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A lower back stress fracture is also known as medical Spondlolysis. Lower back stress fractures are the most common overuse injury to affect the lower back. It is quite common in young adolescent boys whom are in the midst of a growth spurt, and sports involving hyperextension of the lower back.
First of all let’s discuss where about in the spine a lower back stress fracture would occur. The human spine is made up of 24 smaller segments called vertebrae, which are a “block” of bone; all the vertebras being stacked on top of each other create hollow tubing through the middle in which the spinal cord travels through with the vertebras acting as protection. The part where each vertebra connects with the one before it and after on the side is called a facet joint, and a disc is the name for the connector in the central part of the spine (see diagram1.1).
Each vertebra has a main body which is rather solid and then “bony bits” along the back are the facet joints which are also called pars and are relatively brittle. The spine gives the human body its main upright support. The lower back is called the lumbar spine. The most common area for a stress fracture of the back to occur is the lowest area of the lumbar vertebra called L5. See diagram 1
A stress fracture is when there is a crack in the pars of vertebrae, which can be seen in diagram 2. The cause of the fracture in the pars can be caused when too much force is being placed on the facet joints and it can no longer withstand that amount of compression. If left untreated, or ignored the fracture can become so severe that the par will actually become completely disconnected from the vertebrae. It is very uncommon for a stress fracture to occur on both sides of the spine. A problem with the spinal column can also lead to other problems in supporting structures such as the abdomen and the legs, in particular the hamstring.
View diagram 3
Please now watch the interactive clip “what is a stress fracture” video to understand more.
A lower back stress fracture is a hard tissue injury, as it involves the vertebrae and in most cases more specifically the L5 vertebrae.
Overuse is the most common cause for lower back stress fractures as prolonged time spent hyper extending, for example a cricket fast bowler can gradually fracture the pars of a vertebra and if sufficient rest isn’t given then it will continue to digress. With repeated movement, in particular hyper extending, strain is placed on the lumbar area where the fracture has initiated, and with each movement the fracture is made more severe.
Q2(ii)-PREVALENCE IN SPORT-
Lower back stress fractures are common in all sports which involve any amounts of repeated hyperextension of the back (bending the back further then regularly) as well as those which involve rotation. For example
Fast bowlers in cricket are the most susceptible to this injury, as whilst bowling they are hyper extending and rotation whilst moving very fast. The impact when a fast bowler hits the ground can be anywhere between 8-11 times his or her own body weight, in some people this can be over 1 tonne of impact, all compressing on their spine according to the NSW cricket association based on statistics from their team. In some Australian cricket teams the prevalence of this is up to 55% of their fast bowlers.
It is also common in sports such as gymnastics, dancing, wrestling, high jump, tennis, weightlifting, horse riding and jumping and any other sports which involve throwing for example shot put, javelin and discus.
Lower back stress fractures are also very common in adolescents and affect roughly 6% of teens in the United States of America at one stage or another. It is more common in adolescents which are more active. Lower back stress fractures in adolescents are due to the fact that growth is still occurring and bones are not as strong as that of an adult.
SIGNS AND SYMPTONS
The pain associated with a lower back stress fracture can range from a mild, constant ache, to a sharp jolt of pain when aggravated and the lower lumbar will constantly be stiff. Generally things such as bending over, or standing on one leg cause great amounts on discomfort. The site of the pain will be inflamed after any physical activity which involved the lower lumbar. Inflammation and swelling is caused by chemicals being released whenever a part of the body is injured. The chemicals react and cause the capillaries in the body to expand to allow for an increased blood flow to the area so that the body can begin to repair and the excess blood and fluid in the area provides protection and helps to control infection. Pain can radiate down one or both of the legs, as occasionally when
the par fractures nerves are pinched.
In order for the body to try and heal the fracture, extra cartilage will be produced resulting in a raised bump along the back, where the fracture is. If too much cartilage builds up then it may block nerve signals and cause a pins and needles feeling constantly.
The leg muscles may also become tighter and strained as they have to compensate for the lower back not being able to provide efficient support to the body.
Please now watch “what are the warning signs” video to understand more.
COMMON CAUSE AND PREVENTION
Lower back stress fractures are common in sports which involve hyperextension and rotation is due to the awkward and venerable angle which the back is placed in, combining impact to this then increases the pressure which the pars will be under and something will have to give. Considering that the pars are the weakest area in the spine, which is the area which cannot obtain the strain as effectively.
Overuse is the most common cause for lower back stress fractures, when they arise in sports. As stated above hyperextension, in sports causes the lower lumbar to be placed under a considerable amount of strain and if the vertebrae is exposed to this amount of strain for prolonged periods of time then injuries will occur. If the amount of time which a athlete is participating in activities involving hyperextension is longer than the body and mind can withstand than fatigue will set in and the technique will become “sloppy” and then the risk of injury will be much higher.
More strain can be placed on the lower lumbar if other muscles do not provide efficient support, for example if the hamstring does not support the legs properly than the lumbar area will compensate the leg area to supply support.
Adolescents also suffer from lower back stress fractures as their bones are not as strong as adults so they are more venerable to lower back stress fracture so participating in things which involve hyperextension can be very fatal to the lower lumbar area.
To prevent this injury from happening it is important to carry out training and understand how to do each component of any sport which, you are involved in properly, as having a poor technique will place unwanted strain on the spine and can cause serious injuries.
Employing aids to lower the risk of lower back stress fractures is also very important for example, to reduce the impact the lower back feels when running, a softer surface even, with a little more bounce can reduce the strain that the lower back feels.
The most efficient way to reduce lower back stress fractures is by allowing that there is plenty of rest and recovery time allocated, so that the lower back does not progressively get worse and so it can adapt to more challenging workloads. Also with rest, fatigue will not occur allowing that technique stays at the highest equality, which will prevent a stress fracture of the lower back.
Treatment and Rehabilitation
As soon as the fear of stress fractures arises it is important to stop the activity which sparked the fear, and rest the lower back completely. To reduce the risk of the stress fracture progressively getting worse, it is vital to apply ice as soon as possible. This will also help to prevent swelling as the cold temperature of the ice reduces the blood flow. Trying to elevate the back will also reduce blood flow to the area, however due to the spine being very venerable it can be dangerous to try and elevate the spine as unavertable place strain on the lower lumbar.
Monitoring the problem, to see which activities aggravate the lumbar area. Then modify these movements so that less stress is placed on the fracture.
Rigid back brace, or cast for a time period ranging from 3-4 months. This will restrict the spine movement allowing an appropriate time for the lower back stress fracture to heal. A back brass is often only used in severe instances of a stress fracture. The bones should eventually grow back together, however in some cases they do not.
Rest is the most effective non-surgical treatment of a lower back stress fracture. The main goal in rest is to decrease inflammation. The rest needed will generally be time away from sport and any activities that require hyperextension of the lower lumbar, which only aggravate the stress fractures.
To help ease the pain and other symptoms involved with lower back stress fractures treatments such as ultrasound, electrical stimulation as well as heat and cold treatments are effective.
Physiotherapists are fantastic at evaluating the problem, and providing exercises that strengthen the muscles around the spine, referred to as “core” muscles so that the strength of the muscles can alleviate the strain that the spine will feel. A physio can also provide advice as to how to participate in sport using the correct technique and equipment that will aid performance and prevent future problems. Physios will also advise on posture and other such factors that can improve symptoms of a lower back stress fracture. Continual work in conjunction with a physio, in some cases seeing the practitioner weekly, or however frequently a doctor advises. As well as doing the exercises the physiotherapist recommends daily.
Exercises involving swimming or swiss ball activities are highly regarded as in the water, buoyancy takes a lot of strain of the vertebrae and allows muscles surrounding the spinal column to develop further which encourage the muscles to work in supporting correct posture.
In very extreme cases, where the bones have separated too much and there is nothing a physio can do, or a nerve is in a venerable position, there are operations which can immediately solve lower back stress fractures. The operation consists of moving the vertebrae that is out of place, into correct positions then fusing the two vertebras together to prevent further damage.
This procedure must be done in conjunction with a physio, as operation is only the first step in fixing the problem; in order to prevent this re-occurring strengthening exercises and remedial massage need to be continuously done.
Please now watch “what remedial steps can I take to relieve a stress fracture” video to understand more.
To assess the injury as soon as symptoms such as pain, swelling and stiffness of the back occur, things such as x-rays are the first examination that will be partaken. However pars being situated in awkward angles and fractures varying in size and position, something as simple as a one-dimensional x-ray commonly do not alert signs of there being a fracture.
Things such as an MRI scan are much more thorough as an MRI scan, where coloured ink is injected into the body, then centralises at an area of bone dysfunction, are much more suited in diagnosing a lower back stress fracture.
However there are also some simply exercises such as standing on one leg, and hyper extending the back, whilst rotating which can be used as a gage, if there is pain, quite commonly a par will have a fracture of some degree, these exercises can be seen in the video below.
Please now watch “how do you identify a stress fracture” and “what is a simple test for a stress fracture” video to understand more
what is a simple test for a stress fracture-
Outcomes on individual’s future
If rest is sufficient enough, for the bones in the vertebrae to heal properly, then the impact of this will be minimal to non-existent. However their performance may not be at the same level as before the fracture as fear of being re injured can play mentally on the athlete therefore they will be more protective and hesitant to participate in activities which involve hyperextension of the lower lumbar. However if left untreated and an individual continues to participate in aggravating activity then the fracture will worsen and the likelihood of a complete dismembering of the par will occur.
Children who have a lower back stress fracture, due to growth often notice no signs or re occurrence of this injury in later life presuming the appropriate rest and rehabilitation where followed whilst the injury was occurring. However they may be behind athletes or children, who they were once at the same level as due to rest being needed, they would have missed out on some training sessions.
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