Lumbar Spine Injuries in Adolescents

Lumbar Spine Injuries

Multiple common cricket-related lumbar spine injuries can stem from various causes, such as repetitive bowling or batting, poor conditioning, and delayed diagnosis. Incorrect technique and repetitive extension and rotation overload the lumbar areas (see table 1). Along with inadequate lumbopelvic strength and flexibility and disregarding early discomfort signs, adolescent crickets are at increased injury risk.

Table 1: Common lumbopelvic cricket injuries

Spondylolysis

The spondylolysis clinical presentation is varied and typically on a severity continuum depending on the injury acuteness. Bowlers normally describe an acute or gradual onset of lower back pain, slightly laterally to the spinous process. Pain worsens with activity and settles with rest. Initially, it is uncommon for them to have radicular symptoms, but clinicians must complete a comprehensive neural exam on these high-risk athletes⁽²⁾.

Objectively, tenderness and pain may occur when palpating the affected spinous process. Other objective signs include increased lumbar lordosis or flattening, excessive lumbar mobility, surrounding muscle tension, and gluteal and abdominal muscle weakness. They experience pain on extension and rotation (isolated or combined) and when returning to standing from lumbar flexion. A positive result in the single-leg hyperextension test is useful, though not highly sensitive or specific. Tightness in the hamstrings and hip flexors may also present⁽⁷⁾.

Clinicians can use MRI, CT, and bone scans to confirm the diagnosis⁽²⁾. An X-ray will unlikely present the fracture unless it has been present for a few months. Athletes present in the clinic during the first few weeks following pain onset, so clinicians must conduct an in-depth subjective and objective assessment to avoid missing these injuries. If clinicians do request an X-ray, they should request an oblique view to identify the “Scotty dog collar sign” if the injury is advanced enough (see figure 2)⁽⁸⁾.

Certain patient characteristics can help rule out spondylolysis without the need for imaging. If two of three characteristics are absent, it provides 88% sensitivity in ruling out active spondylolysis⁽⁹⁾. The characteristics are male sex, pain with extension, and disparity between active and resting pain. 

Conservative Management

Conservative management is the primary management strategy for spondylolysis. Rest plays a crucial role in facilitating healing by allowing the tissues to heal and preventing aggravation⁽¹⁰⁾.

Rest Duration
Rest and rehabilitation duration varies from eight weeks to eight months and is individualized⁽¹¹⁾. Proper rest, rehabilitation, and guided return to play are crucial⁽⁷⁾. Return to play after conservative management of spondylolysis takes an average of 4.6 months⁽¹¹⁾.
 
Rehabilitation
Physiotherapy can commence within the rest period and includes targeted exercises to strengthen the core (deep abdominals and multifidus), glutes, spinal extensors and stabilizers, and quadratus lumborum muscles. Clinicians must also include hip flexor and hamstring stretches^(4,10). Furthermore, they must consider motor control as far as possible with all exercises and progress the complexity towards sports-specific training as athletes recover^(2,8). A well-structured phase-by-phase approach is essential to ensure a successful return to sport. It includes a gradual return to activity, i.e., incremental reintroduction of bowling or batting under supervision and continued careful monitoring of symptoms and technique. Coaches play a vital role in ensuring correct form to prevent re-injury, and kinematic movement analysis using video on a phone or free apps is beneficial for analysis and comparison and to give the athlete a visual perspective of what they are doing.

Injury Prevention

Preventing lumbar spine injuries is essential in high-risk athletes, and clinicians should integrate it into pre-season and in-season training programs. Furthermore, coaches play a vital role in ensuring that sports-specific factors are monitored carefully throughout the season. Key measures to consider include:

1. Comprehensive coaching strategies focusing on proper technique and skill development. 
2. Avoiding early specialization. 
3. Age-appropriate limited-over formats.
4. Strength and conditioning programs that incorporate structured pre-season and in-season routines to improve muscular strength, endurance, and overall fitness. 
5. Adequate dynamic warm-up protocols.
6. Visual motor skill development that incorporates exercises to enhance hand-eye coordination and reaction times.
7. Adequate cool-down and recovery procedures to promote recovery and improve mobility.

Bowling Load Management

Load management is the most effective way to reduce the risk of overuse injuries. Cricket boards and sports medicine organizations recommend bowling limits per week for young pace bowlers. These limits minimize the risk of overuse injuries and promote long-term athlete health. It’s important to note that these recommendations can vary, and adjustments may be necessary based on individual factors such as physical maturity, fitness levels, and overall workload (see table 2 and 3).

Table 2: Bowling load directives for matches

*Rest between spells should be the same number of overs from the same end as the completed spell

Table 3: Bowling load directives for training

Suppose bowlers continue to experience pain, particularly in the lower back, despite adhering to these guidelines. In that case, it’s essential to seek assessment from a healthcare professional such as a doctor or physiotherapist. Regular communication between coaches, players, and medical professionals is critical to ensure that bowling workloads are managed effectively, reducing the risk of injuries and supporting the overall development of young pace bowlers.

Conclusion

The interplay between these factors may heighten injury risk, underscoring the need for individualized assessment and management recognizing each athlete’s unique traits. Given the diverse nature of young athletes, comprehensive injury prevention strategies tailored to individual needs are essential. Such an approach fosters holistic development and sustains athletic performance in the long term. Coaches, parents, and young bowlers must prioritize a holistic training approach, emphasizing proper technique, gradual workload increase, strength and conditioning, and sufficient rest and recovery. Vigilant monitoring and education further mitigate the risk of lumbar spine and side strain injuries in young pace bowlers.

References

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