Conquering Lumbar Bone Stress Injuries

By Physiotherapist Maddie Green

I recently completed the Sports MAP masterclass presented by Alex Kountouris on Lumbar Bone Stress Injuries. I personally have suffered from a career ending lumbar bone stress injury from cricket and know just how challenging and long rehabilitation can be.

Here are some key take away points from the masterclass: 

Lumbar bone stress injuries can occur in any sport that involves axial loading of the spine. It is an important injury to identify early due to the lengthy recovery period and possibility of non-union, resulting in ongoing pain and dysfunction. There are different levels of bone stress injury that sit on a continuum, with all subtypes requiring a period of protection, re-loading and then return to sport specific exercise. 

Mode of Injury 

Via repeated facet loading such as lateral flexion, jumping and landing. This can result in an abnormal cycle of bone remodeling. Typically, it takes approximately two weeks between osteoclasts removing bone and osteoblasts laying down new bone. Therefore, excessive loading between this time can result in net bone loss, and thus, a lumbar bone stress injury. 

Bone Stress continuum 

Bone strain – there is radiological evidence of bone stress with the absence of clinical symptoms. It does not limit their sporting activities and typically takes 6-8 weeks for healing to occur. 

Bone stress – there is radiological evidence of bone stress and clinical symptoms are present. However, there has been no breech of the bone cortex. This typically takes 10-12 weeks to heal. 

Stress fracture – there is radiological evidence of bone stress with a fracture and clinical symptoms are present. This can take between 20-30 weeks for healing, and it is typically a season ending injury. If not managed properly, there is a risk of it developing into a spondylolisthesis which is carer limiting. 

Management 

Protect the injury – avoid any provocative activities, especially in extension or laterally flexion. If activities of daily living are painful, then a brace can be used for a short period of time. Unloaded rehabilitation can then commence that is low impact such as walking, lumbopelvic control exercises, glutes, etc. 

Protected re-loading – avoiding repetitive axial loading in extension as well as the activities that caused the injury. The client should resume strength training (avoiding barbell activities) and running. There should be two rest days between any high load day and minimal pain with any rehabilitation exercise performed. Re-imaging needs to be performed before return to sports specific skills 

Return to sport specific exercise and high loads – full, unrestricted return to sport needs to be avoided. Progressive exposure to plyometrics and the original aggravating activity is required for healing. High load days still need to be managed with low load days. Liaison with coaches should also take place to address the client’s technique that could be linked to excessive extension/lateral flexion/rotation.