Introduction:

Lumbar stress fractures are a common cause of lower back pain in adolescence. Up to 30% of athletes between 11-17 may have lower back pain, and a high index of suspicion for stress fracture should be maintained in this age group.

Aetiology:

Lumbar stress fractures occur due to an overload of the pars interarticularis region. The L5 level is most commonly involved. Symptoms occur commonly in adolescence, and generally relate to exercise that involves extension and/or rotation. Classic sports affected include cricket fast bowling or gymnastics, but they may occur in any running or pivoting sport

Stress fractures may occur in structurally normal bone. There are also chronic bony lesions in this area known as ‘pars defects’. A pars defect is not congenital, but develops early in life. It is present in around 5% of the population and is often asymptomatic. It may be aggravated with similar activities that cause acute stress fractures. When the pars defects are bilateral there may be a slippage of one vertebra on another, which is known as a spondylolisthesis.

Fig 1. The single-leg hyper-extension test

Diagnosis:

Historically the patient will complain of a gradually evolving lower back pain, usually unilateral, which is worsened by their chosen sport and improves with rest. At its worst the pain may be present in daily activities or even at night. Often it will grumble on for many months before a diagnosis is mad

Clinical examination will reveal pain that is worsened by positions of spinal extension. More specifically extension/rotation or single leg hyperextension to the affected side may also reproduce pain. Tenderness may be palpated at the lumbosacral level, 1cm lateral to the midline.

Investigation

A plain X-ray is the simplest method to investigate the adolescent with back pain. It may show a pars defect or even a spondylolisthesis. Oblique views are more sensitive for pars defects, but increase the radiation dose. Further investigation may be needed to make the diagnosis. This may initially involve a bone scan, which is very sensitive for diagnosing stress fractures and confirms bony activity, and a limited CT scan to stage the lesion as acute or chronic. MRI scanning may be a viable alternative as it avoids radiation, but is not as sensitive as the combined bone scan/CT.

Treatment:

The prognosis for lumbar stress fractures is generally favorable. The treatment will involve complete rest from all sport for anywhere up to 3 months. Bracing has been used historically, but had not been shown to improve outcomes and is reserved only for recalcitrant pain.

The period of rest required will be guided by the stage of the lesion on the CT scan. A Japanese study demonstrated that with rest, union of the fractures occurred in 75% of early lesions, 40% of progressive lesions and 0% of terminal lesions. As such, terminal lesions only require rest until symptoms resolve as healing is unlikely, as opposed to early lesions where healing is the goal and more prolonged rest is needed. Radiological signs of a terminal lesions include sclerosis and widening of the pars defect, bilateral defects and associated spondylolisthesis

Physiotherapy is required to improve lumbar mobility and flexibility. Home exercises to stretch the hamstrings, hip flexors and gluteals, as well as to strengthen core stabilizing muscles should be performed daily. Technique correction is important, especially in cricket bowlers where a ‘mixed action’ of shoulder and hip counter-rotation is a predisposing factor.

Fig 2.  Representative CT images of  stress fractures  in a) the early stage, b) the progressive stage and c) the terminal stage.

Key Points

• Lumbar stress fracture is an important cause of lower back pain in adolescents and requires a high index of suspicion for diagnosis
• Stress fractures are caused by activities that cause extension and rotation of the spine
• The pain is usually insidious and persistent over a period of time
• Diagnosis requires imaging in the form of an X-ray,  bone/CT scan or MRI
• Treatment involves a period of complete rest from sport but invariably leads to a favorable outcome
• Technique assessment in cricket fast bowlers is essential

Tendinopathy is a significant cause of musculoskeletal presentation to both general practitioners and specialists alike and may take up to 12-18 months to settle down. Tendinopathy is generally a self-limiting degenerative process and the prognosis should be considered favourable. However a small sub-set of patients will fail to improve. This may be despite conventional treatment including anti-inflammatory medications, cortisone injections and eccentric rehabilitation programs

Drawing blood from the cubital fossa in the elbow

It has been postulated that injections of blood products – either autologous whole blood, or PRPP (platelet rich plasma protein) – may be helpful in stimulating tendon regeneration. The theoretical use of blood product injections relates to platelet derived growth factors (PDGF’s) that are carried in the platlets in whole blood. Areas of tendinopathy are characterised by poor blood supply which may contribute to their slow healing. Injecting fresh blood around tendons may introduce growth factors to the area, which may stimulate a healing response. The landmark paper supporting ABI was written by Edwards of the effects on tennis elbow (1). 26 of 28 patients in this study improved after a series of up to 3 injections. Other studies have also shown benefits in other tendon conditions including golfers elbow and patella tendonosis. Thus ABI gives us a treatment option between physio and anti-inflammatory treatment and surgery

ABI is relatively simple procedure to perform. It involves taking a small quantity of venous blood and re-injecting it around the affected tendon. It can be performed on the day of consultation and does not require imaging guidance. A PRPP injection requires 30 mls of blood which must be centrifuged for 15 minutes. It requires more time and expense and there are limited studies showing any benefit over ABI in the treatment of tendinopathy.

The main side effect from these injections is pain at the site of the injection and bruising. The severity and duration of this varies from person to person, but may be anywhere up to 1-2 weeks. This is best treated with ice and simple analgesics. Maintenance exercises may be performed as soon as the local pain settles, and should be encouraged. The recovery time for these injections may be anywhere between 1-6 weeks. They may need to be repeated up to 3 times, generally at 6 week intervals, depending on the level of improvement.

Autologous blood injection for gluteal tendinopathy

In summary a reasonable paradigm for the treatment of tendinopathy may include:

• Initial physiotherapy with an exercise component (generally an eccentric program)
• If pain persists or is interfering with rehabilitation exercises or daily activities then consider 2-3 corticosteroid injections at 4-6 weekly intervals with continuation of rehab exercises
• If pain is recurring or there is limited improvement with this approach then consider second line treatment with a blood product injection.

• ABI is suggested initially as it is a cheaper alternative and more readily administered. The literature would suggest similar levels of efficacy and nothing to suggest that PRPP injections have advantages over and above autologous blood injections.
• If autologous blood unhelpful (up to 3 injections), then consider a trial of PRPP injection.
• Surgery as a last option if persistent pain greater than 12 months and interfering with work/daily activities and all other treatment options exhausted.

1. Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am]. Mar 2003;28(2):272-8.

Whilst head injury in sport is an important topic, there are at present many unknowns with respect to this condition. There are only case reports and certainly no controlling for other factors such as associated recreational drug use, anabolic steroid use or familial or genetic factors. It should also be remembered that American football is a considerably different game to our football sports where the helmet (and head) is regularly used as a battering ram. Our understanding of this condition is also limited as there is no diagnostic test sensitive enough to pick up CTE in the living athlete.

The general consensus of the world experts in concussion management is that if the concussive episode is well managed, and complete resolution of the episode has occurred before return to play, then the risk of long term consequences is low (see Zurich consensus on concussion management). This would include removing any concussed player from the field of play for medical evaluation, not allowing a concussed player to return to play on that same day and following a stepwise protocol for return to sporting activities. This includes monitoring for post-concussive symptoms, neuropsychometric deficits, and balance loss. Once all of these factors have completely resolved then a safe return to play can occur. It is also important that all codes are reviewing the rules of the game to reduce dangerous contact to the head.

The links below are to the Zurich Concussion Consensus and to a recent article in the Medical Journal of Australia entitled ‘Does Football Give You Brain Damage’ which is a rational look at the current concussion debate.

Zurich Statement

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Shoulder instability is one of the major injury concerns of an NRL level rugby league player. The extreme levels of force in the tackle leave the shoulder regularly prone to injury.

It is generally considered that an unstable shoulder, especially in the form of a true dislocation, will have a very high rate of recurrence in the younger athlete. This is certainly well above the 90% mark. In a first grade rugby league player this would be basically a 100% chance, given the nature of the game.

If the instability occurs during the season then an attempt will usually be made to keep the player playing. This may take a period of up to 6 weeks with physio, shoulder strengthening and a rehabilitation program. When the shoulder shows normal movement, power and better stability (as defined by a negative apprehension test) then a return to contact training may be resumed. The shoulder will be stabilised with taping and a brace for all tackling and football activity after this. Once full training is achieved the player will be passed fit to play, but there will always be the possibility of further instability. Even if the player makes it through the rest of the season, strong consideration should be made for a shoulder reconstruction in the off season to prevent further problems the next year.

Apprehension test for shoulder instability

Investigations may play a part in this decision. Most players will obtain an MRI scan of the shoulder. If there is a tear to the glenoid labrum (a thickened ligament on the edge of the shoulder socket) , then this must be repaired surgically as it will not repair on its own. Only surgical repair will confidently allow the player to resume their normal level of training and game play.

Glenoid labrum tear

To understand why we treat acute soft tissue injury the way we do, it is first important to understand what happens in the body when injury occurs. When a muscle or joint is sprained, strained or bruised, we get bleeding of the injured tissue. The more blood vessels that there are in the tissue (like muscle), the more bleeding that will occur. Bleeding will cause soft tissue swelling, and the swelling itself causes further damage to the soft tissues. The aim of acute management is to limit the initial bleeding and swelling, and thereby limit the secondary soft tissue damage. This will then make the process of tissue repair faster as there is less overall damage to heal, resulting in a faster return to normal activity.

The pneumonic RICE is well known to most people. It stands for:

Rest, Ice, Compression and Elevation

Out of this equation ice and compression are the 2 most important elements. Both ice and compression limit the amount of initial bleeding by constricting and closing off the injured blood vessels. Both of these measures are important for the first 48-72 hours (2-3 days) post injury. The most important period is initially and over the first day. Ideally icing should be performed as often as possible, but care needs to be given not to damage the skin, so some rest periods are important. A scheme of 20mins on, 20 mins off is reasonable. Icing is best delivered to the skin directly with the use of a compressive bandage in the interim periods. The bandage should be elasticized to improve the compressive ability. The more cold and compression that can be applied in the first day, the faster the injury will recover.

Elevation of an affected limb will help to keep the swelling accumulating due to the effects of gravity. Rest simply stops motion of the injured tissue, which will decrease further bleeding and swelling. Again rest and elevation are most important in the first 2-3 days post injury.

Once the first 2-3 days has passed then the body’s healing responses are well under way. As such the risk of enhanced swelling and secondary tissue damage are reduced. This is the time where protected motion of the joint becomes important. If a joint or soft tissue is immobilized for too long then there are secondary effects that may include excessive scar tissue formation, muscle wasting, joint stiffness and even bone and articular cartilage weakness. The best way to avoid this is with protected early motion of the joint or soft tissue, that avoids further aggravation of the initial injury. For example, an acute lateral ligament injury to the ankle may benefit from being placed in a stirrup brace to protect the affected ligament whilst allowing movement in the joint.

A last point should be made bet