Pars Stress Fracture - Here's another one

[Amy in AZ.]

I have a 12 yo student with back pain, now. She is the one that the rec coach makes them do "conditioning" once a week. I have found this thread helpful and will point her parents to Pars Stress Fracture.

Yes. Parents need to speak up and say "A growing teen cannot do all of this 6 days a week." But, we don't. (I tried to sign my 5yo GDD up, for 6yo basketball this morning. They said OK."

 

[AUtiger98]

Sorry to hear this, I hope she gets well soon. With a 9 year old, I really appreciate you sharing your story.

 

[Orthodoc]

FWIW, I am not an orthopedic spine surgeon, but I am an orthopedic surgeon that had to learn and do spine surgery to pass my boards. Pars fractures are multi factorial. Yes, there is a genetic component, and yes, there is an environmental component. Some you can change and some that you cannot. Things that you can do are: good nutrition with plenty of calcium and vitamin D, lots of hamstring stretches, lots of core building, and limiting hyperextension of the back (I'm thinking more back walk overs, and back hand springs not basic physiological extension).

That is horrible that it has happened to your daughter, but whatever the treatment plan, she can come back and pitch again, and better than ever before. I don't know where you live, but if you need some advice on who to see, I may be able to help if I know the region. Just PM me

 

[RubberBiscuit]

FWIW, I am not an orthopedic spine surgeon, but I am an orthopedic surgeon that had to learn and do spine surgery to pass my boards. Pars fractures are multi factorial. Yes, there is a genetic component, and yes, there is an environmental component. Some you can change and some that you cannot. Things that you can do are: good nutrition with plenty of calcium and vitamin D, lots of hamstring stretches, lots of core building, and limiting hyperextension of the back (I'm thinking more back walk overs, and back hand springs not basic physiological extension).

That is horrible that it has happened to your daughter, but whatever the treatment plan, she can come back and pitch again, and better than ever before. I don't know where you live, but if you need some advice on who to see, I may be able to help if I know the region. Just PM me

Curious if you would weigh-in on something here Orthodoc?

Our experience was that I had to get my DD past what appeared to be two kinds of inexperienced orthopedic "specialists" types before I found the right doctor. Let me describe:

My DD had the typical chronic lower back pain, just off to one side, that would hurt allot more with extra back extension. The standard case of pars break.

Ortho specialist type #1 = "Ah she just has a muscle imbalance", go to physical therapy and maybe here's an injection, and she'll be fine in a few weeks. (local community ortho specialist)

Ortho specialist type #2 = "Well Mr father of said DD sometimes kids spines weren't meant to pitch and maybe she should give up on her dream. We don't see anything on xray so we think she should just quit pitching...." (this was a senior super-renowned specialist but later came to understand that he treats mostly the elderly)

Ortho specialist #3 = analyzed the specific CASE of my daughter and understood the specific rigors of pitching and had experience with many football players (linemen) AND pitchers. He immediately ordered an MRI and we were finally off down the path of the correct diagnosis. (this was the sports ortho specialist at a BIG medical & sports university)

Is it your experience and recommendation too that any parent of a pitcher that experiences chronic lower back pain, slightly off to one side, should only seek out these experienced pitcher & football linemen orthopedic specialists at big universities? Because my opinion if you don't is that you get shoe-horned down the wrong diagnostic path AND you potentially have the horrid experience that we did where Ortho #1 was putting DD through back "adjustments" and physical therapy that was theoretically re-breaking or at least aggravating her pars.....

 

[Me_and_my_big_mouth]

Wow, I hate it when work gets in the way of my DFP time.

How much do other sports play into this?

Spleen, My DD had just turned 13 when we became aware of her back pain, but she wasn't actually diagnosed until last month so it took us 7 months to realize what we were dealing with. We consider ourselves very lucky, though, because we were able to recognize what was happening after reading bucket pinata's and RubberBiscuit's stories.

You asked about other sports. DD was a figure skater for 4 years & also played volleyball briefly. Somewhere in the thousands of times she fell on her butt on the hard ice, or twisted as she spun, there is a possibility that she was weakening the area that eventually fractured. Who really knows? She gave up skating for softball when she was 12, but didn't get on a higher level tb team until 13. Her injury was also right around the same time that she began a 2x weekly speed & agility class. Looking back, that was in September - and I feel that the new team, the practices starting up again, and the speed & agility were entirely too much at once. What 13 year old actually has the proper warm-up and stretching regimen? Not many. She was also taking pitching lessons and practicing pitching on her own at least 3x a week (sometimes 4). The pitching lessons and practice were often on a hard gym floor indoors.

You said your dd was diagnosed with stress fracture of S1, but I think I may have missed where you said how he arrived at that? Did you have a SPECT or CT? When my dd had the SPECT, it showed "activity" indicating injury at L5, L4 and S1. CT showed fracture at L5, pars interarticularis - unilateral and stable. I know this because I had to DRAG it out of the doctor, and then I put my google skills to work. I was quite amazed at how little the docs want to share with us as parents. It's like they don't trust that we're smart enough to handle the big words. My understanding (Orthodoc, weigh in, maybe?) is that if they're saying S1, there's quite likely L5 or possibly L4 involvement, too? There are some great websites that really go into detail - and they even have videos for us blonde-types. The nice lady in this particular video actually pronounces spondylolylelellsisisusus . . . well, spondy. [video]http://www.spine-health.com/video/lumbar-spondylolysis-video[/video]

Since he said it was an overuse injury, I asked him what the risks were if she followed the same regimen this coming winter and he said there was no risk. He has never had a patient with this injury have a recurrence of the injury.

This is totally contradictory to what I've been told. No risk for reinjury? As I understand it, there is a tremendous risk if regular rest periods aren't observed, and if the proper warm-up, warm-down, and stretching exercises aren't done. This seems like the very definition of insanity: repeating the same actions and expecting different results. We have been advised to watch our dd carefully, make sure she's keeping a strong core, and maintaining her flexibility. In hindsight, that should have been a dead giveaway in the beginning. She was always very flexible (skater, remember) and suddenly she was always, "tight" and could no longer even touch her toes. Speed & agility pushed the athletes to do lots of box jumps, weaving, and running - on a gym floor - and we just thought that she was developed muscle mass and not stretching out properly. We didn't realize that the sudden and extreme tightening of the hamstring and left lower back is indicative of guarding during a fracture.

Yes, there is a genetic component, and yes, there is an environmental component. Some you can change and some that you cannot. Things that you can do are: good nutrition with plenty of calcium and vitamin D, lots of hamstring stretches, lots of core building, and limiting hyperextension of the back (I'm thinking more back walk overs, and back hand springs not basic physiological extension).

That is horrible that it has happened to your daughter, but whatever the treatment plan, she can come back and pitch again, and better than ever before.

Orthodoc, thanks for this. Our dd's need to hear that missing a season won't "end" their careers. Everything is SO big when you're a teenager. I wish more docs would take it seriously, and recognize that by the time an athlete ends up in their office with this issue, it's because they're Type-A's who tend to be overdoing it in all aspects of life. They need to hear that their doc respects what this injury does to them mentally as athletes, and that they're going to be Ok. Not a single doc (and we've seen 3) has actually looked my dd in the eyes and told her, "You'll pitch again. You'll recover and be even better." We changed PT providers, until we found a sports specialist who said exactly that. He looked at her chart, looked in her eyes, and said, "I'll bet you can't wait to pitch again, huh? Let's do some work and get you back in that circle!" I seriously teared up. This was after having to show a windmill pitching video to the prior PT provider, who had zero experience with female athletes and softball. How can you help my kid if you don't know A) How she got here in the first place? and B) What she wants to do again? So aggravating! Don't be afraid to find the right team to treat your dd - because so much of this is mental. The bottom line is that there's darn little anyone can do to speed up bone healing; it's a wait and watch thing. What you do to prevent it from happening again as you wait is what matters. We're choosing to use this time to educate ourselves and our dd about being a true "athlete" - from a standpoint of nutrition, rest, strength, cross training, and listening to your body. It doesn't take the sting off sitting, though. She wants to be in the circle, and said point-blank that if her coach asked her to take the circle this weekend, she'd do it. I gave her an "over my dead body" stare, and told her it's a good thing he wouldn't do that. That just goes to show that the 13-year-old brain still doesn't entirely comprehend what's happening, no matter how mature she seems about it. She's a kid. She just wants to play.

Ortho specialist type #1 = "Ah she just has a muscle imbalance", go to physical therapy and maybe here's an injection, and she'll be fine in a few weeks. (local community ortho specialist)

Ortho specialist type #2 = "Well Mr father of said DD sometimes kids spines weren't meant to pitch and maybe she should give up on her dream. We don't see anything on xray so we think she should just quit pitching...." (this was a senior super-renowned specialist but later came to understand that he treats mostly the elderly)

Ortho specialist #3 = analyzed the specific CASE of my daughter and understood the specific rigors of pitching and had experience with many football players (linemen) AND pitchers. He immediately ordered an MRI and we were finally off down the path of the correct diagnosis. (this was the sports ortho specialist at a BIG medical & sports university)

Is it your experience and recommendation too that any parent of a pitcher that experiences chronic lower back pain, slightly off to one side, should only seek out these experienced pitcher & football linemen orthopedic specialists at big universities? Because my opinion if you don't is that you get shoe-horned down the wrong diagnostic path AND you potentially have the horrid experience that we did where Ortho #1 was putting DD through back "adjustments" and physical therapy that was theoretically re-breaking or at least aggravating her pars.....

RubberBiscuit, Knowing that a wrong diagnosis could re-break or exacerbate my dd's injuries is what made me keep pushing for the CT, instead of heading straight for PT when they first told me it was a "muscle strain" and later "facet syndrome."

I've learned a lot from you & BP, and I'm trying to pass along my information and experience, too. So glad that Amanda Scarborough has jumped on this and is helping us get the word out. It's entirely too common for our athletes, and it's preventable. It would be my hope that coaches and parents become as aware of the potential for this injury as they are about concussions. If we all tell (and re-tell) our stories, hopefully someone, somewhere, remembers "I read about this somewhere" and takes appropriate precautions or seeks early treatment. I'm definitely coming from the perspective of "make your mess your message" on this one.

Best of luck to your DD, Spleen. If she was braced, it seems like your doc identified an unstable injury, so there's a pretty long road ahead. I think I'd press my doctor for more information - ask him to share the radiology reports - and demand that he tell you what kind of injury you're dealing with.

 

[spleen1015]

Thanks for all of that info!

Here's how things went down for us. DD was mentioning back pain on the left for about 3 weeks. Pitching seemed to aggravate it. We assumed it was muscle related, so I looked up stretches online and we had her start doing those as a part of her warmup. Then, she went to an AAU basketball practice and she left the court in tears because it was hurting so bad. That combined with BP's thread led to getting her to the doc.

First time we saw the doc, he said he wanted her to take 2 weeks off. If during those 2 weeks, she went 5 days pain free, then she could resume activity. Just so happens this 2 weeks was over spring break, so she didn't miss anything. After 6 days of no pain, she tried pitching again. After warming up, 6 pitches in, her back started to hurt, so we stopped right then. That was the last day she had any pain. After that, she went to a couple of basketball practices, hitting & pitching lessons, & softball practice. She didn't have any more pain for about 10 days after that. We had the follow up with the doc and he felt like she was fine, but DW wasn't really satisfied and pushed for an MRI.

She had the MRI about a week later and 2 days after that we were told about the S1 fracture. He didn't mention any other fractures. We go back on Friday and I am going to push for more information and ask a lot more questions. I think I am going to try to find a doctor that knows what a softball pitcher is doing and has experience treating them. Based on our previous appoint, I expect him to tell her she doesn't need to wear the brace any more since her told he should would stop wearing it after 4 weeks of no pain. Well, it will be 6 weeks without pain so... We'll have a CT scan 4 weeks from now and he wants to make sure she is healing. He said he could release her to play then if she's healed well enough, but another 8 weeks is likely. So, we'll see.

The whole situation has been frustrating, but it was compounded by the fact that she went about 10 days or so, normal activity with lessons & practices without any pain and she ended up with a stress fracture.

I appreciate everything from everyone here.

 

[Nick_AI]

Dear Parents of a child with a pars fracture,

First and foremost, I am sorry that you kids have experienced a pars fracture. I wish them all the best in their recovery.

Second, and at the risk of sounding like some creepy internet troll… I need your help! … Ok yes, this is over the internet, but I promise I am not creepy!

I am a father of two boys who both play baseball. I am also a medical device engineer and an entrepreneur, running a company in southern California.

Early this year, I took time out of my business to go after a significant National Institute of Health (NIH) grant for a project that I am very passionate about exploring and advancing. It is a minimally invasive pars fracture repair device for adolescents. Now please don’t get too excited, medical products take years and lots of money to commercialize, which is all the more reason why I need your help today.

The NIH grant is an extremely competitive program and unfortunately it looks like I will miss the funding cutoff by a minimal amount of only 4% per their grading score! By many accounts, it is extremely positive to have scored so close to such a coveted grant opportunity within the research community, particularly knowing that it was competing against life threatening illness and widespread health threats.

I am going to reapply this December but I need to up my game for the re-submission. Here is where I really need your help.

I have a collection of adult pars fractures but no appropriate adolescent MRI or CT datasets of pars fractures. I would like your help in acquiring at least one but no more than three such datasets (for now!). I am going to use the datasets in the submission along with 3D fracture re-constructions and preliminary implant designs. If I use your child’s file, I will share the compilation back to you. Also, if you want a really interesting 3D plastic model of the fracture, I can show you how to order one (I have made many pediatric scoli models). I won't use any of your child's personal data and I will sign a document stating that I will protect your child's personal information.

Again I am sorry if this is an inappropriate request on this forum but I am hopeful that you can help me. Please message me if you are interested and I will gladly give you my personnel cell and email so that we can discuss.

Also – just to throw this out there, I am considering a crowdfunding campaign to keep this project moving. (grants are a little slow and have a very low success rate). Let me know if you think this is something that you would promote to your friends (assuming you like it and I move forward).

All the best,

Nick

 

[chinamigarden]

Question for you guys that have gone through this before or are going through it.

How much do other sports play into this?

Here's DD's story and why I am asking.

I'm not sure if DD specifically has a pars stress fracture because the doctor didn't use those terms. He did say DD has a stress fracture of the S1. Friday we go back to the doc after 4 weeks. I know she's not getting released to play. I assume he's going to tell her she doesn't have to wear the brace any more.

So, DD pitched all through the winter, at least once a week at lessons. Some weeks twice a week, with an occasional 3 times in a week. She also took hitting lessons every week, once per week. Her team also had indoor practice every Saturday. DD made to most of them unless she had a basketball conflict.

As far as basketball goes, she plays travel basketball as well as school basketball. Before school ball started, she practiced for travel twice a week. They played 1 game every Saturday and 2 every other Sunday. Once school ball started, they practiced every day unless there was a game. No travel practice, but they did keep the weekend schedule since there wasn't a conflict with school ball.

And to top it all off, she would go to strength & agility classes at the high school if she was free that night.

The doctor said the injury was caused by overuse. It is a fairly common injury in kids her age that play lots of sports. DD is 12 years old.

Since he said it was an overuse injury, I asked him what the risks were if she followed the same regimen this coming winter and he said there was no risk. He has never had a patient with this injury have a recurrence of the injury.

I've seen this injury mentioned a lot with pitchers. I know of 1 other girl in our area with the same injury and she is a pitcher. On this forum, I believe I have only seen it mentioned with pitchers.

The plan going into this winter once she recovers it to keep playing basketball, but take December & January off from pitching & hitting lessons to give her a body rest from softball activities.

Any other advice is very welcome.

EDIT - one other thing, DD started having back pain sometime around with bucket pinata mentioned his DD's issues here. That thread made DW & I take DD to the doctor much sooner than we would have without it. So, thanks, bp!

i would just remember that this isn't the only possible over use injury. Just because the doc has never seen it a second time doesn't eliminate all other possible injuries.