Thoracic Hyperkyphosis in the
Young Athlete: A Review of the
Biomechanical Issues
James A. Ashton-Miller, PhD
Address
Biomechanics Research Laboratory, Department of Mechanical
Engineering, 3208 G.G. Brown, 2250 Beal/Hayward, University
of Michigan, Ann Arbor, MI 48109-2125, USA.
E-mail: jaam@umich.edu
Current Sports Medicine Reports 2004, 3:4752
Current Science Inc. ISSN 1537-890x
Copyright 2004 by Current Science Inc.
Can intense athletic training cause progression of a tho-
racic hyperkyphosis in the immature athlete? The lack of
prospective, controlled trials addressing this issue pre-
cludes a definitive answer. Hyperkyphosis is defined
radiographically as a thoracic kyphosis exceeding 55 in
10- to 20-year-olds, and 65 using back surface mea-
surements. In this paper we review the biomechanical
scenarios that could lead to an increase in kyphosis in
the immature athlete via excessive mechanical loading.
These include fall-related impacts, rapid acceleration/
deceleration of heavy weights, and maximum effort
trunk extensor muscle lengthening contractions.
Research is needed on whether the number and magni-
tude of vertebral loading cycles, the recovery interval
between loading cycles, and the frequency of training
affect apophyseal growth during periods of rapid growth
of the apical vertebrae in a hyperkyphotic spine.
Introduction
Hyperkyphosis of the nonpostural (nonreversible) type
involves a fixed deformity, usually as the result of a con-
genital abnormality [1], a pathology, or an iatrogenic con-
dition. Thoracic hyperkyphosis in the juvenile or
adolescent is often associated with Scheuermans disease.
Although its etiology is idiopathic, both genetic factors [2]
and mechanical factors are thought to play a role in the
development of Scheuermanns disease. The diagnosis and
clinical management of this condition have been reviewed
elsewhere [3], as has its natural history [4,5]. In this review
we focus on the biomechanical factors that might cause
progression of a hyperkyphotic spine under intense ath-
letic training.
Definition of Hyperkyphosis
Scheuermans disease is characterized by 5 or more of verte-
bral wedging (measured radiographically using the Cobb
method) in at least three adjacent vertebrae [6]. The incidence
of Scheuermanns disease has been estimated to be 0.4% in a
prospective study of 1060 children followed for 3 years [7].
How large must a thoracic kyphosis be to qualify as hyperky-
phosis? To determine the answer, we need to first define the
normal range of kyphosis. One set of values, 20 to 50, has
been published by Boseker et al. [8], who noted no age or sex
differences in their sample of 121 normal children. Another
well-regarded study enrolled several hundred children in each
age strata and found mean (SD) thoracic kyphosis angles of
36.7 (6.9), 37.5 (8.0), and 38.5 (8.1) in 5- to 9-, 10- to 14-,
and 15- to 20-year-olds, respectively [9]. The authors measured
the kyphosis angle, using the Cobb method, from T2 to T12,
when possible, and otherwise from T3 to T12. If one defines
the normal range of kyphosis as the mean plus or minus two
SDs, then the normal range of kyphosis, from these radio-
graphic data, is from 22 to 51 in the 5- to 9-year-olds, and
from 22 to 55 in the 15- to 20-year-olds. Hence, we can
define hyperkyphosis as being a kyphosis of 52 or more in the
youngest age group and a kyphosis of 56 or more in 10- to 20-
year-olds. Unless a lateral radiograph is taken with the arms in
a forward reach posture, the upper thoracic vertebrae may not
be visible on the standard lateral radiograph. Therefore, a mea-
surement of thoracic kyphosis on a standard lateral radiograph
can sometimes underestimate the true angle of kyphosis.
For screening and research purposes one can estimate
kyphosis without using radiographs by measuring the mid-
sagittal plane profile of the dorsal surface of the thorax. This
has been done using a variety of methods, including panto-
graph, Moir fringe patterns, and rasterstereography. An alter-
native measurement method involves the Debrunner
kyphometer [10]. These surface shape methods often yield a
surface kyphosis angle that is slightly greater than that
obtained radiographically. In a classic study of 40 adolescents,
Willner [11] found a mean (SD) surface thoracic kyphosis
angle of 39.7 (12.2). Thus, using the plus or minus two SD
criterion to define normality, a kyphosis angle of 65 or more
can be classified as hyperkyphosis when using his panto-
graphic method of measuring back surface shape.
48 Spine Conditions
Vertebral Morphology
In the axial plane, the thoracic vertebra has a relatively tri-
angular shape, with its apex pointing ventrally in compari-
son with the more elliptically shaped lumbar vertebra.
Thus, the thoracic vertebra has relatively little cross-sec-
tional area anteriorly with which to resist the compressive
stresses associated with a flexion bending moment. This
means that the compressive stresses in the narrowed ante-
rior region tend to be higher under a flexion moment than
those in the larger posterior region of the centrum. In the
sagittal plane, the thoracic vertebrae are naturally wedge-
shaped, with the amount of wedging being correlated with
the local kyphotic curvature in that region [12]. The height
of each vertebra is determined by heredity, whereas the
diameters of the centrum are influenced by the level of
physical activity.
The centrum of juvenile and adolescent thoracic verte-
brae is characterized by the apophyseal rings, cartilaginous
secondary growth centers that form the anterolateral mar-
gins of its superior and inferior endplate surfaces. These
structures are most highly stressed when axial compression
loads are combined with a bending moment. Given the
narrow anterior aspect of the thoracic vertebra, the most
ventral region of the apophyseal ring will experience the
highest compressive stress under a flexion bending
moment.
The length of the thoracic spine grows most rapidly
between the ages of 10 and 16 years [13]. It may be during
this time that the columnar arrangements of cells in the ring
apophyses are most vulnerable to excessive loading and
repetitive loading. Indeed, Scheuermann posited that the
abnormal thoracic wedging could be due to abnormalities in
the growth regions of the immature vertebra based on radio-
graphic evidence that he noted. More recent work in animal
models has confirmed that sustained asymmetric loading
can cause wedging in the immature vertebra [14].
The Influence of Asymmetric Loading on
Vertebral Growth
The presence of wedged vertebrae in Scheuermanns
kyphosis suggests that asymmetric mechanical loading can
alter vertebral endplate alignment. Studies of immature rat
tail vertebrae have shown similar alterations in vertebral
growth [15,16]. Similarly, a study in immature rat verte-
brae shows that a vertebral wedge deformity can be cor-
rected by reversing the load used to create it [14]. This
finding provides a sound rationale for the Boston (or
equivalent) brace to treat and reduce hyperkyphosis in the
immature spine.
Excessive compressive loading of the spine is known to
affect normal spinal development at the apophyses [17].
For example, in biopsy specimens from seven patients with
hyperkyphosis, the endosteal vertebral bone growth was
stunted beneath the abnormal apophyseal plates. In severe
cases, regions of the vertebra and apophyses were missing
entirely. This growth retardation led to altered ossification
of the vertebra along with wedging and unevenness at the
vertebral surface. Finally, studies in immature rat tail have
demonstrated that disc height can also be modulated by
mechanical loading history [16]. In summary, these find-
ings suggest that in both immature animals and humans,
alterations in mechanical loading can affect both vertebral
and disc shape and thereby, potentially, spine curvature.
Athletic Training and Hyperkyphosis
What is the risk that intense athletic training can cause pro-
gression of a thoracic hyperkyphosis in the immature ath-
lete? The lack of a prospective controlled trial in these
patients precludes a definitive answer. Such a trial would
require documentation of the age and sex of the partici-
pant, sport, level of play, as well as repeated measures of
kyphosis angle, training methods, training intensity, and
duration. The study would require the cooperation of the
athletes, their coaches, and parents. Methods would have
to be found to circumvent the possible bias engendered in
self-reported training methods, intensity, and duration.
Strenuous physical activity is known to cause structural
abnormalities in the immature vertebral body. Concern
that exposure to years of intense athletic training may
increase the risk for developing adolescent hyperkyphosis
in certain sports, as well as the known association between
hyperkyphosis and adult-onset back pain, led us to exam-
ine the association between cumulated hours of athletic
training and the magnitude of the sagittal curvature of the
immature spine in a cross-sectional study [18]. We stud-
ied a convenience sample of 2270 children (407 girls)
between 8 and 18 years of age. An optical rasterstereo-
graphic method was used to measure the mid-sagittal cur-
vatures of the surface of the back in the upright standing
position in order to quantify the angles of thoracic kypho-
sis and lumbar lordosis. These data were then correlated
with self-reported hours of training measured by interview
and questionnaire. The possible effects of age, sex, sport,
and upper and lower body weight training were investi-
gated. Hyperkyphosis was defined as 65 or greater on
these back surface measurements. Gymnasts trained the
most each year (439 h/y), followed by swimmers (379 h/
y), football players (282 h/y), and wrestlers (228 h/y); the
remaining sports trained less than 200 hours per year. The
results in these young athletes showed that larger angles of
thoracic kyphosis and lumbar lordosis were associated
with greater cumulative training times (h/y; P < 0.001);
gymnasts showed the largest curves (mean SD thoracic:
42.4 13.4; lumbar: 52.1 16.7). Lack of sports par-
ticipation, on the other hand, was associated with the
smallest curves (sedentary controls: thoracic 16.1 10.4;
lumbar 17.6 15.6). Age and sex did not significantly
affect the degree of curvature.
 Thoracic Hyperkyphosis in the Young Athlete: A Review of the Biomechanical Issues Ashton-Miller
How are Thoracic Vertebrae Loaded?
Any vertebra is normally loaded by two types of forces: ten-
sile forces in any muscles that directly insert onto the verte-
bra, and the forces and moments applied to the vertebral
centrum by the intervertebral disc above and below it. Of
particular concern are flexion moments when they are
applied to an already-wedged (kyphotic) vertebra, especially
if they are not equilibrated by the thoracic extensor muscles.
Extensor muscle fatigue would be one scenario in which a
flexion moment is not fully equilibrated. Flexion moments
that are not equilibrated by the extensor muscles would tend
to increase the angle of wedging. Similarly, compressive
forces on the centrum of a wedged vertebra could also cause
wedging to progress if they slow the growth of the apophy-
seal ring anteriorly. We now consider how these flexion
moments and compression forces arise.
We start by considering the quiet, upright standing pos-
ture. The forces applied by the disc above the vertebra of
interest include axial compression and shear forces. The
latter may be oriented in the anterior or posterior, left or
right directions, or any combination of these. These forces
include the effect of gravity acting on the superincumbent
body mass as well as the muscle forces needed to equili-
brate it. The moments applied by the adjacent disc above
the vertebra include flexion or extension, lateral bending
and/or axial torsion, or any combination of these. Typi-
cally, the line of gravity of superincumbent body weight
acts forward of a thoracic vertebra, and therefore applies a
flexion moment to it. This must then be equilibrated by
tensile forces developed by the thoracic extensor muscles.
As a result, the vertebra of interest must then resist a com-
pression force that results from both the gravitational force
and these muscle forces. The higher the level of torso mus-
cle co-contraction at the vertebral level of interest, the
larger the muscles forces involved, and therefore the larger
the compression force acting on the vertebra. In general, in
quiet standing, less than half the total compression force
acting on a vertebra is derived from the effect of gravity on
the superincumbent body above that level, and the other
half comes from the muscle forces required to equilibrate
that effect.
The forces and moments applied by the disc below the
vertebra of interest are simply the reaction forces and reac-
tion moments required (from Newtons third law, action =
reaction) to equilibrate the aforementioned forces and
moments, as well as the negligible weight of the vertebra
itself, and any muscle or rib forces acting directly on the
vertebra itself.
In an upright individual, a flexion moment acts on all
the thoracic vertebrae via the weight of the rib cage, and
this is greatest at the apex of the thoracic curve because this
vertebra lies furthest from the line of gravity of the head
and the thorax. This apical vertebra is then the vertebra
most exposed to the greatest flexion moment, especially
49
when the extensor muscles develop an insufficient
moment to counter it. In general, the apical vertebra is also
placed under considerable axial compression because the
extensor muscle forces have to equilibrate the large gravita-
tional flexion moment.
The thoracic vertebra of interest can be acted on
directly by a third type of force applied directly to the
spinous process via the overlying skin. This can occur when
the athlete falls and contacts the ground, a support surface,
or is hit by another player on the dorsal surface of the neck
or back. This type of loading would tend to translate the
vertebra anteriorly, and load the inferior vertebrae in flex-
ion. Thus, a ventrally directed force applied to the head or
spine above the vertebra of interest would exert an addi-
tional flexion moment on the vertebra of interest. The fur-
ther cranial this force acts, the larger the flexion moment it
applies about the vertebra of interest will be. Likewise, a
caudally directed impact force on the head, neck, or shoul-
ders will also induce a flexion moment on the thoracic ver-
tebra of interest.
Finally, inertial forces can also load the apical thoracic
vertebrae. For example, flexion loading can occur when the
upright body, having forward momentum, collides with a
surface or object such that the body below the vertebra of
interest is abruptly decelerated. This type of loading will
apply a forward shear force to the vertebra via its upper
facet joints and superincumbent disc, along with a flexion
bending moment that must be equilibrated by the thoracic
extensor muscles. A similar argument holds for the case in
which the inverted athlete performs a handspring: now it is
the downward momentum of the upper body that is
abruptly decelerated by the ground. In this case the lower
thorax and body will now load the apical thoracic verte-
brae in compression and flexion, along with the thoracic
extensor muscle forces. Weight lifting, a ubiquitous form of
athletic training, can cause significant thoracic compres-
sion and flexion loading when rapidly lifting a heavy
hand-held weight. The magnitude of the inertial force is
directly proportional to the product of the weight lifted
multiplied by its upward acceleration (along with the
weight and acceleration of the arms themselves). Likewise,
weights having downward momentum that are then
abruptly decelerated using the upper extremities will exert
a similar load for the same reason. Finally, a large flexion
moment and compression loading can be exerted on the
apical vertebrae by the rapid deceleration of the body
below the vertebra of interest, as when landing from a drop
jump. In this case, the upper body has downward momen-
tum prior to the feet impacting the ground. After impact,
the upward force on the feet is transmitted up the skeleton
to decelerate the vertebra of interest via the disc and facet
joints below it. The straighter the knees and the more flat-
footed the landing, the larger the deceleration, and the
larger the flexion moment exerted on the apical vertebrae.
50 Spine Conditions
What Determines the Magnitude of an Impact
Force on the Body?
The biomechanical factors that determine the magnitude
of an impact in fall have recently been determined [19
22]. If the impact force were to act on the body above the
level of the target vertebra, for example the dorsal aspect
of the neck region, then that force would act to deceler-
ate the neck from the impact velocity (just prior to
impact) to the final velocity of zero after impact. That
impact force, in turn, acts to apply a bending moment
on, and a shear force to, the thoracic vertebra of interest;
hence our concern that it not exceed the ability of the
vertebral tissues to resist it without injury. What deter-
mines the magnitude of the impact force? Apart from the
stiffness of the impact surface (the higher the stiffness,
the higher the impact force), the magnitude of the
impact force will then depend upon two variables: the
impact velocity and the effective mass of the body part
impacting the surface. The product of those two variables
is a measure of the momentum of the body part immedi-
ately prior to impact, for instance, with the ground. At
impact, the ground exerts a reaction force on the neck,
slowing its momentum to zero. The magnitude of that
impact force may be found by considering the impulse
(defined as force multiplied by the time that it acts)
required to decrease the neck momentum to zero. For
example, if the mass of the neck is 5 kg and it impacts the
ground with a downward velocity of 3 m/sec, then its
momentum is 15 kg-m/sec. This momentum can be
completely arrested by an impact force of 1500 N acting
for 10 msec, 150 N acting for 100 msec or 15 N acting for
1 second. Notice that the shorter the impact time, the
higher the impact force must be. The higher the impact
force, the more concerned we have to be with the poten-
tial for it to injure the apophysis. Shorter impact times
are typically associated with collisions with a hard or stiff
surface or object. The higher the impact force, the more
concerned we have to be with the potential for apophy-
seal injury in the hyperkyphotic region.
The Significance of Extensor Muscle
Lengthening Contraction on
Vertebral Loading
It is well known that the force developed by a striated
muscle depends both upon its neural activation level
(number of motoneurons recruited and their firing fre-
quency) as well as the external load. For a given neural
activation level, when the external load is less than the
contractile force developed by the muscle, the muscle will
shorten, a so-called shortening contraction. When the exter-
nal load exactly equals the contractile force in the muscle,
it will contract isometrically (at a constant length). And
when the external load exceeds the contractile force devel-
oped by the muscle, then the muscle will undergo a so-
called lengthening contraction. The terms shortening and
lengthening contraction are used here in preference to the
less accurate corresponding terms, concentric and eccentric
contraction [23].
It is well known that lengthening contractions result in
significantly higher muscle forces than shortening contrac-
tions. In fact, at sufficiently high velocities, the maximum
force developed by a muscle undergoing a lengthening
contraction can reach 1.6 times the maximum volitional
force developed isometrically [24,25]. Of course, the well-
known hyperbolic relationship between contractile force
and shortening velocity means that even a small shorten-
ing velocity causes a large decrease in the maximum force
than can be developed by the muscle. As the shortening
velocity increases the force that can be developed further
decreases to very low values. In summary, the largest mus-
cle forces occur in a maximally activated muscle when that
muscle is forcibly lengthened.
It follows then that the largest muscle forces exerted on
the vertebra of interest will occur when the adjacent thoracic
extensor muscles are maximally contracting and being
lengthened by forced flexion of the torso. This can happen,
for example, when an athlete who is running forward trips.
In an effort to slow his or her forward and downward
momentum of the head and upper body and arms, the tho-
racic extensor muscles have to contract maximally. As they
gradually slow the forward-moving upper body, they are
placed under a lengthening contraction condition. As a
result, these muscles develop large tensile forces which in
turn place the flexing thoracic spine under a considerable
compression. Because a single cycle of forceful flexion and
compression loading can cause a mature lumbar disc to her-
niate, there is some concern that the anterior portion of an
immature vertebral apophysis could also be at risk for injury
under such combined loading.
Repetitive Vertebral Loading
There is presently only indirect evidence that repetitive
loading can cause vertebral centrum abnormalities. The
original observations of Scheuermann were that approxi-
mately half of his patients who presented with three or
more wedged vertebrae were engaged in heavy agricultural
labor. In a later study, Wassman [26] also noted an associa-
tion with heavy physical work. Blazek et al. [27] found in a
cross-sectional study that Scheuermanns disease was
present in 41% of top athletes compared with 10% in non-
sporting controls. One can not differentiate between the
possible effects of repetitive loading, excessive single loads,
or impact loading in these studies; all are possible in an
agricultural setting. Working with an immature rat tail
model, Revel et al. [28] found that repetitive tail bending
caused endplate abnormalities, along with disruptions of
the columnar arrangement of chondrocytes in the deep
zone of the cartilaginous endplate. These findings are con-
sistent with similar findings in Scheuermanns patients
[29]. Because ossification of the anterior apophysis has
 Thoracic Hyperkyphosis in the Young Athlete: A Review of the Biomechanical Issues Ashton-Miller
been noted in gymnasts [30], athletes who are routinely
exposed to repetitive impact loading via gymnastic jump
landings, inadvertent falls, and lengthening contractions of
their torso extensor muscles, one cannot exclude the possi-
bility that repetitive loading may play a role in causing ver-
tebral wedging. However, the experiments are required to
determine apophyseal injury risk from a few cycles of
excessive loading versus many cycles of moderate loading.
Handedness
Using a threshold for hyperkyphosis of 45, 20 less than
is defined here using back surface shape analysis, left hand-
edness has been found to be associated with a fourfold
higher risk for hyperkyphosis during the pubertal growth
spurt in Finnish children from 10.8 to 13.8 years [31]. Why
this should be so remains unclear. It remains to be seen if
the findings can be replicated using a more rigorous defini-
tion of hyperkyphosis.
Conclusions
A prospective randomized trial would help determine
whether or not intensive athletic training can increase a
pre-existing hyperkyphosis in a juvenile or adolescent ath-
lete. From a biomechanical perspective, both impact forces
and large thoracic extensor muscle forces, associated with
lengthening contractions as a result of torso flexion, could
cause excessive stress on the anterior thoracic apophyses.
However, the effect on the vertebral apophyses of loading
type, magnitude, and number of repetitions in a given
interval remain to be clarified. Coaches, parents, and sports
physicians should, therefore, remain vigilant for any
changes in hyperkyphosis as a result of intense athletic
training regimens.
References and Recommended Reading
Papers of particular interest, published recently, have been
highlighted as:
Of importance
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52 Spine Conditions

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