Bilateral Lower Extremity

Bilateral Lower Extremity Water-Resistive Neuromuscular Re-education

Fast Bowling Injuries in Cricket

Introduction

Cricket is one of the oldest sports known to mankind. In the 19th and the early 20th century, cricket was meant to be played and enjoyed at a leisurely pace. However, with the advent of one day cricket in the mid 1970s and twenty20 cricket in the early 2000s, its popularity has soared immensely. The frenetic pace at which matches are being organised and played means players are at an increased risk of getting injured.

Epidemiology of back injury

A longitudinal study done in South Africa found that bowling (41%), fielding and wicket keeping (30%) and batting (16%) accounted for most of the injuries in cricket. The primary mechanism by which most of these occurred was found to be the delivery and follow through of the fast bowler (26%), fielding (23%), overuse (17%), ball impacts (17%), training (4%) and participation in other sports accounting for 3%. Whereas, an Australian study reported the injury prevalence as 14% for pace bowlers, 4% for spin bowlers and batsmen and 2% for wicketkeepers. Furthermore, the study goes on to state that pace bowlers who had bowled more than 20 match overs in the week leading up to the current match were more likely to sustain a injury in that match and the risk was even greater if the player was bowling second in the match- that is, having already batted in the first innings.

Lower back injury in fast bowlers

Of greatest concern are those conditions that occur due to overuse or repetitive stress like lumbar stress fractures. Bowling involves concomitant hyperextension of lumbar spine and rotation of the thoracic spine. In addition,, there is an added impact loading at back foot contact. This can cause injuries to the bones, joints, ligaments and muscles in and around the lumbar spine. The main lesions are spondylosis and spondylolisthesis.

Spondylosis

Is a stress fracture occurring at the pars interarticularis (a joint in the vertebral column). It is more likely to occur in a fast bowler having a mixed action rather than a side-on or front-on one.

Spondylolisthesis

Here the vertebral body has bilateral ununited fractures; the upper vertebral body tends to slide forwards on the vertebra situated below causing tensile stresses on the adjoining connective tissue. This condition is associated with severe back pain.

Clinical presentation

The usual presentation is of a dull lower back ache or pain. It is usually unilateral, occurring on the non bowling arm, i.e. a right handed bowler develops spondylosis on the left pars and vice versa. It is gradual in onset and is characteristically described as the ‘crescendo-type’ of pain, i.e. occurring at the end of day’s play initially, then earlier the next time around and so on, until the bowler is unable to bowl in the middle of a spell.

Clinically, spondylosis can be picked by the one-legged hyperextension test, i.e., occurrence of pain when the player bends backwards especially if standing on one leg. Clinical suspicion should be backed up by investigations. Use of plain radiographs, with oblique views, 99 Tc bone scans and CT is warranted. Bone response to spondylosis is in the form of pedicle sclerosis and hypertrophy. Absence of fracture with increased bone density in and around the pars, the pedicle and the posterolateral margin of the vertebral body is usually diagnostic.

Risk Factors

Traditionally, fast bowling lower back injuries have been thought to occur due to hereditary factors, lack of proper technique, poor physical conditioning, lack of pre-season preparation and overuse or increased workload in terms of the amount of deliveries bowled per spell or week or a season without allowing for recovery to occur. Various phases of delivery of a cricket ball by a fast bowler have been defined: pre-delivery stride (gather), mid-bound (delivery jump), back foot impact, stride length, front foot impact, release / delivery and follow through. A number of technical and biomechanical parameters are considered crucial to predict injury potential, namely the speed of and the angle of the run-up, positioning of feet at the bowling as well as the popping crease, shoulder alignment, attitude of the upper torso, non bowling arm position, release height, front knee angle during front foot impact and last but not the least, the follow through.

Also, there are two distinct ways in which pace bowlers deliver a cricket ball, side-on action and the front on action. These are defined in terms of the attitude of the feet, the non bowling arm, the shoulders, upper torso and the follow through. A third kind of action involves some features of either of these actions; characterised by the lower half of the body being front-on while the upper half is side-on. The biggest disadvantage of mixed action is that it involves greater rotation of the shoulders to realign with the rest of the body. This is then responsible for greater amounts of lumbar hyperextension and rotation than the other two actions and thus more injury prone. A recent study of fast bowling biomechanics done in 2008 has revealed a greater risk associated with a mixed action rather than with purely side-on or front on actions.

Treatment

Persistent back pain indicates underlying vertebral injury. In most cases, complete rest from the sport is the treatment of choice. It should ideally take 6 weeks for the bone to heal. During this time a progressive rehabilitation program can be initiated. This involves strengthening of the structures supporting the lumbar spine like the transverses abdominis, multifidus, spinal erectors and abductors of hip. Improving trunk core stability and flexibility of the trunk and lower extremity is also undertaken. Subtle modifications are made to the action to reduce the stresses on the vertebrae. Use of a brace while bowling to support the back is also advocated. Surgical intervention is rarely required.

Segmental wire fixation is probably the treatment of choice if surgery is indicated. Injury prevention Improved biomechanics (beyond the scope of this article)

Individualised fitness programs

· for strengthening the musculature of the mid section and the lower extremities and improving flexibility

Player management at professional level · 1. Pre-season sport specificity training, concentrating on rhythm to start off with and gradual building up of pace. · 2. Record of the bowling work load and rest periods should be maintained so that the fast bowlers in the squad can rested on a rotation policy, picking and choosing the players according to the work load and the importance of the match.

Player management at junior level

· 1. Work load is of more important in young fast bowlers since the vertebral growth cartilage is less resistant to repetitive stresses than the adult cartilage. Thus, young fast bowlers, especially, in their teens, should be discouraged form bowling long spells.

· 2. Mixed actions are best altered at an early age. Attempt to alter the action at a professional level are usually fraught with risks of the bowler losing quite a lot of pace and consequently confidence in his ability.

· 3. Early diagnosis of stress in the lumbar vertebrae thus preventing progression to spondylosis and spondylolisthesis. Regular investigations in this direction should be undertaken at a very early age so that corrective interventions can be implemented.

Application of these recommendations may not necessarily produce genuinely quick bowlers but may help them pursue prolonged 'pain free' careers and realise their full potential.

Shmiran Part 1 - Meningioma, Weakness, Back, Hip, Neck, Shoulder, Leg Pain, Facial Pain, Tremor

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