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Stress Fractures of Pars Interarticularis in Adolescent Athletes a Classification System with MRI and CT Enabling Evaluation of The Healing Process
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Sports medicine.
Department of Orthopaedics, Spinal Unit, Akademiska sjukhuset, Uppsala, Sweden.
Diagnostic Radiology, Skellefteå, Sweden.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Clinical Physiology. The Swedish School of Sport and Health sciences, Dean’s office, Stockholm, Sweden.
2018 (English)In: Journal of Exercise, Sports & Orthopedics, E-ISSN 2374-6904, Vol. 5, no 1Article in journal (Refereed) Published
Abstract [en]

Introduction: The purpose of this study was to evaluate healing frequency in different stages of stress reactions in the Pars Interarticularis (PI) using a classification system with MRI and CT. The intervention was 3-month rest from physical activity, without a brace, with the exception of activities of daily living.

Materials & Method: Twelve adolescent athletes with different stages of Spondolysis were included in the study. They had pathology in the Pars Interarticularis and were clinically examined with MRI and CT 3-6 weeks after debut of Low Back Pain (LBP) and re-evaluated after 3 months intervention with rest from physical activity.

Results: A combination of MRI and CT scanning to investigate suspected injuries to Pars Interarticularis in adolescent athletes revealed 6 different stages of Spondolysis that ranged from marrow oedema to pseudoarthrosis. After 3 months of rest from physical activity the early stages of Pars Interarticularis injuries healed significantly better than the later stages with rest from physical activity.

Conclusion: The combination of MRI and CT revealed 6 stages of stress reactions instead of 4 as in Hollenberg’s staging with MRI only. In the 3 earliest stages, of these 6, rest from physical activity for 3 months can heal the stress reaction.

Place, publisher, year, edition, pages
2018. Vol. 5, no 1
Keywords [en]
Low Back Pain, Oedema, Pseudoarthrosis, Spondylolysis, Medical and Health Sciences, Health Sciences, Sport and Fitness Sciences, Medicine/Technology
Keywords [sv]
Oedema, Pseudoarthrosis, Spondylolysis, Medicin och hälsovetenskap, Hälsovetenskaper, Idrottsvetenskap, Medicin/Teknik
National Category
Other Medical Sciences
Research subject
Sports Medicine
Identifiers
URN: urn:nbn:se:umu:diva-154472DOI: 10.15226/2374-6904/5/1/00169OAI: oai:DiVA.org:umu-154472DiVA, id: diva2:1272231
Available from: 2018-12-18 Created: 2018-12-18 Last updated: 2019-01-30Bibliographically approved
In thesis
1. Low back pain in adolescent athletes
Open this publication in new window or tab >>Low back pain in adolescent athletes
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Globally Low back pain (LBP) is one of five leading causes of years lived with disability (YLD), and LBP is a common complaint among adults as well as adolescents and adolescence athletes. During adolescents, the LBP often is considered as non- specific without structural findings and thus not needed to be further diagnosed or treated specifically. However, LBP that begins in adolescence often continue through adulthood, and since adolescent athletes with high physical activity seems to have more LBP than less physically active adolescents, high physical loading during adolescence, might be a risk factor for LBP later in life.

Studies: Epidemiology: The Standardized Nordic Questionnaire adjusted for adolescence was used to investigate the prevalence of LBP during adolescence (16-19 years old individuals).

Retrospective study: A ten-year follow-up on symptomatic low back spondylolysis patients identified on MRI or CT. Sixteen out of nineteen identified patients agreed to answer a questionnaire and to have their case-history reviewed.

Case-control study: Twenty-five patients (13-19-year-old boys and girls) with LBP and 13 pain free individuals (controls, 14-19-year-old boys and girls) were investigated with physical examination and MRI. If the patients had findings on MRI a CT investigation was performed.

Clinical study: Twelve of 14 patients (a subgroup from the case-control study) with Spondylolysis on MRI and CT were evaluated with a modified Hollenberg classification (six levels). These patients were re-evaluated with MRI and CT after 3 months of treatment with complete rest from sports activity.

Differential diagnosis: Five adolescent patients with on-going LBP/thigh pain previously treated in other clinics, were reevaluated for a “second opinion”.

Results: Epidemiology study: The prevalence of LBP among adolescents was 46% (N= 2522) with an annual incidence of 42 %. Girls reported more LBP than boys (52 % versus 40 %). Individuals who were active in sports > 6 h/w had significantly more LBP compared with less physically active individuals. 

Retrospective study: Thirteen of the 16 individuals had a second MRI/CT investigation and thus 52 out of the initial 64 pars interarticularis where investigated a second time (mean 3 months after the first investigation). These patients had had different treatments, most commonly rest for 3 months. In total, 7 out of 16 individuals healed (44%).

Case control study: In 22/25 patients (88%) there were clinical findings and MRI findings such as spondylolysis, disc herniated discs, disc degeneration and injuries to the vertebral body. In 13/25 patients (52%) spondylolysis of different stages were found. No clinical test alone, or in combination, could reliably diagnose spondylolysis, and could thus not be used as a selection test for patients who need further diagnostics with MRI and CT.

Clinical study: Using a combination of MRI and CT examination the early signs of skeletal injury (oedema, incomplete fracture) to the pars interarticularis were detected. Patients diagnosed with these early stages healed significantly better than if diagnosed in later stages (complete fracture and pseudoarthrosis).

Differential diagnosis: The second opinion with careful physical examination and MRI examination diagnosed stress reactions in the pelvic ischial tuberosity in the patient seeking help for pain in the lower back/thigh. After guided rehabilitation, all these patients returned to previous sport activities.

Conclusions: LBP is common during adolescence, more common in girls and in highly active individuals. LBP must be taken seriously, especially in adolescent athletes who not seldom have fractures in pars interarticularis (Spondylolysis). If diagnosed early, there seems to be good potentials to heal the fracture with 3 months ́ of rest from loading (sport activity). Differential diagnoses such as stress reactions in the pelvic ischial tuberosity should be taken into consideration.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2019. p. 59
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2014
Keywords
Adolescence, Ischial Tuberosity, Low Back Pain, Oedema, Pars Interarticularis, Physical Activity, Pseudoarthrosis, Sport Activity, Stress fracture, Stress reaction
National Category
Physiotherapy
Research subject
Sports Medicine
Identifiers
urn:nbn:se:umu:diva-155848 (URN)978-91-7855-024-1 (ISBN)
Public defence
2019-02-22, Aulan, Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish National Centre for Research in Sports, 330610018
Available from: 2019-02-01 Created: 2019-01-30 Last updated: 2019-01-31Bibliographically approved

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Sundell, Claes-GöranJonsson, HåkanLarsén, Karin

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