PFATS Articles

Multi-Level Transverse Process Fractures In A Professional Football Player: A Case Study

Tom Hunkele, MPT, ATC, Eric Sugarman, MS, ATC,
Robert Roche MS, ATC, David Fischer, MD, Gary Fetzer, MD

Evaluating and discerning underlying conditions associated with lower back injuries can be difficult. During physical examination, vertebral transverse process fractures can be easily overlooked. Usually associated with blunt force trauma, transverse process fractures regularly occur in high energy impacts and can be concomitant with internal abdominal injuries. Due to this complication, a thorough evaluation must be conducted in order to rule out any internal injuries.

This case study follows a 6’3”, 215-lb wide receiver in his 10th year in the NFL. He suffered his initial injury during the third quarter of a regular season game when the player jumped to catch a ball and was struck in his low back while being tackled.

The injury

The athlete came off the field complaining of low back pain on his right side. During the sideline evaluation, the athlete demonstrated full mobility of the spine with no radicular symptoms and was able to return to play with no limitations. Late in the game, the player jumped up to catch another pass and was struck in his legs. He fell awkwardly onto his right buttocks and limped off the field. Specifically, he experienced pain in his right lumbar paraspinals as well as pain and numbness radiating into his right buttocks.  Upon further evaluation, the athlete was unable to return to the game.

The transverse processes of the lumbar vertebrae have attachments to three major muscles:

• psoas major
• quadratus lumborum
• erector spinae muscle mass  

Injury, including fracture, to the transverse process can result in spasms and movement dysfunction within these major muscles.  Higher energy trauma can also injure vital structures that lie anterior to the transverse processes.  With a significant amount of blunt force, a transverse process fracture can be coupled with a hematoma or laceration of the spleen, liver, kidney, or ureters.  While these abdominal injuries are not common with a transverse process fracture during athletic competition, it is important to note the dangers and rule-out associated intra-abdominal injuries.¹

The evaluation

As the evaluation progressed, the athlete’s ability to move steadily decreased.  During the post-game examination by the physician, the following symptoms were noted:

• Significant spasm in his right paravertebral muscle mass
• Postural lean to his left secondary to pain
• Restricted AROM in all directions secondary to pain
• Tenderness to palpation and percussion over right upper lumbar paravertebral muscle mass
• No pain to palpation or percussion directly over the midline of the lumbar spine

The following morning, the athlete underwent a CT scan of his lumbar spine revealing fractures of his right
L1, L2, and L3 transverse processes. Also noted in the CT scan were moderate degenerative changes in his right sacroiliac joint.   Concomitant abdominal injuries were ruled out by the CT scan.  Sagittal and coronal reconstructions, as well as three-dimensional reconstructions can be helpful in determining additional injuries.

The treatment and rehabilitation program

The initial treatment focused on returning the athlete to proper posture and reducing pain and other symptoms.  During this phase, the athlete completed all exercises in symptom-free motion. The athlete began with tabletop flexion exercises to re-establish core control and stability and to increase normal lumbar vertebral motion.  Since extension was more painful than flexion, the focus of treatment was to regain lumbar flexion from a neutral spine position.  In the case of concomitant sacroiliac injury, re-establishing normal right hip flexion, internal rotation, and external rotation range of motion became a priority. 
As lumbar flexion and trunk rotation increased and pain symptoms decreased, the athlete began weight bearing exercises at nine days post injury.   He slowly gained full forward flexion through a variety of exercises from seated forward flexion to standing weighted ball pickups. As his trunk movement progressed his main limiting factor became burning pain in his right buttocks due to his right sacroiliac joint injury. The sports medicine staff used manual techniques (muscle energy, trigger point therapy and grade III to grade IV mobilizations) to treat his sacroiliac anterior torsion of left on left.

By 16 days post-injury, the athlete had progressed to higher intensity exercises.  He began footwork activities within his base of support to prevent stride extension, such as with jump rope and toe taps. He began 25% weight-bearing running in the HydroWorx® pool.  As the athlete progressed to running on the field, he began to get referred neural symptoms from his right buttocks to his right posterior thigh.  He was treated with neural glides and exercises to increase his right leg stride length. 

Twenty-four days after the initial injury, the athlete returned to practice on a limited basis. Though his symptoms increased following the initial practices, the pain alleviated by the next morning.  As he continued to receive treatment for his symptoms, he returned to competition using a shoulder back pad extender covering his low back at 28 days post-injury.  At 36 days post-injury the athlete was asymptomatic with no physical limitations.

Conclusion

Once the presence of concomitant abdominal injuries is ruled out, the treatment for transverse process fractures is primarily symptomatic.  As the initial inflammation and muscle spasm are reduced, motion is gained slowly.  Sports medicine professionals should follow the fine line between progressing with exercises and exacerbating the symptoms.  A previous study showed that players with one transverse process fracture missed an average of 16 days, two levels of fractures missed an average of 19 days, and three levels of fracture missed an average of 36 days.²  In most situations, the athlete should have a safe return to competition with the appropriate protective equipment to help with comfort and decrease the risk of re-injury.

References

1. Hollinshead, W. H. and Rosse, C. Textbook of Anatomy, 4th Edition. Harper & Row, 1985.
2. Tewes, M.D., Douglas, P., Fischer, M.D., David A., Quick, Donald C., Zamberletti, F., Powell, J.  Lumbar Transverse Process Fractures in Professional Football Players. American Journal of Sports Medicine, 23(4), 507-509, 1995.