Lumbar Stress Fractures (Cricket Fast Bowlers)
Article by John Miller
Lumbar Stress Fractures in Cricket Fast Bowlers
What is a Lumbar Stress Fracture?
Cricket fast bowling is a unique asymmetrical action which loads the trunk through rotation, extension and side flexion at the delivery stride. This action repeated time after time can lead to the development of stress fractures in adult and adolescent populations.
Repeated microtrauma to the pars interarticularis is usually to blame for your pain. The pars interarticularis, or ‘pars’ for short, refers to the portion of bone between the superior and inferior articular facets of your facet joints. The facet joints are synovial joints between each vertebrae in your spine. Each spinal vertebra has two facet joints (left and right). When the ‘pars’ sustains a fracture it is termed a spondylolysis.
The terms spondylolysis, lumbar stress fracture, pars fracture and pars defect are often used interchangeably. Spondylolysis is classified as dysplasic (usually congenital), degenerative (age related), isthmic (sport related stress fractures) or traumatic. A cricket spondylolysis can be classified as isthmic due to a fast bowler's repetitive flexion and extension moments shearing the pars. Pars defects most commonly occur at the L5 level with L4 being the next most common (Crewe et al. 2012). Bowling techniques which incorporate large moments of hyperextension and rotation pose the greatest risk.
What Causes a Lumbar Stress Fracture?
Athlete age, bowling technique and overall load (i.e. total number of deliveries bowled) have the largest impact on your likelihood of developing a spondylolysis. One study of 180 patients showed the mean age of pars stress fractures to be 20 years old (Brukner et al. 1996). Your bowling techniques can be classified as front on (left image), side on (middle image) or mixed (right image) techniques. Studies have shown that if you bowl with a mixed bowling technique you have a greater risk of lower back injury than if you bowl with a side or front on technique.
Back Stress Fracture Symptoms?
Some pars interarticularis fractures are asymptomatic. Symptoms you may complain of include:
If your physiotherapist suspects you may have a spondylolysis they will likely refer you for an X-ray or other scan. Consult your physiotherapist if you suspect you may have a lumbar stress fracture and they will guide you as to your best scanning option.
Treatment: How do I get back to bowling?
Treatment for spondylolysis revolves primarily around restricting your pain provoking activity (usually bowling) and preventing the spondylolysis from progressing to a bilateral defect or spondylolisthesis. A spondylolisthesis is where part or all of the vertebrae can slip forward on one another. It is important that you consult your physiotherapist if you are experiencing lower back pain from bowling as a quick and accurate diagnosis is key to best management and spondylolisthesis prevention.
Your physiotherapist should work in close association with the fast bowling coach to determine adequate load and bowling technique correction applies.
PHASE I - Pain Relief & Protection
The first phase of physiotherapy aims to protect your fracture site and provide pain relief. This most commonly means a rest from bowling for 6 weeks. Other aggravating activities including running may be prohibited in this phase. Consult your physiotherapist for guidance as to what exercise you are permitted to perform.
PHASE II - Restoring Normal ROM, Strength and Deep Muscle Control (Hip & Core)
During this phase you will typically remain restricted from bowling. Your physiotherapist will look at regaining your pain free range of motion and commence you on PhysioWorks’ Back Stability Program in preparation for return to bowling. Adjacent joints around the stress fracture site will be mobilised and strengthened by your physiotherapist and any pre existing muscle imbalances will be corrected in this phase. Towards the end of phase II you may begin other activities including net batting, fielding and short throwing.
PHASE III - Restoring Full Function
Running and technique modified bowling will begin to be introduced once you reach phase III of your rehab. It is at this phase that the underlying technical faults which have placed you in compromising positions need to be addressed. It is now time for you to commence a graded return to running program in preparation for your pending return to bowling.
PHASE IV - Return to Sport
Once cleared safe to do so by your physiotherapist you will recommence bowling. Ask your physiotherapist and coach as to how many overs you will be permitted to bowl on your first game back as your workload is likely to be reduced. It is important to note that exercises and treatment plan adherence remain of vital importance in this stage.
What next? Am I at Risk of a Getting a Stress Fracture Each time I Bowl?
The more you bowl the more you are at risk of developing a stress fracture. The good news is that your physiotherapist is an expert at identifying and reducing your risk factors. One of the most important things to consider is the age of the bowler. PhysioWorks follows and recommends adherence to Cricket Australia’s Bowling Workload Guidelines for playing and training:
Cricket Australia Guidelines
Recently Cricket Australia published a number of guidelines surrounding fast bowling loads for adolescents. These have been designed to minimize the risk of injury.
AGE GROUP SPECIFIC GUIDELINES
*weekly targets are a combination of training and match bowling.[source: Cricket Australia]
In adult populations, load management remains an integral part of your rehabilitation plan. Your physiotherapist will assist you in ensuring you can minimise your risk of getting a stress fracture because of your bowling.
Please contact your physiotherapist for more advice regarding your stress fracture.
Crewe, Helen et al. (2012), The lumbar spine of the young cricket fast bowler: An MRI study, Journal of Science and Medicine in Sport, Volume 15, Issue 3, 190 - 194
Cricket Australia. (n.d.). Well Played - Bowling Guidelines. Retrieved from http://www.cricket.com.au
Brukner, P., Bradshaw, C., Khan, K. M., White, S., & Crossley, K. (1996). Stress Fractures. Clinical Journal of Sport Medicine, 6(2), 85-89. doi:10.1097/00042752-199604000-00004
Please consult your physiotherapist or doctor for their professional opinion on how best to manage your spondylolysis.
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Please contact PhysioWorks for more information or advice.
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