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An 11-year-old high-level competitive gymnast with back pain
  1. Charlotte Nusman1,
  2. Rick vanRijn1,
  3. Liesbeth Lim2,3,
  4. Mario Maas1
  1. 1Radiology Department, Academic Medical Center, Amsterdam, Netherlands
  2. 2The Sports Physicians Group, St. Lucas Andreas Hospital, Amsterdam, The Netherlands
  3. 3Sport Medical Advice Center, District Haarlem-Kennemer Gasthuis Hospital, Haarlem, The Netherlands
  1. Correspondence to Charlotte Nusman, Radiology Department, Academic Medical Center, Meibergdreef 9, Amsterdam 1105AZ, Netherlands; c.m.nusman{at}

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Case summary

An 11-year-old high-level competitive female gymnast presented with back pain. Approximately 10 months earlier, she experienced acute pain in the (thoracic-lumbar) mid-spine during a training camp, on the uneven bar. She reported no acute trauma. The pain was located at the paravertebral right side and was provoked by rotation movements to the right. Night-time pain existed. She went to a physiotherapist, who at physical examination found a movement with typical local fixation in the spine (paradox movement). There were no neurological symptoms. The pain was mainly felt when her posture changed from anterior flexion to extension of the spine and with rotation to the right. At this first presentation of symptoms, she trained 20 h a week.

Although physiotherapy, manual therapy and a period of rest slightly improved the situation, a setback occurred after another intensive training camp, now with continuous pain, increasing during jumping (like dismounts from the gymnastics apparatus) and running.

On examination, there was a painful right straight leg raise without neurological symptoms. There was painful limited range of motion during extension of the spine; anterior flexion was only slightly painful. The pain was again located on the right side (paravertebral) and on palpation of the vertebra in the proximal lumbar spine.

The patient was first referred for conventional radiography (figure 1) and 1 month later for MRI of the lumbar spine (figures 2 and 3).

Figure 1

Lateral conventional radiography of the lumbar spine.

Figure 2

Sagittal T1-weighted MRI at the level of the lumbar spine.

Figure 3

Sagittal STIR MRI at the level of the lumbar spine.

What is your diagnosis based on clinical examination and imaging findings?


Avulsion of the anterior ring apophysis of L1 vertebral body.

Imaging findings

Conventional lateral radiography of the lumbar spine (figure 4) showed an irregular anterior …

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  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.