[hanson1995]

#29025

Hi Dr. Corenman,

I’m just wondering if it is possible to return to an elite level of athletics after being diagnosed by “MRI of the Lumbar spine without contrast” with a “high probability of bilateral L5 pars defects-CT scanning at L5 would be required to confirm)” and “T2 hyperintensity within the left and right L5 pedicles indicative of chronic increased mechanical stess”?(STIR technique and T1 and T2 imaging)Almost everything I have read about this condition relates to setbacks and complaints about never being quite right again!

My 14 year old daughter was diagnosed via MRI after having mild to moderate pain on her lower back side for a few weeks which eventually spread to her right side after a night of heavy tumbling. She is a competitive all star cheerleader whose “job” on the team is to tumble. After viewing MRI results, first orthopedist said start PT after 6 -8 weeks if pain free with a full return at 12 weeks.No brace just rest during those initial 6-8 weeks. 2nd opinion with a dual board certified sports medicine and ortho doctor said out 6 weeks(again no brace and no activity) and then a gradual return. He didn’t feel PT was necessary at all. We are trying to go in the middle by keeping her out 6 weeks (which was up last week) and then do physical therapy until cleared for a return by the physical therapist.

She has not had any pain at all in daily activities for 5 weeks 3 days-only had pain the first 4 days after stopping tumbling(the cause of the problem). She walks normal, sits normal, sleeps normal-attends school with no issues at all including carrying backpack. She has since started physical therapy( 1 visit)and was able to touch her toes easily with no pain and complete all given exercises with a 0 to 10 pain score. He told her when we left she could ride a stationary bike and do the elliptical which she did today (again no pain at all). He almost seemed reluctant to see her again-just gave her some exercises and said come back if you would like or you can just do these exercises at home if you want to save yourself a trip . We will see a new PT tomorrow to see if he is anymore helpful.

We are thinking of having her do a very slow return to tumbling at the 8 week point if she continues to be pain free. Her 2nd opinion doctor told her to do a back bridge before returning as the last thing and if that produced no pain to resume her sport slowly.

So, I guess my questions are the following:
1. Is the fact that she has no pain at all normal given the MRI results I provided in Paragraph 1? Is this pain free 6 weeks a good predictor she might be able to successfully return to high level tumbling (similar to gymnastics floor exercise)?
2. Would you feel comfortable letting her start back to her sport very slowly at 8 weeks if she continues to demonstrate no pain in daily activities and PT? Everything I have read has said pain should be the guide to return but then I hear a lot of 3 months. I am nervous about allowing her to go back but with no pain don’t know how much longer I can keep her down.
3. When she does go back, would it be normal to expect any pain as she will not have tumbled in 8 weeks?
4. Would you recommend any pain relievers when she return to play?

I want so badly to be a success story but wonder if the pain free lifestyle she feels now is just because she stopped tumbling and it will start up when she starts twisting, bending and landing which are unavoidable in her sport. One thing the first doctor said to her is when she does go back the area would be stronger than ever due to the way it heals. Is that true?

My daughter is 5 feet 7 inches which is tall for a tumbler. She has been a gymnast since age 3 then switched to competitive cheerleading at age 12. Her sport is year round but she really only has to tumble 2-3 nights a week.

As a quick side note “the remaining pars are normal, vertebral bodies are well formed, discs are normal and conus medullaris is normal. No spinal stenosis or foraminal narrowing. Paravertebral soft tissues are normal-transverse images T12-L1, L1-2, L2-3, L3-4, L4-5, L5-S1 normal”.

Doctor will monitor her every 3 months once she returns to tumbling for slippage.

Any opinions/advice you can give would be so appreciated. I am looking for someone to tell me she might be able to return to her old lifestyle:)

Respectfully yours,
Kim Hanson

[Donald Corenman, MD, DC]

#29027

Treating pars fractures has many different physicians suggesting all sorts of rest times and treatments. It is understandable that you are confused.

The real question is what stage is she in? There are three stages. The initial stage is the stress reaction of the bone(s) with initial onset of pain. In this stage, the bone is fatiguing due to continued stressed extension of the spine but is still intact. There is no complete fracture of the pars but there are “cracks” that don’t go fully through the bone. If you can catch it at this stage, many of these go on to heal with proper treatment. My opinion is that the adolescent needs to be in a flat back brace, no physical therapy and can ride a stationary bike. No running, impact activities and there is need to use a wheeled book bag for all school supplies. No backpacks. No activities that require extension.

If there is a potential “line” noted on the MRI through the pars or pedicle, it is my opinion that this adolescent needs a limited CT scan of only the area in question (noted on the MRI). A complete fracture of one side with an intact opposite side (stress reaction is OK) has a reasonable chance of healing in 3-6 months with the above noted protocols. Complete fractures of both sides are another issue. It might take as long as six months to heal and many will not heal, even with rest. This is where consideration is given to surgical repair of the pars.

Finally, if there is a slip, significant pars separation of the fracture ends, atrophy of these fracture ends or tears of the disc, it is less likely that these noted treatments will be successful and activity curtailment or even fusion of the slipped segment needs to be considered.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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