title: A posterior ring apophyseal fracture and disc herniation in a 21-year-old competitive basketball player: a case report.
abstract: OBJECTIVE
  To describe the diagnosis and management of a competitive male basketball player with discogenic low back pain and presence of an old posterior ring apophyseal fracture (PRAF). This case will highlight the importance of early recognition and considerations regarding patient management for this differential of radiating low back pain.
  
  
  METHODS
  A 21-year-old provincial basketball player presented with recurrent radiating low back pain into the left groin and lower limb. After several weeks of persistent symptoms including pain, muscle weakness, and changes in the Achilles deep tendon reflex, imaging was obtained that revealed a large disc extrusion with an old posterior ring apophyseal fracture. In collaboration with a spine surgeon and family physician, the patient was treated using a conservative, multimodal approach. Treatment consisted of graded mobilizations, spinal manipulative therapy, interferential current, and soft tissue therapy to the lumbar spine. Rehabilitation exercises focused on centralizing symptoms and improving strength, proprioception and function of the lower limb. After a period of 8 weeks, the patient was able to complete all activities of daily living without pain in addition to returning to basketball practice.
  
  
  CONCLUSIONS
  PRAF is a unique condition in the immature spine and recent evidence suggests that those involved in sports requiring repetitive motion of the lumbar spine may be at increased risk. The astute clinician must consider this differential in young populations presenting with discogenic low back pain, as a timely diagnosis and necessary referral may allow for effective conservative management to reduce symptoms. Equally as important, one must be aware of the complications from PRAF as a contributing source of low back pain and dysfunction into adulthood. Knowing when to refer for advanced imaging and/or a surgical consult given the variable clinical presentation and prognosis is an essential component to care.
authors.affiliation: Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario.
authors.forename: Trevor
authors.initials: T
authors.lastname: Deleo
authors.affiliation: Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario.
authors.forename: Samuel
authors.initials: S
authors.lastname: Merotto
authors.affiliation: Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario.
authors.forename: Colyn
authors.initials: C
authors.lastname: Smith
authors.affiliation: Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario; Sports Sciences Resident, Division of Graduate Studies.
authors.forename: Kevin
authors.initials: K
authors.lastname: D'Angelo
keywords: PRAF; case report; chiropractic; posterior limbus bone; posterior ring apophyseal fracture
references.citation: Childs Nerv Syst. 2007 Nov;23(11):1295-9
references.pmid: 17541606
references.citation: Int J Sports Med. 2012 Jul;33(7):586-90
references.pmid: 22510797
references.citation: Childs Nerv Syst. 2014 May;30(5):897-902
references.pmid: 24301611
references.citation: Aust J Physiother. 2003;49(2):89-97
references.pmid: 12775204
references.citation: Skeletal Radiol. 1986;15(3):201-8
references.pmid: 3704673
references.citation: Clin Imaging. 2012 Nov-Dec;36(6):797-802
references.pmid: 23154012
references.citation: Childs Nerv Syst. 1998 Mar;14(3):131-4
references.pmid: 9579870
references.citation: Orthop Surg. 2011 Feb;3(1):72-7
references.pmid: 22009984
references.citation: Spine (Phila Pa 1976). 2008 Jul 15;33(16):1750-4
references.pmid: 18628708
references.citation: Neuroradiology. 1994 Aug;36(6):453-5
references.pmid: 7991090
references.citation: J Neurosurg Spine. 2011 Apr;14 (4):475-83
references.pmid: 21294611
references.citation: Pediatr Neurosurg. 2007;43(2):77-81
references.pmid: 17337916
references.citation: J Bone Joint Surg Am. 1988 Apr;70(4):589-94
references.pmid: 3356726
references.citation: Australas Radiol. 1998 Feb;42(1):34-7
references.pmid: 9509602
references.citation: Eur Spine J. 2013 Mar;22(3):475-88
references.pmid: 23179980
references.citation: Acta Neurochir (Wien). 1991;113(1-2):52-6
references.pmid: 1799144
references.citation: Pediatr Neurosurg. 2013;49(1):16-20
references.pmid: 24192523
references.citation: Acta Neurochir (Wien). 2003 Jun;145(6):461-6; discussion 466
references.pmid: 12836070
references.citation: Curr Opin Pediatr. 2008 Feb;20(1):37-45
references.pmid: 18197037
references.citation: J Orthop Surg (Hong Kong). 2009 Apr;17 (1):85-9
references.pmid: 19398801
references.citation: Spine (Phila Pa 1976). 1992 Dec;17 (12 ):1489-96
references.pmid: 1471007
references.citation: Eur Spine J. 2010 Feb;19(2):205-14
references.pmid: 19890666
references.citation: J Manipulative Physiol Ther. 1998 May;21(4):281-7
references.pmid: 9608383
references.citation: Eur Spine J. 2006 Jun;15(6):923-9
references.pmid: 16614857
references.citation: Clin Biomech (Bristol, Avon). 2007 Dec;22(10):1063-7
references.pmid: 17897759
references.citation: Spine J. 2003 Nov-Dec;3(6):460-5
references.pmid: 14609690
references.citation: J Korean Neurosurg Soc. 2013 Mar;53(3):145-9
references.pmid: 23634263
references.citation: Clin Sports Med. 2012 Jul;31(3):423-40
references.pmid: 22657993
references.citation: J Am Acad Orthop Surg. 2011 Nov;19(11):649-56
references.pmid: 22052641