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Semin Musculoskelet Radiol 2020; 24(03): 262-276
DOI: 10.1055/s-0040-1709484
Review Article

Stress Injuries of the Spine in Sports

Jenn Shiunn Wong
1   Department of Radiology, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
,
Radhesh Lalam
2   Department of Radiology, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom
,
Victor N. Cassar-Pullicino
2   Department of Radiology, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom
,
Prudencia N.M. Tyrrell
,
Jaspreet Singh
2   Department of Radiology, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom
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Abstract

Spine sports stress injuries account for a significant amount of time loss at play in athletes, particularly if left unrecognized and allowed to progress. Spondylolysis makes up most of these stress injuries. This article focuses on spondylolysis, bringing together discussion from the literature on its pathomechanics and the different imaging modalities used in its diagnosis. Radiologists should be aware of the limitations and more importantly the roles of different imaging modalities in guiding and dictating the management of spondylolysis. Other stress-related injuries in the spine are also discussed including but not limited to pedicle fracture and apophyseal ring injury.

Keywords

spine - sports - stress injury - spondylolysis - pars fracture


Publication History

Article published online:
28 September 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • Reference

  • 1 Swärd L, Hellström M, Jacobsson B, Nyman R, Peterson L. Disc degeneration and associated abnormalities of the spine in elite gymnasts. A magnetic resonance imaging study. Spine 1991; 16 (04) 437-443
    CrossrefPubMedGoogle Scholar
  • 2 Orchard JW, Kountouris A, Sims K. Incidence and prevalence of elite male cricket injuries using updated consensus definitions. Open Access J Sports Med 2016; 7: 187-194
    CrossrefPubMedGoogle Scholar
  • 3 Guermazi A, Hayashi D, Jarraya M. , et al. Sports injuries at the Rio de Janeiro 2016 Summer Olympics: use of diagnostic imaging services. Radiology 2018; 287 (03) 922-932
    CrossrefPubMedGoogle Scholar
  • 4 Roche MB, Rowe GG. The incidence of separate neural arch and coincident bone variations; a survey of 4,200 skeletons. Anat Rec 1951; 109 (02) 233-252
    CrossrefPubMedGoogle Scholar
  • 5 Sakai T, Sairyo K, Takao S, Nishitani H, Yasui N. Incidence of lumbar spondylolysis in the general population in Japan based on multidetector computed tomography scans from two thousand subjects. Spine 2009; 34 (21) 2346-2350
    CrossrefPubMedGoogle Scholar
  • 6 Simper LB. Spondylolysis in Eskimo skeletons. Acta Orthop Scand 1986; 57 (01) 78-80
    CrossrefPubMedGoogle Scholar
  • 7 Soler T, Calderón C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med 2000; 28 (01) 57-62
    CrossrefPubMedGoogle Scholar
  • 8 Rossi F, Dragoni S. Lumbar spondylolysis: occurrence in competitive athletes. Updated achievements in a series of 390 cases. J Sports Med Phys Fitness 1990; 30 (04) 450-452
    PubMedGoogle Scholar
  • 9 Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995; 149 (01) 15-18
    CrossrefPubMedGoogle Scholar
  • 10 Fournier PE, Rizzoli R, Slosman DO, Theintz G, Bonjour JP. Asynchrony between the rates of standing height gain and bone mass accumulation during puberty. Osteoperosis Int 1997; 7 (06) 525-532
    CrossrefPubMedGoogle Scholar
  • 11 Cyron BM, Hutton WC. The fatigue strength of the lumbar neural arch in spondylolysis. J Bone Joint Surg Br 1978; 60-B (02) 234-238
    CrossrefPubMedGoogle Scholar
  • 12 Dietrich M, Kurowski P. The importance of mechanical factors in the etiology of spondylolysis. A model analysis of loads and stresses in human lumbar spine. Spine 1985; 10 (06) 532-542
    CrossrefPubMedGoogle Scholar
  • 13 Sairyo K, Katoh S, Takata Y. , et al. MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents: a clinical and biomechanical study. Spine 2006; 31 (02) 206-211
    CrossrefPubMedGoogle Scholar
  • 14 Terai T, Sairyo K, Goel VK. , et al. Spondylolysis originates in the ventral aspect of the pars interarticularis: a clinical and biomechanical study. J Bone Joint Surg Br 2010; 92 (08) 1123-1127
    CrossrefPubMedGoogle Scholar
  • 15 Dunn AJ, Campbell RS, Mayor PE, Rees D. Radiological findings and healing patterns of incomplete stress fractures of the pars interarticularis. Skeletal Radiol 2008; 37 (05) 443-450
    CrossrefPubMedGoogle Scholar
  • 16 Ogilvie JW, Sherman J. Spondylolysis in Scheuermann's disease. Spine 1987; 12 (03) 251-253
    CrossrefPubMedGoogle Scholar
  • 17 Ward CV, Latimer B. Human evolution and the development of spondylolysis. Spine 2005; 30 (16) 1808-1814
    CrossrefPubMedGoogle Scholar
  • 18 Ward CV, Latimer B, Alander DH. , et al. Radiographic assessment of lumbar facet distance spacing and spondylolysis. Spine 2007; 32 (02) E85-E88
    CrossrefPubMedGoogle Scholar
  • 19 Sagi HC, Jarvis JG, Uhthoff HK. Histomorphic analysis of the development of the pars interarticularis and its association with isthmic spondylolysis. Spine 1998; 23 (15) 1635-1639 ; discussion 1640
    CrossrefPubMedGoogle Scholar
  • 20 Sarvazyan A, Rudenko O, Aglyamov S, Emelianov S. Muscle as a molecular machine for protecting joints and bones by absorbing mechanical impacts. Med Hypotheses 2014; 83 (01) 6-10
    CrossrefPubMedGoogle Scholar
  • 21 Cheung KK, Dhawan RT, Wilson LF, Peirce NS, Rajeswaran G. Pars interarticularis injury in elite athletes—the role of imaging in diagnosis and management. Eur J Radiol 2018; 108: 28-42
    CrossrefPubMedGoogle Scholar
  • 22 Kumar DS, Fotiadou A, Lalam R. , et al. Ossicles of lumbar articular facets: normal variant or spondylolytic variant?. Skeletal Radiol 2012; 41 (12) 1559-1566
    CrossrefPubMedGoogle Scholar
  • 23 Kaup M, Wichmann JL, Scholtz JE. , et al. Dual-energy CT-based display of bone marrow edema in osteoporotic vertebral compression fractures: impact on diagnostic accuracy of radiologists with varying levels of experience in correlation to MR imaging. Radiology 2016; 280 (02) 510-519
    CrossrefPubMedGoogle Scholar
  • 24 Yamashita K, Sakai T, Takata Y. , et al. Utility of STIR-MRI in detecting the pain generator in asymmetric bilateral pars fracture: a report of 5 cases. Neurol Med Chir (Tokyo) 2018; 58 (02) 91-95
    CrossrefPubMedGoogle Scholar
  • 25 Hollenberg GM, Beattie PF, Meyers SP, Weinberg EP, Adams MJ. Stress reactions of the lumbar pars interarticularis: the development of a new MRI classification system. Spine 2002; 27 (02) 181-186
    CrossrefPubMedGoogle Scholar
  • 26 Campbell RS, Grainger AJ, Hide IG, Papastefanou S, Greenough CG. Juvenile spondylolysis: a comparative analysis of CT, SPECT and MRI. Skeletal Radiol 2005; 34 (02) 63-73
    CrossrefPubMedGoogle Scholar
  • 27 Johnson DW, Farnum GN, Latchaw RE, Erba SM. MR imaging of the pars interarticularis. AJR Am J Roentgenol 1989; 152 (02) 327-332
    CrossrefPubMedGoogle Scholar
  • 28 Saifuddin A, Burnett SJ. The value of lumbar spine MRI in the assessment of the pars interarticularis. Clin Radiol 1997; 52 (09) 666-671
    CrossrefPubMedGoogle Scholar
  • 29 Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L. Lumbar spondylolysis: a review. Skeletal Radiol 2011; 40 (06) 683-700
    CrossrefPubMedGoogle Scholar
  • 30 Sherif H, Mahfouz AE. Epidural fat interposition between dura mater and spinous process: a new sign for the diagnosis of spondylolysis on MR imaging of the lumbar spine. Eur Radiol 2004; 14 (06) 970-973
    CrossrefPubMedGoogle Scholar
  • 31 Ang EC, Robertson AF, Malara FA. , et al. Diagnostic accuracy of 3-T magnetic resonance imaging with 3D T1 VIBE versus computer tomography in pars stress fracture of the lumbar spine. Skeletal Radiol 2016; 45 (11) 1533-1540
    CrossrefPubMedGoogle Scholar
  • 32 Finkenstaedt T, Siriwanarangsun P, Achar S. , et al. Ultrashort time-to-echo magnetic resonance imaging at 3 T for the detection of spondylolysis in cadaveric spines: comparison With CT. Invest Radiol 2019; 54 (01) 32-38
    CrossrefPubMedGoogle Scholar
  • 33 Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J Sports Med 2006; 40 (11) 940-946 ; discussion 946
    CrossrefPubMedGoogle Scholar
  • 34 Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology 1991; 180 (02) 509-512
    CrossrefPubMedGoogle Scholar
  • 35 Zukotynski K, Curtis C, Grant FD, Micheli L, Treves ST. The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain. J Orthop Surg Res 2010; 5: 13-13
    CrossrefPubMedGoogle Scholar
  • 36 Anderson K, Sarwark JF, Conway JJ, Logue ES, Schafer MF. Quantitative assessment with SPECT imaging of stress injuries of the pars interarticularis and response to bracing. J Pediatr Orthop 2000; 20 (01) 28-33
    CrossrefPubMedGoogle Scholar
  • 37 Sairyo K, Sakai T, Yasui N. Conservative treatment of lumbar spondylolysis in childhood and adolescence: the radiological signs which predict healing. J Bone Joint Surg Br 2009; 91 (02) 206-209
    CrossrefPubMedGoogle Scholar
  • 38 Sairyo K, Sakai T, Yasui N, Dezawa A. Conservative treatment for pediatric lumbar spondylolysis to achieve bone healing using a hard brace: what type and how long? Clinical article. J Neurosurg Spine 2012; 16 (06) 610-614
    CrossrefPubMedGoogle Scholar
  • 39 Sundell CG, Jonsson H, Ådin L, Larsén K. Stress fractures of pars interarticularis in adolescent athletes a classification system with MRI and CT enabling evaluation of the healing process. J Exerc Sports Orthop 2018; 5 (01) 1-6
    CrossrefPubMedGoogle Scholar
  • 40 Fujii K, Katoh S, Sairyo K, Ikata T, Yasui N. Union of defects in the pars interarticularis of the lumbar spine in children and adolescents. The radiological outcome after conservative treatment. J Bone Joint Surg Br 2004; 86 (02) 225-231
    CrossrefPubMedGoogle Scholar
  • 41 Arima H, Suzuki Y, Togawa D, Mihara Y, Murata H, Matsuyama Y. Low-intensity pulsed ultrasound is effective for progressive-stage lumbar spondylolysis with MRI high-signal change. Eur Spine J 2017; 26 (12) 3122-3128
    CrossrefPubMedGoogle Scholar
  • 42 Gregory PL, Batt ME, Kerslake RW, Scammell BE, Webb JF. The value of combining single photon emission computerised tomography and computerised tomography in the investigation of spondylolysis. Eur Spine J 2004; 13 (06) 503-509
    CrossrefPubMedGoogle Scholar
  • 43 van den Oever M, Merrick MV, Scott JH. Bone scintigraphy in symptomatic spondylolysis. J Bone Joint Surg Br 1987; 69 (03) 453-456
    CrossrefPubMedGoogle Scholar
  • 44 Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies. J Pediatr Orthop 2009; 29 (02) 146-156
    CrossrefPubMedGoogle Scholar
  • 45 Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports 2004; 14 (06) 346-351
    CrossrefPubMedGoogle Scholar
  • 46 Sairyo K, Katoh S, Sasa T. , et al. Athletes with unilateral spondylolysis are at risk of stress fracture at the contralateral pedicle and pars interarticularis: a clinical and biomechanical study. Am J Sports Med 2005; 33 (04) 583-590
    CrossrefPubMedGoogle Scholar
  • 47 Alway P, Brooke-Wavell K, Langley B, King M, Peirce N. Incidence and prevalence of lumbar stress fracture in English County Cricket fast bowlers, association with bowling workload and seasonal variation. BMJ Open Sport Exerc Med 2019; 5 (01) e000529
    CrossrefPubMedGoogle Scholar
  • 48 Robertson PA, Grobler LJ. Stress fracture of the pedicle. A late complication of posterolateral lumbar fusion. Spine 1993; 18 (07) 930-932
    CrossrefPubMedGoogle Scholar
  • 49 Ganiyusufoglu AK, Onat L, Karatoprak O, Enercan M, Hamzaoglu A. Diagnostic accuracy of magnetic resonance imaging versus computed tomography in stress fractures of the lumbar spine. Clin Radiol 2010; 65 (11) 902-907
    CrossrefPubMedGoogle Scholar
  • 50 Ulmer JL, Elster AD, Mathews VP, Allen AM. Lumbar spondylolysis: reactive marrow changes seen in adjacent pedicles on MR images. AJR Am J Roentgenol 1995; 164 (02) 429-433
    CrossrefPubMedGoogle Scholar
  • 51 Butler RW. The nature and significance of vertebral osteochondritis [Abridged]. Proc R Soc Med 1955; 48 (11) 895-902
    PubMedGoogle Scholar
  • 52 Huang PY, Yeh LR, Tzeng WS. , et al. Imaging features of posterior limbus vertebrae. Clin Imaging 2012; 36 (06) 797-802
    CrossrefPubMedGoogle Scholar
  • 53 Epstein NE, Epstein JA. Limbus lumbar vertebral fractures in 27 adolescents and adults. Spine 1991; 16 (08) 962-966
    CrossrefPubMedGoogle Scholar
  • 54 Rothfus WE, Goldberg AL, Deeb ZL, Daffner RH. MR recognition of posterior lumbar vertebral ring fracture. J Comput Assist Tomogr 1990; 14 (05) 790-794
    CrossrefPubMedGoogle Scholar
  • 55 Sairyo K, Goel VK, Masuda A. , et al. Three-dimensional finite element analysis of the pediatric lumbar spine. Part I: pathomechanism of apophyseal bony ring fracture. Eur Spine J 2006; 15 (06) 923-929
    CrossrefPubMedGoogle Scholar
  • 56 Akhaddar A, Belfquih H, Oukabli M, Boucetta M. Posterior ring apophysis separation combined with lumbar disc herniation in adults: a 10-year experience in the surgical management of 87 cases. J Neurosurg Spine 2011; 14 (04) 475-483
    CrossrefPubMedGoogle Scholar
  • 57 Wu X, Ma W, Du H, Gurung K. A review of current treatment of lumbar posterior ring apophysis fracture with lumbar disc herniation. Eur Spine J 2013; 22 (03) 475-488
    CrossrefPubMedGoogle Scholar
  • 58 Takata K, Inoue S, Takahashi K, Ohtsuka Y. Fracture of the posterior margin of a lumbar vertebral body. J Bone Joint Surg Am 1988; 70 (04) 589-594
    CrossrefPubMedGoogle Scholar
  • 59 Koyama K, Nakazato K, Min S-K. , et al. Anterior limbus vertebra and intervertebral disk degeneration in Japanese collegiate gymnasts. Orthop J Sports Med 2013; 1 (03) 2325967113500222
    CrossrefPubMedGoogle Scholar
  • 60 Swärd L, Hellström M, Jacobsson B, Karlsson L. Vertebral ring apophysis injury in athletes. Is the etiology different in the thoracic and lumbar spine?. Am J Sports Med 1993; 21 (06) 841-845
    CrossrefPubMedGoogle Scholar
  • 61 Battié MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K. 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine 1995; 20 (24) 2601-2612
    CrossrefPubMedGoogle Scholar
  • 62 Koyama K, Nakazato K, Min S. , et al. COL11A1 gene is associated with limbus vertebra in gymnasts. Int J Sports Med 2012; 33 (07) 586-590
    Article in Thieme ConnectPubMedGoogle Scholar
  • 63 Mok FP, Samartzis D, Karppinen J, Luk KD, Fong DY, Cheung KM. ISSLS prize winner: prevalence, determinants, and association of Schmorl nodes of the lumbar spine with disc degeneration: a population-based study of 2449 individuals. Spine 2010; 35 (21) 1944-1952
    CrossrefPubMedGoogle Scholar
  • 64 Dar G, Masharawi Y, Peleg S. , et al. Schmorl's nodes distribution in the human spine and its possible etiology. Eur Spine J 2010; 19 (04) 670-675
    CrossrefPubMedGoogle Scholar
  • 65 Pfirrmann CW, Resnick D. Schmorl nodes of the thoracic and lumbar spine: radiographic-pathologic study of prevalence, characterization, and correlation with degenerative changes of 1,650 spinal levels in 100 cadavers. Radiology 2001; 219 (02) 368-374
    CrossrefPubMedGoogle Scholar
  • 66 Abu-Ghanem S, Ohana N, Abu-Ghanem Y, Kittani M, Shelef I. Acute Schmorl node in dorsal spine: an unusual cause of a sudden onset of severe back pain in a young female. Asian Spine J 2013; 7 (02) 131-135
    CrossrefPubMedGoogle Scholar
  • 67 Hellström M, Jacobsson B, Swärd L, Peterson L. Radiologic abnormalities of the thoraco-lumbar spine in athletes. Acta Radiol 1990; 31 (02) 127-132
    CrossrefPubMedGoogle Scholar
  • 68 Witwit WA, Kovac P, Sward A. , et al. Disc degeneration on MRI is more prevalent in young elite skiers compared to controls. Knee Surg Sports Traumatol Arthrosc 2018; 26 (01) 325-332
    CrossrefPubMedGoogle Scholar
  • 69 Rachbauer F, Sterzinger W, Eibl G. Radiographic abnormalities in the thoracolumbar spine of young elite skiers. Am J Sports Med 2001; 29 (04) 446-449
    CrossrefPubMedGoogle Scholar
  • 70 Baranto A, Hellström M, Cederlund CG, Nyman R, Swärd L. Back pain and MRI changes in the thoraco-lumbar spine of top athletes in four different sports: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc 2009; 17 (09) 1125-1134
    CrossrefPubMedGoogle Scholar
  • 71 Kyere KA, Than KD, Wang AC. , et al. Schmorl's nodes. Eur Spine J 2012; 21 (11) 2115-2121
    CrossrefPubMedGoogle Scholar
  • 72 Baranto A, Hellström M, Nyman R, Lundin O, Swärd L. Back pain and degenerative abnormalities in the spine of young elite divers: a 5-year follow-up magnetic resonance imaging study. Knee Surg Sports Traumatol Arthrosc 2006; 14 (09) 907-914
    CrossrefPubMedGoogle Scholar
  • 73 Singer KP, Breidahl PD, Day RE. Variations in zygapophyseal joint orientation and level of transition at the thoracolumbar junction. Preliminary survey using computed tomography. Surg Radiol Anat 1988; 10 (04) 291-295
    CrossrefPubMedGoogle Scholar
  • 74 Cyron BM, Hutton WC. Articular tropism and stability of the lumbar spine. Spine 1980; 5 (02) 168-172
    CrossrefPubMedGoogle Scholar
  • 75 Hou Y, Luo Z. A study on the structural properties of the lumbar endplate: histological structure, the effect of bone density, and spinal level. Spine 2009; 34 (12) E427-E433
    CrossrefPubMedGoogle Scholar
  • 76 Scheuermann HW. The classic: kyphosis dorsalis juvenilis. Clin Orthop Relat Res 1977; (128) 5-7
    PubMedGoogle Scholar
  • 77 Zaidman AM, Zaidman MN, Strokova EL. , et al. The mode of inheritance of Scheuermann's disease. BioMed Res Int 2013; 2013: 973716
    CrossrefPubMedGoogle Scholar
  • 78 Revel M, Andre-Deshays C, Roudier R, Roudier B, Hamard G, Amor B. Effects of repetitive strains on vertebral end plates in young rats. Clin Orthop Relat Res 1992; (279) 303-309
    PubMedGoogle Scholar
  • 79 Scoles PV, Latimer BM, DigIovanni BF, Vargo E, Bauza S, Jellema LM. Vertebral alterations in Scheuermann's kyphosis. Spine 1991; 16 (05) 509-515
    CrossrefPubMedGoogle Scholar
  • 80 Sørensen KH. Scheuermann's Juvenile Kyphosis: Clinical Appearances, Radiography, Aetiology, and Prognosis. Copenhagen, Denmark: Munksgaard; 1964
    Google Scholar
  • 81 Stoddard A, Osborn JF. Scheuermann's disease or spinal osteochondrosis: its frequency and relationship with spondylosis. J Bone Joint Surg Br 1979; 61 (01) 56-58
    CrossrefPubMedGoogle Scholar
  • 82 Palazzo C, Sailhan F, Revel M. Scheuermann's disease: an update. Joint Bone Spine 2014; 81 (03) 209-214
    CrossrefPubMedGoogle Scholar
  • 83 Ristolainen L, Kettunen JA, Heliövaara M, Kujala UM, Heinonen A, Schlenzka D. Untreated Scheuermann's disease: a 37-year follow-up study. Eur Spine J 2012; 21 (05) 819-824
    CrossrefPubMedGoogle Scholar
  • 84 Ali RM, Green DW, Patel TC. Scheuermann's kyphosis. Curr Opin Pediatr 1999; 11 (01) 70-75
    CrossrefPubMedGoogle Scholar
  • 85 Makurthou AA, Oei L, El Saddy S. , et al. Scheuermann disease: evaluation of radiological criteria and population prevalence. Spine 2013; 38 (19) 1690-1694
    CrossrefPubMedGoogle Scholar
  • 86 Blumenthal SL, Roach J, Herring JA. Lumbar Scheuermann's. A clinical series and classification. Spine 1987; 12 (09) 929-932
    CrossrefPubMedGoogle Scholar
  • 87 Summers BN, Singh JP, Manns RA. The radiological reporting of lumbar Scheuermann's disease: an unnecessary source of confusion amongst clinicians and patients. Br J Radiol 2008; 81 (965) 383-385
    CrossrefPubMedGoogle Scholar
  • 88 Gokce E, Beyhan M. Radiological imaging findings of Scheuermann disease. World J Radiol 2016; 8 (11) 895-901
    CrossrefPubMedGoogle Scholar
  • 89 Greene TL, Hensinger RN, Hunter LY. Back pain and vertebral changes simulating Scheuermann's disease. J Pediatr Orthop 1985; 5 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 90 Swärd L. The thoracolumbar spine in young elite athletes. Current concepts on the effects of physical training. Sports Med 1992; 13 (05) 357-364
    CrossrefPubMedGoogle Scholar
  • 91 Tyrakowski M, Mardjetko S, Siemionow K. Radiographic spinopelvic parameters in skeletally mature patients with Scheuermann disease. Spine 2014; 39 (18) E1080-E1085
    CrossrefPubMedGoogle Scholar
  • 92 Heithoff KB, Gundry CR, Burton CV, Winter RB. Juvenile discogenic disease. Spine 1994; 19 (03) 335-340
    CrossrefPubMedGoogle Scholar
  • 93 Koehler SM, Lin JD, Stets KC, Qureshi SA, Martins DA, Hecht AC. Lumbar spinous process avulsion fracture in an adolescent dancer. Clin J Sport Med 2010; 20 (03) 213-214
    CrossrefPubMedGoogle Scholar
  • 94 Schmitt HG, Wisser P. Shoveler's disease in adolescents (apophyseal fractures of the spinous processes of the thoracic vertebra [in German]. Langenbecks Arch Klin Chir Ver Dtsch Z Chir 1951; 268 (03) 333-340
    PubMedGoogle Scholar
  • 95 Koehler SM, Rosario-Quinones F, Mayer J. , et al. Understanding acute apophyseal spinous process avulsion injuries. Orthopedics 2014; 37 (03) e317-e321
    CrossrefPubMedGoogle Scholar
  • 96 Mannor DA, Lindenfeld TN. Spinal process apophysitis mimics spondylolysis. Case reports. Am J Sports Med 2000; 28 (02) 257-260
    CrossrefPubMedGoogle Scholar
  • 97 Linstrom NJ, Heiserman JE, Kortman KE. , et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine 2009; 34 (04) 309-315
    CrossrefPubMedGoogle Scholar
  • 98 Hangai M, Kaneoka K, Hinotsu S. , et al. Lumbar intervertebral disk degeneration in athletes. Am J Sports Med 2009; 37 (01) 149-155
    CrossrefPubMedGoogle Scholar
  • 99 Annear PT, Chakera TM, Foster DH, Hardcastle PH. Pars interarticularis stress and disc degeneration in cricket's potent strike force: the fast bowler. Aust N Z J Surg 1992; 62 (10) 768-773
    CrossrefPubMedGoogle Scholar