Back pain in a teenage girl: What she isn't telling you

You are the pediatric resident working at apediatric orthopedic clinic for the month. The chartyou are reviewing belongs to a 13-year-old femalewho is returning today for the third time in the pasttwo months due to continued lower back pain. Yourecall from your monthly readings that 70% to 80%of adolescents will complain of back pain at somepoint in time by age 20.1

You enter the room and see a petite and slender female resting in a chair in no apparent distress. Since this is your first encounter with the patient, you take a thorough history, starting with the onset of her pain. She reports that the pain came on gradually approximately two months ago. She initially saw her pediatrician, who then referred her to orthopedics. The orthopedic surgeon concluded that her back pain was likely musculoskeletal in origin, and therefore prescribed an anti-inflammatory and a muscle relaxant for two weeks. She was instructed to follow up in one month if there was no improvement.

The pain continues

The patient continues to complain of lower back pain and has had no relief since starting the prescribed medications. "They just make me feel loopy," she reports. On further questioning she tells you that her pain is constant and located down both sides of her lower back. Nothing seems to make the pain better or worse. The pain is not associated with exercise and doesn't seem to limit her in activities of daily living.

She denies any history of previous back injury or recent trauma. Review of systems is negative for any dysuria, frequency, hematuria, fever, or chills. She denies any recent viral illness or course of antibiotics. She has no tick exposure or history of swollen tender joints. She denies numbness or tingling in her extremities and has normal bladder and bowel control.

Upon further questioning, she does admit to a feeling of constipation and a difficulty fully emptying her bladder. She has no significant past medical or surgical history. Her family history is unremarkable. She lives with both parents at home and has no siblings. She denies any recent travel.

You begin your physical exam by first watching the patient walk from the chair to the examination table. She demonstrates a normal gait with no difficulties standing or boosting herself up to the table. Her cardiac exam demonstrates a regular rate and rhythm, with no murmurs. Her lungs are clear to auscultation, and her respiratory rate is normal. On neurological exam you note that cranial nerves II to XII are intact. Her motor exam reveals normal bulk and tone in all extremities, with 5/5 strength. Her sensation to light touch is intact, and deep tendon reflexes are 2+ bilaterally at the biceps, brachioradialis, patellar, and achilles reflexes.

Next you have the patient stand, and observe her extending and flexing her back without any difficulties or pain. She has no bony tenderness along her spine, and forward bending reveals only mildly asymmetric scapulae. Straight leg raises are negative for pain or discomfort.

You are collecting your thoughts in preparation to present your patient to the attending. You wonder why a patient with an essentially normal physical exam and a relatively mild degree of scoliosis could be in so much pain. As your hand touches the doorknob to exit the room, you hear the expression that every physician fears. "By the way doc, one more thing, can you take a look at my belly?"