Blog # 12 – Lumbar Stress Injuries

Overuse lumbar injuries in the spine are estimated to affect 10-15% of the athletic population. A lumbar stress reaction is an early-stage bone stress injury in the lower back where microscopic bone damage and remodelling occurs due to repeated stress or impact. This is often presented in athletes who participate in repeated hyperextension and rotation sports. 

A lumbar stress reaction is considered a precursor to a lumbar stress fracture, which is a small crack or break of the bone which is specifically located in the pars interarticularis. A fracture in the pars interarticularis is often referred to as spondylolysis.

We have seen an increase in prevalence of spondylolysis in youth and adolescent athletes estimated to be 7-21% and 1.6-4.5 times more prevalent in adolescent males than females that report lumbar back pain.

The Anatomy

A spondylolysis may be unilateral (one sided) or bilateral and most commonly occurs at the L5 vertebra due to the anatomy of the lumbosacral spine and the biomechanical load that is placed on that level of the vertebrae.

Risk Factors in Youth Athletes

There are several risk factors that increase the likelihood of lumbar stress reactions or stress fractures which include:

1. Growing Spine

   • The adolescent spine is still growing and has immature areas of growing cartilage and ossification which are prone to torsion, compression and distraction injuries. These can be seen as more susceptible to stress.

2. Biomechanics/Load

   • Youth athletes that participate in sports with constant, high volume of  repeated hyperextension and rotational movements. Sports such as gymnastics, cricket, diving and weightlifting are at more risk due to the high volume of thos repeated movements. These compressive forces over time can result in lumbar stress fractures.

3. Nutrition

   • While males are likely to have a higher prevalence of lumbar stress injuries, female sports and participation of girls in organised sport has significantly increased in recent years. With that in mind, I believe it is important to acknowledge the female athlete triad. This condition due to poor nutrition, disordered eating, decreased weight and reduced estrogen can lead to decreased bone density and ultimately increase the risk of boney stress injuries.

Symptoms

Typically youth and adolescent athletes will complain of an atraumatic, insidious onset of lumbar pain which worsens with participation in activity that particularly involves extension movements.

Symptoms may also include:

• Gradual increase in lumbar pain

• Night pain including difficulty sleeping

• Usually unilateral (one side)

• Pain with prolonged standing, extension (leaning back) or running

• Pain radiating to the glute

• Reduction in pain with rest

Diagnosis

If you or your child is experiencing similar symptoms, it is important to consult with a healthcare professional such as a doctor or physiotherapist to guide you through the important management and to rule out any serious bone injuries like a lumbar fracture. Early diagnosis and imaging can be crucial to prevent any further development of symptoms.

Treatment

Typical rehab for a lumbar stress injury can take several months (+6 months) to return to sport. Following a physical assessment and diagnosis of a lumbar stress injury, the initial priority is the cessation of sport activity and aggravating movements to allow symptoms to resolve. This also includes being able to perform daily functional tasks such as pain-free sitting and standing.

Secondly, the focus will be to address any lumbar range deficits, lumbopelvic control and beginning to incorporate core and glute strengthening exercises.

Thirdly, gradually progressing strength measures globally as we introduce sport specific movements patterns and return to running/skills training.

These exercises need to be guided by a rehabilitation plan and tailored to the area of injury, severity of the injury, the type of athlete and sport in which they participate in to ensure they return to their sport safely.

Stage 1: Acute Repair Phase

• The focus acutely needs to be to optimise healing through load and symptom management. We need to respect the joint and settle the inflammation around the vertebra/s affected. Priority is to work with your physiotherapist to address impairments such as any range of motion deficits, poor glute and core strength and stability and gentle global functional movements. The goal is to be able to return to normal daily tasks pain free such as sitting and standing. 

  
  

Stage 2: Reload

• Once the athlete has progressed past the acute phase, the priority changes to focus on returning to functional movement patterns. This phase consists of isolated trunk loading, lateral hip activation and capacity.

• It is essential that the joint above and below the injury are not neglected particularly with the spine. Thoracic spine and hip mobility movements need to be included in your rehab program. This may include hip lock movement drills, single leg stability exercises.

• Low amplitude running drills such as marches, pogos, and isometric change of direction (COD) can be included into this phase to ensure good foundations are built as the athlete progresses to return to running.

Stage 3: Rebuild

• The rebuild phase focuses on rebuilding strength, capacity and returning to running loads. Progression through lumbar loading, pelvic and lateral hip strength should be a key focus of your rehab during this phase.

• Strength testing will also form a large role in the progression of an athletes rehabilitation with both isolated and global strength measures being assessed.

• During this phase an athlete will also complete jump testing, such as counter movement jumps, single leg hops and drop jumps to assess impairments and potential areas of weakness.

• Here at Rehab Advantage we tailor our testing to both their injury and the athlete’s sport to ensure they can handle the demands required for them to execute their sport.

• From a running perspective, progressing linear volume and introduction of acceleration would occur during this phase. Throughout this phase the athlete will also progress from planned to reactive COD drills, as well as any return to contact drills that are essential before the athlete returns to any form of team training.

  
  

Stage 4/5: RTT/RTS

• This stage occurs once an athlete meets a testing criteria which includes a combination of both objective and subjective assessments. Once athletes meet this criteria they will enter a staged return to training phase before returning to sport.

• Return to training needs to progress from controlled drills into chaos that will reflect the stimulus of the athlete’s sport. This would involve end stage plyometrics drills, spinal engine work and further continue lateral hip stability control. This is to ensure the spine can withstand the demand and intensity of training.

• Progression through modified team training and contact as well as constant monitoring of symptoms should be performed.

• Discussions with your physio for symptoms throughout but also after training is essential to ensure the spinal is managing and withstanding load appropriately.

  
  

Stage 6: Injury Prevention and Resilience

• Continuing training and building on performance and resilience is vital for the athlete once they return to their sport. Once returned to full training and return to sport, it is essential that load management is monitored for youth athletes as they go through their growth stages. Ongoing trunk and hip loading through strength training needs to be performed alongside their sport specific training to ensure we minimise the risk of re-injury along with ensuring the athlete doesn’t fall back into old compensatory patterns.

Prevention

Prevention of lumbar spine stress injuries and fractures really comes down to a few key things:

1. Load Management: ensuring gradual increase in training load over time is implemented without any sudden spikes in their training.

2. Recovery: While young athletes are full of energy, it is crucial that they are having time to recover after their workouts and high training loads. This includes recovery days, adequate and good nutrition, sleep and dehydration.

3. Mechanics: Good lumbo-pelvic positioning, strength training and mobility should be involved in their training program even after rehab to reduce the likelihood of reinjury.

Conclusion

Early management of lumbar stress injuries are crucial in ensuring a safe and gradual return to sport is made by the athlete. While it can be a frustrating injury that not only affects your performance, but also their day to day life and development. Being guided by a health professional like your physiotherapist will ensure that appropriate interventions are put in place to set your child or yourself up for success.