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Available online at

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Review

Scheuermann’s disease: An update

Clémence Palazzo a,∗ , Frédéric Sailhan b , Michel Revel a
a
Université Paris Descartes, UFR de Médecine; AP–HP hôpital Cochin, service de rééducation et de réadaptation de l’appareil locomoteur et des pathologies du rachis, 27, rue du
faubourg Saint-Jacques, 75014 Paris, France
b
Université Paris Descartes, UFR de Médecine; AP–HP hôpital Cochin, service de chirurgie orthopédique, 27, rue du faubourg Saint-Jacques, 75014 Paris, France

a r t i c l e i n f o a b s t r a c t

Article history: Scheuermann’s disease is a juvenile osteochondrosis of the spine. It is a disease of the growth cartilage
Accepted 27 November 2013 endplate, probably due to repetitive strain on the growth cartilage weakened by a genetic background.
Available online xxx The radiographic aspects are related to the vertebral endplate lesions and include vertebral wedging,
irregularity of the vertebral endplate, and Schmorl’s node (intraossous disk herniation). Disc alterations
Keywords: are frequent and may be secondary to dysfunction of the disc–vertebra complex. The definitions of
Scheuermann’s disease Scheuermann’s disease are varied; it can refer to the classical form of juvenile kyphosis, described by
Scheuermann’s kyphosis
Scheuermann as well as asymptomatic radiographic abnormalities. Lumbar involvement is probably as
Osteochondrosis
frequent as the thoracic form and might be more painful. The first-line treatment is medical and includes
rehabilitation and bracing. The earlier the start of treatment, the better the outcome, which highlights
the importance of early diagnosis. Surgery is uncommon and must be limited to severe involvement after
failure of conservative treatment. The natural history of Scheuermann’s disease is unknown, but it might
be associated with increased risk of back pain. The evolution of thoracolumbar and lumbar disease is
unknown.
© 2013 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.

1. Introduction
Scheuermann’s disease was first described in 1921 as a painful,
fixed, dorsal kyphosis consisting of wedged vertebrae, with dis-
turbances of the vertebral endplates, occurring in adolescents [1].
Sorensen later proposed the now widely accepted radiographic
criteria of three adjacent wedged vertebrae, angled by at least
5◦ [2]. For some authors, one wedged vertebra is sufficient to
conclude a diagnosis of Scheuermann’s disease if associated with
irregular vertebral endplates [3]. The prevalence of Scheuermann’s
disease differs widely depending on the definition. An estimated
2.8% of people report Scheuermann’s disease [4], but 76% have
radiographic Schmorl’s nodes [5]. For a long time, Scheuermann’s
disease was thought to be more frequent in men than women. The
sex ratio is actually considered to be close to 1 [6,7].
2. The vertebral endplate
Scheuermann’s disease is characterised by defective growth
of the vertebral cartilage endplate. The vertebral endplate is the
physical shield separating the disc from the vertebra [8]; it is
composed of a cartilaginous and an osseous component. As a
∗ Corresponding author.
E-mail address: clemence.palazzo@cch.aphp.fr (C. Palazzo).
mechanical interface between the stiff bone and resilient disc,
the endplate is the weakest portion of the disc–vertebra complex
and is predisposed to mechanical failure [8,9]. It is also the main
gateway of nutrient supply to the disc, which is not vascularised.
Consequently, if the endplate is of low quality, as in Scheuermann’s
disease, the disc will be affected.
3. Pathophysiology of Scheuermann’s disease
Scheuermann’s disease may result from excessive mechanical
stress on a weakened vertebral endplate during growth of the spine.
3.1. Histological findings
Histological studies showed disorganized enchondral ossifica-
tion, reduced collagen level, and increased mucopolysaccharide
levels in the endplate with the disease [7,10,11]. The main hypoth-
esis is that disorganized enchondral ossification results from the
defective growth of the cartilage endplate.
3.2. Genetic background
The weakness of the vertebral endplate probably results from
a predisposing genetic background that influences the quality of
matrix components (collagen types II and IX) and chondrocytes. A
Danish cohort of 35,000 twins found a heritability of 74%, which

1297-319X/$ – see front matter © 2013 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jbspin.2013.11.012

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indicates a major genetic contribution [6,12]. An autosomal dom-

inant form of inheritance is suspected [13]. The main candidate
genes are COL2A1 and COL9A3. An Arg75 -Cyst mutation in COL2A1
was found associated with a spondyloepiphyseal dysplasia similar
to Scheuermann’s disease with severe osteoarthritis [14,15], and
a mutation in COL9A3 was found in patients reporting low back
pain with radiographic Scheuermann’s lesions [16,17]. The role of
COL1A1 and COL1A2, initially suspected, was not confirmed [13].

3.3. Mechanical stress

Mechanical stress influences the severity of spinal impairment.

This theory is suggested by several observations. First, some
authors reported similar lesions of localized lumbar osteochon-
drosis in twin sisters, worse in the twin who practiced strenuous
sports activities [18]. Second, the prevalence of Scheuermann’s
disease seems to be higher in manual workers who began work
at a young age [1] and in high-level athletes of sports involving
large motions of the trunk in flexion/extension [19,20]. Finally,
repetitive strain on vertebral endplates in young rats led to
typical Scheuermann’s lesions [21]. A high body mass index may
be another risk factor of Scheuermann’s disease [22]. However,
the role of height and weight remains unknown. Some have
hypothesized that overweight results in excessive mechanical Fig. 1. Thoracolumbar form of Scheuermann’s disease.
stress on growing vertebral bodies [18]; others suggested that
Scheuermann’s disease and overweight could occur with the Neurological complications have been described in a small
same genetic background [22]. Fotiadis et al., investigating the number of patients with untreated kyphosis. They were caused
length of the sternum of 10,057 students, found that 175 ado- by dural cysts [30,31] or thoracic disc herniation [30,32] and were
lescents with Scheuermann’s disease had a short sternum [23]. often triggered by trauma. Neurological complications may occur
This short sternum might result from excessive pressure on the frequently if the curve is small and angular [32].
front part of vertebral bodies associated with a particular genetic
background.
5. Radiographic aspects

4. Clinical features The radiographic aspects of Scheuermann’s disease related to

The classical form of Scheuermann’s disease is characterized by
painful, fixed, dorsal kyphosis occurring in adolescents [1]. Sev-
eral morphological types have been described depending on the
level and the bending radius of the curve (e.g., “hunchbacked” or
“hypotonic” aspect). The excessive dorsal kyphosis generally leads
to non-structural lumbar hyperlordosis, pelvis anteversion, and
rounding of the shoulders. Pain might be caused by several factors.
Scheuermann’s lesions, such as disc impairment or inflammatory
lesions, can induce pain, particularly, at the apex of the kyphosis.
Lumbar pain often arises from muscular tension but may result
from spine impairment (disc herniation or spondylolysis [24]). The
thoracolumbar and lumbar forms of the disease were described
later; these correspond to a lowering of the apex of the kyphosis at
the thoracolumbar junction (T11–T12) for the thoracolumbar form
and loss of lumbar lordosis for the lumbar form [25]. Such cases
concern between 25% and 80% of Scheuermann’s disease [26,27]
and may be more painful than the classical form. The cervical
form of Scheuermann’s disease has not been described. It might
be explained by the uncus, which is not mobile during puberty
and could protect the vertebral endplate against mechanical stress
(Fig. 1).
Between 15% and 20% of Scheuermann’s cases are associated
with scoliosis [26,28]. Such cases often exhibit a small bending
radius, poor rotation, and a slow rate of progression. They probably
arise from asymmetry of Scheuermann’s lesions. However, scolio-
sis can also develop independently of Scheuermann’s disease; in
this case, the apex of the kyphosis does not correspond to the apex
of the scoliosis curve, and the rate of progression may be greater
[29]. The follow-up and treatment of this type of scoliosis must be
the same as for “classical” scoliosis.
the histological lesions of the vertebral endplate has been described
previously. The elementary lesions are vertebral wedging, irregular
vertebral endplate and Schmorl’s node (intraossous disk hernia-
tion) (Fig. 2).
5.1. Vertebral wedging
Vertebral wedging occurs during the primary ossification and
increases during the secondary one according to Delpech’s law.
The phenomenon could be described as excessive pressure on the
vertebral endplate, inducing vertebral wedging and the wedging
itself increases the mechanical stress on the vertebral endplate.
This defective growth of the front part of the vertebral body may
be associated with excessive lengthwise growth (Knutsson’s sign)
[33]. Sometimes, a flattening of the whole vertebral body can be
observed, with a lengthening of the adjacent vertebra as compen-
sation (Edgren’s sign) [25]. Malley et al. described a radiographic
sign that appears before the wedging that could help diagnose
Scheuermann’s disease at disease onset; this sign corresponds to
the projection of the ring apophyse under the vertebral endplate
[34] (Fig. 3).
5.2. Irregular vertebral endplate and Schmorl’s node
The defective vertebral endplate that characterizes Scheuer-
mann’s disease can be seen on standard X-ray. Schmorl node
occurs during the secondary ossification. It can be central, corre-
sponding to a nucleus herniation in the vertebral body through
a weak point of the endplate. It also can be premarginal pos-
terior or retromarginal anterior, corresponding to a fracture of
the ring apophysis followed by an interposition of the annulus

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between the fracture and the vertebral endplate. The prevalence

of Schmorl node varies from 16% (radiographic study) [9] to 48%
(skeletal study) [35]. Nodes often are non-symptomatic in patients
younger than 20 years [36], although several radiographic studies
suggest their association with disc degeneration [9,37]. Sometimes,
cases of Schmorl node can be isolated, without other Scheuer-
mann’s lesions. Their prevalence seems to be stable in patients
older than 20 years [9], which suggests that they develop during
the growth of the spine. As in Scheuermann’s disease, previous
data suggested a genetic background [37]. Schmorl node must be
distinguished from intraosseous disc herniation that occurs dur-
ing adulthood and is probably closer to vertebral fracture [38]. The
frequency is not higher in the osteoporotic than non-osteoporotic
population [9]. Previous studies showed that 10% of intraosseous
disc herniations were edematous and were enhanced after con-
trast injection [39,40]. Edematous lesions were associated with
back pain (43% of patients reporting back pain had an edematous
lesion vs 14% of asymptomatic patients in the Stabler et al. study
[40] and 100% vs 0% in the Takahashi et al. work [38]). Another
factor associated with back pain is the size of the disc hernia-
tion (7.9 mm mean diameter in symptomatic patients vs 5.2 mm
in asymptomatic patients [40]). As observed for vertebral frac-
ture, the edematous signal gradually decreases in 6 to 72 months
[38,40].

5.3. Impaired ring apophysis

Impaired ring apophysis is less frequent in the disease

Fig. 2. The elementary radiographic lesions of Scheuermann’s disease: vertebral
wedging, Schmorl’s node, irregular vertebral endplate, impaired ring apophysis,
impaired disc.
(1% of Scheuermann’s disease according to Stoddard et al.
[41]). The mechanism is close to epiphysitis diseases, such as
Osgood–Schlatter and Sinding–Larsen syndromes, although no epi-
demiologic study has shown an association of Scheuermann’s
disease and these diseases.

5.4. Disc impairment

Finally, disc impairment is observed more frequently in

Scheuermann’s disease than in normal spines. An MRI study found
50% disc degeneration in 20-year-old patients with Scheuermann’s
disease as compared to 10% in patients without [42]. This obser-
vation might be explained by defective disc nutrition because of
altered exchange between the disc and the vertebral endplate
(Fig. 4).

Fig. 3. Thoracic form of Scheuermann’s disease. Vertebral wedging and irregular

vertebral endplate. Fig. 4. Lumbar form of Scheuermann’s disease. Irregular vertebral endplates, central
Schmorl’s nodes from T11 to L4, retromarginal anterior Schmorl’s nodes of L2 and
L5, impaired disc between L2–L3 and L4–L5.

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Fig. 5. Milwaukee brace.
6. Natural history
The literature lacks agreement regarding the natural history
of Scheuermann’s disease. However, two recent studies found an
increased prevalence of back pain in the classical thoracic form
[28,43] (Fig. 5). The first study involved a Finnish retrospective
cohort with a 37-year follow-up of 49 patients (mean age 59 years
old); the prevalence of low back pain was 39%, which was 2.5 times
higher than in the control population [28]. The second study was
a 32-year follow-up of 67 patients from North America that found
an increased prevalence of thoracic back pain (28% vs 0% in the
control population) [43]. In both studies, the presence of back pain
was not associated with the degree or apex level of the kypho-
sis. Restrictive lung disease was observed only when the kyphosis
was > 100◦ [43]. Although lumbar Scheuermann’s disease may have
good prognosis, the evolution remains unknown. A 25-year follow-
up of 481 teenagers showed an increased prevalence of low back
pain during adolescence (58% with Scheuermann’s disease vs 33%
controls) but not adulthood [44]. A systematic review of obser-
vational studies comparing radiographic lesions in people with
low back pain versus a population without symptoms found the
same prevalence of Scheuermann’s lesions in the two groups [45].
However, the disc impairment and loss of lordosis encountered in
lumbar Scheuermann’s disease are associated with low back pain
[45–48]. Consequently, we need further follow-up studies for better
knowledge of the natural history of the lumbar form.
7. Treatment
Treatment of Scheuermann’s disease includes rehabilitation,
bracing, and, for a very few patients, surgery. However, mild forms
of the disease can be managed with advice and observation. Sports
involving excessive pressure on the spine, such as weightlifting,
and with repetitive strains on the vertebra, such as rugby, must be
avoided for all cases.
7.1. Rehabilitation
Rehabilitation is recommended to relieve pain and to improve
sagittal balance when the kyphosis can be reduced. Different reha-
bilitation techniques [49] include postural control, strengthening
and stretching of the trunk, and musculotendinous stretching,
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doi:10.1016/j.jbspin.2013.11.012
particularly of hamstring and pectoral muscles, which are often
stiff. Respiratory rehabilitation can be useful in case of restrictive
lung disease. To our knowledge, no study with a high level of
evidence of the effectiveness of rehabilitation in Scheuermann’s
disease has been conducted. Two open studies without a control
group (published by the same team) suggested that an intensive
rehabilitation program might be effective for pain [50] and kyphosis
[51]; however, the content of the program was not described.
7.2. Orthopaedic treatment
Orthopaedic treatment aims to reduce pressure on the front
part of the vertebral endplates and relieve pain. It may also help
in healing certain localized lesions [18,52] Consequently, bracing is
indicated for painful Scheuermann’s disease and/or mild kyphosis
(between 45◦ and 65◦ ) [53and/or with ineffective physiotherapy].
Although disputed, the efficacy of orthopaedic treatment to cor-
rect severe kyphosis > 70◦ has been suggested [54]. Different types
of braces can be proposed. The principle consists of one posterior
support at the apex of the kyphosis and two anterior supports that
compensate the first one. This type of brace, an underarm brace, is
indicated for lumbar and thoracolumbar Scheuermann’s disease. In
the classical thoracic form, the brace is larger and extends from the
pelvis to the high sternum; it has another posterior sacral support,
and the anterior supports are higher (e.g., the Milwaukee brace). A
plaster cast may be recommended for a short period (1–3 months)
for very stiff kyphosis, at the end of the puberty, or with insuffi-
cient compliance. The orthopaedic treatment must be started as
soon as possible [49]. By analogy with scoliosis, the brace should
be worn 21 h per day until the patient reaches skeletal maturity
[49,54]. Compliance may be worse with the Milwaukee brace than
other braces, probably because of the aesthetic and psychological
impact of the neck ring [54].
Studies showed good efficacy of the Milwaukee brace in children
with kyphosis; after 32 to 34 months, the curvature was reduced by
35% to 50% [53–56]. Five years after bracing, the results were still
good; 66% showed improvement of the initial curvature (estimated
between 10% and 20%) and 24% a worsening; 10% of kyphosis cases
were similar to the kyphosis before bracing [55] (Fig. 5).
7.3. Surgical treatment
Surgery is uncommon in Scheuermann’s disease. It is used for
stiff and symptomatic kyphosis with marked and progressive cur-
vature (> 70◦ ) after failure of conservative treatment [7,56,57].
It must be performed by trained surgeons in skeletally mature
patients. The posterior operative technique was the first surgical
method used to treat Scheuermann’s kyphosis [57]. Different meth-
ods have been proposed. They all consist of three steps: a release
of spine structures, a correction of the kyphosis (at least 50% of the
curve), and arthrodesis with instrumentation. Some authors com-
bined an anterior release to facilitate posterior correction of the
curve. However, the benefits of the additional anterior approach
remain unclear, and side effects may be more frequent [58,59].
Previous studies reported good results with surgery on spine defor-
mity and pain [7,57]. The most frequently observed complications
were neurological (paraplegia), infectious, and respiratory [7]. Neu-
rological complications that could occur during surgery are now
controlled, particularly during kyphosis reduction, by electrophys-
iologic monitoring. Junctional syndrome is often described: the
degrading of the segment above or under the arthrodesis [60].
8. Conclusions
Scheuermann’s disease is prevalent and has a great vari-
ety of clinical presentations. Its definition is actually based on
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radiographic criteria. Although its pathophysiologic aspects remain
unclear, lesions may result from excess mechanical stress on a
weakened vertebral endplate during the growth of the spine. The
weakness of the vertebral endplate results from a predisposing
genetic background, which influences the quality of matrix com-
ponents (collagen types II and IX) and chondrocytes; an autosomal
dominant form of inheritance is suspected, with hereditability of
74%. Conservative treatment, including rehabilitation and bracing,
are usually sufficient to improve sagittal balance and relieve back
pain. The efficacy of treatment depends on early diagnosis and
care. Surgery is uncommon. Further cohort studies are needed to
better address the natural history of the disease and to identify
prognostic factors of back pain during adulthood.
Disclosure of interest
The authors declare that they have no conflicts of interest con-
cerning this article.
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Please cite this article in press as: Palazzo C, et al. Scheuermann’s disease: An update. Joint Bone Spine (2014),
doi:10.1016/j.jbspin.2013.11.012