CASE REPORT
1 SAJSM VOL. 30 NO. 1 2018
Stress fracture of the thoracic spine in a male rugby player: a
case report
A Shafik,1,2 BSc (Hons) Sports and Exercise Sci; K Schwabe,1, 2 MBChB, MPhil (Sport and Exercise Med); R de Villiers,4 MBChB,
MMed (Rad. D); J T Viljoen,1, 2, 3 BSc (Hons) Physio, MPhil (Exercise Sci); W Derman,1, 2 MBChB, BSc (Med) (Hon), PhD, FFIMS.
1 Institute of Sport and Exercise Medicine, Division of Orthopedics, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
2 IOC Research Centre, Cape Town, South Africa
3 Campus Health Service, Stellenbosch University, South Africa
4 Winelands Radiology, Institute of Orthopaedics and Rheumatology, Stellenbosch, South Africa
Corresponding author: J T Viljoen (jtviljoen@sun.ac.za)
Professional rugby union players are at high
risk of spinal injuries due to scrummaging,
tackling and weight training activities.[1]
Spondylolysis or stress fractures of the
vertebral pars interarticularis or other spinal
stress fractures are uncommon injuries in rugby which, to the
best of these authors’ knowledge, have only previously been
described in the lumbar spine and sacrum.[2, 3] Here the case of
a stress fracture in the thoracic spine of a professional rugby
union player is presented.
Case report
History
A 21-year-old male professional tighthead prop presented
with a three-month history of nocturnal right-sided mid-
thoracic dorsal pain, which started progressively increasing in
severity and was further aggravated by playing rugby. The
only injury the player could recall was a sternal contusion
when he landed on a ball three months prior to the initiation
of the back pain. Furthermore, the patient’s medical history
was unremarkable, with no additional symptoms.
Examination
The initial clinical examination demonstrated mild scoliosis
and midline lower thoracic spinal tenderness to palpation.
Provocative manoeuvres recreating right lower thoracic pain
included standing, lateral rib cage compression, forward
flexion (fingertips reached mid-tibial level), bilateral rotation
and lateral flexion. Moreover, resisted flexion of the right hip
caused lower thoracic pain. Additional examinations revealed
nothing further of significance. At this point, a differential
diagnosis of soft tissue injury, bony fracture (rib or vertebra),
arthritis, infective process and malignancy were considered.
Investigations: Blood tests and imaging studies
The patient was initially referred for standard plain
radiographs (X-rays) of the thoracic spine. These showed mild
dorso-lumbar scoliosis without any further abnormalities.
Additionally, a comprehensive laboratory blood workup was
requested consisting out of a full blood count, an assessment
of urea and electrolytes, CRP (C-reactive protein) levels, ESR
(erythrocyte sedimentation rate) as well as serum protein
electrophoresis and serum 25-hydroxy vitamin D
concentration. All blood results proved to be normal with the
exception of slightly elevated phosphate concentration and a
low serum 25-hydroxy vitamin D concentration at 22ng/mL.
Further investigation using magnetic resonance imaging
(MRI) revealed bone oedema of the T6, T7 and T8 pedicles and
superior articular processes with early degenerative disc
disease at the cervico-thoracic junction (Fig. 1A and 1B).
Computed tomography (CT) confirmed chronic bone stress
reactions on the right T7, T8, T9, T10 pedicles and superior
articular processes. Chronic bone stress fractures of the right
T8 and T9 superior articular processes were also found (Fig.
1C). A technetium bone scan plus single-photon emission
computed tomography (SPECT) showed increased uptake in
the medial aspect of the T8, T9 and, to a lesser extent, of the
T10 pedicles on the right. The uptake extended onto the
superior articular processes of the respective vertebrae on the
right. Based on these findings, the diagnosis of bone stress
injury with stress fractures of the right T8 and T9 pedicles was
made.
Treatment
The athlete’s most important aspect of his treatment was
physical rest from all aggravating exercise, with carefully
scheduled reassessment of repeated clinical examinations.
Once asymptomatic, the athlete participated in a gradual
incremental return to individual training and fitness utilising
deep water aqua therapy and swimming in warm water before
rejoining the squad for further comprehensive sport specific
rehabilitation, and eventual return to play. Oral vitamin D
supplementation in the form of Calciferol (50 000 IU weekly)
was administered. His blood concentrations had returned to
normal when remeasured after two months.
This case report discusses a stress fracture of the thoracic spine in a professional South African rugby union player. This is a rare
anatomical location for this type of injury in this population and has not previously been described. Physicians should be aware
that performance of rugby specific movements may lead to rare stress fractures in certain anatomic locations.
Keywords: Overuse injury, sport, bone, back
S Afr J Sports Med 2018; 30:1-2. DOI: 10.17159/2078-516X/2018/v30i1a4592
mailto:jtviljoen@sun.ac.za
http://dx.doi.org/10.17159/2078-516X/2018/v30i1a4592
CASE REPORT
SAJSM VOL. 30 NO. 1 2018 2
Discussion
A rare case of a stress fracture of the thoracic vertebrae in a
professional rugby union player was presented in this case
study. Spondylolysis is thought to occur due to repeated stress
on the vertebra and most commonly occurs in the lumbar
spine in rugby players.[2] To date, the only thoracic spinal
fracture reported in a rugby player was a traumatic fracture
that occurred in a rugby league game.[4] According to these
authors, this is the first case study describing a thoracic stress
fracture in a rugby union game. This injury should be
considered as a differential diagnosis when evaluating rugby
players, especially in front row players, who are more
susceptible to spinal injuries due to the repeated extreme force
experienced during scrum engagement.[5]
The pathogenesis of the case is still unclear. Consultant
opinion from a spinal orthopaedic specialist was discussed
with the athlete and it was suggested that the injury might
have arisen due to weakness of the athlete’s left shoulder
girdle, which resulted in difficulty with binding. The athlete
confirmed that his thoracic trunk did indeed flex to the right
when scrumming which could explain the unusual right-sided
bony stress response. It was suggested that the muscle
strength of both shoulders be evaluated and a series of
ongoing strengthening exercises be considered if deficits were
identified. Further suggestions for management included
playing in the loosehead position and use of his stronger right
arm for firm binding.
Due to the rarity of this condition, it could be missed and
therefore team physicians need to be aware of the possibility
of this type of injury in the case of dorsal pain. This is even
more crucial in young rugby union players where failure to
detect this early on in a diagnosis may result in acute-on-
chronic injuries throughout a player’s career. Finally, it is of
interest to note that a series of lumbar spine stress fractures
caused the French National Professional Rugby League to
include X-ray and MRI of the cervical and lumbar spine as part
of systematic screening in academy centres to detect
congenital or developmental anomalies that may potentially
increase spinal injuries for aspiring professionals.[2]
Conclusion
A thoracic spinal injury, especially bone stress, within sports
medicine is a rare but important pathology to consider as a
differential diagnosis. A clinician assessing and managing
rugby union players should consider this rare injury when
confronted with ongoing thoracic pain, particularly in
scrumming players. MRI and CT form an important modality
for diagnosis when a suspicion of injury for these conditions
is raised.
Study funding and conflict of interest: The authors report no
funding or conflict of interest.
References
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Fig. 1A. Magnetic resonance imaging of thoracic spine (sagittal view), showing bone marrow oedema of the pedicle.
Fig. 1B. Magnetic resonance imaging of T8 vertebrae (axial view) revealing bone marrow oedema in relation to the stress fracture.
Fig. 1C. Computed tomography of thoracic spine (sagittal view) showing significant, unilateral sclerosis of the pedicle and superior articular
process with associated fracture lines.