Acute Bony Stress Reaction

Question 1

Pathophysiology

Answer 1

Mainly happens to the pars interarticularitis
- lamina between teh inferior and superior articular processes
- lateral border of the lamina to the upper border
- junctional border of vertical lamina and horizontal peduncle
bending force is greatest at this point

typically caused by repetitive hyperextension with rotation
- gymnastics, fast bowling, tennis

Stress reaction eventually develops into a fracture - need to diagnose stress reaction early in order to prevent a fracture

Question 2

Subjective History

Answer 2

young athlete participating in high risk activities
localised unilateral back pain
may describe specific hyperextension incident or be progressive onset
pain generally intermittent though persistent
usually describe an increased training load
relief with rest and avoiding activity
be aware of RED-S potential

Question 3

Physical Examination

Answer 3

Findings non-specific need to be considered alongside subjective history
unilateral leg pain reproduced with extension and ipsilateral side flexion
sensitive to posterior closing combined movements
tender on palpation
tender with PAIVM - likely to have a muscle spasm
need to consider their history

Question 4

Rehab Overview

Answer 4

Early Stage

• weeks 0-8
• fracture healing
• completely unload

Middle Stage

• week 9-16
• protected reloading
• need to be pain free on clinical testing

late Stage

• week 17 onwards
• transition to full function

Question 5

Psychological Function

Answer 5

maladaptive beliefs - okay to continue training
need to address other external influencers - coach, parents
everyone needs to be aware of cause, course of rehab and how to progress to eventual RTS

Question 6

General Function

Answer 6

Early Rehab

• cease activities that load the posterior arch
• allow for general, non-provocative physical activity
• diet advice for good bone health

Middle Rehab

• jogging
• body weight LL exercise
• sports specific rehab
• technique modification

Late Rehab

• running
• progression to sport specific drills
• monitored RTS

Question 7

Tissue Sensitivity

Answer 7

pathology very important - need initial rest from adverse loading
carefully monitor symptoms throughout progression
if conservative treatment fails = surgical referral

Question 8

Local Function - movement

Answer 8

not in the early phase!
not really a priority 
maybe begin in middle phase 
some flexion 
general mobility exercises 
don't do joint manipulation

Question 9

Local Function - muscle performance

Answer 9

begin in early phase 
independent flexion and rotation/SG 
easy unilateral extension and rotation control exercises 
gradually progress to harder exercises 
later stages focus on hgih load control

Question 10

Remote Function

Answer 10

promote hip and thoracic spine extension and rotation

• being early
• don’t extend/rotate the lumbar spine

use thoracic and hip movement independent from lumbar spine 
- early - funcional load 
middle - body weight 
- late - high load 
focus on independent extension