(Kiosk 2) Double Trouble: Lumbar Spine Pathology in a Female Volleyball Player Presenting with Chronic Low Back Pain

Case Diagnosis: Resolved bilateral L5 pars interarticularis bone edema with persistent lumbar discogenic pain

Case Description: 17-year-old female volleyball player presents with dull, non-radiating low back pain of five months duration. Pain occurs while playing volleyball, sitting and bending forward. Pain worsened after a three-day tournament. She had recently switched to a back row position, which included more frequent digs. Initial MRI revealed bilateral L5 pars interarticularis bone edema without cortical fracture. She had not played volleyball for 6 weeks when she presented to physiatry sports medicine for management. Pain remains localized to the bilateral low back. Physical exam reveals mild thoracolumbar scoliosis with moderately restricted lumbar flexion, which elicits axial pain.

Discussion: After modified rest for the bilateral L5 pars interarticularis bone edema, her pain was more consistent with discogenic etiology, given the recent increased lumbar loaded flexion/rotation required in her new position. The L5 pars stress reaction is likely asymptomatic and healed at this point after adequate rest. She was referred to physical therapy to focus on lumbopelvic and core stability. She was cleared to start spine-neutral strength training and volleyball drills. At two-week follow-up, her symptoms were 30% improved. At two-month follow-up, symptoms were 90% improved and she was cleared for a gradual return to running and full readiness for the season.

Setting: Sports medicine clinic

Assessment/Results: Lumbar spine MRI: slight retrolisthesis and bulge of L5-S1 disc, with possible sclerosis of L5 pars interarticularis, left greater than right.

Conclusion: A thorough examination and workup can help properly identify the etiologies of low back pain. Low back pain can be concomitantly caused by multiple pain generators. Physicians must have a high index of suspicion of this when pain is resistant to initial treatment of the presumed etiology. In these cases, all pain generators must be adequately addressed for the successful treatment of symptoms.