Scheuermann’s disease was first described by Holger Scheuermann in 1920, who noted that it could distinguish kyphosis clinically and radiographically into functional kyphosis (due to poor posture) and organic or Scheuermann type kyphosis. In Scheuermann’s kyphosis, there is a developmental deformity of the vertebrae, where the front surface of the vertebral body grows less than the back surface, causing the vertebrae to take on a wedge shape. Scheuermann’s kyphosis is the most common type of kyphosis and is the second most frequent spinal condition after Adolescent Idiopathic Scoliosis. It affects 0.4% to 8.3% of individuals, primarily between the ages of 12 and 15, when there is rapid skeletal growth, with a slightly higher prevalence in boys (2:1).
The diagnosis of Scheuermann’s kyphosis is made clinically and radiographically.
Clinical findings include:
A slouched posture, with shoulders falling forward and internally rotated.
Stiffness of the spine.
Visible hump on the back during the forward bend test (Adam’s test).
Inability to actively extend the back during the forward bend test.
Frequent loss of elasticity in the hamstring muscles.
Usually increased lumbar lordosis and forward head posture.
Pain occurs in 20%-60% of cases.
Radiographic findings include:
Cobb angle > 45 degrees, measured from T3 to T12 vertebrae (though sometimes Scheuermann’s kyphosis can be present with an angle <45 degrees).
Wedge-shaped deformity in at least 3 consecutive vertebrae, with each vertebra having at least a 5-degree wedge shape.
Changes in the upper and lower surfaces of the vertebral bodies (irregular end-plates).
Schmorl’s nodes. These nodes result from the nucleus pulposus pushing into the spongy vertebral body.
Visible narrowing of the intervertebral spaces.
Differential diagnosis of Scheuermann’s kyphosis from functional kyphosis, which is purely a muscular problem caused by poor posture, is crucial for devising the appropriate treatment plan and is done clinically and radiographically. In functional kyphosis, the Cobb angle may be greater than 45 degrees, but there is no wedge-shaped vertebrae deformity or Schmorl’s nodes, and clinically, there is no characteristic spinal stiffness seen in Scheuermann’s kyphosis.
Types of Scheuermann’s kyphosis:
Thoracic kyphosis (Type I): The apex vertebra is usually between T7 and T9. This is by far the most common type of Scheuermann’s kyphosis.
Thoracolumbar kyphosis (Type II): The apex vertebra is usually between T10 and T12.
Lumbar kyphosis: The deformed vertebrae and Schmorl’s nodes appear in the lumbar vertebrae.
Treatment:
Scheuermann’s kyphosis is mostly treated conservatively with a brace and specific exercises for kyphosis. Unlike scoliosis, where the natural progression has been extensively studied, the natural course of Scheuermann’s kyphosis is uncertain, and there is no research that allows for prediction of its progression. However, the therapeutic role of bracing is widely accepted in international scientific communities. The Scoliosis Research Society (SRS) guidelines for treating Scheuermann’s kyphosis state that bracing should only be applied to children with a Cobb angle of 55 to 80 degrees, and when the child has not yet completed their bone growth (Risser stage 0-3). In some cases, early diagnosis and less severe kyphosis, without significant stiffness, may make a special exercise program for kyphosis sufficient, without the need for a brace. The duration of brace wear can vary from 16 to 22 hours a day. The average time for wearing the brace is about 2 years, with gradual reduction in brace wear during the weaning phase.
The brace aims to correct the wedge-shaped vertebrae deformity and to open the intervertebral spaces while the child is still growing. Unlike Adolescent Idiopathic Scoliosis, where the long-term effect of the brace is debated, research shows that the therapeutic effect of the brace in Scheuermann’s kyphosis is retained, although there may be slight worsening initially after the brace is removed. According to international scientific communities (SRS and SOSORT), the use of a brace must always be accompanied by specific exercises for kyphosis. SOSORT scientists suggest that these exercises should precede the initial brace application to improve spinal flexibility and enhance the corrective effect of the brace. In cases of significant spinal stiffness, a brace without accompanying exercises will not yield any correction because the brace pressure will not produce any improvement.
A key predictor for therapeutic success is good correction while the child is wearing the brace (in-brace correction), which should be a minimum of 15-20 degrees. Additionally, consistency in wearing the brace and performing the prescribed exercises is crucial for success.
The exercises for kyphosis should focus on active spinal elongation, posture correction, strengthening in a corrected position, stretching shortened musculoskeletal structures, and training to maintain corrections during daily activities. In contrast to functional kyphosis, where traditional exercises for the abdominals and back muscles can help, Scheuermann’s kyphosis requires more specialized and dynamic exercises to address the accompanying stiffness. The Schroth method encompasses all the necessary elements for kyphosis exercises. No athletic activity can replace the role of these special exercises, but children are encouraged to participate in any sport they enjoy for the overall benefits of physical activity. However, in cases where a brace is worn, contact sports should be avoided.
Thoracolumbar and lumbar Scheuermann’s kyphosis, which have been minimally studied, require different treatment approaches than thoracic kyphosis. A different brace type is needed, and the exercise program should also aim to improve lumbar lordosis and maintain functionality and stability in the lumbar spine. It’s been shown that loss of normal lumbar lordosis is directly related to chronic low back pain, making it one of the frequent causes of pain.
Surgical treatment for Scheuermann’s kyphosis is now used very rarely and only when appropriate conservative treatment has failed or when the patient does not cooperate with bracing therapy. This has been aided by the highly successful and lasting corrective results of conservative treatment (a combination of bracing and exercises). Surgery is typically reserved for cases with kyphosis greater than 80 degrees and significant pain.
The most commonly used surgical technique is posterior spinal fusion. In cases of significant spinal stiffness, a posterior Smith-Peterson osteotomy is applied, in which the posterior facet joints are removed to facilitate spinal extension. The correction of the kyphotic angle after surgery is satisfactory, but the spinal fusion significantly limits mobility, and there are several medium- and long-term complications. Additionally, the pain may not fully resolve. Nowadays, combined anterior and posterior approaches are used with fewer complications, but the decision is made by the surgeon after detailed preoperative assessment.
Physio-Remedy is a specialized center for the treatment of spinal disorders. We provide diagnosis of kyphosis, radiographic measurement of the angle, detailed clinical assessment, and the appropriate treatment plan for your case. The kyphosis exercise program is tailored to each individual’s needs, age, and capabilities, so people of all ages can benefit. At Physio-Remedy, we also ensure proper monitoring of your treatment progress with a series of clinical measurements conducted at regular intervals, so you can track the effectiveness of your kyphosis treatment. Sessions are conducted individually or in small groups, always under the supervision of a Specialized Physiotherapist.
Bibliography:
- Sorensen KH. 1964. Scheuermann’s Juvenile Kyphosis: Clinical Appearances, Radiography, Aetiology and Prognosis. Copenhagen: Munksgaard.
- Zaina F1, 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;45(4):595-60.
- De Mauroy et al, 7th SOSORT consensus paper: conservative treatment of idiopathic & Scheuermann’s kyphosis. Scoliosis 2010, 5:9
- Papagelopoulos et al, Current concepts in Scheuermann’s Kyphosis. Orthopedics. 2008 Jan;31(1):52-8
- Weiss H, Turnbull D. 2010. Kyphosis (Physical and technical rehabilitation of patients with Scheuermann’s disease and kyphosis). In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online:
- https://cirrie.buffalo.edu/encyclopedia/en/article/125/
- www.srs.org
- www.schrothmethod.com
- https://www.schroth-barcelonainstitute.com/
