Apophyseal ring fracture is a unique disease in children and adolescents. Its clinical features include low back pain, sciatica, paravertebral muscle spasm and tenderness, restricted back motion, neurological symptoms, and tight hamstrings. For all athletes, body flexibility is one of the most important factors for better performance. Therefore, persistent tight hamstrings has a negative influence on athletic performance. In this report, we present two adolescent athletes with apophyseal ring fracture treated successfully by conservative treatment for severe low back pain (LBP) and leg pain, despite having persistent tight hamstrings for more than one year. Unlike herniated nucleus pulposus, bony fragments in the spinal canal never disappear. Although conservative treatment can alleviate LBP and leg pain, surgical removal of fragments is considered when symptoms such as tight hamstrings and restricted lumbar motion due to canal stenosis are found, particularly in athletes

Dezawa, Akira

Kitagawa, Yasuhiro

Miyagi, Ryo

Sairyo, Koichi

Sakai, Toshinori

Tezuka, Fumitake

Tokushima University Institutional Repository

INTRODUCTIONPosterior apophyseal ring fracture is an avulsionfracture characterized by separation of an osseousfragment at the posterior edge of the vertebral body,where fusion the between ring apophysis and theadjacent vertebral body does not complete fully un-til the age of approximately 18 years (1). Thus, pos-terior apophyseal ring fracture usually occurs inchildren and adolescents with immature spines.Although its etiology is unclear, chronic stress andrepetitive trauma are thought to be causative fac-tors. Clinical features of posterior apophyseal ringfracture are similar to those of lumbar disc hernia-tion (LDH), for which conservative treatment shouldinitially be given. However, unlike patients withLDH, conservative treatment is not always effectivebecause the bony fragments never resolve sponta-neously. Some authors have suggested that the in-dication for surgical treatment depends on the sizeof the bony fragment (2-5). However, resection ofthe fractured endplate can lead to instability of thespinal segment. Therefore, conservative treatmentis favorable.Tight hamstrings are typical symptoms of LDH,especially in children, and are related to traction ofthe cauda equina or nerve roots that innervate thehamstrings. Limitation of forward flexion and poorCASE REPORTPersistent Tight Hamstrings Following ConservativeTreatment for Apophyseal Ring Fracture in AdolescentAthletes : Critical AppraisalRyo Miyagi1, Koichi Sairyo1, 2, Toshinori Sakai1, Fumitake Tezuka1,Yasuhiro Kitagawa2, and Akira Dezawa21Department of Orthopedics, Institute of Health Biosciences, the University of Tokushima GraduateSchool, Tokushima, Japan, 2Department of Orthopedics, Teikyo University Mizonokuchi Hospital,Tokyo, JapanAbstract : Apophyseal ring fracture is a unique disease in children and adolescents. Itsclinical features include low back pain, sciatica, paravertebral muscle spasm and tender-ness, restricted back motion, neurological symptoms, and tight hamstrings. For all ath-letes, body flexibility is one of the most important factors for better performance. There-fore, persistent tight hamstrings has a negative influence on athletic performance. In thisreport, we present two adolescent athletes with apophyseal ring fracture treated success-fully by conservative treatment for severe low back pain (LBP) and leg pain, despite hav-ing persistent tight hamstrings for more than one year. Unlike herniated nucleus pulposus,bony fragments in the spinal canal never disappear. Although conservative treatment canalleviate LBP and leg pain, surgical removal of fragments is considered when symptomssuch as tight hamstrings and restricted lumbar motion due to canal stenosis are found,particularly in athletes. J. Med. Invest. 61 : 446-451, August, 2014Keywords : Immature spine, Apophyseal ring fracture, Tight hamstrings, Conservative treatmentReceived for publication May 26, 2014 ; accepted July 1, 2014.Address correspondence and reprint requests to Koichi Sairyo,MD and PhD, Professor, Department of Orthopedics, Instituteof Health Biosciences, the University of Tokushima GraduateSchool, 3 -18-15 Kuramoto-cho, Tokushima, 770-8503, Japan andFax : +81-88-633-0178.The Journal of Medical Investigation Vol. 61 2014446scores in the restricted straight leg raising test(SLRT) are the main symptoms of tight hamstrings.For all athletes, body flexibility is one of the mostimportant factors for better performance. Therefore,persistent tight hamstrings has a negative influenceon athletic performance.In this paper, we present two adolescent athleteswith persistent tight hamstrings following conserva-tive treatment for posterior apophyseal ring fracturefor critical appraisal.CASE REPORTSCase 1A 12-year-old boy who belongs to a tennis clubof his junior high school noticed low back pain(LBP) and bilateral leg pain after rope jumping. Hewas diagnosed as having lumbar apophyseal ringfracture and referred to our hospital for surgicaltreatment. On physical examination, neurologicalfindings such as muscle weakness or sensory dis-turbance were not observed, but the SLRT was posi-tive at 20 degrees on the right and positive at 10degrees on the left.Plain radiography revealed a small bony fragmentposterior to the upper L4 endplate (Fig. 1). As ver-tebral bodies were immature in the cartilaginousstage, no ossification was identified at the corner ofthe vertebral bodies. Magnetic resonance imaging(MRI) showed central protrusion of the L4/5 disc,but the corresponding bony fragment was not clearlyseen (Fig. 2A, B and C). Computed tomography(CT) revealed an apophyseal ring fracture in thelower L4 endplate (Fig. 3).The patient was successfully managed by conser-vative treatment, and his LBP and leg pain resolvedFigure 1 Lateral plain radiograph showing a bony fragment(arrowed) posterior to the upper L4 endplateFigure 2 Sagittal (A) and axial T1 (B) and T2 (C)-weightedmagnetic resonance image showing degenerative change andprotrusion of the L4/5 disc, but no corresponding bony fragmentwas clearly seenFigure 3 Sagittal reconstructed computed tomography scanshowing the fractured apophyseal ring of the lower endplate of L4The Journal of Medical Investigation Vol. 61 August 2014 447completely. Although he experienced no difficultiesin daily life, a limitation of forward lumbar flexionremained at the four-month follow up. His finger tofloor distance (FFD) was still about 60 cm, and theSLRT was negative (painless), but limited to 40 de-grees on the right and 10 degrees on the left dueto tight hamstrings. He still has difficulty in forwardlumbar flexion as a tennis player.Case 2A 12-year-old girl who was a high-level figureskater experienced severe LBP during practice. Shewas the high-ranking junior figure skater. Despiterefraining from sports activities for two weeks, herLBP increased and right leg pain developed. Physi-cal examination revealed no neurological findings.Range of lumbar motion during flexion was severelyrestricted due to LBP. FFD was limited to 36 cm,and the SLRT was positive at 40 degrees bilaterallydue to leg pain.On plain radiography, no fracture fragment wasclearly seen (Fig. 4), and vertebral bodies were inthe cartilaginous stage. MRI revealed severe centralL5/S1 disc protrusions (Fig. 5A and B), and CTshowed a central curvilinear bony fragment arisingfrom the S1 superior endplate (Fig. 6A and B). Thebony fragment’s relationship to the disc protrusionand S1 corner truncation was particularly well dem-onstrated on reconstructed sagittal images (Fig. 6Aand B).The patient was treated conservatively, and herLBP subsided gradually over six months. At thenine-month follow up, her tight hamstrings had im-proved. The FFD was 0 cm and SLRT was negative,but limited to 70 degrees on the right. However, shewas unable to achieve sufficient flexibility for figureskating so finally retired from the sport.Figure 5 Magnetic resonance image showing severe central L5/S1 disc protrusionsFigure 4 Plain radiograph showing no clear fracture fragmentVertebral bodies are in the cartilaginous stageR. Miyagi, et al. Apophyseal Ring Fracture in Athletes448DISCUSSIONThe vertebral ring apophysis in the immaturespine develops as a cartilaginous rim at the marginsof the superior and inferior lumbar endplates (1).Ossification of these cartilaginous processes startsaround the age of 5 years, and apophyses are fusedto the vertebral bodies by the age of approximately18 years (1). The vertebral body is firmly attachedto the annulus fibrosis by Sharpey fibers (6). Untilthis fusion is complete, this osteocartilaginous junc-tion is relatively weak against biomechanical stress(7, 8).Apophyseal ring fractures occur frequently at theposterior endplate of L5 and the sacrum (3). Chronicstress and repetitive trauma may cause apophysealring fracture, and it can develop insidiously. Acutetrauma is also thought to be an important etiologicfactor mediating the onset of symptoms (9, 10). In abiomechanical study, Sairyo et al. used three-dimen-sional finite element pediatric lumbar models toinvestigate the effect of ring ossification in the lum-bar spine (11). They found that increased stress un-der repetitive extension might damage and weakenthe posterior ring apophysis during the early stageof bone formation, resulting in avulsion of the weak-ened posterior corner in response to traction stressduring flexion (11). In the present cases, there wereno acute significant traumatic episodes ; repetitivehyperextension and hyperflexion of the lumbarspine during athletic activities might have causedthis fatigue phenomenon.The most common symptoms and physical find-ings of apophyseal ring fracture include low backpain, sciatica, paravertebral muscle spasms and ten-derness, tight hamstrings, restricted back motion,and neurological dysfunction caused by a com-pressed nerve root (12). Typical features of this dis-ease are a limitation of forward flexion, restrictedSLR, and tight hamstrings due compression of thedura mater. The hamstrings are innervated by theL4-S3 spinal nerves, and their motor fibers are verysensitive to traction (7). It has been thought thattight hamstrings are related to traction of the caudaequina or the nerve roots that supply the hamstrings(13). Anatomically, nerve roots in the immaturespines are too short in relation to the spinal canal,which may render the nerve roots sensitive to trac-tion, even with minor encroachments compared withadults (14).Conservative treatment should be prescribed in-itially (15-17). The principle of conservative treat-ment is similar to that for an avulsion fracture ofthe extremities and consists of bed rest, analgesicand nonsteroidal anti-inflammatory drugs, physicaltherapy, and limited physical activity with lumbarbraces. Jack-knife stretching, which can promoteflexibility of tight hamstrings, was not prescribed ineither case because of the severe pain during for-ward flexion (18). Surgical treatment is performedin cases of failed conservative treatment, with per-sistent back pain adversely affecting the patient’sability with or without neurological deficits (19, 20).Most adolescents and adults who are treatedFigure 6 Sagittal (A) and axial (B) reconstructed CT scans showing the fractured apophyseal ring of the superior endplate of S1The Journal of Medical Investigation Vol. 61 August 2014 449surgically for apophyseal ring fractures show goodto excellent results, and their symptoms are satisfac-torily relieved (2-5). In some studies, the clinicalresults of simultaneous excision of apophyseal frag-ments with discectomy are satisfactory (3, 4, 21),while the results of other studies have suggestedthat only discectomy and decompression have beensufficient (15, 22). Chang et al. reported patientswith small apophyseal fragments that had no clinicalsignificance, but the large apophyseal fragments hadmore chance of producing chronic back pain andlimitations in daily activities (21).Compared with disc herniation, osseous materialmay trigger more severe symptoms because thebony fragment never disappears and may lead tobony spinal stenosis (21). The bony fragments inthe present cases were large and therefore occu-pied a large space in the spinal canal. Although LBPand leg pain were resolved, tight hamstrings, whichwere thought to be due to canal stenosis, persisted.On the basis of this clinical experience, surgicalremoval of fragments should be considered whensymptoms such as tight hamstrings or restrictedlumbar motion due to canal stenosis are found. Highflexibility is required by almost all sports. We thinkthat restricted lumbar flexion caused by tight ham-strings is fatal on playing sports. For athletes in par-ticular, surgical removal should be considered.In this case series we can report only two cases.We should collect same cases and state the treat-ment algorithm for apophyseal ring fracture. In anycase, we should consider the treatment based onvarious factors such as age, neurological findings,size of bone fragment or the kind of sport.CONFLICT OF INTERESTNo funds were received in support of this study.REFERENCES1. Bick EM, Copel JW : The ring apophysis of thehuman vertebra. J Bone Joint Surg Am 33 :783-7, 19512. Albeck MJ, Madsen FF, Wagner A, Gjerris F :Fracture of the lumbar vertebral ring apophy-sis imitating disc herniation. Acta Neurochir(Wien) 113 : 52-56, 19913. Epstein NE : Lumbar surgery for 56 limbusfractures emphasizing noncalcified type IIIlesions. Spine (Phila Pa 1976) 17 : 1489-1496,19924. Farrokhi MR, Masoudi MS : Slipped vertebralepiphysis (report of 2 cases). J Res Med Sci14 : 63-66, 20095. 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Persistent Tight Hamstrings Following Conservative Treatment for Apophyseal Ring Fracture in Adolescent Athletes : Critical Appraisal

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Persistent Tight Hamstrings Following Conservative Treatment for Apophyseal Ring Fracture in Adolescent Athletes : Critical Appraisal

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