Pars Defect

What is a Pars Defect?


Pars Defect, also known as Spondylolysis is the presence of a bony fracture in the lower spine. It is generally classified as a stress fracture and occurs in the region of the spine known as the Pars Interarticularis (see figure 1.1) this section of bone keeps the vertebra in place and a fracture of this section of bone may force the vertebra to slip forward between the disks in the spine. Pars defect is caused by repetitive strain to the lumbar section of the vertebra can be seen in athletes of sports involving extension and rotation of the back. Pars defect’s normally occur on one side of the vertebra and are opposite of the working side of the body for example: a right handed bowler in cricket may receive Spondylolysis on the left side of the vertebra if repetitive strain is placed on the back. However in rare cases a Pars Defect may appear on both sides of the body. Most cases of Spondylolysis are simply noticed by a physiotherapist as a small laceration in the pars section of the vertebra however with excessive force and pressure this small laceration can become a large fracture causing increasing pain and discomfort to the patient.



Figure 1.1


4413W.jpg
Figure 1.1


What type of injury is a Pars Defect?



Pars Defect or Spondylolysis is considered to be an overuse injury. It is classified b the fact that it caused by repeated use of the same muscle, bone or joint and is generally due to excessive training or incorrect training techniques. Overuse injuries are usually diagnosed by the presence of inflammation and pain often only felt by the patient. As Pars Defect is a bony fracture of the Pars Interarticularis bone in the lumbar spine it is considered to be a hard tissue overuse injury. Many tests have been performed in an attempt to dissect spodylolysis and its associated risk factors and prevention techniques. One study taken place in 2001 by Folco Rossi and Stefano Dragoni. It showed the comparison of the cases of Pars Defect in non-athletes compared to those in athletes. The results of non-athletes showed that approximately 3-5% of non athletes were found to have a pars defect. Then 4243 male and female athletes between the ages of 15-27 had their lumbar spine radiographed. For these results 590 of those athletes (13.90%) had a diagnosis of a mild Pars Defect men being greater with 484 cases and women with 106 cases. Out of this 590, 280 (47.45%) of those were found to have had a more sever fracture. (Folco Rossi, Stefano Dragoni, 2001). Another study taken on 40 athletically active people all with back pain showed chronic non healed fractures of the pars in 18 subjects (45%) acute fractures in stages of healing in 16 subjects (40%) and no fractures in only (6%) (Folco Rossi, Stefano Dragoni, 2001) these results of both tests clearly suggest that cases of Pars Defect are a lot more common and evident in athletes then in normal citizens. Reasons for this are that athletes have increased extension through the lumbar spine and for this reason cases of Spondylolysis are increased significantly in athletes.



Figure 1.2



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Table 1- The prevalence of Spondylolysis in different sports and athletic population.



Sport
No. Athletes
Spondylolysis
% with Spondylolysis
Diving 40.35
57
23
40.35
Wrestling
80
20
25
Track/field
353
61
17.28
Sailing
128
22
17.18
Gymnastics
673
112
16.64
Football
400
65
16.25
Skiing
154
25
16.23
Judo and martial arts
64
10
15.62
Bobsleighing
36
5
13.88
Cycling
95
13
13.68
Fencing
143
19
13.28
Tennis
306
36
11.76
Canoeing
69
8
11.59
Water Skiing
18
2
11.11
Boxing
27
3
11.11
Water Polo
307
34
11.07
Rugby
65
7
10.76
Volleyball
150
16
10.66
Shooting
76
8
10.52
Basketball
174
17
9.77
Luge
25
2
8
Rowing
246
19
7.72
Ice and Field Hockey
170
13
7.64
Handball
42
3
7.5
Ice Skating
42
3
7.5


From this table we can see that diving, wrestling and track and field have the highest percentage of athletes with cases of Spondylolysis. (Folco Rossi, Stefano Dragoni, 2001)


What are the Signs and Symptoms of Pars Defect?

There are a lot of signs and symptoms associated with Pars Defect that unlike a lot of other sports injuries are not visible but are only felt by the individual. These symptoms can range from slight discomfort to the loss of ability to perform simple daily tasks such as walking sitting and lying. The symptoms associated with Pars Defect are pain in the lower back, which may be on one side, or both sides of the spine and that can gradually radiate to the buttocks, upper thigh and even extend all the way to the foot. Pins and needles or a tingling sensation may also be felt down into the leg due to the nerves being pressed by the slipping vertebra. This tingling is only normally felt in more severe cases where a full fracture is present. These signs and symptoms can be increased by activities involving extension and rotation of the lower back, including prolonged standing and sitting forcing pressure on to the vertebra of the spine, running, back work during gymnastics or bowling in cricket. These activities all involve extension and rotation and place significant stress on the L4 and L5 vertebra and the pars region of the spine. Pain can also be felt when external pressure is placed on the area and the observer can see a clear sensitivity. These signs and symptoms increase gradually as the injury worsens over an extended period of time.

Figure 1.3

PARS_DEFECT.jpg
Figure 1.3

(Red arrow refers to fracture in the pars interarticularis)

What Causes a Pars Defect?

Causes of a Pars defect are repetitive and forceful hyperextension of the lower back. A pars defect is considered a fatigue injury and is the result repetitive stress and an eventual overload to the Pars Interarticularis. It may often be the completion of a developing fracture when pain is felt as apposed to the creation of the initial fracture. A study was taken that observed 143 patients whom had never walked and had an average of 27 and the results showed not one case of Spondylolysis was found in any of the patients. (E Medicine Web MD, 2010) this evidence supports the theory that overloading of the Pars Interarticularis during up right activities is the reason for so many people being diagnosed with these lesions. Athletes that participate in sports requiring lumbar extension and rotation are those more susceptible to getting Pars Defect. These sports include cricket, tennis, gymnastics, high jump, pole vaulting, dance, weight lifting, javelin, wrestling and baseball pitching. All of these sports contain and extended amount of extension and rotation and therefore these athletes are more likely to develop these fractures in their Pars Interarticularis. Some other contributing factors include poor sporting technique, inappropriate playing surfaces, poor posture, lack of core stability, muscle weakness or tightness and inappropriate training volumes. These factors can all significantly increase the chances of developing Pars Defect.

What is the Treatment and Rehabilitation for a Pars Defect? Treatment of most cases of Pars Defect involves an initial period of rest from the aggravating activity. In extreme cases of a full fracture or excessive pain a back brace may be employed to assist in limiting the initial pain for the patient. An average of 2-4 weeks rest is recommended for patients suffering from Pars Defect however until the patient is pain free completing day to day activities (walking, sitting, lying, and standing) rest must continue and the main process of rehabilitation cannot be started. To begin the rehabilitation phase exercises assisting in core stability and posture are used to maintain muscle to support the pars whilst recovering and to prevent the region from further injury. Applying ice for 20 mins 3-4 times a day as well as gentle stretches of the hamstring and quadriceps is the next step in the rehabilitation process. During the entirety of the rehabilitation phase hyperextension of the lumbar back should be completely avoided. Flexion exercises building strength in preparation for hyperextension may also be a path taken in rehabilitation. After this period of time the patient should be referred to a physiotherapist for correct treatment. There are different approaches in physiotherapy depending on the individual patient’s injury however general treatments of a Pars Defect include:


  • · Soft Tissue Massage

  • · Electrotherapy

  • · Dry needling

  • · Back brace

  • · Hydrotherapy

  • · Clinical Pilates


EXERCISES/ACTIVITIES INVOLVING EXTENSION OF THE LUMBAR SPINE ARE EXTREMELY PROHIBITED.

If after more than 6 weeks rest improvement is not visible the use of the back brace may be essential to assist in preventing extension of the back and help in core stability.


What are some Appropriate Rehabilitation Exercises?



Knees to Chest

Begin this exercise lying on your back with your knees bent take both knees towards your chest as far as possible and comfortable without pain or discomfort. Repeat 10 times.

{Physio Adviser, 2010}

13000256(300x300).jpg
Figure 1.4

Rotation in Lying

Begin this exercise lying on your back with your knees bent and your feet flat and holding them together, gently take both knees from side to side as far as possible, with comfort and without increasing symptoms or pain. Repeat this ten times.

{Physio Adviser, 2010}

12998256(400x400).jpg
Figure 1.6


How is Pars Defect Diagnosed?

A diagnosis of Pars Defect is determined through thorough investigation and examination from a physiotherapist, GP or Chiropractor . Occasionally an x-ray may show a stress fracture but more often than not, unless an extremely severe fracture, the fracture is not visible on an x-ray. Other methods of diagnosis include a bone scan, which is a nuclear scanning test that identifies new areas of bone growth or breakdown. (Web MD 2010) this scan can confirm bony damage/breakdown in the Pars Interarticularis. Following on from these a CT scan, a painless, sophisticated x-ray procedure (where) multiple images are taken.... and a computer compiles them into complete, cross-sectional pictures ("slices") of soft tissue, bone, and blood vessels.(E health MD) May be used to assist in the diagnosis of Spondylolysis. Finally an MRI scan may be used in identifying a fracture of the Pars Interarticularis. These are the most effective scans as they give a clear indication of the Pars region and the presence of a fracture.


Figure 1.7

MRIscan.jpg
Figure 1.7

(MRI scan www.soe.ucsc.edu/.../ images/general/MRIscan.jpg)
What are the possible outcomes of the injury on an individuals performance?

As mentioned earlier the rehabilitation process for Spondylolysis can occur for weeks to months after the diagnosis of the fracture. Most minor stress fractures should be able to reconnect (reach bony union) within 6-12 weeks and after this time a slow progression back to activity should be possible and although the worse the fracture the longer the rehabilitation most cases of Pars Defect should be able to return to their sport with no issues or pain with the pars and simply an increased awareness of the chance of the injury to worsen. This is the case for most patients suffering from a Spondylolysis however in some cases the stress fracture may not reconnect resulting in non-union of the bone and therefore extensive ongoing problems relating to the Pars region. This can generally be avoided with accurate treatment, diagnosis and management in the early stages of the injury. If all of these actions have been taken to prevent the injury and a fracture is still present other Interventions may be taken in order to control the injury these included the intervention of pharmaceuticals, a corticosteroid injection or seeking the expertise of an orthapaedic specialist to advise on appropriate further procedures. Although non-union can occur generally patients with a Pars Defect/Spondylolysis can begin to return to their activity within 4-12 weeks depending on the severity of the injury and once bony union has occurred they should not have any further issues affecting their activity.
Figure 1.8

spondy2.gif

(Pars interarticularis http://indyspinemd.com/images/spondy2.gif)



Interactive Activity

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· What is another name for a Pars Defect?
· According to the table which sport has the least percentage of athletes with cases of Sponsylolysis?

· What is the name given when to bones are able to reconnect?
· Begin with P what is the name of a specialist that can assist in the rehabilitation process?

· The boney region associated with Pars Defect. The Pars…….

· What should be applie for 20 mins 3-4 times a day in the rehabilitation process?

· Which Sport are 13.88% of all athletes diagnosed with Spondylolysis?

· What type of movement is extremely prohibited in the rehabilitation of Pars Defect?

· Soft Tissue ……… Can be used in rehabilitation of a Pars Defect.

· A back ___ should be used if after 6 weeks no improvement has been made.

· What type of injury is a Pars Defect?

· In reference to the spine, another word for lower






Helpful Links and information


http://www.physioadvisor.com.au/8369950/Spondylolysis-pars-defect-lumbar-stress-fractu.htm
http://www.physioadvisor.com.au/
http://scienza.coni.it/fileadmin/immagini/news/PREVALENCE_SPONDYLOLYSIS_SPONDYLOLISTHESIS.pdf
http://www.righthealth.com/topic/Spondylolisthesis?p=l&as=goog&ac=404
http://emedicine.medscape.com/article/95848-overview

http://www.healthscout.com
http://www.medcyclopaedia.co








References:

Internet

Author,
Init.
Year,
Title.
Retrieved day Month year, from
Folco Rossi, Stefano Dragoni

2001
The prevalence of Spondylolysis and Spodylolithesis
6 May
http://scienza.coni.it/fileadmin/immagini/news/PREVALENCE_SPONDYLOLYSIS_SPONDYLOLISTHESIS.pdf
E Medicine

2010
Pars Interarticularis Injury
10 May
http://emedicine.medscape.com/article/95848-overview
Physio Adviser

2010
Spondylolysis
5 May
http://www.physioadvisor.com.au/8369950/spondylolysis-pars-defect-lumbar-stress-fractu.htm

Bibliography





Internet

Author,
Init.
Year,
Title.
Retrieved day Month year, from
A.D.A.M

2009,
Spondylolisthesis Guide
8 May 2010
http://www.righthealth.com/topic/Spondylolisthesis?p=l&as=goog&ac=404
Health Central Network

2009
Spondylolysis and Spondylolisthesis
9 May 2010
======http://www.healthscout.com/ency/1/424/main.html======

Health Grades

2010
What is Spondylolysis?
10 May 2010
http://www.wrongdiagnosis.com/s/spondylosis/basics.htm

n/a

2010
Spine Injury - Pars Defect and Spondylolisthesis
10 May 2010
http://catalog.nucleusinc.com/generateexhibit.php?ID=4413

Books – One Author

Author,
Initial
Year,
Title,
Publisher,
Place.
Lisa Howell
L.H
2008
Front Splits Fast
Perfect Form Physiotherapy
Australia
Chris McNab
C.N
2004
Gymnastics
Mason Crest
USA
Carol Cromie
C.C
2004
Sports Injuries: Play it Safe
ACP pub...
Sydney
Justin Howse
J.H
2009
Anatomy, Dance Technique and Injury Prevention
Methuen Drama
London


Created By Morgan Higgins 12GP