Management of lumbar bone stress injury in cricket fast bowlers and other athletes

Abstract

Background: Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain. Objective: To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults. Method: Narrative review. Results: Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important ‘specific’ diagnostic subset within adult low back pain. Conclusion: Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

Intrinsic variables associated with low back pain and lumbar spine injury in fast bowlers in cricket: a systematic review

“…Comparing the significance of variables derived from studies that defined outcomes as varied as LBP in the absence of radiology [48,50,57,58,61,62], radiological abnormalities in the absence of LBP [43,[53][54][55][56]65], or a combination of LBP, abnormal radiology and missed playing time [42, 44-47, 51, 52, 59, 60, 63, 64] is problematic. Whilst the appearance of LBP has been reported to be a common finding in fast bowlers without accompanying missed playing time [9]; spondylolysis is the most common cause of LBP in young athletes [106], and LBSI should be suspected in a fast bowler presenting with LBP contralateral to their bowling arm side [12]. The significance of LBP as a surrogate for lumbar spine injury in fast bowlers is yet to be determined due to previously described attrition biases in the published literature [41-43, 45-50, 53, 60, 61, 65], and studies being cross sectional [54-56, 62, 63], retrospective [57][58][59][60][61]64], or prospective with limited follow up periods [42, 46-50, 52, 61].…”

“…Stress fractures of the lumbar spine represent 15% of all missed playing time in cricket [1], and up to 67% of fast bowlers will sustain this injury during their career [11]. Furthermore, stress fractures of the lumbar spine present potentially serious consequences for fast bowlers [11] as they generally cause many months of absence from cricket [12][13][14], and if not appropriately managed can result in chronic lesions characterised by non-union and recurrence [12,13].…”

“…The relationship between lumbar spine pathology, missed playing time and LBP in fast bowlers is not straightforward [30], and this is illustrated by asymptomatic fast bowlers presenting with MRI detected pathology [31] as well as high incidences of adolescent fast bowlers presenting with LBP not causing an absence from bowling [9]. Notwithstanding this, lumbar bone stress injuries (LBSI) have been long recognised as a common cause of LBP in fast bowlers [8], and young fast bowlers presenting with LBP contralateral to their bowling arm side represent a high yield population for which an MRI scan provides value for the diagnosis of LBSI [12]. To better understand biases and evidence in the previous literature, it is necessary to examine intrinsic variables that have been associated in studies reporting both LBP and lumbar spine injury, regardless of the presence or absence of symptoms, radiological findings and missed playing time.…”

Navigating the AI Innovation: A Publisher's Balancing Act with Fundamental Principles

“…The paper with the most downloads in 2023 was “ The effectiveness of intratissue percutaneous electrolysis for the treatment of tendinopathy: a systematic review ” [ 2 ] which was downloaded 767 times, followed by “ Management of lumbar bone stress injury in cricket fast bowlers and other athletes ” [ 3 ] (n = 489 downloads).…”