Back Pain-Triple Jumper

HISTORY: 19-year-old female collegiate triple jumper with history of a few years of progressive right-sided low back pain without radiation. She has an ongoing work-up for a rheumatologic etiology due to genital/oral ulcers, enthesitis, positive HLA-B27, and recurrent respiratory infections. Her rheumatologist has recommended adalimumab for a suspected diagnosis of ankylosing spondylitis. Pain is worse in the morning and is exacerbated by jumping, prolonged sitting, and transitioning from sit to stand. Pain has started to impair her activities of daily living and she has a difficult time competing in track events. She has been taking ibuprofen and acetaminophen daily for many months. PHYSICAL EXAMINATION: She is tender at the right sacroiliac joint, posterior superior iliac spine, and right lower lumbar paraspinal muscles. Pain is provoked in the right low back with squatting, lumbar extension, lateral bending, and rotation. She has full hip range of motion with no pain or intra-articular provoking symptoms. She has no neurologic deficits including full strength, intact sensation, and normal reflexes. There is a positive Ober on the right, positive posterior sacral thrust, and reduced range of motion on right-sided FABER. DIFFERENTIAL DIAGNOSIS: Ankylosing spondylitis, lumbosacral spondylolysis, sacroiliitis, Behcet's disease. TEST AND RESULTS: Lumbar radiograph: no spondylolisthesis or evidence of dynamic instability. Lumbar spine magnetic resonance imaging (MRI): mild bilateral neural foraminal narrowing at right L4-L5 and bilateral L5-S1. MRI Pelvis: no evidence of productive or erosive arthritis of either sacroiliac joint. Single-photon emission computed tomography of the lumbar spine: increased focal radiotracer uptake on bone scan localized to a pars interarticularis defect of the L5 vertebral body. FINAL WORKING DIAGNOSIS: Right L5 spondylolysis. TREATMENT AND OUTCOMES: Active-aided postural support orthosis provided as needed. Weeks 0-8: stop high impact activities, stop trunk extension/rotation and begin physical therapy focusing on core stabilization. Weeks 9-13: progressively reintroduce higher intensity activity including weight training, bodyweight trunk rotation/extension and jogging. Week 14: discontinue all restrictions and progress back to sport participation.