Elsevier

Injury

Volume 34, Issue 12, December 2003, Pages 915-919
Injury

Stress fractures of the lumbar pars interarticularis in athletes: a review based on long-term results of 18 professional cricketers

https://doi.org/10.1016/S0020-1383(03)00034-2Get rights and content

Abstract

The physical demand of the modern game of cricket on the fast bowler is known to cause stress fractures of the lumbar spine. Between 1983 and 2001, we diagnosed pars interarticularis defects in 18 professional cricketers contracted to a single English County Cricket Club. Eight of these players were treated conservatively, with rest, supervised rehabilitation, bowling action analysis and re-education where necessary. The remaining 10 were treated operatively, 9 by Buck’s repair of the spondylolytic lesion. All 18 players returned to professional sport.

We recommend treatment of this select group of sportsmen in a unit consisting of a specialist physiotherapist, a bowling coach and a spinal surgeon. Should conservative measures fail, we recommend Buck’s repair as the operation of choice.

Introduction

Cricket has been the summer game in many countries of the old British Empire since the 19th century. The era of professionalism has brought with it injuries due to the intensity of playing the sport at the highest level and indeed professional cricketers are involved in up to 99 days of cricket in the English season of 149 days [7], excluding days of practice. If players are not involved in winter touring, most play overseas in the closed season to return to intense training prior to the following home season. In essence, the modern professional cricketer plays for 12 months of the year.

The action of fast bowling places immense stresses on the spine, taking place as many as 300–500 times per week [11]. In addition to the increasing demands, it has been suggested by Denness [4] who led the England side to Australia in 1974–1975 that there was a change in style of fast bowling at this time. This new style caused the ball to rise more steeply from a good length and obviously relied upon increased effort on the part of the bowler. Low back pain has now become common and many young fast bowlers are being lost to the game because of this [8]. The movements of hyperextension [3], lateral flexion and thoracolumbar rotation in combination with a jerk force occurring when the fast bowler lands during his delivery stride are all major aetiological factors in the development of spondylolysis and spondylolisthesis [9].

Newman [16] has classified lumbar spondylolisthesis into following five types:

  • Type I: Dysplastic with associated congenital abnormality of the upper sacrum and the arch of the lumbar vertebra.

  • Type II: Isthmic with a defect in the pars interarticularis.

  • Type III: Degenerative due to long standing intersegmental instability.

  • Type IV: Traumatic due to fractures in areas of the posterior elements other than the pars interarticularis.

  • Type V: Pathological due to generalised or localised bone disease.

It is well known that the incidence of Type II spondylolysis and spondylolisthesis is higher in sportsmen and women [10], [14], [18] and this is confirmed in young cricketers by Hardcastle et al. who reported an incidence of pars interarticularis defects in 54% of a prospective study group [12].

We report our experience with a single English County Cricket Club over an 18-year period.

Section snippets

Patients and methods

All cricketers contracted to a single English County Cricket Club developing musculoskeletal back pain that caused loss of significant playing time (approximately 2 weeks) were referred to our department over an 18-year period. The club physiotherapist was the source of referral.

The diagnosis of a pars interarticularis fracture could occasionally be made on clinical presentation. This was usually of a fast bowler suffering an acute breakdown with pain and spasm in the lower back. On examination

Results

Between 1983 and 2001, we diagnosed pars interarticularis defects in 18 professional cricketers, with an average age of 20.8 years (18–31 years).

Of these defects, nine were bilateral and five of these were associated with spondylolistheses. Seven of the remaining nine lesions were on the opposite side to the bowling arm.

Of the 18 cricketers with pars defects, 7 were opening pace bowlers, 6 were medium pace all rounders, 1 was a spin bowler and 4 were specialist batsmen.

Two opening pace bowlers

Discussion

All of the 18 cricketers whom we diagnosed with pars interarticularis fractures returned to first class cricket and of this group, 9 have played at international level.

Our study showed some similarities with those of Hardcastle et al. [12]. We diagnosed bilateral lesions in 9/19 of our group, with 5 of this group developing subsequent spondylolisthesis (Grade 1). This prior study diagnosed bilateral lesions in 6/12 with 4 of this group developing spondylolisthesis (Grade 1). Of the remaining

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