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How can an athlete tell if he or she is developing a pars stress fracture in the lumbar spine?

A pars stress fracture is the most common cause of lower back pain in adolescent athletes. It predominantly causes pain on one side of the back versus the center of the back.  It is caused by overuse in activities and athletics.  The symptoms usually start as mild pain which gradually worsens with running, jumping, and kicking activities. Spinal movements which commonly cause pain are arching backwards, twisting at the waist, or straightening up from a bent forward position. Pain is typically worse with sports and improves with rest. Athletes will often rest for a few days or weeks and feel better, but the pain returns when they resume sports. 

How do you prevent getting a pars stress fracture?
  • Maintain good physical conditioning during the offseason and ease into new sports seasons gradually.
  • Increase hours of sports participation gradually.
  • Increasing high impact activities (running/jumping), activities requiring rotation and arching of the back gradually.
  • Take at least one day off from sports each week and several weeks off every several months.
  • Avoid year round participation or participating on more than one team in the same sport at the same time
  • Maintain good hip flexibility (hamstrings/hip flexors) and good strength in the abdominal, lumbar spine, and core muscles.
What is a “stress fracture” and how does it develop?

A stress fracture, like other fractures, is a break in the bone.  A stress fracture develops from repetitive stresses and overuse associated with sports participation, rather than from a specific injury or event.  A stress fracture starts as a stress reaction in a weak area of the bone. If the repetitive stress continues it will continue to break down bone progressing to a partial fracture in the outer surface of the bone. A complete fracture can occur if it progresses through the entire bone.

During sports, due to repetitive movements and activity demands, pressure and force is exerted on the facet joints of the lumbar spine and the stress is transmitted to a small area of bone called the pars interarticularis which connect the facet joints for each vertebral segment. The facet joints press against each other during activities such as running, jumping, kicking, twisting, and arching movements. The pars interarticularis is elongating during adolescent growth, causing it to be thinner and weaker; making this area more prone to injury with adolescents. Most pars stress fractures occur in the lower lumbar spine; usually at the fifth lumbar segment (L5), but may also occur at other levels.  Pars stress fractures will first develop on one side, but if not treated can progress to both sides.  Once stress fractures develop on both sides the healing rate is much lower and a permanent pars defect can result. 

How is a pars stress fracture diagnosed?

Pars stress fractures are not typically seen on X-rays until they have been present for many months. By the time a pars fracture is seen on X-ray they do not have the ability to heal well. The stress fracture can be diagnosed by MRI, CT-Scan, or a Bone Scan. Most athletes seek medical attention because of significant pain before the stress fracture is visible on X-ray. Many will return to sports long before imaging studies show resolution of the problem, so imaging studies are not useful in determining when the athlete can resume sports participation. Following the safe progression of rest, physical therapy, and progression of increasing sports participation will allow the athlete to return to sports in approximately 3 months from the time of diagnosis.

Will a pars fracture heal or get worse?

When pars fractures are detected early, bone healing can occur and the issue can resolve completely without increasing the risk of future back problems.  However, if a pars fracture fails to heal it can progress to permanent pars defect on both sides, called Spondylolysis.  When this occurs it can allow the segment to slip forwards over time, causing a condition called Spondylolisthesis. This condition significantly increases the chances of degenerative back conditions, disc herniations, and nerve impingement. This progression of back problems can be prevented by early diagnosis and proper treatment of pars stress fractures.

What do you do once you are diagnosed with a pars stress fracture of the lumbar spine?

Since a pars fracture is a break in the bone, only rest and time promote healing. Healing can be delayed if the athlete continues to play sports and does not rest appropriately. Rest is the most important aspect for the initial stages of a stress fracture. After about a month of rest, exercises under the direction of a physical therapist will help improve strength and flexibility to reduce the risk of reoccurrence.

Treatment can be broken down into 3 phases with each phase lasting one month:

Phase 1 (First Month):

  • Begins as soon as the diagnosis of a pars stress fracture is considered; even if not confirmed with diagnostic imaging. 
  • Athlete should stop all exercise and begin resting.
  • Avoid anything that causes pain
  • If resting properly, pain should begin resolving in about 3 weeks.  If pain persists, the athlete is not resting enough or may need a back support/brace.
  • If no pain during daily activities and physical exam testing then the athlete can progress to Phase 2.

Phase 2 (Second Month):

  • Athlete should begin formal physical therapy with a Physical Therapist experienced in treating pars stress fractures.
  • Exercises will include lumbar stabilization exercises, core stability exercises, hip/leg strengthening, and flexibility and a home exercise program should be provided.
  • Low-impact activities can be introduced
  • High-impact activities and activities requiring repetitive rotation of the spine and back arching should be avoided at this time.
  • If able to perform low-impact activities and physical therapy without pain then the athlete can progress to Phase 3.

Phase 3 (Third Month):

  • Athlete should continue with their home exercise program independently
  • Progressive increase of exercises in physical therapy.
  • Gradual, progressive return to sports under the parameters outlined by the physician and physical therapist with the goal of reaching full participation over a month.
  • Avoid participation on consecutive days for the first two weeks.
  • If there is a reoccurrence of pain then activities should be reduced and return to sports participation will be delayed.
  • A reasonable guideline is to increase participation 25% per week