Stress Fractures in the Lower Back

What is it?

Often referred to as pars defect and is an incomplete fracture with in rear portion of the vertebral arch.  If it occurs on both sides of the vertebrae and the vertebral body 'slips' forward it is called a spondylolisthesis (These are graded 1 to 4, depending on severity)

How does it happen?

It usually results from an overuse injury with activities requiring excessive extension (arching) and/or rotation (eg. fast bowling). The rear portion of the vertebra is placed under stress and reacts by increasing bone turn over (replacing the old with new).  If this process results in greater re-absorption than new bone formation then an area of weakness develops and a fracture can take place if the bone is continually loaded (stress fracture). 

How does it feel?

The condition may cause pain in the low back (typically one sided) with the possible presence of buttock or leg pain. The condition is aggravated by activities involving extension and rotation. As it worsens you may experience pain with prolonged standing and with lying. Pars defects and a spondylolisthesis can be congenital and asymptomatic.  These are typically found incidentally on X-rays for varying low back conditions.

How is the diagnosis made?

Diagnosis is made via a thorough history and physical assessment.  X-rays, bone scans and/or CT scan can be requested to confirm the diagnosis and stage of healing.

Management

·      The assistance of physiotherapist and doctor is important in the successful management of pars defects.  Structuring a rehabilitation program that incorporates the constraints of the diagnosis is vital in returning to activities.

·      Rest from the pain producing activities. It is particularly important to avoid forceful hyperextension as this may lead to further symptom provocation and condition deterioration.

·      Isolated functional strengthening of the deep trunk musculature.  There has been a great deal of research performed by physiotherapists across Australia, which supports the very specific sub-maximal re-training of the 'core muscles'. This work can be incorporated into more general trunk strengthening and specific functional strengthening as your condition improves.   

·      Review the biomechanics of the aggravating activity. Changing the loading on the bone is vital to limit the recurrence of the injury and technique changes may be needed in your given sport.

Could there be any long-term effects?

It is possible that defects may never heal, and that a spondylolisthesis may remain the same. But despite this, appropriate management can usually return to your desired level of activity.

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