Lumbar Stress Injury or Not? - Cricket Player

Abstract

HISTORY: An 18 year old male cricket player (fast bowler) presented with longstanding symptoms of stiff calves and hamstrings, and pain in the gluteal and lower back regions. He had been treated conservatively for a lumbar stress injury (including a full rehabilitation program) however his symptoms persisted. On further enquiry he had previous problems with his left Achilles tendon and a right-sided tennis elbow. His back pain felt better as he warmed up but did not respond to non-steroidal anti-inflammatory drugs. No further systemic complaints were elicited. He has a family history of an uncle diagnosed with Reiter’s Syndrome. PHYSICAL EXAMINATION: He had slight tenderness of the lower lumbar area to the left of the spinous process. Neurological examination was normal. The Schöber test and chest expansion were normal. The FABER test was positive on the right and left, and the sacroiliac joints were tender on palpation. DIFFERENTIAL DIAGNOSIS: 1. Lumbar spondylolysis 2. Ankylosing spondylitis 3. Vertebral disc lesion TEST AND RESULTS: Blood tests - Erythrocyte sedimentation rate: Normal - C-reactive protein: Normal - Human Leukocyte Antigen B27: Positive X-rays - Lumbar: No spondylolysis or spondylolisthesis. Slight narrowing noted of the L4/L5 intervertebral disc space. No vertebral body margin osteophytes or end plate changes identified. - Pelvis: Normal MRI - Sclerosis of the lower lumbar facets, left (L4/L5 and L5/S1). Thought to be due to overuse. - Slightly narrowed L4/L5 disc space, but no herniation or prolapse. - Reactive changes of the right sacroiliac joint, but no bony edema. TREATMENT AND OUTCOME: 1. Because of the clinical picture, inconclusive radiography and positive HLA B27, the athlete was treated for inflammatory arthritis. He was prescribed a course of prednisone to which he responded dramatically. 2. Following the significant improvement, a decision was made to treat for Ankylosing Spondylitis and include a stringent rehabilitation program for the other problems identified. 3. The athlete responded well, and after 20 weeks returned to full training. However this patient will need to be monitored frequently and remain on a rehabilitation program. FINAL DIAGNOSIS: Ankylosing spondylitis complicated by overuse of the lumbar facets possibly due to his sport.