Striking Out: An Elusive Cause Of Back Pain In An Adolescent Baseball (& Soccer) Player

HISTORY: A 14yo healthy male baseball/soccer player presented to clinic with atraumatic, insidious onset, constant right-sided lumbar pain radiating to the right buttock for 3 weeks initially triggered while batting. No numbness, tingling, weakness. Pain partially responsive to massage, ice, heat, ibuprofen, chiro and rest. Twisting, batting, kicking and forward flexion all make the pain worse. He is anxious to play in a national soccer tournament in 2 weeks. PHYSICAL EXAMINATION: Normal gait, posture. Nontender over the L1-S1 spinous processes. TTP along right paraspinal musculature, and PSIS bilaterally. Standing/seated flexion tests both + on left side. Rotation to right is painful. SLR, FABER, FADIR testing - bilaterally. LE strength 5+/= DIFFERENTIAL DIAGNOSIS: 1.Lumbar strain 2.Spondylolysis 3.Lumbar radiculopathy 4.Bertolotti syndrome 5.Ankylosing spondylitis 6.Sacroiliitis/SI dysfunction TEST AND RESULTS: XR lumbar spine: mild straightening of normal lumbar lordosis. MRI lumbar spine: Hyperintense T2/STIR signal right L4 pedicle w/ trace extension to adjacent facet, consistent with stress reaction. No definite evidence of spondylolysis. Transitional lumbosacral anatomy with sacralization of L5 vertebral body. MRI pelvis: No acute findings including evidence of sacroiliitis or fracture. FINAL WORKING DIAGNOSIS: 1.Bertolotti syndrome 2.L4 pars stress reaction 3.Lumbar facet syndrome TREATMENT AND OUTCOMES: 1. Initial clinical differential diagnosis favored strain, felt better with rest & meloxicam, attempted soccer tournament but withdrew due to recurrent pain. 2. Post MRI RESULTS: treated as spondylolysis. No sports, started PT, and LSO brace for 6 weeks. 3. 6 weeks: any attempt to twist or bend out of brace triggered pain. Lumbar CT normal except for redemonstration of lumbosacral transitional vertebra (LSTV). Consulted ortho spine: no surgery, activity as tolerated, continue therapy. 4. Consulted pain service: right L4-S1 medial branch facet injection performed 6 months post injury with anesthetic pain relief achieved. 5. Post-injection back in rehab, no brace, slow activity progression