Stress Fractures

Sports: Football, gymnastics, weight-lifting and javelin throwing

What: Lower lumber spinal stress fractures (Spondylolysis) is a fracture on one or both of the wing-shaped parts of a vertebra, usually in the lower lumbar region.

How: The wing-shaped parts of the vertebra may become damaged from strenuous exercise. Certain types of athletes are at increased risk of developing to this condition. It usually starts as a stress fracture and it never completely heals.

Treatment: Most people can manage spondylolysis by resting from strenuous activity, stretching and strengthening exercises and taking pain relief medication, such as ibuprofen. Surgery is rarely needed, although it may be considered for people who do not respond to other treatment.

• Interview with Dr. Kenneth Vereschagin, 9/15/2008
• Story from athlete (Hilary Braun)

Interview with Dr. Kenneth Vereschagin, 9/15/2008

What causes lower lumbar spinal fractures?

Some people think that it has mostly to do with posture, while others blame early specialization in sports for the higher incidence of these fractures. Frankly, it is a combination of both.

The spine has bones with disks in between that allow your back to move forward, backward and twist a little. Another part of the spine that is important for movement are the facet joints. These joints are about the size of a knuckle and they allow the spine to move even more. They are the most common source of pain from either overuse or one hard hit.

When you have overused or overstressed your facet joints, they become fibrotic and scarred, which means that they are get hard and move less. If you keep overusing your joints, your body can't adjust and compensate for the stress, which is when the spine fractures. The fracture is the spine's way of compensating for stress on the bone when the bone can't move. These fractures are most common in women and are seen a lot in female college athletes.

How are the fractures diagnosed?

The official diagnosis of spondylolysis is not a very common thing. Backpain, however, is very common. Because everyone is different, each case of back pain is treated differently. Usually an x-ray is taken and typically it comes back normal. In theses common cases, the back pain is probably mechanical. This means that it is not a disease but can be fixed with changes in posture.

If pain persists, a bone scan or an MRI may be done to see whether or not there are fractures in spine.

What is the common treatment?

Typically back pain is treated with decreased activity, ibuprofen and ice to decrease the pain. But if you have fractures, there are treatment steps that need to be made to treat these fractures. First, it is important to stop playing your sport or modify your activity while you recover. Second, you need to change your anatomy and posture so that when you start playing your sport again, there is less stress on your lower back.

One way to change your posture and to protect your back is to have stronger abs which allow you to have a flatter back. In addition to strengthening protective muscles like abs, ice and physical therapy can reduce facet joint stress and damage from overuse.

How can these fractures be prevented?

Focusing on three main aspects of fitness can help to protect your back from damage: flexibility, good posture and good body mechanics. Flexibility in the joints around your back will prevent your back from having to compensate when your moves – areas like hamstrings and hip flexors are really important. Having strong abs allows you to maintain a neutral spine and off loads stress from the facet joints onto other disks in the spine. This decreases the risk of fractures. Finally, learning how to move correctly and protect your back in your sport is crucial in avoiding these injuries.

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Story from athlete (Hilary Braun)

I played ice hockey from the ages of eight to 19. It was demanding both in and out of the rink. On the ice, I played defense and was required to be very physical in a specific pushing motion that required a lot of extension, especially from my lumbar spine. Off the ice, we had intense lifting regimens that involved a lot of squatting, lunging, and other movements that compressed the lumbar spine.

Around the age of 13, I fell. I had intense pain in my lower back, and had to crawl off the ice. I was unable to sit up straight without pain for several weeks, but I thought I was just experiencing severe muscle cramps. The pain eventually subsided to a tolerable level. I saw a physical therapist, and had to make changes in my daily life in order to manage the pain. For example, I slept with a pillow between my legs, sat with a rolled up sweatshirt between my lower back and the chair and did back exercises.
Ever since that game, lower back pain has plagued me throughout my athletic career. I feel it with everyday motions such as lying flat, and with movements required by sports like ice hockey, field hockey and golf. When I came to Stanford, I played field hockey. After my freshman year, my back pain was back in full force.

I had an MRI, x-rays, and a bone scan in the fall of 2006 and was finally diagnosed (six years later) with inactive pars fractures in my L4 and L5. They were stress fractures in my vertebrae that were not currently healing, but might eventually go away with a lot of rest. During the winter of 2006/2007, I stopped field hockey/impact activities and did a lot of physical therapy. I had small improvements but nothing remarkable.

In the summer and fall of 2008, I had two rounds of six cortisone injections in the L4/L5/SI region of my back. The injections provided an incredible amount of relief after the first four or five days that lasted for three to five weeks. However, after adding my field hockey training back into my activities, the relief dissipated rather quickly. I am thankful that I have had access to outstanding medical care thus far and hope to manage my back pain more practically and effectively when I am finished with my field hockey career.

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