Adolescent back pain - a pars injury rehab framework (Part 1)

If you work with adolescents, particularly athletic youngsters, you should know about Pars interarticularis injuries. This should be high up on the list of possible diagnoses whenever you see an active teenager with low back pain.

There are plenty of resources online (here for example) that outline the pathology in more detail but this blog is going to focus on the rehabilitation of these injuries. I will detail exercise selection and outline a framework for rehabilitation progression. I will follow this post up with a piece more focused on football specific, pitch based rehab progression.

Firstly, a disclaimer. If you are suspecting the patient/athlete in front of you has this type of injury, a specialist opinion from an orthopaedic or sports medicine colleague can be useful. They can organize the appropriate imaging to confirm the severity of the injury and determine the necessary offload from sport and activity.

As well as the above, it goes without saying that the process detailed below is the way I approach these injuries. I am not saying this is the only way to approach the rehab of these athletes but hopefully people find it useful.

With the gym based component of rehabilitation of this injury, I like to think of it as layering components of muscular function on top of one another (see above). Each component, once developed, works in synchrony with the others. Particular exercises will be able to be used to work on more than element whilst certain aspects may require very specific exercises or movements.

Although these exercises will be performed in the gym, I think its really important to keep the end of goal of what sports and activities the athlete will be returning to in mind. Its also important to identify the key movement patterns that need re-training. A diverse programme is likely to cover most bases but it is important to be specific to the athletes needs. For example, most athletes with this issue will benefit from controlling movement in all planes. But there is likely to be one or more directions that needs particular focus and you should weight your exercise selection and programming accordingly.

Assessment

I don’t think there is a particular assessment or test that will give you all the answers but taking a good history and establishing what the main aggravating or provocative movements have been will give you a good start. From there, and once you’ve carried out your physical assessment, observing and/or videoing the athlete perform a range of movement patterns can highlight what aspects need particular work to improve.

Control phase

For me, this is where the foundation for a successful rehabilitation is built. Depending on the outcome of your assessment it is likely to involve working on spinal dissociation and the ability to resist extension, rotation, and/or side flexion. Initially this ability might be focused on static positions but I always find it useful to assess this capability in dynamic positions early on. Whilst Pilates based exercises and other mat based variations can be useful, I like to include standing work from day 1. This might be in the form of pallof press variations (see below) or supported leaning tower or running man variations.

Strength & Endurance

It is often not necessary to change exercises in order to develop strength and endurance. I tend to focus on endurance earlier in the rehab process as I want the people I am working with to be able to maintain control (for want of a better term) during sporting activities that may last close to two hours. Because of this, fatigue resistance is an important quality to develop.

Strength is important to develop to ensure that the high forces involved in sporting activity are able to be resisted. Progressive overload in the movement patterns you are honing in on will help the athlete be able to do that. Ensure that the different positions that the athlete will find themselves in their sport are being addressed. Multi-directional lunge variations, step ups, are deadlifts are just a few to consider but don’t forget running specific postures.

Rate of Force Development (RFD)

An often neglected, but extremely important, component of gym based rehabilitation is to program exercises that develop power. A high rate of force development (RFD) is important in athletic tasks and the patient needs to be exposed to this in a progressive manner during their rehab to ensure that their body is used to working at high velocities. Examples include slams, throws, and catches in different positions.

Thanks for reading and I hope you find this of some use the next time you see an athlete with low back pain. I plan to post part two focussing on pitch based rehab in the next week or two. If you have any questions, please feel free to get in touch.