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Bone marrow oedema on MRI is associated with increased risk of lumbar stress fracture in junior cricket fast bowlers
Abstracts / Journal of Science and Medicine in Sport 20S (2017) 40–42
of medical causes (e.g. heart attacks) while playing cricket, or the nine documented cases of cricketers killed by lightning strikes. Results: We obtained details of 174 deaths, the first being in 1864 and the most recent the Hughes death in 2014. Of the 152 years of our study, there were 52 deaths in the first 50 years (1864–1914), 101 in the second 50 years (1915–1964) and 21 in the last 52 years (1965–2016). There have only been three deaths recorded so far this century. There were 81 deaths in organized matches or training, and 93 deaths in informal settings of which 31 were at school and the rest in backyard/street/beach cricket. Most batsmen who were killed suffered blows to various parts of the head – the temple, forehead or face, on the side of the head, below or behind the ear or on the neck – and died from cerebral haemorrhage or other brain injury. Since the advent of helmet use at all levels of cricket, the incidence of deaths after a blow to the head has been minimal. Commotio cordis, internal abdominal injuries and subarachnoid haemorrhage secondary to vertebral artery dissection have been other causes of deaths. Discussion: The deaths in cricket are fairly evenly spread among organized games/training and informal settings such as school play, backyard or street cricket. In the last thirty years there has only been five deaths. This coincides with the widespread use of helmets by batsmen. In the thirty year period since the advent of helmets, the five confirmed deaths are divided between three cases of commotio cordis and two confirmed cases of vertebral artery dissection. It is clear that the introduction of helmets for batsmen and close infielders had dramatically reduced the incidence of overall deaths in cricket and specifically virtually eliminated deaths from blows to the head. https://doi.org/10.1016/j.jsams.2017.09.274 82 The relationship between cricket fast bowling workload and lumbar stress fracture K. Sims ∗ , A. Kountouris, J. Orchard, D. Beakley, A. Saw Cricket Australia, Australia Background: Cricket fast bowlers are highly susceptible to lumbar stress fractures. These injuries typically affect younger players (less than 22 years old) and require prolonged recovery times. Aside from younger age, other known risk factors include excessive trunk rotation during the delivery and bowling workload. It has been demonstrated that a safe zone for bowling load exists with deviations above or below this zone associated with an increased injury risk. More recently rapid increases in workload (causing spikes relative to what the player is used to), measured using the acute:chronic workload ratio (ACWR) have also been associated with injury in fast bowlers. However to date, the ACWR has not been investigated with respect to a possible relationship with stress fractures. Methods: 65 young fast bowlers (average age 17) were recruited and prospectively followed over the course of a cricket season for the development of a lumbar stress fracture. In addition, players recorded the bowling volumes and this was used to investigate the relationship between stress fracture and workload variables such as the ACWR, balls per week and sessions per week. Results: Over the course of the season there were 12 lumbar stress fractures diagnosed. There was no relationship between the ACWR and the development of a lumbar stress fracture. However the risks of developing a stress fracture increased with less days between sessions (on average < 2). Discussion: Our data did not support the concept of spikes in workload as measured by the ACWR being a factor in the develop-
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ment of lumbar stress fractures. Rather, the relationship supported by our data was that cumulative loading over time is more likely to increase the risk of developing a lumbar stress fracture. This is consistent with previous research showing increased stress fracture risk in cricket fast bowlers with high loads over a 3 month time period and low career workload. https://doi.org/10.1016/j.jsams.2017.09.275 83 Bone marrow oedema on MRI is associated with increased risk of lumbar stress fracture in junior cricket fast bowlers A. Kountouris 1,∗ , K. Sims 1 , D. Beakley 1 , A. Rotstein 3 , J. Orchard 1 , J. Cook 2 1
Cricket Australia, Australia La Trobe University, Australia 3 Victoria House Medical Imaging, Australia 2
Background: Lumbar stress fractures (also known as spondylolysis) are a common and costly (match-time lost) injury amongst junior cricket fast bowlers. Bone marrow oedema (BMO) detected using Magnetic Resonance Imaging (MRI) may precede the progression from, pre-symptomatic bone stress to end-stage symptomatic stress fracture. This study investigated the relationship between BMO and subsequent lumbar stress fracture in junior fast bowlers during a cricket season. Methods: 65 junior fast bowlers (mean 17.3 years, range 14.7–18.8) were prospectively monitored over the course of a cricket season. Players had up to 6 MRI scans at set times in the season, with findings withheld from participants and their medical teams. Standard practices for symptom recording, and injury diagnosis and reporting were followed. Results: 15 (23%) participants developed a symptomatic stress fracture during the study. All 15 players who developed a symptomatic lumbar stress fracture had BMO on at least one of the preceding MRI scans, including the scan immediately prior to diagnosis. There was, on average, 96 days (range 5–224) between the detection of BMO and first reported symptoms of stress fracture. 19 (29%) participants had BMO at baseline (pre-season) testing, of which 10 (67%) progressed to a symptomatic stress fracture. Another 21 (32%) participants developed BMO during the season, of which 5 (24%) progressed to a symptomatic stress fracture. Participants with BMO were 20 times more likely to sustain a lumbar stress fracture during the season compared to participants with no detectable BMO during the season. Discussion: Sequential MRI over the course of a cricket season has established that the presence of BMO in asymptomatic cricket fast bowlers represents a high injury risk. BMO may be present for a months prior to injury, and may be carried from a previous season. MRI may be used to screen asymptomatic junior fast bowlers, and allow clinicians to make informed decisions regarding the risk management of fast bowlers. https://doi.org/10.1016/j.jsams.2017.09.276
of medical causes (e.g. heart attacks) while playing cricket, or the nine documented cases of cricketers killed by lightning strikes. Results: We obtained details of 174 deaths, the first being in 1864 and the most recent the Hughes death in 2014. Of the 152 years of our study, there were 52 deaths in the first 50 years (1864–1914), 101 in the second 50 years (1915–1964) and 21 in the last 52 years (1965–2016). There have only been three deaths recorded so far this century. There were 81 deaths in organized matches or training, and 93 deaths in informal settings of which 31 were at school and the rest in backyard/street/beach cricket. Most batsmen who were killed suffered blows to various parts of the head – the temple, forehead or face, on the side of the head, below or behind the ear or on the neck – and died from cerebral haemorrhage or other brain injury. Since the advent of helmet use at all levels of cricket, the incidence of deaths after a blow to the head has been minimal. Commotio cordis, internal abdominal injuries and subarachnoid haemorrhage secondary to vertebral artery dissection have been other causes of deaths. Discussion: The deaths in cricket are fairly evenly spread among organized games/training and informal settings such as school play, backyard or street cricket. In the last thirty years there has only been five deaths. This coincides with the widespread use of helmets by batsmen. In the thirty year period since the advent of helmets, the five confirmed deaths are divided between three cases of commotio cordis and two confirmed cases of vertebral artery dissection. It is clear that the introduction of helmets for batsmen and close infielders had dramatically reduced the incidence of overall deaths in cricket and specifically virtually eliminated deaths from blows to the head. https://doi.org/10.1016/j.jsams.2017.09.274 82 The relationship between cricket fast bowling workload and lumbar stress fracture K. Sims ∗ , A. Kountouris, J. Orchard, D. Beakley, A. Saw Cricket Australia, Australia Background: Cricket fast bowlers are highly susceptible to lumbar stress fractures. These injuries typically affect younger players (less than 22 years old) and require prolonged recovery times. Aside from younger age, other known risk factors include excessive trunk rotation during the delivery and bowling workload. It has been demonstrated that a safe zone for bowling load exists with deviations above or below this zone associated with an increased injury risk. More recently rapid increases in workload (causing spikes relative to what the player is used to), measured using the acute:chronic workload ratio (ACWR) have also been associated with injury in fast bowlers. However to date, the ACWR has not been investigated with respect to a possible relationship with stress fractures. Methods: 65 young fast bowlers (average age 17) were recruited and prospectively followed over the course of a cricket season for the development of a lumbar stress fracture. In addition, players recorded the bowling volumes and this was used to investigate the relationship between stress fracture and workload variables such as the ACWR, balls per week and sessions per week. Results: Over the course of the season there were 12 lumbar stress fractures diagnosed. There was no relationship between the ACWR and the development of a lumbar stress fracture. However the risks of developing a stress fracture increased with less days between sessions (on average < 2). Discussion: Our data did not support the concept of spikes in workload as measured by the ACWR being a factor in the develop-
41
ment of lumbar stress fractures. Rather, the relationship supported by our data was that cumulative loading over time is more likely to increase the risk of developing a lumbar stress fracture. This is consistent with previous research showing increased stress fracture risk in cricket fast bowlers with high loads over a 3 month time period and low career workload. https://doi.org/10.1016/j.jsams.2017.09.275 83 Bone marrow oedema on MRI is associated with increased risk of lumbar stress fracture in junior cricket fast bowlers A. Kountouris 1,∗ , K. Sims 1 , D. Beakley 1 , A. Rotstein 3 , J. Orchard 1 , J. Cook 2 1
Cricket Australia, Australia La Trobe University, Australia 3 Victoria House Medical Imaging, Australia 2
Background: Lumbar stress fractures (also known as spondylolysis) are a common and costly (match-time lost) injury amongst junior cricket fast bowlers. Bone marrow oedema (BMO) detected using Magnetic Resonance Imaging (MRI) may precede the progression from, pre-symptomatic bone stress to end-stage symptomatic stress fracture. This study investigated the relationship between BMO and subsequent lumbar stress fracture in junior fast bowlers during a cricket season. Methods: 65 junior fast bowlers (mean 17.3 years, range 14.7–18.8) were prospectively monitored over the course of a cricket season. Players had up to 6 MRI scans at set times in the season, with findings withheld from participants and their medical teams. Standard practices for symptom recording, and injury diagnosis and reporting were followed. Results: 15 (23%) participants developed a symptomatic stress fracture during the study. All 15 players who developed a symptomatic lumbar stress fracture had BMO on at least one of the preceding MRI scans, including the scan immediately prior to diagnosis. There was, on average, 96 days (range 5–224) between the detection of BMO and first reported symptoms of stress fracture. 19 (29%) participants had BMO at baseline (pre-season) testing, of which 10 (67%) progressed to a symptomatic stress fracture. Another 21 (32%) participants developed BMO during the season, of which 5 (24%) progressed to a symptomatic stress fracture. Participants with BMO were 20 times more likely to sustain a lumbar stress fracture during the season compared to participants with no detectable BMO during the season. Discussion: Sequential MRI over the course of a cricket season has established that the presence of BMO in asymptomatic cricket fast bowlers represents a high injury risk. BMO may be present for a months prior to injury, and may be carried from a previous season. MRI may be used to screen asymptomatic junior fast bowlers, and allow clinicians to make informed decisions regarding the risk management of fast bowlers. https://doi.org/10.1016/j.jsams.2017.09.276