Low Back Pain in High Level Cricketer


Case Study – Mr F

A high-level cricketer, trying to break into the professional ranks, but with a bad back.

Before Seeing The Chiropractor

Mr F is 19 years old. He has been playing cricket since he can remember and is currently playing first team cricket in the top division of the amateur game.
He is a medium pace bowler and a top order batsman, but during the off-season has noted generalised lower back pain affecting him whilst bowling and for at least a day after.
In addition to sport-specific training twice a week, Mr F has been increasing his gym time, focussing on heavier lifts. Deadlifts and squats in particular can aggravate his back pain.
Mr F has had no previous treatment, but has been using painkillers on a preventative basis.

At the Chiropractor’s

Mr F self-referred to Sure Health Chiropractic. His medical history is unremarkable, he is very fit and healthy.
On questioning, his low back pain may be more persistent than he first admits, but it varies greatly.
He has no leg pain or other complicating factors.
Physical exam reveals good, or even slightly increased, range of movement in Mr F’s lumbar spine. There is pain on leaning backwards.
All nerve tests are normal. Muscle development is good, although some movement patterns are slightly altered, with increased reliance on the large muscles in the lower back.
Spinal alignment is slightly altered, with a more acute curve in the lower back and at the top of the thoracic spine. This is a relatively common posture and, on its own, not a concern.
Palpation of Mr F’s lower back is slightly painful, particularly at the very base of the spine. Tests designed to evaluate stability of the lower back are also painful.
This finding is the most important.
In young cricketers, bowlers in particular, there is an increased risk of stress fracture in the lumbar spine, and occasionally spondylolisthesis.

Further Investigation
Because of the increased risk of stress fracture and positive tests for lumbar instability, it was decided to refer Mr F for imaging. In this case, x-ray was the preferred method.
As suspected, x-ray showed a stress fracture of the spine, technically termed a spondylolysis.

Management

Spondylolysis occurs when the spine fails to adapt quickly enough to stress placed upon it, particularly from extension movements (bending backwards).
The first step in management is to remove this stress. For Mr F, that meant no bowling for a time. It also meant remodelling his bowling action to lessen spinal extension.
In addition to this, Mr F was treated with manual therapy to help decrease load on the affected area of his lower back. Predominantly this entailed manipulation, aimed at improving mobility of other areas of his spine, and stretching of particular muscles around his hips and thighs.
Mr F also had to perform a very strenuous and progressive rehabilitation programme. This was very difficult for Mr F because, in attempting to change how he stands and does even the most basic of movements, we had to start at level zero.
In total, from consulting Sure Health to being able to bowl at full intensity again, this process took twelve months. Happily, there has been no recurrence.
No repeat imaging was requested, with feedback from Mr F being the key criteria to progressing his workload.

Thoughts

Chiropractors are trained to take and read x-rays and to read MRI scans, but imaging is something that we use very infrequently.
As most musculoskeletal problems do not require imaging, it is only requested to rule out a suspected complicating factor. These vary from sinister pathologies to congenital malformations, but are fortunately rare.
In this instance some clinicians may have chosen not to image, purely treating Mr F under the assumption that he had a lower back stress fracture. The reason we chose to image was to be sure there had been no movement of part of Mr F’s spine, but also to be sure that the rehabilitation and treatment for Mr F was as appropriate as possible, thus saving him time.
In an elite sport setting, Mr F would have had much the same treatment, but with more regular imaging. It is difficult to see the reason for this.

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