low back pain, how common is the dreaded pars fracture?

[spleen1015]

Concerning the reimaging....

DD had an MRI to find the stress fracture in S1. At 90 days, she had a CT Scan that still showed the stress fracture. Since she went 90 days without pain, the doc said she healed with scar tissue and she can resume activity. If she has any pain, to come back. She hasn't had any pain since. Her doc seems to be heavily influenced by pain. He always talked about pain. No pain = good recovery. He said he's treated hundreds of kids with similar injuries. So, we feel we can trust him.

So, maybe your doc is the same way.

 

[josh]

Rubber, thanks for weighing in again. Trust me when I tell you, I am not looking for shortcuts to the healing process, concern #1 is DD's long term health. With that said, we need another opinion. The doc and the radiographer are interpreting this MRI vastly differently. "If" she has a stress reaction and not a true break which at this point I don't even know, there would be some disagreement about whether to brace or not. Most importantly why we need a 2nd opinion, is this doc said straight out he will not order additional imaging. I will not feel comfortable with DD getting back to any kind of activity without some evidence of healing.

It doesn't matter all that much on the stress reaction vs break, the prescription will be rest, then core exercise, healing will be determined by the symptoms in any event. The doc sounds reasonable if a bit lacking in manners and sounds to be conversative by ordering a brace given the report, but peace of mind is valuable and its your daughter, get a second opinion if you like and it makes you feel better, that doctor can decide if another image is necessary, my guess is that it wont be that helpful to reimage.

 

[stickpile39]

Concerning the reimaging....

DD had an MRI to find the stress fracture in S1. At 90 days, she had a CT Scan that still showed the stress fracture. Since she went 90 days without pain, the doc said she healed with scar tissue and she can resume activity. If she has any pain, to come back. She hasn't had any pain since. Her doc seems to be heavily influenced by pain. He always talked about pain. No pain = good recovery. He said he's treated hundreds of kids with similar injuries. So, we feel we can trust him.

So, maybe your doc is the same way.

Spleen thank you for this perspective

 

[stickpile39]

Hey all, DD gets her brace today. She actually already had her first pain free day yesterday which is nice. What was everybody's experience with bracing? All day? During Sleep? Only during activity? I know studies are mixed and Drs. seem to disagree on this. Other questions/thoughts I have.
What was the first activity that your DD returned to? I read stationary cycle might be a good one. How many weeks after pain resolution was her first activity?
When the time finally comes for my DD to return to the field, it occurs to me it should be as a position player first, with pitching being slowly reintroduced after.
I am also wondering if a flexible type brace product exists for athletes returning from injuries of this sort. Taking stress off the spine during reintroduction to activity seems like a great idea. I wonder if something like this exists?
Best, Stick

 

[spleen1015]

As far as bracing goes, DD had to wear hers all of the time unless she was sleeping. All day, every day for 30 days. No gym, nothing. After 30 days, she had no pain, so she didn't have to wear the brace anymore. It was tough at this point because she felt fine. No pain, no brace. She really wanted to get back out there.

DD was cleared on a Tuesday, practiced with her team that night.

Doc said participate 25% first day back, 50% second day if there was no pain. 75% for the next 3 days if there wasn't any pain. 100% after 5 days with no pain. Her team played in a tournament that weekend and she played 100% but didn't pitch. We decided to not let her pitch until the next week, seeing if she made it through the tournament with no issues. She didn't, so we took it a little easy the next week,pitching 2 days, then returned to normal the next week. She's never had any pain since.

 

[stickpile39]

Thought I would update this thread and perhaps generate a little additional discussion as we are still learning and digesting. I also hope this will help someone in the future. While there are many similarities here, each case has it's differences. Some additional information about my DD's diagnosis. The white “Stress reaction” on her MRI showed an active acute stress reaction at L4 or “pending spondylolisis” which means it was about to occur. My DD's case is a bit unusual in two regards. It seems it is unusual to find these injuries before they fracture. Also with her, the injury is in the pedicle at L4, much more uncommon.
While this finding of "active stress reaction" is better for my daughters long term health it is wise to treat it conservatively due to the fact that 100% healing is very likely. IF there was no edema on the MRI it would be considered “inactive”. In this case the rest period would be much shorter and the goal would be for symptom management, whereas it would be unlikely for the bones to grow back together. It seems so much of this diagnosis is built around one image Viewed through STIR (a fat saturated view) from the hundreds taken in the MRI. I will try and attach it. So it is clear that the reaction is occurring but the exact specifics of the how/why are unclear. While it is quite likely (In my opinion) that overuse from pitching is the primary culprit, she never complained of pain until getting hit by a pitch so perhaps this was some type of trigger. Additionally, leading up to the week where she first complained of pain, she had really started to do quite a lot of core strengthening and for the first time (through the school) had begun lifting weights and squatting etc. Perhaps the why is a combination of all of these factors. I guess we will never really know. What matters most, is that she does not reinjure again, and this is why we are slowly coming to terms with the fact that perhaps she should return to the field as a position player first, and then later as a pitcher.
Here is her timeline thus far: First complained of mild pain/tightness during pitching 2/6, again on 2/8 and 2/10. Each time activity was stopped at that point. Last activity of any sort was batting practice early morning 2/13. This was a pain free event. She then saw her primary doc who shut her down completely that day. She has been completely resting since that time with some mild pain each of the first few days during movements up from the couch etc., nothing significant. 2/18 was her first completely pain free day, and she has not anymore since. 2/19 was her first day in the brace which she has worn faithfully other than at night since that time. This coming week is an appointment with a Sports Med Dr. and in two weeks 3/16 her follow up with the Ortho which will be at 5 weeks of rest.
DD is of course going crazy from the inactivity. She is anxious to start PT with or without the brace as soon as she can, and she is hoping the Sports Med appointment this week will be the beginning of some start of rehab. Her high school season starts first week of April and goes through May. Her Travel team begins in June. We will let the Drs. decide if either/both of these are likely for her. As i said our position right now is perhaps she should return as a player first. She had "only" one week of pain and only during pitching. So we will hopefully be formulating a target date on the calendar to return as a player, and then later as a pitcher.

Thanks all!
Stick

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[javasource]

Hey Stick,

Really sorry to read of this. I've been so hit and miss on here... this thread had escaped me until I saw your email. Hope N is doing ok... sounds like she has the right mind set.

Although I'm not a doctor... I've a bunch of stuff I can add to this post if I've your permission to post a video analysis of N on here... let me know.

This makes me cringe:

...leading up to the week where she first complained of pain, she had really started to do quite a lot of core strengthening and for the first time (through the school) had begun lifting weights and squatting etc.

School's should not allow this kind of activity until a student has passed and proven that they have the necessary core stability... as well as perform this kind of activity without a trained professional for supervision. Even then, I truly question the efficacy of this type of activity in a HS. This likely took her to the 'breaking point'... but there's no doubt that there are a bunch of other underlying issues (weaknesses) in N's pelvic/lumbar region.

Anyway, give her my best. Let me know if you want more... I'll check in later and update this post. Best, ~JS

 

[stickpile39]

Java, I think it would be great for you to post on this thread as it will be greatly helpful to me, and I'm sure to many others. I think the videos I posted earlier in the thread are very typical. I can add game video if that would also be helpful. Her return process will take a while. My understanding is rest/brace then PT then strengthening and sport related exercises and then the eventual return. My goal here is to arm myself with knowledge and have her ease her way back from PT into pitching, PROPERLY and EFFECTIVELY. WE are also trying to understand the timetable for her "specific situation". I also want to learn from whatever mistakes we have made and make sure her little sister does not go down the same road. As for DD, she is taking it pretty hard. The bracing and all of the protective measures we have put in place, don't seem real to her. She had a "little pain and tightness" that has since passed almost immediately after shut down. She of course wants to get ready to play again. I am thankful that from the information learned here on DFP, I ran to the doc and got an MRI for her "little pain and tightness". When I bent her backwards on her right leg (stork drill) and this reproduced the pain, I had a bad feeling. Hopefully this made a big difference here in the short and long term.

Thanks!

 

[javasource]

I'll just make another post. Hope this post accomplishes a few things:

1. First and foremost, helps Stick understand the importance of QUALITY of movements as well as the timing of movements - so that when N returns to the activity, she can build from a healthier foundation.
2. Alert other BD/BM's (bucketdads/moms) about the importance of seeking out a pitching coach and personal trainer that has more to their resume than having been an athlete themselves.
3. Help spell out a simple approach to preventitive wellness. As a PC, this is a thankless undertaking. People never thank you for what you prevented... which is ok by me... as the opposite of that is much worse.

Let's look at a checklist:

• Posture. Backbone of pitching. More than just how you stand, it's the quality of ALIGNMENT when you perform an athletic movement(s).
• Qaulity of Movement. We get so preoccupied with perfecting a spin or speed, that we forget to address the importance of making sure that the movements we perform happen safely and as efficiently as they should... while happening with...
• Correct Timing. We perform an absurd amount of movements in one pitch. Pitching is more than performing the movements... the sequence in which they happen is most important, because...
• Pitching is a multi-planar activity. Unlike squats, or deadlifts, or curls, or sit-ups, or push-ups, etc... we pitch in THREE PLANES... NOT ONE (transverse, sagittal, frontal). Therefore we must...
• Train in Multiple Planes with the right progression. The ability for our body to understand where it is at all times in these three planes is called...
• Proprioception. This starts from the ground up. We are not ready for performance training and should not even go crazy pitching until we have good proprioception. Ankle stability and knee stability are a requisite prior to ANY training of ANY sort. Here's a list within a list for the order that we should train - ANd TRAIN IN ALL THREE PLANES:

• Proprioception (start with ankle and knee stability).
• Core Stability, not core performance.
• Plyo
• Core Performance

The reason I LOVE the redcord is that it allows you to do all FOUR at the same time in all three planes... and adjust the ability of the athlete to a movement that is safe for her. You tackle proprioception, stability, and a little plyo - as well as getting a great boost in performance. Documented, proven, and safe... providing you don't rush through the learning part in the beginning...

As far as return from injury...

1. YOU MUST CORRECT THE MOVEMENTS, POSTURE, and TIMING before TRAINING.
2. You must complete physical therapy that CORRECTS MOVEMENT PATTERNS, STRENGTHENS STABILIZERS, AND ADDRESSES POSTURE.
3. You should not do any training... the next 6 months should be about wellness. Rest, recovery, stability, quality of movement, and posture... before anything else.
4. N has some lordosis. N has some tight hamstrings. N has some hip mobility issues, and definitive core stability weaknesses. When you package all of this and then ask her to either perform or interpret pitching mechanics... at times it can lead what may appear as an ok motion... but when you really look at it... you can see how it can exacerbate underlying conditions/weaknesses.

As this is only a side profile... you miss out on the opportunity to see the lordotic collapse... but look at the full pitch link he posted on the first page... and then add that movement to these ones:

Let's talk about what is happening here...

The vertical green lines that appear are a reference to spinal alignment throughout the motion.
The horizontal line is merely there as a reference to see the lateral shift/instability she has in her lower lumbar region.

You can see that N's laterally (sideways) flexing the lumbar (lower) part of her spine...
It's very evident that she is TRYING to get open.
It is very evident that her foot alignment (90 degrees) is causing her knee to lock out... and not act as a joint... but a single column... leading straight to the next joint in the pelvis.
Due to the lateral displacement, the ground reaction force is causing a lot of shock and movement in the pelvic region on plant.
What you don't see as much... is also how much her lower back is arched forward.

Take all of this and think about the planes of movement.

She is traveling forward through the sagittal plane... while laterally flexing in the frontal plane (sideways), while bracing for a return collision... which is followed by transverse movement (rotational). Read that again.

So.. the moment she makes contact with the ground her lower back is experiencing movements in THREE PLANES. It is unstable, out of alignment, and mistimed. The result is a collision that the misaligned joint(s) must try and correct. In this case, it's her lower spine.

Point being, this fix is about more than just getting her core stability in shape. Yes... you must do that, but she must also fix her lordotic posture... the stride foot orientation, the hamstring tightness and general lack of hip flexion, striding out to get open, etc.

Once you injure an area, recurrence is common. We forget to do more than simply get a doctor's clearance. We cannot depend on these physicians to be experts at softball pitching... they've enough on their plate. It's this reason that I put all those exercises, and hours into the DM sticky. All the areas listed above are referenced there. Make sure that the quality of PT is as good as or better than specialist who found the injury.

Hope there is some helpful stuff in here for you stick... and whoever else stumbles on it. Spent four hours on the phone with Coach James... gotta hit the sack!

Give my best to your family, Stick. Hope she comes back stronger! Best, ~JS

 

[stickpile39]

Java, Can't thank you enough for this and all that you do here at DFP. I will be digging quite deeply into this as well as the sticky you have provided us with for additional detail. Should I direct any specific follow up questions to you here or by email? I have a lot to sort through and I want to do this properly. I am even more convinced now that the pitching return will come AFTER returning as a player.
My most important question is of course the fact that the living room clip is very old. The accumulation of all of those reps during this time frame no doubt contributed to the issue she is currently experiencing. But I am hopeful that it will be agreed that her more recent clips are showing less and less of these issues. I of course would need an expert eye to help with that assessment. Please let me know private or public for the further questions.
Thanks so much!
I will also be sharing some of this at the Dr. Appt. tomorrow.