Clinical Utility of Physical Examination Findings in Pediatric and Adolescent Acute Spondylolysis.

Background: Previous research describes imaging via magnetic resonance imaging (MRI) as the gold standard for the diagnosis of spondylolysis after clinical examination. Existing literature on the accuracy of physical examination findings related to positive acute spondylolysis on MRI is limited. Purpose: To evaluate the diagnostic value of clinical examination maneuvers in assessing acute spondylolysis in adolescent athletes with low back pain related to positive radiographic findings. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Data were abstracted from a sports medicine registry that prospectively collects data from the electronic health record (EHR) for patients seen for orthopaedic conditions across a regional health care network. Patients aged 8 to 18 years assessed for lumbar back pain via a standardized lumbar back pain assessment protocol and who had completed an MRI study between January 2019 and February 2024 were included. Patient information, pain duration, radiographic findings, and pain-associated physical assessment maneuvers were abstracted from the EHR. Results: Of 733 patients meeting study criteria, 260 (35.5%) had findings of acute spondylolysis on MRI. The mean age at initial evaluation was 14.8 years, with most patients (40.6%) presenting with 1 to 3 months of lumbar back pain. Overall, 94.2% of patients with acute spondylolysis on MRI had pain with hyperextension of the lumbar spine on physical examination, and 52.3% had pain with the single-leg hop maneuver. Those reporting pain with both hyperextension and single-leg hop had the highest prevalence of acute spondylolysis. Male patients, patients aged 13 to 14 years, and those presenting with 2 to 4 weeks of back pain had the highest prevalence of MRI-confirmed acute spondylolysis. Conclusion: This study evaluates the clinical accuracy of physical examination and patient characteristics associated with prevalence of acute spondylolysis in patients who present with lumbar back pain confirmed via MRI. A higher prevalence of acute spondylolysis was observed across several subgroups, including males, early to mid-adolescents, those with shorter symptom duration, and those demonstrating both hyperextension and single-leg hopping pain. Incorporating both maneuvers improved diagnostic accuracy for identifying acute spondylolysis. Findings demonstrate that both hyperextension and single-leg hopping pain may warrant advanced imaging to rule out acute spondylolysis as a cause of lumbar back pain.