Scheuermanns kyfose

Scheuermann’s kyphosis, also known as juvenile kyphosis or juvenile discogenic disease, is a structural hyperkyphosis affecting the vertebral bodies and intervertebral discs. The condition is characterised by wedge-shaped vertebrae with at least 5 degrees of anterior wedging in three or more consecutive vertebrae. The thoracic spine is most often involved, but the thoracolumbar and lumbar regions can also be affected¹.

It is most commonly diagnosed in adolescents between 12 and 17 years of age, often after parents or teachers observe a postural change. Back pain may be the first symptom, especially in the region of hyperkyphosis. Scheuermann’s disease is the most common cause of kyphotic deformity in adolescents².

Types

Thoracic type: Most common, with the apex at T7–T9².

Thoracolumbar type: Apex at T10–T12, with a greater risk of progression into adulthood²³⁴.

Anatomy

In adults, the spine has a natural S-curve. The cervical and lumbar regions have lordosis, while the thoracic and sacral regions have kyphosis. Normal thoracic kyphosis: 20–40 degrees. Scheuermann’s disease produces a kyphosis of 45–75 degrees, as well as wedge-shaped vertebrae (>5 degrees) in at least three consecutive vertebrae⁵. This rigid hyperkyphosis is often compensated by cervical and lumbar hyperlordosis.

Aetiology

The cause of Scheuermann’s kyphosis is unknown. Hereditary factors are thought to play a role, but the mode of inheritance is unclear. One hypothesis is disturbed mineralisation and ossification of the endplates during growth, leading to uneven growth of the vertebral bodies and wedge-shaped vertebrae¹. Other theories include mechanical, metabolic, and endocrine factors, but none have been conclusively proven.

Epidemiology

Prevalence: 1–8% in the USA

Sex: More common in boys (2:1)

Age: 12–17 years

Classification

Type I (classic): Thoracic spine, apex T7–T9

Type II: Thoracolumbar spine, apex T10–T12¹

Clinical Presentation

According to Sørensen⁵, the following criteria are required for diagnosis:

• At least three consecutive vertebrae with ≥5 degrees of anterior wedging.

• No signs of congenital, infectious, or traumatic spinal disease.

Common findings:

• Cosmetic or postural deformity

• Subacute thoracic pain, often worsened by activity

• Rigid hyperkyphosis, accentuated by forward bending

• No correction in extension or when lying supine

• Increased cervical and lumbar lordosis

• Tight hamstrings

• Muscle stiffness, reduced mobility

• In rare cases: impaired cardiac and pulmonary function or neurological symptoms

Many patients report reduced participation in activities, work, and leisure, as well as cosmetic concerns⁶.

Differential Diagnoses

• Postural kyphosis (flexible deformity)

• Hyperkyphosis secondary to other disease

• Postoperative kyphosis

• Ankylosing spondylitis

• Scoliosis

Diagnostic Investigations

Diagnosis is established by history, clinical examination, and radiographs (AP and lateral). Diagnostic criteria:

• Rigid hyperkyphosis >40 degrees

• Anterior wedging ≥5 degrees in three or more consecutive vertebrae¹⁸

Other findings:

• Irregular endplates

• Schmorl’s nodes

• Loss of disc height

• Spondylolysis or spondylolisthesis

• Scoliosis

MRI is considered when preoperative planning is needed. CT is rarely necessary. Laboratory tests have no diagnostic role¹.

Outcome Measures

• Occiput-to-wall distance

• Questionnaires: SRSI, VAS, QBPDS, Roland–Morris, ODI, SF-36⁹⁶

Examination

• Postural analysis: anterior, posterior, lateral• Neurological screening⁴

• Adam’s forward bend test¹¹

• Muscle testing: tight pectoralis, hamstrings, suboccipitals, and hip flexors²³

• Mobility testing: flexibility of the spine and extremities¹¹

• Strength testing: abdominals, core, back extensors, and gluteal muscles

Medical Management of Scheuermann’s Kyphosis

Non-operative management

Measures

• Stretching exercises

• Lifestyle modifications

• NSAIDs

• Physiotherapy as needed

Indication

• Kyphosis less than 60 degrees and asymptomatic

Course

• Most patients fall into this category

• Typically good prognosis without serious long-term problems

Extension bracing with adjunct treatment

• Used for kyphosis between 60–80 degrees with or without symptoms

• Bracing usually lasts 12–24 months

• Brace types include Milwaukee brace, Kyphologic brace, or Boston brace (TLSO)

• Most effective in patients with open growth plates

• Often not curative for the curve, but inhibits further progression

Operative Treatment

Surgical technique

• Spinal fusion, often combined with anterior release and fusion as well as posterior instrumentation and fusion

Indications

• Kyphosis over 75 degrees with significant cosmetic deformity

• Kyphosis over 75 degrees with pain

• Neurological deficits or spinal cord compression

• Severe pain not responding to conservative treatment

Course

• Most patients experience symptom relief and improved curvature after surgery

• It is important to consider the risk of complications pre- and postoperatively¹

Physiotherapy Management for Scheuermann’s Kyphosis

Non-operative management

Observation and guidance

Children and adolescents with mild kyphosis are often managed with observation, postural guidance, and activity advice from a physiotherapist. Most require no further treatment unless the curve or pain worsens. Many improve without long-term problems, while others may have mild thoracic kyphosis yet function well and pain-free¹².

Bracing

• Indication: Kyphosis between 60–80 degrees, with or without pain.

• Use: Bracing is recommended prior to skeletal maturity, typically from the onset of puberty and for approximately two years until skeletal maturity is reached⁴⁵.

• Brace types: Milwaukee, Kyphologic, or Boston brace (TLSO). Worn continuously, including at night (except during bathing). As the curve improves, part-time wear (8–12 hours daily) may be used.

• Adults may also benefit from bracing for pain reduction when surgery is not indicated¹².

Physiotherapy combined with bracing

Exercise strengthens the supporting musculature and enhances brace effectiveness. Guidance on posture and activity modification is useful with or without a brace¹².

Other physiotherapy measures

• Postural training: Emphasis on stretching the hamstrings and pectoralis muscles, and strengthening the back extensors for improved function¹³

.• Postural guidance: Exercises for correct posture in standing and sitting¹⁵¹⁶¹⁷¹⁸¹⁹.

• Flexibility exercises: Stretching of hamstrings and other tight muscle groups²⁰.

• Core strength: Strengthening of core musculature, back extensors, and gluteal muscles¹⁵¹⁶¹⁷¹⁸¹⁹.

Recommended Activity

Recommended sports: Activities involving extension such as gymnastics, aerobics, swimming, cycling, and specific back extension exercises.

Sports to avoid: High-impact loading, jumping, and activities with significant mechanical stress on the back²¹²².

Postoperative Physiotherapy

Following surgery, the programme should include breathing exercises, mobilisation, and strengthening²³.

Scheuermann’s Disease in Adults

In adults, pain predominates over cosmetic concerns. Outpatient functional rehabilitation is the first choice. Surgery and bracing are seldom necessary. The Schroth method is used to correct posture²⁰.

The Schroth Method

Principles:

• Elongation and expansion of the trunk

• Symmetrical sagittal correction with bilateral thoracic and lumbar expansion exercises

• Shoulder traction to open the thorax and correct the spine

• Breathing correction to promote expansion in the collapsed area

• Muscle activation for balance, stability, and proprioception

Combination with a SpinoMed brace can be effective in adults²⁴.

Limitations of Bracing

 Low compliance in adolescents

• Risk of developing low back pain with prolonged use

• Limited effect in rigid curves or Cobb angles over 75 degrees

• Soft braces show no effect in rigid deformities⁵⁴.

Clinical Considerations

Most patients respond well to conservative treatment. Pain often decreases after skeletal maturity, but the risk of chronic pain is higher in this population. Patients with kyphosis less than 60 degrees at skeletal maturity usually have no long-term problems¹.

Sources

1. Mansfield JT, Bennett M. Scheuermann Disease. InStatPearls [Internet] 2019 Jan 17. StatPearls Publishing. :https://www.ncbi.nlm.nih.gov/books/NBK499966/

2. Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Mitsiokapa EA, Themistocleous GG, Soucacos PN. Current concepts in Scheuermann's kyphosis. Orthopedics (Online). 2008;31(1):52.

3. Lowe TG, Line BG. Evidence based medicine: analysis of Scheuermann kyphosis. Spine. 2007 Sep 1;32(19):S115-9.

4. Weiss H, Turnbull D. Kyphosis (Physical and technical rehabilitation of patients with Scheuermann's disease and kyphosis). International encyclopedia of rehabilitation. 2010.

5. Soerensen KH. Scheuermann's juvenile kyphosis. Munksgaard; 1964.

6. Ristolainen L, Kettunen JA, Heliövaara M, Kujala UM, Heinonen A, Schlenzka D. Untreated Scheuermann’s disease: a 37-year follow-up study. European Spine Journal. 2012 May;21(5):819-24.

7. Bezalel T, Carmeli E, Been E, Kalichman L. Scheuermann's disease: current diagnosis and treatment approach. Journal of back and musculoskeletal rehabilitation. 2014 Jan 1;27(4):383-90.

8. Ali RM, Green DW, Patel TC. Scheuermann's kyphosis. Current opinion in pediatrics. 1999 Feb 1;11(1):70-5.

9. Poolman R, Been H, Ubags L. Clinical outcome and radiographic results after operative treatment of Scheuermann's disease. European Spine Journal. 2002 Dec;11(6):561-9.

10. Lemire JJ, Mierau DR, Crawford CM, Dzus AK. Scheuermann's juvenile kyphosis. Journal of manipulative and physiological therapeutics. 1996 Mar 1;19(3):195-201.

11. Hart ES, Merlin G, Harisiades J, Grottkau BE. Scheuermann's thoracic kyphosis in the adolescent patient. Orthopaedic Nursing. 2010 Nov 1;29(6):365-71.

12. Advantage Physiotherapy SCHEUERMANN'S DISEASE :https://www.advantagephysiotherapy.com/Injuries-Conditions/Upper-Back-and-Neck/Upper-Back-Issues/Scheuermann-s-Disease/a~5944/article.html

13. Weiss HR, Turnbull D, Bohr S. Brace treatment for patients with Scheuermann's disease-a review of the literature and first experiences with a new brace design. Scoliosis. 2009 Dec;4(1):1-7.

14. Goodman CC, Fuller KS. Goodman and Fuller’s Pathology E-Book: Implications for the Physical Therapist. 3rd edition Elsevier Health Sciences; 2009.

15. Weiß HR, Dieckmann J, Gerner HJ. Outcome of in-patient rehabilitation in patients with M. Scheuermann evaluated by surface topography. Research into Spinal Deformities 3. 2002:246-9.

16. Weiß HR, Ddeckmann J, Gerner HJ. Effect of intensive rehabilitation on pain in patients with Scheuermann’s disease. InResearch into Spinal Deformities 3 2002 (pp. 254-257). IOS Press.

17. Ball JM, Cagle P, Johnson BE, Lucasey C, Lukert BP. Spinal extension exercises prevent natural progression of kyphosis. Osteoporosis International. 2009 Mar 1;20(3):481.

18. Montgomery SP, Erwin WE. Scheuermann's kyphosis--long-term results of Milwaukee braces treatment. Spine. 1981 Jan 1;6(1):5-8.

19. Zaina F, Atanasio S, Ferraro C, Fusco C, Negrini A, Romano M, Negrini S. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. Eur J Phys Rehabil Med. 2009 Dec 1;45(4):595-603.

20. Bezalel T, Kalichman L. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. Journal of bodywork and movement therapies. 2015 Apr 1;19(2):232-7.

21. Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. JBJS. 2006 Oct 1;88(10):2133-6.

22. Sturm PF, Dobson JC, Armstrong GW. The surgical management of Scheuermann's disease. Spine. 1993 May 1;18(6):685-91.

23. Lowe TG. Scheuermann disease. JBJS. 1990 Jul 1;72(6):940-5.

24. Berdishevsky H. Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann’s disease evaluated by radiologic imaging—a case report. Scoliosis and spinal disorders. 2016 Oct;11(2):47-51.