Background: A 16 year old, female, field hockey player was hit from be-hind during competition. The athlete had mild symptoms that relieved with motion, therefore the athlete continued to play. A few months later during deadlifting the athlete reached full ex-tension, felt a sharp pain in her back and dropped to the floor, unable to move. Athlete and parents did not seek medical care until seven months later because pain progressively worsened. Most pain was reported with prolonged sitting and sleeping. Differential Diagnosis: Vertebral fracture, vertebral stress fracture, bilateral pars fracture, spondylolysis, spondylolisthesis, lumbar herniated disk. Treatment: When seen by a sports medicine physician, a diagnosis of an acute bilateral pars defects was determined by X-rays. The athlete was removed from participation for one month but returned early to compete for a national championship. After failed conservative treatment for three months, the athlete opted for surgery. The pars interarticularis repair, consisted of a bone graft from the iliac crest including two screws and a metal wire which required a five day hospital stay. The following three months, the athlete was not allowed to lay fl at, bend, twist, or lift anything more than five pounds. ADL's required a back brace. At four months, she returned to school and began rehabilitation, which limited bending and twisting with core strengthening. At seven months, the athlete was cleared for running and lifting progressions. Participation was restricted to field hockey practice but not games. At one year the CT showed an unsuccessful surgery. The athlete returned to training anyway, however in a short period she experienced pain and paresthesia in her legs. She was experiencing extreme pain causing losing consciousness and throwing up. At year and a half post-op, the fracture was becoming increasingly worse, with more forward slippage. The new diagnosis of spondylolisthesis was accompanied with instructions to discontinue field hockey and consideration of more surgery. Other treatments like injections and cauterization of the nerves around her fracture site were not successful therefore surgery was selected. At 2 years and 4 months after onset, the athlete underwent an anterior lumbar interbody fusion (ALIF) and a posterior lumbar interbody fusion (PLIF). She was again braced during ADLs and had similar lifting restricts as stated early. Her rehabilitation plan began at 3 months with running at 6 months and weightlifting at 11 months. RTP was not recommended. Uniqueness: An adolescent requiring this degree of back stabilization after multiple surgeries is a rare event. Typically a bilateral pars defects will become less inflamed with rest and core rehabilitation, unfortunately this case is quite the opposite. A year after injury, a minimally invasive procedure known as a pars repair (which in not very common) was necessary to treat the chronic pain. However, due to a failed bone graft, a combination surgery of ALIF and PLIF were performed 2.41 years after onset. This final surgery is rarely performed in young athletes due to possible complications, limit-ed motion, and longevity of success. Conclusions: Back injuries for youth can be devastating and debilitating. Atypical cases can linger for years and require multiple surgeries. Early physician referral is necessary with back pain. A 19 years old athlete is now pain-free with normal ADL's, however, she is restricted in motion and does not play high impact or collision sports. Too of-ten the youth have an invincible mental attitude that playing is more important than their health and well-being. Based on life changing consequences certified athletic trainers should take ample time to explain the risks of continued play while dealing with back pain.
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