Sports Medicine Research: In the Lab & In the Field: The Importance of Regular Examination and Educating Athletes to Report Pain (Sports Med Res)
Tuesday, January 17, 2012

The Importance of Regular Examination and Educating Athletes to Report Pain

The lumbar spine of the young cricket fast bowler: An MRI study

Crewe H, Elliott B, Couanis G, Campbell A, Alderson J. J Sci Med Sport. 2011 Dec 21. [Epub ahead of print]

Medical imaging (e.g., radiographs, magnetic resonance [MR] imaging, ultrasound) is commonly used to diagnose pathology; however, it is unclear what MR imaging findings are common among junior cricket fast bowlers in cricket (a population at high risk for lumbar pain). Therefore, Crewe et al described the prevalence and nature of MR-identified lumbar spine abnormalities among 46 asymptomatic adolescent cricket fast bowlers. MR imaging scans were performed before the start of the season. All of the athletes were injury free at the time of the MRI and reported not experiencing low back pain in the preceding three months. The MR images were assessed by two experienced musculoskeletal radiologist who primarily assessed the pars interarticularis and intervertebral discs. The authors found that 15 (33%) athletes had at least one lumbar pars abnormality (9 unilateral, 5 bilateral, and one subject had a bilateral defect at L5 and a unilateral defect at L4). Typically the pars abnormalities occurred at the L5 vertebra (19 out of 22 abnormalities; where we often observe spondylolysis and spondylolisthesis). Thirteen of the 22 abnormalities were subtotal stress fractures. Other abnormalities included 3 chronic stress reactions, 5 chronic stress fractures, and 1 acute stress fracture. Among 11 participants with acute stress injuries, 4 admitted to symptoms during clinical history questions after they were informed of the MR imaging results and on clinical examination 3 others were found to have pain with extension, single-legged extension, quadrant testing, or direct palpation.  Sixteen (35%) athletes were found to have degeneration of at least one lumbar disc (six with multiple lumbar discs having abnormalities). Most of the disc abnormalities were L4/L5 or L5/S1.

This study has two very interesting findings: 1) 33% of young cricket fast bowlers who reported being asymptomatic for 3 months had evidence of lumbar abnormalities on MR images, and 2) on closer examination 7 of 11 patients with signs of acute stress injuries ended up reporting being symptomatic or had positive findings during clinical examination. The athletes who ended up having positive clinical findings often attributed their symptoms to “general soreness” or as insignificant. The authors suggest that this is further support for “thorough clinical questioning” to elicit the difference between acceptable soreness and pain that warrants further evaluation. SMR had a post last year that stressed the importance of not rushing through asking about a patient’s medical history.  The authors also advocate for providing more education to our athletes about the potential risks of playing through pain (something we can apply to all of the injuries we treat). The other aspect of this study that was intriguing and relevant to other aspects of sports medicine is whether some of these imaging findings represent structural changes that precede symptoms or a normal sign of the body adapting to the stress of mechanical loading. Most likely these findings reflect normal adaptation to mechanical loading but if adequate recovery is not provided then these findings progress to changes that induce symptoms (e.g., stress fracture). In osteoarthritis research, for example, structural changes are sometimes perceived as risk factors for developing joint symptoms. The authors note that it’s not financially feasible to order MR imaging for all of our high-risk athletes but instead suggest that young athletes should undergo regular physical exams (including a thorough questioning) and be educated about the importance of reporting pain to avoid a delayed diagnosis; which if you think about it could hold them out of play even longer. Do you find that young athletes sometimes can’t distinguish pain from exercise-induced soreness?

Written by: Jeffrey Driban
Reviewed by:  Stephen Thomas

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Crewe H, Elliott B, Couanis G, Campbell A, & Alderson J (2011). The lumbar spine of the young cricket fast bowler: An MRI study. Journal of Science and Medicine in Sport PMID: 22197065

2 comments:

Mike Cornelia said...

It is truly amazing that Lumbar Pain was found in 46 different adolescent cricket fast bowlers. I can't believe that 33% of athletes suffer from this abnormality in the back. This post has really useful and great information. Thank you!

Jeffrey Driban said...

Actually Mike, you'll notice that none of the athletes had lumbar pain.

"and reported not experiencing low back pain in the preceding three months." Despite being a pain-free population "the authors found that 15 (33%) athletes had at least one lumbar pars abnormality (9 unilateral, 5 bilateral, and one subject had a bilateral defect at L5 and a unilateral defect at L4). "

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