Adolescent back pain - a pars injury rehab framework (Part 2)
In Part 1 I explained my framework for gym based progressions in the management of pars articularis injuries. In this second blog I will map out the basis of running and field based progressions to help take the player/patient/athlete from the gym floor all the way back to training. As I said in my previous blog, I am not saying this is the only way to approach the rehab of these athletes but hopefully people find it useful.
Reduced Weight Bearing
Reduced weight bearing running and sport/functional drills play a key part in getting the player comfortable and confident with sport specific movements.
If you are lucky enough to have access to a Hydroworx system, Alter G or similar (see below) then you can start running with a significant percentage of bodyweight offloaded.
A walk / run programme can commence with the run component initially being relatively slow and the overall volume of the session low. Over time you can manipulate the key variables – weight bearing, speed and volume. I see it almost like an equalizer where you may have to reduce one variable when progressing another, and looking to avoid progressing them all in one go.
If you have access to a pool with a varied or adjustable depth, multi-directional work can take place to help the player’s body start to adapt to the specific demands these movements place in a reduced weight bearing environment. This can involve reactive work in the latter stages as well as throwing and catching a ball even if the player usually uses their feet!
The pool can only really be progressed to about 60% weight bearing so an Alter-G treadmill can be used to bridge the gap between this and full weight bearing. The weight bearing percentage can be easily increased over a timescale agreed with the medical staff and external specialists. It is worth noting that there is research to suggest that increasing the running speed has a bigger impact on joint loading (albeit plantar force) than increasing weight bearing. This takes us back to my earlier point about being mindful not to increase weight bearing, speed, and volume all at the same time.
Outdoor Rehab
Once the player has progressed to 95%+ weight bearing then they can transition to pitch based work. In my experience players – and their backs - actually prefer the multi-directional nature of pitch based sessions to the extension biased treadmill running. At this stage weight bearing on our equalizer of parameters is replaced with intensity.
When planning, I work backwards from the provisional RTT timescale that has been proposed by the specialist. In my experience, a time frame of 6 weeks is advised to progress through reduced weight bearing modalities, onto the grass and then into modified training. This can be quicker if the injury has been a stress response rather than fracture, or longer if there are any potential complicating factors.
The first goal is to gradually build volume and this usually starts with a schedule of one day on grass followed by an indoor recovery day for an initial period. If this is comfortable, then the player may work outdoors on consecutive days but this somewhat depends on their normal training schedule and your access to the player.
Once the player can tolerate a sufficient amount of volume – active duration and GPS markers such as total distance and distance per minute can be useful to guide this – then we progress to add blocks of higher intensity work. This is initially in the form of more controlled work before progressing to more reactive work and position specific drills towards the end stage of outdoor rehabilitation. Matt Taberner’s work does a great job at outlining a framework for this. GPS measures can be useful to inform whether the player is at a level to drop into modified training but if you don’t have this technology than a simple rating of perceived exertion (RPE) from the player can give you good information about how hard they are working in specific drills and sessions.
Returning To Training
It is tempting to think for both you and the player that your job is done once they have returned to training. However they are likely to need their training load and content modified while they transition back into full training. There are no recipes for this and how this transition is managed will depend on the player, their position, the training schedule, the coaching staff, you and your team’s experiences, and a number of other factors.
I hope you’ve found these blogs a useful summary of my approach to rehabilitating these often tricky injuries. If you have any questions or comments, please don’t hesitate to reach out via email or social media.
