{"id":10358,"date":"2026-07-27T00:15:55","date_gmt":"2026-07-27T08:15:55","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=10358"},"modified":"2026-06-30T12:26:43","modified_gmt":"2026-06-30T20:26:43","slug":"usmle-step-1-question-of-the-day-low-back-pain","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day:\u00a0Low back pain"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 1 Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain\/#Major_Takeaway\" >Major Takeaway&nbsp;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-low-back-pain\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>Today\u2019s USMLE\u00ae Step 1 question of the day features a 16-year-old patient with low back pain after training for a gymnastics competition. What\u2019s the underlying cause of his condition? Let\u2019s find out!<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 16-year-old boy presents to the clinic for evaluation of&nbsp;<strong>low back pain<\/strong>. The patient is&nbsp;participating&nbsp;in&nbsp;<strong>gymnastics&nbsp;<\/strong>training and has had difficulty preparing for an upcoming competition due to persistent low back pain that is&nbsp;<strong>worse with movement<\/strong>&nbsp;and&nbsp;<strong>relieved with rest<\/strong>. The patient is otherwise healthy. He has not had any recent&nbsp;injury&nbsp;or trauma. Vital signs are within normal limits. On physical examination, the&nbsp;low&nbsp;back is noted to be&nbsp;<strong>hyperlordotic<\/strong>. Pain is elicited with&nbsp;<strong>passive extension<\/strong>&nbsp;of the back. The&nbsp;<strong>straight leg test<\/strong>&nbsp;is negative bilaterally.&nbsp;A&nbsp;<strong>radiograph&nbsp;<\/strong>of the lumbar spine is shown below.<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"570\" height=\"428\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/07\/image_6a8017.png\" alt=\"Lateral X-ray of the lower lumbar spine showing forward displacement of one vertebra relative to the vertebra below it at the lumbosacral junction, with narrowing of the intervertebral disc space. The image demonstrates abnormal spinal alignment consistent with spondylolisthesis.\" class=\"wp-image-10369\" style=\"width:398px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/07\/image_6a8017.png 570w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/07\/image_6a8017.png?resize=300,225 300w\" sizes=\"auto, (max-width: 570px) 100vw, 570px\" \/><figcaption class=\"wp-element-caption\">Image reproduced from&nbsp;<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:SpondylolisthesisL5S1.jpg\" target=\"_blank\" rel=\"noreferrer noopener\">Wikimedia Commons<\/a><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following <em>best <\/em>describes the etiology of this patient\u2019s clinical presentation?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Repetitive stress on the pars interarticularis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Compression of L4 nerve root<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Lytic bone lesions<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Degeneration of the intervertebral disc<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Narrowing of the intraspinal canal<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 1 Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Repetitive stress on the pars interarticularis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Compression of L4 nerve root<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Lumbar radiculopathy most commonly results from bulging intervertebral discs. The symptoms often include low back pain with associated radiation down the lower extremities. A straight leg raise is often positive with this condition.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Lytic bone lesions<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> The above lumbar film does not demonstrate lytic bony lesions, which often appear as punched-out areas of bone.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Degeneration of the intervertebral disc<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Degenerative changes of the intervertebral discs and facet joints are a common cause of spondylolisthesis in older adults. However, in this adolescent gymnast, repetitive stress on the pars interarticularis is the more likely cause.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Narrowing of the intraspinal canal<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect: <\/strong>Spinal stenosis is an uncommon condition in adolescent patients. It most commonly presents in elderly patients with pain that is worsened with walking or activity and is relieved by sitting, lying down, or bending forward at the waist.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This adolescent patient presents for evaluation of&nbsp;<strong>low back<\/strong>. Imaging reveals grade 1 spondylolisthesis<strong>.<\/strong>&nbsp;<strong>Spondylolisthesis&nbsp;<\/strong>refers to&nbsp;<strong>anterior displacement<\/strong>&nbsp;of the&nbsp;vertebral body&nbsp;with respect to the adjacent vertebral bodies. Spondylolisthesis can be caused by degenerative changes in the spine in adult patients. It can also be congenital and seen in children. In both adolescents and children,&nbsp;<strong>pars defects<\/strong>&nbsp;can be caused by&nbsp;<strong>overuse&nbsp;<\/strong>of the low back,&nbsp;mainly from&nbsp;<strong>sports that involve repetitive back bend-like motion.&nbsp;<\/strong>This can lead to fracture of the&nbsp;<strong>pars interarticularis<\/strong>&nbsp;(<strong>spondylolysis<\/strong>) which may progress to&nbsp;<strong>anterior subluxation<\/strong>&nbsp;of one vertebral body with respect to an adjacent vertebral body (<strong>spondylolisthesis<\/strong>).&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Lumbar spondylolisthesis<\/strong>&nbsp;can present with intermittent localized&nbsp;<strong>low back pain<\/strong>.&nbsp;The pain is typically worsened with lumbar&nbsp;<strong>extension&nbsp;<\/strong>and activities involving&nbsp;<strong>repetitive hyperextension<\/strong>. There may be pain with direct palpation on physical examination. Patients can also have radicular pain if the exiting nerve roots become compressed.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Radiography&nbsp;<\/strong>is the&nbsp;best&nbsp;initial test for diagnosing spondylolisthesis.&nbsp;CT of the spine has the highest sensitivity and specificity for diagnosis and may be performed after spinal radiographs are completed.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Overuse&nbsp;<\/strong>of the low back may lead to&nbsp;<strong>spondylolysis&nbsp;<\/strong>and&nbsp;subsequent&nbsp;<strong>spondylolisthesis<\/strong>, or the&nbsp;<strong>anterior displacement<\/strong>&nbsp;of the vertebral body with respect to the adjacent vertebral bodies, and present in children or adolescents&nbsp;as<strong>&nbsp;low back pain<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Overuse&nbsp;<\/strong>of the&nbsp;low&nbsp;back may lead to&nbsp;<strong>spondylosis&nbsp;<\/strong>and&nbsp;<strong>spondylolisthesis<\/strong>, or the&nbsp;<strong>anterior displacement<\/strong>&nbsp;of the vertebral body with respect to the adjacent vertebral bodies, and present in children or adolescents as low back pain.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Learn more about this condition: <a href=\"https:\/\/www.osmosis.org\/learn\/Spondylolisthesis\">Spondylolisthesis<\/a><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Gagnet, P., Kern, K., Andrews, K.,&nbsp;Elgafy, H.,&nbsp;Ebraheim, N. (2018)&nbsp;<strong>Spondylolysis&nbsp;and&nbsp;spondylolisthesis: A review of the literature.<\/strong>&nbsp;<em>Journal of&nbsp;Orthopaedics<\/em>. 15(2), 404-407. Doi: 10.1016\/j.jor.2018.03.008.&nbsp;<\/li>\n\n\n\n<li>Matz, P.G., Meagher, R.J., Lamer, T., et al. (2016)&nbsp;<strong>Guideline&nbsp;summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis.<\/strong>&nbsp;<em>The Spine Journal<\/em>. 16(3), 439-448. Doi: 10.1016\/j.spinee.2015.11.055.&nbsp;<\/li>\n\n\n\n<li>Walls, R.,&nbsp;Hockberger, R.,&nbsp;Gausche-Hill, M. (2017)&nbsp;<strong>Rosen&#8217;s&nbsp;emergency medicine: Concepts and clinical practice.<\/strong> Philadelphia, PA: Elsevier. ISBN:&nbsp;978-0323354790.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/01\/Blog_Display_Ads_GENERAL2_2023.png?w=700\" alt=\"\" class=\"wp-image-5098\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/01\/Blog_Display_Ads_GENERAL2_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/01\/Blog_Display_Ads_GENERAL2_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Get your Osmosis from Elsevier <a href=\"http:\/\/osmosis.org\/plans\">free trial<\/a> today to discover why millions of clinicians and caregivers love learning by Osmosis<\/strong>!<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A young athlete develops persistent low back pain during gymnastics training. Can you identify the underlying pathology behind this common sports-related spinal condition?<\/p>\n","protected":false},"author":208,"featured_media":10370,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,1369,44],"tags":[3205,2967,3108,3204,84,3206,2913,3207,2897,2661,3203,3202,638,664],"class_list":["post-10358","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-1-questions","category-step-1","tag-adolescent-athletes","tag-board-exam-prep","tag-clinical-vignette","tag-low-back-pain","tag-medical-education","tag-musculoskeletal-medicine","tag-orthopedics","tag-pediatric-orthopedics","tag-radiology","tag-spinal-disorders","tag-spondylolisthesis","tag-spondylolysis","tag-sports-medicine","tag-usmle-step-1"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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