  Prescribe flexible custom orthotics as a first step in balancing their biomechanics.

Family Drs.—Admit this isn’t your specialty, and work with the families to find a chiropractor or physical therapist who will help with the biomechanical needs of the athlete.

Athletic Directors—Realize you are the lynchpin to all parents and athletes in your school district.  Your role is critical.  Work with those who are capable of providing more biomechanical information to this group.  Don’t settle for that age old response, “We’ve done fine without this so why do we need it now”.

Coaches—You’re the ones who have the most contact with these athletes.  Teach them about prevention and the importance of being disciplined in taking care of themselves.  Help to build the bridge between families and biomechanical providers in your communities.  Small injuries are warning signals.  Please don’t promote the “No Pain, No Gain” mantra.  Realize that pain is a warning signal for underlying biomechanical imbalances.

Parents—Don’t stop until you find someone who will perform a biomechanical exam on your child.  It will help detect the predictable sights of injuries, and will uncover the reasons why chronic injuries persist.  And, encourage corrective recommendations.

Other than that, have a great month.

Dr. Maggs currently practices full time, while also lecturing for Foot Levelers. He is the developer of The Structural Management Program, as well as the 10 Week Webinar Series, "How to Build Your High School Athlete Practice".  He can be reached at 1-518-393-6566 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it . His website is www.StructuralManagement.com

Back injuries can occur from single episodes of blunt trauma -—like being pushed or hit in the back-— to repetitive microtrauma (overuse) from activities of repetitive lumbar extension from practicing sports like gymnastics and diving. Commonly seen back-related injuries in adolescents can result in fractures, which usually are not associated with the severity of a cervical spine fracture that can lead to catastrophic spinal cord injuries. Acute disc herniation, contusions, sprains, strains, spondylolysis and spondylolisthesis, facet syndromes and lordotic low back pain are common. Injuries associated with flexion can be both Atypical and Typical Scheuermann’s Kyphosis, compression or end plate fractures. All of these mechanisms will result in and contribute to vertebral subluxation complexes.

All of these mechanisms will result in and contribute to vertebral subluxation complexes.

I would like to focus on just one of the above-mentioned conditions due to it being commonly missed diagnostically. This is “lordotic low back pain.” As doctors of chiropractic, we commonly see adolescents in our office with low back pain that ranges from many causes, and often the patient or parent cannot give a mechanism of injury. One of the most important consideration factors when treating an adolescent is to first determine if they are going through a growth spurt.

Let us look at Elyse, a 12-year-old female gymnast who enters our office with low back pain. Elyse complains of lower back pain which she describes as being on and off for several weeks in duration. The severity ranges from a 0 to a 10 on a pain scale and can change for no related reason. Today, the pain is at a 10, which is why the appointment was made. History indicates Elyse is an active gymnast who practices four days a week, averaging about two hours per practice. Some days the pain restricts her practice time. She describes that location of the pain varies from along the tops of both hip bones (crest of the ilium) to the middle of her low back. Both mother and Elyse deny any recent fall or trauma in the last six months.

Examination shows a normal 12-year-old in height and weight. She can heel-toe walk normally. Balance and coordination appear normal. Ranges of motion demonstrates full ranges of all extremities, cervical spine, and dorsolumbar spine with exception of pain on dorsolumbar extension and restricted flexion that was less painful. Palpation notes symmetrical tightness of the lumbar musculature with no spasms. Palpation of the iliac crest and especially the lumbar spinous process bring about a response of soreness.

Based on our examination findings, we determine the need for lumbar radiographs. The AP view shows a nice straight spine with no rotation. It also shows normal height and formation of the vertebrae with no wedging. Iliac crest and femoral heads all are equal in comparison. Open growth places are noted along the iliac crest and pelvis. The lateral view also shows normal vertebral heights and disc heights. No evidence of degeneration, fracture or other pathology. With additional viewing of the lateral film, we note a slight hyperlordosis of the lumbar spine with no interruption of George’s line.

I am sure I am not the only DC who has looked at an X-ray and found very little of anything structurally wrong on the films. You then question yourself as to how you are going to explain to the parents and child why they are experiencing such pain. It’s easy when we can reference a scoliosis, or point out disc wedging caused by misaligned vertebrae, rotated spinous processes, and phases of disc degeneration. But what are we going to tell the parents and child now as to why Elyse is having low back pain and why she needs chiropractic care? What are we going to adjust? Yes, chiropractic care should be part of everyone’s health program, but we have a child in pain that is looking for answers to why she hurts.

This is why this condition is commonly misdiagnosed. The key diagnostic signs here are the areas of pain, restricted flexion and extension ranges of motion, and the only radiographic finding is the hyperlordosis of the lumbar spine. Above all, the key sign is her age, because she is going through a growth spurt!

This is a time that the spine and its supporting tissues are usually very elastic and pliable.

In this case, as the lumbar vertebrae are growing, the thoracolumbar fascia is not stretching at the same rate. This phenomenon is what causes the hyperlordosis of the lumbar spine. The fascia is so strong and isn’t expanding, so the growing lumbar vertebrae have no place to go but forward, causing the increased hyperflexion. Considering the anatomy of the fascia and where it originates from across the iliac crest, the body is actually causing a tractioning on the apophysis. The low back pain can be caused from the lumbar spinous processes being jammed upon each other.

Commonly, when we adjust this patient, the lumbar spine is very tight and you will usually not get any movement of the spine. The patient may tell you it was very painful when the lower back was adjusted. I am sure as we described this episode, many of you were able to recall patients of this age that you encountered with the same scenario, and often we lose this patient because he or she gets discouraged because the episodes of pain are so sporadic. More commonly than not, on the days the pain is worse, they are going through a growth spurt.

This patient is truly a chiropractic patient. We must be able to educate the patient and parents on what is actually happening during the child’s development. This is a time that the spine and its supporting tissues are usually very elastic and pliable. Therefore, monitoring structural alignment during these episodes of growth is essential to maintain good spinal development and prevent possible structural problems from developing in the future. Additional considerations you could recommend to help with pain are stretching and use of an anti-lordotic brace.

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

References:

1. Micheli, LJ. “Back Pain in Young Athletes.” Arch Pediatr Adolesc Med 149:15-18, 1995.

2. Mundy, DJ. “Epidemiologic study of sports and weight lifting as possible risk factors for herniated lumbar and cervical disc.” Am J Sports Med 21:854-860, 1993.