Farhart - Intrinsic Variables Associated With Low Back Pain and Lumbar Spine Injury in Fast Bowlers in Cricket A Systematic Review, BMCSSMR 2023

Farhart et al.
BMC Sports Science,

BMC Sports Science, Medicine and Rehabilitation (2023) 15:114
https://doi.org/10.1186/s13102-023-00732-1 Medicine and Rehabilitation
RESEARCH Open Access
Intrinsic variables associated with low back

pain and lumbar spine injury in fast bowlers
in cricket: a systematic review
Patrick Farhart1,2,3,4* , David Beakley5 , Ashish Diwan2,6 , Rob Duffield1 , Elizabeth Pickering Rodriguez1 ,
Uphar Chamoli2,7 and Mark Watsford1
Abstract
Background Lumbar spine injuries in fast bowlers account for the greatest missed playing time in cricket. A range
of extrinsic and intrinsic variables are hypothesised to be associated with low back pain and lumbar spine injury
in fast bowlers, and an improved understanding of intrinsic variables is necessary as these may alter load tolerance
and injury risk associated with fast bowling. This review critically evaluated studies reporting intrinsic variables associ-
ated with low back pain and lumbar spine injury in fast bowlers and identified areas for future investigation.
Methods OVID Medline, EMBASE, SPORTDiscus, CINAHL, Web of Science and SCOPUS databases were last searched
on 3 June 2022 to identify studies investigating intrinsic variables associated with low back pain and lumbar spine
injury in cricket fast bowlers. Terms relevant to cricket fast bowling, and intrinsic variables associated with lumbar
spine injury and low back pain in fast bowlers were searched. 1,503 abstracts were screened, and 118 full-text articles
were appraised to determine whether they met inclusion criteria. Two authors independently screened search results
and assessed risk of bias using a modified version of the Quality in Prognostic Studies tool.
Results Twenty-five studies met the inclusion criteria. Overall, no included studies demonstrated a low risk of bias,
two studies were identified as moderate risk, and twenty-three studies were identified as high risk. Conflicting results
were reported amongst studies investigating associations of fast bowling kinematics and kinetics, trunk and lumbar
anatomical features, anthropometric traits, age, and neuromuscular characteristics with low back pain and lumbar
spine injury.
Conclusion Inconsistencies in results may be related to differences in study design, injury definitions, participant
characteristics, measurement parameters, and statistical analyses. Low back pain and lumbar spine injury occurrence
in fast bowlers remain high, and this may be due to an absence of low bias studies that have informed recommen-
dations for their prevention. Future research should employ clearly defined injury outcomes, analyse continuous
datasets, utilise models that better represent lumbar kinematics and kinetics during fast bowling, and better quantify
previous injury, lumbar anatomical features and lumbar maturation.
Trial registration Open Science Framework https://doi.org/10.17605/OSF.IO/ERKZ2.
*Correspondence:
Patrick Farhart
patrick.j.farhart@student.uts.edu.au
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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Farhart et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:114 Page 2 of 39
Key points
• No included studies were judged to have an overall low risk of bias.
• Inconsistencies in results of studies investigating associations between intrinsic variables and low back pain and lum-
bar spine injury may be due to differences in study design, injury definitions, participant characteristics, measurement
parameters, and statistical analyses.
• Clearly defined injury outcomes, use of continuous datasets, models that better represent lumbar kinematics
and kinetics during fast bowling, and improving the quantification of lumbar maturation, previous injury, and lumbar
anatomical features represent areas for future research.
Keywords Low back pain, Lumbar spine injury, Fast bowling, Intrinsic variables, Neuromuscular, Kinematics, Kinetics,
Technique, Radiology
Background associated with injury [15]. Identifying intrinsic vari-

Although cricket is a non-contact sport, injury preva- ables is important because they can affect the load tol-
lence rates for fast bowlers have been reported to be as erance of tissues [23], and an improved understanding
high as 20.6% [1] and exceed those reported in football of their significance may contribute to the formation
(20%) [2] and rugby (12.0%) [3]. Injury rates of this mag- of a “cumulative risk profile” [24] for an individual fast
nitude may stem from the fast bowling action, which bowler. This would represent a holistic assessment of
comprises a run-up and straight-arm hurling movement the cumulative influence of intrinsic variables on injury
[4], resulting in extreme lumbar motions [5] and tor- risk with thoughtful consideration of their interaction
ques [6] in the presence of high ground reaction forces with one another and with extrinsic variables [24], as
(GRF) [7]. These events are postulated to place the lum- this may determine a fast bowler’s capacity to with-
bar region of fast bowlers at a heightened risk of injury; stand specific training and competition bowling loads,
reflected in high incidences of low back pain (LBP) [8, 9] and influence planning and management of the same.
and lumbar spine injury [1], often manifesting as lumbar No prior systematic review has specifically reported
intervertebral disc and pars interarticularis abnormalities on intrinsic risk factors associated with LBP and lum-
[10]. Stress fractures of the lumbar spine represent 15% bar spine injury in fast bowlers. A narrative review con-
of all missed playing time in cricket [1], and up to 67% ducted by Johnson et al. [11] reported that excessive
of fast bowlers will sustain this injury during their career shoulder counter rotation (SCR) in adolescents, and
[11]. Furthermore, stress fractures of the lumbar spine excessive contralateral lumbar side-flexion in adults
present potentially serious consequences for fast bowl- were features of the fast bowling technique that were
ers [11] as they generally cause many months of absence associated with an increased risk of developing a lum-
from cricket [12–14], and if not appropriately managed bar stress fracture (LSF). A systematic review examin-
can result in chronic lesions characterised by non-union ing the association of intrinsic risk factors and successful
and recurrence [12, 13]. interventions for LBP in all cricketers (batters, bowlers
Multiple risk factors or variables are proposed to and wicketkeepers) by Morton et al. [25] identified acute
interact with one another to contribute to injury sus- bone stress on MRI scans as a risk factor for LBP and LSF
ceptibility in athletes [15], and a range of extrinsic in bowlers. Subsequent systematic reviews examined the
and intrinsic variables are hypothesised to be associ- association of extrinsic and intrinsic risk factors with all
ated with LBP and lumbar spine injury in fast bowlers non-contact (lower limb, lumbar, trunk and upper limb)
[16]. Extrinsic variables include bowling workloads [4], injuries in adult [16] and adolescent [26] fast bowlers.
match formats [1], and footwear [17]; whereas intrin- Olivier et al. [16] reported that bowling biomechanics,
sic variables may incorporate muscular strength and bowling workload, neuromuscular factors, and previous
endurance [18], ranges of motion [18], previous injury injury were risk factors for injury, whereas Forrest et al.
[19], biomechanics of the fast bowling technique [5], [26] concluded that injury was associated with bowling
age [20], and muscle activation [21], morphology [10] biomechanics (excessive lateral trunk flexion and pelvis/
and morphometry [22]. Since intrinsic and extrin- hip kinematics), reduced trunk endurance, poor lumbo-
sic variables do not act in isolation, intrinsic variables pelvic-hip movement control, and early signs of lumbar
may determine the level of risk predisposed [15] to bone stress on MRI.
a fast bowler, as elevated risk may cause subsequent The above mentioned systematic reviews [16, 25,
exposure to fast bowling to become an inciting event 26] presented risk of bias assessments as summary
numerical scores using the Downs and Black tool [25], should be targeted at established causal associations
the Joanna Briggs Institute Meta Analysis of Statis- [33].
tics Assessment and Review Instrument [16], and the Given the burden and potential long-term conse-
Newcastle–Ottawa Quality Assessment Scale [26]. The quences of LBP and LSF in fast bowlers, it is important
Cochrane Risk of Bias Tool recommends when assess- to better investigate strategies to reduce their incidence
ing the risk of bias in studies, it is advisable to select [11], and the identified gap in the literature provides an
a tool that does not present assessments as summary opportunity to conduct a more robust appraisal of intrin-
numerical scores [27], as these have been demonstrated sic variables associated with these entities in fast bowl-
to be poor indicators of study quality [28]. The use of ers. The purpose of this review was to critically evaluate
a tool that facilitates a structured assessment, is not studies reporting intrinsic variables that have been asso-
based on a scoring system, and is easily adapted for ciated with LBP and lumbar spine injury in fast bowlers.
specific needs, is advisable when assessing a study’s risk A further aim was to identify areas for future investiga-
of bias [28]. Furthermore, previous systematic reviews tion to assist in the development of effective strategies
[16, 25, 26] have not provided detailed information for the prevention of LBP and lumbar spine injury in fast
regarding risk of bias evaluations for individual studies, bowlers.
and it has been recommended that researchers should
provide supporting statements to justify how risk of Methods
bias judgements were reached to minimise subjectivity This systematic review was specified a priori through
and maximise consistency of interpretation [29]. protocol registration with the Open Science Framework
The relationship between lumbar spine pathology, (https://doi.org/10.17605/OSF.IO/ERKZ2, 30 July 2020),
missed playing time and LBP in fast bowlers is not and was developed and reported in accordance with the
straightforward [30], and this is illustrated by asymp- PRISMA-P guidelines for Systematic Reviews [34].
tomatic fast bowlers presenting with MRI detected
pathology [31] as well as high incidences of adoles- Data sources and search strategy
cent fast bowlers presenting with LBP not causing an For the purposes of data extraction, aspects of a modi-
absence from bowling [9]. Notwithstanding this, lum- fied PICOC (Population, Intervention, Comparison,
bar bone stress injuries (LBSI) have been long recog- Outcome, and Context) framework were applied. Stud-
nised as a common cause of LBP in fast bowlers [8], and ies evaluating intrinsic variables as risk factors (Interven-
young fast bowlers presenting with LBP contralateral tion) in the development of pain and injuries (Outcome)
to their bowling arm side represent a high yield pop- to the lumbar spine (Context) in cricket fast bowlers
ulation for which an MRI scan provides value for the (Population) were systematically identified, and the
diagnosis of LBSI [12]. To better understand biases and search algorithm was derived from this PICOC frame-
evidence in the previous literature, it is necessary to work. Studies published in English or with an available
examine intrinsic variables that have been associated English translation from inception to 27 July 2020 were
in studies reporting both LBP and lumbar spine injury, considered for inclusion into this systematic review.
regardless of the presence or absence of symptoms, OVID Medline, EMBASE, SPORTDiscus, CINAHL,
radiological findings and missed playing time. Web of Science and SCOPUS databases were searched,
Despite extensive research and resources dedicated and the following Boolean search strings were used:
to identifying intrinsic and extrinsic variables as inde- (“Cricket” OR “Fast Bowling” OR “Fast Bowler”) AND
pendent markers for risk of developing LBP and lum- (“Risk Factor*” OR “Risk” OR “Factor*” OR “Variable” OR
bar spine injury in fast bowlers, there has been limited “Intrinsic” OR “Age” OR “Adolescent” OR “Young” OR
success in predicting and preventing these issues [1]. “Adult” OR “Technique” OR “Biomechanic*” OR “Kin-
Whether this lack of predictive insight is related to yet ematic*” OR “Kinetic*” OR “Strength” OR “Flexibility”
to be identified independent variables, heterogeneity OR “Range of motion” OR “Muscle” OR “Asymmetry”
of participant populations [16] or diversity of research OR “Cross Sectional Area” OR “Volume”) AND (“Pain”
methodologies [30] requires further exploration. For OR “Injury” OR “Fracture” OR “Stress” OR “Stress Frac-
example, a recent systematic review reported minimal ture” OR “Stress Reaction” OR “Reaction” OR “Pars inter-
strength in reported associations between lower back articularis” OR “Pars” OR “Pedicle” OR “Spondylolysis”
injury and fast bowling workload metrics due to biases OR “Spondylolisthesis” OR “Bone” OR “Oedema” OR
within injury and workload measurements in the exist- “Edema”) AND ( “Low Back” OR “Back” OR “Lumbar”
ent literature [32]. Furthermore, the use of causal infer- OR “Lumbar Spine”). A detailed search strategy for each
ence to classify markers of risk as causal or non-causal database is included in Additional file 1 and this search
may be required, since interventions to prevent injury was repeated on 21 September 2021 and 3 June 2022
to identify new literature. The reference lists of previ- blindly screened study titles and abstracts to determine
ous systematic reviews were examined to ensure that all their eligibility for inclusion in full text screening. Narra-
potentially relative articles were located, and additional tive reviews, systematic reviews, meta-analyses, opinion
studies were extracted via manual searches of bibliogra- pieces, non-peer-reviewed articles, conference proceed-
phies, relevant journals, and websites. ings, and articles with full-text unavailable were excluded.
The full text of eligible studies was then blindly evaluated
Eligibility criteria in an independent manner by the same authors to deter-
The following criteria were employed to determine the mine inclusion into the main body of the review. Any
eligibility of literature for inclusion in this review: disagreements regarding article inclusion were resolved
independently by a third author (MW).
Types of studies
A range of peer-reviewed journal articles that investi- Data extraction
gated intrinsic variables associated with the incidence Data from included studies was extracted by two review-
of LBP and lumbar spine injury during fast bowling in ers (PF and DB) using a modified template based on
cricket were eligible for inclusion. This incorporated both the Checklist for critical Appraisal and data extraction
observational (prospective cohort, retrospective cohort, for systematic Reviews of prediction Modelling Stud-
case control, cross-sectional, case series) and interven- ies (CHARMS) [36]. Extracted data included authors,
tional (randomised controlled trial, non-randomised design, study inference, location, duration, dates, par-
controlled trial, quasi-experimental) study designs. ticipant information (number, playing level, age, gender,
presence of control group), investigated variables, injury
Types of participants outcome, and reported results. Disagreements were
Studies included male and female fast bowlers of all age resolved through discussion, and if consensus could not
groups and playing levels as participants. A fast bowler be reached, the third reviewer (MW) was consulted.
was defined as a bowler with a fast run-up, with ball
release (BR) speed generally above 100 kph and a wick- Risk of bias assessment
etkeeper generally standing back from the stumps due to The methods of risk of bias assessment for included stud-
increased BR speed [4]. ies were changed from the review protocol registered on
the Open Science Framework. Risk of bias was assessed
Types of outcome measures using a version of the Quality in Prognostic Studies
Outcome measures included any lumbar spine condition (QUIPS) tool [37] modified for this review. QUIPS con-
that resulted in the loss of at least one day of sporting siders the following six domains to assess potential risk
activity, a match time loss injury [1], abnormal radiologi- of bias: study participation, study attrition, prognos-
cal features of the lumbar spine, LBSI or LSF, LBP expe- tic factor measurement, outcome measurement, study
rienced at time of testing or during a study period, a confounding, and statistical analysis and reporting [37].
history of LBP, a history of lumbar spine injury, a history Each bias domain contained prompting and considera-
of LBSI or a history of LSF. tion items assessed with the terms ‘yes’, ‘partial’, ‘no’ or
‘not reported’; and methodological comments support-
Types of intrinsic variables ing each item’s assessment were recorded. Additional
Intrinsic variables associated with LBP and lumbar spine file 2 details defined criteria for the rating of studies.
injury during fast bowling in cricket that included, but Since responses to individual items may balance or over-
were not limited to participants’ age, previous injury or ride others, item responses were considered together to
pain, biomechanics of the fast bowling technique, mus- assess the risk of bias of each domain, and each domain
cle strength and endurance, ranges of motion, posture, was rated as having a high, moderate, or low risk of bias.
anthropometric measures, proprioception, bone marrow In line with the Cochrane Risk of Bias Tool for inter-
oedema (BMO) detected on Magnetic Resonance Imag- vention studies [27] and the QUADAS-2 Tool for diag-
ing (MRI), bone mineral density (BMD), bone mineral nostic studies [38], computing summated scores for
content (BMC), spinal and trunk muscle thickness, cross overall study quality using QUIPS is not recommended
sectional area (CSA) and volume. [27], and this approach was used for this review. Over-
all study risk of bias was determined as follows: 1) If all
Study selection domains were low risk, or if one domain was no higher
All studies identified through search strategies were than moderate risk, then a study was classified as low
uploaded into Covidence software [35] and follow- risk, 2) If one or more domains were high risk, or if ≥ 3
ing this, two authors (PF and DB) independently and domains were moderate risk, then a study was classified
as high risk, 3) All studies in between were classified as retained for full text evaluation, 93 were excluded, leav-
moderate risk [39]. Two reviewers (PF and DB) assessed ing 25 studies [41–65] for inclusion into this review.
risk of bias independently, but were not blinded to
authors, title, or journal, and a Quadratic Weighted Risk of bias of studies
Kappa score [40] was calculated to determine the level The results of risk of bias assessments for each of the six
of agreement of individual risk of bias domain judge- QUIPS domains are presented in Table 1, and Additional
ments between the two reviewers. Disagreements were file 3 contains detailed information regarding these
resolved through discussion, and if consensus could not evaluations. The study screening reviewers (PF and DB)
be reached, the third reviewer (MW) was consulted. agreed on 124 of 150 items prior to consensus, result-
ing in a Quadratic Weighted Kappa [54] of 0.84 (95% CI
Results 0.75–0.92). Agreement on domains ranged from 76%
Study selection (prognostic factor measurement) to 88% (study par-
As depicted in Fig. 1, database searching generated 2109 ticipation and study confounding). No included studies
studies, and a further 15 were identified following man- were categorised as having an overall low risk of bias,
ual searching. 1503 studies remained after duplicates two were moderate risk [51, 63], and twenty-three were
were removed, and 1385 were deemed irrelevant during high risk [41–50, 52–62, 64, 65]. Figure 2 depicts a sum-
the title/abstract screening process. Of the 118 studies mary of judgements for each domain’s risk of bias as
Fig. 1 PRISMA flow diagram of search and included studies

Table 1 Results of quality assessment of studies using the QUIPS tool

Study Study Study Prognostic Outcome Study Statistical Overall risk of
participation attrition factor measurement confounding analysis and bias
measurement reporting
Foster et al. 1989 [42] High Moderate High High Moderate High High
Elliott et al. 1992 [54] Moderate Low High High Moderate High High
Hardcastle et al. 1992 [55] Moderate Low High High High High High
Elliott et al. 1993 [56] Moderate Low High Moderate Moderate Moderate High
Burnett et al. 1996 [43] Moderate High High High High Moderate High
Elliott & Khangure 2002 [65] Moderate High High Moderate High Moderate High
Portus et al. 2004 [60] Moderate Moderate High Moderate High Moderate High
Engstrom et al. 2007 [44] Moderate Low High Moderate Low Low High
Stuelcken et al. 2008 [57] High Low Low Moderate Low Moderate High
Ranson et al. 2010 [45] High Moderate Low Low High Moderate High
Stuelcken et al. 2010 [58] High Low Moderate Moderate High Low High
Kountouris et al. 2012 [46] Moderate Moderate High Low Low Moderate High
Kountouris et al. 2013 [47] High Moderate High Low Low Moderate High
Olivier et al. 2014 [48] Moderate Moderate Moderate Moderate Moderate Moderate High
Gray et al. 2016 [62] Moderate Low Low Low High Moderate High
Bayne et al. 2016 [49] Moderate High Low High Low High High
Olivier et al. 2017 [50] Moderate Moderate Moderate Low High Low High
Alway et al. 2019 [51] Moderate Low Low Low Moderate Low Moderate
Alway et al. 2019 [63] Moderate Low Moderate Moderate Moderate Low Moderate
Kountouris et al. 2019 [52] Moderate Low Moderate Low Moderate Low High
Senington et al. 2020 [61] High Moderate Moderate Moderate High Low High
Alway et al. 2021 [53] Moderate Moderate High High High Low High
Taylor et al. 2021 [64] High Low High Low Moderate High High
Sims et al. 2021 [59] Moderate Low High Low Low Low High
Keylock et al. 2022 [41] Moderate High Low High Low Low High
percentages. Potential sources of bias (moderate risk %, Africa [48, 50, 62]. Dates of data collection ranging
high risk %) were classified as study participation (72%, from 1986 [42] through to 2020 [59] were reported in
28%), study attrition (36%, 16%), prognostic factor meas- twelve studies [42, 43, 45, 46, 51, 52, 54, 56, 59–61, 65].
urement (24%, 52%), outcome measurement (36%, 28%), A causal association between investigated variables and
study confounding (32%, 40%), and statistical analysis LBP and lumbar spine injury was implied in twenty-one
and reporting (40%, 20%). studies [41–43, 45, 48–56, 58–65].
Study characteristics Participants

General Mean chronological age was reported in all studies
Extracted data from included studies [41–65] is pre- [41–65], ranging from 13.2 [65] to 24.9 years [51], and
sented in Table 2. Studies consisted of thirteen prospec- four studies included age-matched control groups [44,
tive cohort [41–53], five cross-sectional [54–56, 62, 51, 55, 64]. Only two studies did not contain exclusively
63], three retrospective cohort [57–59], two combined male participants, with one including females only [58]
retrospective/prospective cohort [60, 61], retrospective and another females and males [57]. Studies recruited
case series [64], and interventional [65] designs. Pro- elite level adults [45, 47, 51, 53, 57, 58, 60, 61, 63, 64],
spective research was conducted over one cricket sea- elite level adolescents [46, 54, 55, 59, 61, 62, 65], club
son [42, 46–50, 52, 61] or multiple years [41, 44, 45, 51, and/or school level adolescents [42, 43, 46, 56], adoles-
53, 60, 65]. Sixteen studies were conducted in Australia cents at varying skill levels [41, 44, 49], and club level
[42–44, 46, 47, 49, 52, 54–60, 64, 65], six in the United adults [48, 50]. At commencement of seventeen studies
Kingdom [41, 45, 51, 53, 61, 63] and three in South [41–50, 52–54, 56, 61, 64, 65], bowlers were deemed fit
Fig. 2 QUIPS risk of bias domain judgements presented as percentages across included studies
to bowl and had no knowledge of abnormal radiological findings as an injury outcome [48, 50, 57, 58, 61, 62];
features, but may have experienced LBP in two of these derived from questionnaires investigating previous LBP
[43, 56]. Six studies [55, 57, 58, 60, 62, 63] included occurrence [48, 50, 61, 62], self-reported LBP in the
bowlers with and without injury outcomes at com- previous 12 months [57, 58], recording of LBP during a
mencement, and two studies [51, 59] exhibited incom- study [48, 50, 61], or self-reported LBP verified by medi-
plete disclosure of injury status at commencement. cal records [57, 58].
Studies describing injury in the absence of symptoms
Injury outcomes [43, 53–56, 65] reported LBSI determined from MRI
Eleven studies [42, 44–47, 51, 52, 59, 60, 63, 64] reports [53], disc degeneration determined by MRI fea-
reported injury if a combination of lumbar symptoms, tures [43, 54–56, 65], and Computed Tomography (CT)
abnormal radiology and missed playing time were pre- diagnosed bone abnormalities categorised as spondyloly-
sent. LBSI was defined across studies [46, 47, 52, 59, sis, spondylolisthesis, or pedicle sclerosis [54, 55]. Two
64] as an MRI confirmed stress reaction (BMO with no studies [41, 49] categorised injury in bowlers with and
cortical breach) or stress fracture (BMO with cortical without symptoms; with one defining injury as LBP affect-
breach) [52]. LSF [42, 45, 51, 60, 63] and pars interar- ing a bowler’s ability to perform in a match and expanded
ticularis lesions [44] were reported as partial or com- this to include asymptomatic bowlers with MRI detected
plete fractures [45], or with no description of cortical lumbar bone stress [49]. Subsequent research categorised
breach presence [42, 44, 51, 60, 63]. Soft tissue inju- injury as symptomatic LBSI causing missed playing time as
ries [42, 46, 47, 60] were reported without elucidation well as MRI reported LBSI in asymptomatic bowlers [41].
[42], or defined as disc, muscle, or ligament injury [46],
injuries other than bone stress [47], or categorised as Intrinsic variables measured
back sprain (disc, facet joint or ligament) injuries [60]. A summary of intrinsic variables reported in included
Six studies described LBP in the absence of radiology studies is contained in Table 3 and definitions for these
Table 2 Data extraction for included studies (n = 25)
Author Study Design. Inference of Participants – Number. Playing Intrinsic variables measured Lumbar injury outcome Results
study level. Age. Gender. Location.
Presence of control group.
Study dates. Study duration
if prospective. Reporting of
injury history. Calculation of
sample size
Foster et al. [42] Prospective cohort. Causality n = 82. Potentially high perfor- Body mass, skinfold levels, CT diagnosed LSF and soft tissue Stress fracture group bowlers
implied mance from club and school anthropometric measurements, injuries that resulted in a partici- had lower longitudinal foot arch
teams. Mean age 16.8 years, age hamstring and quadriceps pant missing at least one cricket height, greater non-dominant
range 15 to 22 years. Male. Aus- torque, shoulder strength, trunk match. quadriceps torque, higher BR
tralia. No control group included. strength, abdominal muscle height than non-injured bowlers
1986–87 cricket season. One endurance, posture, shoulder (p < 0.05) and displayed increased
cricket season duration. No and hamstring muscle flexibility, SCR (> 40°) between BFC
reporting of injury history. No aerobic capacity. Bowling kin- and FFC (non-injured bowlers
calculation of sample size ematics (shoulder and hip align- rotated 15.7°). No association
ment at BFC, SCR, BR height). between peak vertical or hori-
Farhart et al. BMC Sports Science, Medicine and Rehabilitation
Bowling kinetics (GRF) zontal GRF during FFC and back

injury. Bowlers who sustained
a back injury had greater bowl-
ing arm shoulder depression
and horizontal flexion strength
and displayed a shoulder align-
(2023) 15:114
ment > 240° at BFC (p < 0.05).

Higher BR position in stress frac-
ture bowlers as a result of more
extended front hip and knee joint
angles and a more upright trunk
during FFC phase
Page 8 of 39
Table 2 (continued)
sample size
Elliott et al. [54] Cross sectional. Causality implied n = 20. Western Australian fast Skinfold levels, hamstring/ Disc degeneration determined Bowlers with radiological
bowling development squad. lower back flexibility, abdominal by MRI. CT scan diagnosed abnormalities had a more front
Mean age 17.9 ± 1.6 years. Male. muscular endurance, posture, bone abnormalities categorised on alignment (no injury 179°, disc
Australia. No control group trunk extension/flexion strength. as spondylolysis, spondylolisthe- abnormality 206°, LSF 197°) at BFC.
included. 1989–90 cricket Bowling kinematics (shoulder sis, or pedicle sclerosis (p < 0.05) and higher degrees
season. No reporting of injury and hip alignment at BFC, SCR, of SCR during the delivery stride
history. No calculation of sample BR height). Bowling kinetics (no injury 0°, disc abnormality 25°,
size (GRF) LSF 12°). Bowlers who adopted
a side on technique had the least
likelihood of abnormal radiologi-
cal features, in contrast to those

who employed a mixed technique
who had the highest rate of radio-
logical abnormalities. LSF bowlers
had significantly higher BR height
relative to standing height (114%
(2023) 15:114
vs 110% in non-injured bowl-

ers) and increased minimum
shoulder alignment (LSF 193°,
disc 181°, no injury 179°). Age
of fast bowlers in injury free group
(median 16.4 years) significantly
younger than LSF group (median
18.4 years). Sit and reach scores
significantly lower in intervertebral
disk abnormality group (4.5 cm)
than the injury free group (8.0 cm)
Hardcastle et al. [55] Cross sectional. Causality implied n = 24. Special training Kinematics of fast bowling action Disc degeneration determined 75% of fast bowlers with a mixed
in a Western Australian squad. relating to difference in rotation by MRI. CT scan and radiograph technique experienced LBP. 100%
Mean age 17.9 years, age range of the shoulders and the line diagnosed bone abnormalities of fast bowlers who rotated >
16 to 18 years. Male. Australia. of the back foot at the time categorised as spondylolysis, 10° demonstrated a radiological
Control group 13 batsmen of BFC. Classification of the fast- spondylolisthesis, or pedicle abnormality and 80% of these
from the same age group. Study bowling action whether it sclerosis experienced LBP
dates not described. No report- was side on, mixed or front
ing of injury history. No calcula- on based on shoulder and hip
tion of sample size alignment
Page 9 of 39
Table 2 (continued)
sample size
Elliott et al. [56] Cross sectional. Causality implied n = 24. School/club level Body height, body mass, skinfold Lumbar intervertebral disc Fast bowlers who counter rotated
and showed most potential levels, hamstring/lower back abnormalities (degeneration their shoulders by 30° or more
as determined by match flexibility, abdominal muscular and bulging) identified by MRI were more likely to sustain a disc
statistics. Mean age 13.7 years. endurance. Bowling kinematics scan abnormality then bowlers who
Male. Australia. No reporting (shoulder and hip alignment counter rotated their shoulders
of injury history. No control at BFC, SCR and BR height). Bowl- by 18.9° with p = 0.088. Signifi-
group included. 1991–92 cricket ing kinetics (GRF) cance level set at 0.1. All abnormal
season. No calculation of sample scans recorded from bowlers who
size used a mixed bowling technique
and no bowlers who used side-on,
or front-on technique recorded

scans with abnormal discs
in the lumbosacral region
Burnett et al. [43] Prospective cohort. Causality n = 19. School/club level Kinematics of fast bowling Presence of disc degeneration Significant increase in occur-
implied and showed and showed action relating to classification as measured by MRI rence of disc degeneration (21%
potential as genuine fast as either side on, mixed or front and 58%, p = 0.008) and LBP (5%
(2023) 15:114
bowlers. Mean age at session on based on shoulder and hip and 53%, p = 0.002) between ses-
1; 13.6 ± 0.6 years, at ses- alignment at BFC. Degree of SCR sions 1 and 2. The progress of disc
sion 2; 16.3 ± 0.6 years. Male. degeneration was found to be
Australia. No control group related to those bowlers who
included. Session 1; commence- used a mixed bowling action
ment of the 1991–92 cricket and was seen in 80% of bowl-
season. Session 2; conclusion ers who used a mixed action
of the 1993–94 cricket season. during both sessions as opposed
Study duration 3 years. No to 14% using this technique
reporting of injury history. No during one of these sessions
calculation of sample size only (p = 0.015).
Page 10 of 39
Table 2 (continued)
sample size
Elliott & Khangure [65] Intervention. Causality implied n = 41. Western Australian Cricket Maximum knee flexion angle. Abnormal radiological appear- Bowlers who used a front-on
Association fast bowling devel- Shoulder alignment at BFC, FFC, ance of the intervertebral disk, or side-on action recorded signifi-
opment squad. Group 1 mean and at the position of maximum such as disk degeneration cantly lower levels of lumbar disk
age 13.4. Group 2 mean age 13.2. SCR. Classification of fast bowling or bulging assessed by MRI. degeneration when compared
Male. Australia. No control group action whether it was side on, Intervertebral disk degeneration with mixed action bowlers (chi-
included. Group 1; 1997 to 2000. mixed or front on square value 9.5126; p = 0.002).
Group 2; 1998 to 2000. Study In year 1, bowlers who used
duration 3 years. No reporting a front-on or side-on action
of injury history. No calculation recorded significantly lower
of sample size levels of lumbar disk degen-
eration (12.5%) when compared

with mixed action (27%) bowlers.
The incidence and progres-
sion of lumbar disk degenera-
tion were significantly reduced
in parallel with decreased SCR
(2023) 15:114
from 35.4° at the commence-

ment of the study to 21.3° in year
4. Progression of the number
and/or severity of degeneration
only occurred with bowlers who
used the mixed action
Page 11 of 39
Table 2 (continued)
sample size
Portus et al. [60] Combined retrospective cohort n = 42. National/international Fast bowling technique-related Radiologically diagnosed injuries SCR significantly higher in LSF
and prospective cohort. Causal- level. Mean age 22.4 ± 3.5 years. factors; hip-shoulder separation in the presence of pain classi- group (41°) than the no trunk
ity implied Male. Australia. No control group angle at BFC, SCR, hip coun- fied as either stress fractures injury group (19°) (F = 4.5, p = 0.01).
included. Outcomes gathered ter rotation. Classification of the lumbar spine pars interar- Hip counter rotation was high-
from 1992 to 2000. No calcula- into side-on, semi-open, front-on ticularis or back sprain injuries, est in the LSF group and low-
tion of sample size and mixed techniques, as well including injury to disc, facet est in the no injury group. The
as styles of front lower limb joint or ligament LSF group had the most front-on
actions during FFC phase shoulder orientation at BFC. At
BFC, soft tissue injury group exhib-
ited a larger hip-shoulder separa-
tion angle than the no injury

group (p = 0.03). The LSF group
was characterised by a more
upright hip joint angle at FFC
and at BR, whereas a more flexed
knee characterised the non-trunk
(2023) 15:114
injured group, but this was statisti-

cally non-significant
Engstrom et al. [44] Prospective cohort. Causality n = 56 at commencement and 51 QL CSA and muscle volume Symptomatic pars interarticu- Significant association
not implied at conclusion. Club to national through the lumbar spine laris lesions of the lumbar spine between increasing QL asymme-
level fast bowlers within respec- and subsequent percent QL diagnosed by MRI. try and the development of symp-
tive age groups. Age range asymmetry score for individual tomatic L4 pars lesions in ado-
13 to 17 years. Male. Australia. bowlers relative to the bowling lescent fast bowlers with greater
Control group of 20 swimmers. arm side and swimmers relative QL volumes on the bowling arm
Study dates not described. Study to the dominant arm side side. Increasing QL asymmetry
duration for fast bowlers 4 years. was associated with increased risk.
No reporting of injury history. No 105% QL asymmetry = 4% risk,
calculation of sample size 125% QL asymmetry = 58% risk,
and 130% QL asymmetry = 78%
risk. The area under the non-
parametric ROC curve was 0.89
(p ≤ 0.001), indicating excellent
discrimination between fast bowl-
ers with and without symptomatic
L4 pars lesions, according to per-
cent QL asymmetry
Page 12 of 39
Table 2 (continued)
sample size
Stuelcken et al. [57] Retrospective cohort. Causality n = 34; 26 females and 8 males. Range of motion of lumbar flex- History of LBP if self-reported Female fast bowlers with a his-
not implied Females—elite level, Males— ion, extension, and lateral flexion pain had occurred (1) in the pre- tory of LBP (16.9 ± 3.1°) exhibited
Australian Capital Territory in standing. Range of motion vious 12 months, or (2) at any a restriction in lumbar lateral flex-
representative squad Mean of hip flexion and hip extension. stage in the bowler’s career ion range of motion to the bowl-
age of females 22.5 ± 4.5 years. Trunk extensor endurance and could be verified by records ing arm side compared to those
Mean age of males 21.5 ± 3 years. kept by team medical support female bowlers with no history
Australia. Control group not spe- staff. Episodes of self-reported of LBP (20.6 ± 7.5°) (p = 0.05)
cifically mentioned but results LBP that did not meet these
in females compared to males. criteria were disregarded to mini-
Study dates not described. mise recall bias
Reporting of injury history

in addition to assessment of LBP
and study commencement. No
calculation of sample size
Ranson et al. [45] Prospective cohort. Causality n = 28. ECB Elite Fast Bowling Appearance of lumbar interver- If bowler missed 7 or more Principal finding was that acute
implied Group, England U19 or senior tebral discs and BMO in the pos- consecutive days of cricket stress changes such as oedema
(2023) 15:114
men’s team. Mean age 19 years, terior bony elements on lumbar because of LBP. Lumbar stress and periostitis in the posterior
age range 16 to 24 years. Male. MRI scans fracture was recorded if his- bony elements are related
United Kingdom. No control tory was corroborated by MRI to the subsequent development
group included. 2005—2008. and/or subsequent CT which of a stress fracture. Significant
Study duration 2 years. No confirmed acute bone stress association between appear-
reporting of injury history. No changes associated with partial ance of acute bone stress on MRI
calculation of sample size or complete fracture of the pos- and subsequent LSF. Of the 15
terior elements of the lumbar players who had MRI scans which
spine included presence of acute
bone stress on an MRI scan, 11
developed LSF within a mean
of 10 weeks from scan time
(p < 0.001). Of these 15, 9
had no fracture line at scan
and they developed LSF at mean
of 11 weeks, but 6 did have a frac-
ture line on initial scan and they
all went on to develop a LSF
within the next 4 weeks. No asso-
ciation found between interver-
tebral disc degeneration and MRI
changes of bone stress (p = 0.544)
or subsequent LSF (p = 0.124)
Page 13 of 39
Table 2 (continued)
sample size
Stuelcken et al. [58] Retrospective cohort. Causality n = 26. Elite; national/inter- Pelvis-shoulder separation LBP history if self-reported pain The mean maximum lateral
implied national level. Mean age at BFC. SCR during the delivery had occurred in the previous flexion range of the thorax relative
22.5 ± 4.5 years. Female. Australia. stride. Angle of thorax relative 12 months, or at any stage to the pelvis during the delivery
No control group included. to pelvis during the delivery in the bowler’s career and could stride was significantly greater
Study dates not described. stride. Classification of bowling be verified by records kept for the LBP subgroup compared
Reporting of injury history. No technique as side-on, front-on, by team medical support staff with the no LBP subgroup
calculation of sample size or mixed (p = 0.004), with a large effect size
(g = 1.25). The thorax of the LBP
subgroup was more laterally
flexed away from the bowl-
ing arm relative to the pelvis

between 73–79% of the delivery
stride with upper and lower
confidence limits surrounding
the difference between the group
means being < 0
(2023) 15:114
Kountouris et al. [46] Prospective cohort. Causality n = 38. Club level adolescents. QL CSA bilaterally at the L3–L4 Bowlers who reported LBP Significantly higher BMI in bowlers
not implied Mean age 14.9 ± 1.34 years, age vertebral levels. BMI and subsequently assessed that sustained a LBSI. All 4 asymp-
range 12 to 17 years. Male. Aus- and diagnosed by a sports physi- tomatic participants with radio-
tralia. No control group included. cian with either LBSI (lumbar logical evidence of lumbar bone
2002–03 Australian cricket stress fracture or stress reaction stress at baseline developed
season. Study duration of one of the posterior vertebral ele- symptomatic LBSI. No association
cricket season. No reporting ment) or soft tissue injury (disc, between average QL asymmetry
of injury history. No calculation muscle, or ligament injury) for players who sustained lumbar
of sample size spine injury (soft tissue (12.5%)
and bone stress (15.7%) and play-
ers who were uninjured (12.4%)
(p = .537). When participants were
grouped as either LBSI (mean
QL asymmetry 15.7%) or no LBSI
(mean QL asymmetry 12.4%),
there was no difference in QL CSA
(p = .267).
Page 14 of 39
Table 2 (continued)
sample size
Kountouris et al. [47] Prospective cohort. Causality n = 23. Identified by respective QL CSA bilaterally LBSI; lumbar stress fracture Fast bowlers with no injury had
not implied selection panels as potential between the L2 and L4 vertebral or stress reaction of the poste- significantly larger asymmetries
national and international play- levels. BMI rior vertebral element), which when compared with those
ers. Mean age 24 ± 3.6; years, age was confirmed radiologically in the soft tissue and bone stress
range 19 to 32 years. Male. Aus- (scintigraphy, MR, or CT), Soft groups (p = 0.050). When partici-
tralia. No control group included. tissue lumbar spine injury (any pants were grouped as either hav-
Study dates not described. Study other injury other than bone ing no injury or any (soft tissue
duration of one cricket season. stress) and bone stress) lumbar injury,
No reporting of injury history. No there was a significant differ-
calculation of sample size ence between groups (p = 0.025).
When LBSI group was compared

to the two other groups com-
bined, there was no significant
difference in mean asymmetry
(p = 0.949). Four participants (17%)
had radiological evidence of lum-
(2023) 15:114
bar bone stress at baseline, and all

went on to develop symptomatic
LSF
Olivier et al. [48] Prospective cohort. Causality n = 17. Recruitment derived Lumbar proprioception (lumbar A musculoskeletal condition Of 9 position sense variables
implied from questionnaires and tel- reposition error) in the neutral to the lower back that resulted tested, lumbar reposition error
ephone calls, but response rate lumbar spine position as well in loss of at least 1 day of sport- on 8 associated with previous low
not reported. Amateur premier as lumbar positions corresponding activity or that occurred back injury; F/E neutral (p < 0.01),
league club level. Age range ing to those at FFC and BR during a sporting activity average neutral (p < 0.01), F/E FFC
18 to 26 years, but mean age of the fast-bowling action that required medical attention, (p < 0.02), left/right FFC (p < 0.03),
not reported. Male. South Africa. and which forced the bowler average FFC (P < 0.01), F/E BR
No control group included. to quit the activity. (p < 0.01), left/right BR (p < 0.03),
Study dates not described. Study average BR (P < 0.01). Lumbar
duration of one cricket season. reposition error on 2 variables
Injury history reported. No calcu- associated with low back injury
lation of sample size sustained during the period
of the study: F/E neutral (p < 0.04),
average neutral (p < 0.03)
Page 15 of 39
Table 2 (continued)
sample size
Gray et al. [62] Cross sectional. Causality implied n = 25. Representative cricket Thickness of the TrA, IO and EO Experiencing LBP for minimum Total combined thickness of TrA,
at a provincial level. Age range muscles assessed on the domi- of 6 weeks associated with fast IO and EO on non-dominant
14 to 18 years. Male. South Africa. nant and non-dominant side bowling, or bowlers who side > dominant side in fast bowl-
No control group included. and resultant asymmetry were currently playing cricket ers without LBP (post hoc p = 0.01)
Study dates not described. No between these measurements but experienced LBP that caused but did not differ between sides
reporting of injury history prior bowler to miss a match or prac- for bowlers with LBP (post hoc
to study commencement. No tice session in the previous p = 1.0). Greater total thick-
calculation of sample size 6 weeks ness in bowlers without pain
(3.0 ± 0.4 cm) than with pain
(2.4 ± 0.4 cm) on non-dominant
side (post hoc—p = 0.03), but simi-

lar for both groups on dominant
side (no pain: 2.5 ± 0.4 cm; pain:
2.5 ± 0.4 cm) (post hoc—p = 1.0).
Thickness of each abdominal
muscle > on non-dominant
(2023) 15:114
side in no pain group (post

hoc—p < 0.001) but did not dif-
fer between sides in bowlers
with pain (post hoc—p = 0.01).
Thickness of OI < in pain group
than no pain group (post hoc—all
p = 0.02)
Page 16 of 39
Table 2 (continued)
sample size
Bayne et al. [49] Prospective cohort. Causality n = 46 who volunteered Ranges of motion of ankle LBP that affected bowler’s ability Injured bowlers had: lower front
implied and underwent initial MRI assess- dorsiflexion, hip internal to perform in a match, consistent hip angle at FFC (46 ± 6° vs 51 ± 6°,
ment. 25 included in final analy- and external rotation. Foot arch with the consensus of cricket t = 2.076, p = 0.049), greater thorax
sis. District and/or state junior ratio. Trunk extensor endur- injury. Definition of injury lateral flexion at FFC (20 ± 6°
level. Mean age 15.8 years, age ance, hold times for prone plank was later expanded to include vs 15 ± 5°, t = 2.187, p = 0.039)
range 14 to 19 years. Male. Aus- and side plank. Tests for lum- asymptomatic participants and at BR (50 ± 6° vs 40 ± 8°,
tralia. No control group included. bopelvic stability, calf endurance, with radiological evidence t = 3.396, p = 0.002), increased pel-
Study dates not described. Study bridge capacity and lower limb of lumbar bone stress vis rotation beyond front-on at BR
duration of a 6-month cricket movement control. Kinematics (287 ± 11° vs 277 ± 11°, t = 2.408,
season. No reporting of injury of the trunk, pelvis, and lower p = 0.024), increased normalised
history. No calculation of sample limbs during the fast-bowling peak flexion (10.5 ± 4.9 Nm/kg/m
size action. Kinetics of the lower vs 6.9 ± 2.5 Nm/kg/m,t = 2.292,
limbs and lumbar spine dur- p = 0.036), and lateral flexion
ing the fast-bowling action lumbar moments (12.5 ± 2.6
Nm/kg/m vs 10.6 ± 1.9 Nm/
kg/m,t = 2.079, p = 0.049) and peak
(2023) 15:114
lateral flexion power (25.8 ± 16.2

W/kg/m vs 14.4 ± 7.7 W/kg/m,
t = 2.203,p = 0.043), reduced
Biering-Sorensen test hold time
(103 ± 33 s vs 132 ± 33 s, t = 2.220,
p = 0.037), increased knee valgus
angle during single leg decline
squat on dominant (9 ± 3° vs 5 ± 4°,
t = 2.299, p = 0.031) and non-dom-
inant leg (9 ± 4° vs 6 ± 3°, t = 2.362,
p = 0.027). A score of 0 on lumbo–
pelvic stability test associated
with increased risk of low back
injury (RR = 1.7, CI 0.78–4.10)
Page 17 of 39
Table 2 (continued)
sample size
Olivier et al. [50] Prospective cohort. Causality n = 26. From 14 different cricket CSA of lumbar MF at the L3, L4, A musculoskeletal condi- In bowlers who sustained a lower
implied clubs in Premier league. Mean and L5 vertebral levels tion of the lower back back injury, the nondominant
age 21.8 ± 1.8 years, age range 18 that resulted in loss of at least CSA of MF at L3 (p = 0.04)
to 26 years. Male. South Africa. one day of sporting activity and L5 (p = .0.04) were smaller
No control group included. or that occurred during a sport- than the dominant side MF,
Study dates not described. Study ing activity that required medical however, the percentage dif-
duration of an 8-month cricket attention, and which forced ference of the low back injured
season. Injury history reported. the bowler to quit the activity groups was similar to the non-
No calculation of sample size injured group. No statistically
significant differences were found
in bowlers with/without asym-

metry and bowlers who did/did
not sustain lower back injuries (L3
p = 0.28; L4 p = 0.60; L5 p = 1.00)
Alway et al. [51] Prospective cohort. Causality n = 368. English County first Match bowling workload LSF with diagnosis based 74% of LSF occurred in bowlers
implied or second X1 fast bowlers. Mean across all formats of cricket. Age on symptomatic presentation aged under 25 years, and 56%
(2023) 15:114
age 24.87 ± 6.01 years. Male. at time of LSF of fast bowlers and radiological evidence (MRI, occurred between the ages
United Kingdom. No control within this cohort CT, or SPECT), which resulted 18 and 22. Risk of LSF great-
group included. 2010 to 2016 in a player being unavailable est in bowlers aged 18 to 22,
England cricket seasons. Study for match selection, with match incidence at 0.32
duration of 6 years. No reporting per 10 000 deliveries, annual inci-
of injury history prior to study dence of 4.90 per 100 fast bowlers,
commencement. No calculation and prevalence of 3.21% of squad
of sample size days. This compared to match
incidence of 0.13 per 10 000 deliv-
eries, annual incidence of 2.46
per 100, and prevalence of 1.37%
of squad days in the entire cohort
of fast bowlers
Page 18 of 39
Table 2 (continued)
sample size
Alway et al. [63] Cross sectional. Causality implied n = 23. Selected from existing DEXA measured BMC and BMD LSF history determined Fast bowlers who never suffered
national senior or develop- of the lumbar spine as a whole from England and Wales Cricket LSF had 3.6% greater BMD
mental squads. Mean age (assessed from L1 to L4) Board medical records with any in the dominant side of lumbar
24.58 ± 3.93 years. Male. United and the posterior elements of L3 diagnosis confirmed by MRI, CT, vertebrae and 1.7% greater
Kingdom. Controls consisted or SPECT CT scans BMD in the non-dominant side
of 14 other cricketers (11 batters, of lumbar vertebrae compared
2 wicketkeepers, 1 spin bowler), with those who did suffer LSF,
22 rugby players and 20 inactive but this was not statistically
control participants. Study dates significant (p = 0.08). No significant
not described. Injury history interaction found between side,
reported. No calculation of sam- vertebra and LSF history on BMC

ple size (p = 0.34). No significant interac-
tion between side, vertebra,
and disc injury history on BMD
(p = 0.61) or BMC (p = 0.77)
Kountouris et al. [52] Prospective cohort. Causality n = 65. Australian junior elite BMO being present Development of LBP that caused BMO detected on one or more
(2023) 15:114
implied fast bowlers who were selected or absent through the left a participant to be unable scans during season associ-
in an under 17 or under 19 and right posterior vertebral arch to bowl for a period in the study ated with 39% of these bowlers
state or territory squad. Mean at each vertebral level from L1 period. Diagnosis of LBSI made suffering a symptomatic LBSI,
age 17.3 years, age range 14.7 to L5 on sagittal and coronal T2 with use of clinical judgement 37% having persistent BMO
to 18.8 years. Male. Australia. fat suppressed or short-tau inver- and imaging modalities but no symptoms, and 24% expe-
No control group included. July sion recovery MRI sequences riencing a reversal of detected
2014 to March 2015. Study dura- BMO. All bowlers with a symp-
tion of 8 months. No reporting tomatic LBSI had BMO detected
of injury history. No calculation at corresponding site of the verte-
of sample size bra in the scan immediately prior
to diagnosis. The number of days
between the first appearance
of BMO on MRI and the player
reporting LBSI related symp-
toms was a mean of 96 days
and a median of 112 days. Par-
ticipants who had BMO detected
at any scan at increased risk of BSI
(RR = 22.3 (95% CI 1.4—356.6),
OR = 36.3 (95% CI 2.1—639.5),
with positive predictive value 39%,
and negative predictive value
100%
Page 19 of 39
Table 2 (continued)
sample size
Senington et al. [61] Combined retrospective cohort n = 35; 14 seniors and 21 Spinal orientation at BFC Retrospective: history of LBP. No statistically significant results
and prospective cohort. Causal- juniors. Participants recruited and FFC, spinal range of motion, Prospective; any LBP expe- found, but large effect sizes
ity implied through coaches from profes- SCR and hip separation angle. rienced during season. LBP observed. In juniors without LBP
sional county cricket clubs. Mean Sacral accelerations. Peak defined as any pain affecting history; more thoracic rotation
age senior group 24.1 ± 4.3 years, tibia and sacral accelerations the area of the back inferior away from direction of delivery
junior group 16.9 ± 0.7 years. along three orthogonal axes to the lower ribs, superior (d = 1.3), and a larger range
Male. United Kingdom. No with resultant acceleration. Nor- to the inferior gluteal folds of thoracic rotation between BFC
control group included. 2015 malised accelerations (to body and medial to the midaxillary line and FFC (d = 0.9). In seniors
England cricket season. Dura- weight), time-to-peak accelera- that impacted on ability to bowl with LBP history; less peak
tion of prospective portion tion, loading rate and time taken for a minimum of 3 days acceleration around tibial z axis
of study one cricket season. to reach peak acceleration at BFC (d = − 1.5), faster time-to-
Injury history reported. Sample peak resultant tibial acceleration
size was derived from data at FFC (d = − 1.5), and greater
from [48] with an alpha of 0.05, thoracolumbar extension at BFC
beta 0.8, effect size of 2 and allo- (d = 1.0) In seniors who did
cation ratio of 0.75 not develop LBP; higher time-to-
(2023) 15:114
peak resultant tibial acceleration

at BFC (d = 1.55), higher tibial
loading variables at FFC (d = 0.9),
less lumbar extension (d = 1.9)
at BFC, more lumbar lateral flexion
away from direction of delivery
at BFC (d = 1.0), less lumbar exten-
sion at FFC (d = 0.9) and less lum-
bar rotation at FFC (d = 1.3). In sen-
iors who did develop LBP; greater
time-to-peak vertical and resultant
acceleration at the sacrum (d > 1.6)
Page 20 of 39
Table 2 (continued)
sample size
Alway et al. [53] Prospective cohort. Causality n = 50. Elite cricket fast bowlers Kinematic parameters of the fast- LBSI defined as either stress At instance of BFC, LBSI bowl-
implied enrolled on an international bowling action; SCR, pelvis- reactions or stress fracture ers had a more flexed rear hip
performance pathway. Mean shoulder separation, front leg determined from radiological (d > 0.8, p < 0.05) and knee (d > 0.5,
age 18.9 ± 1.9 years. Male. plant angle, front and rear leg reports the England and Wales p < 0.05), less contralateral thora-
United Kingdom. No control hip and knee angles, lumbopel- Cricket Board injury database. columbar side flexion (d > 0.5,
group included. Study dates vic angles, thoracolumbar side Stress reactions: evidence p < 0.05) and more contralateral
not described. Study duration flexion and rotation. Kinetic of bone marrow edema (without thoracolumbar rotation (d > 0.8,
two years. No reporting of injury parameters of the fast-bowling fracture line). Acute stress frac- p < 0.05). At FFC, LBSI bowlers had
history. No calculation of sample action; peak forces, average load- tures: evidence of incomplete, a more flexed front hip (d > 0.8,
size ing rates and impulse in the ver- complete, or multilevel stress p < 0.05), more anterior pelvic
tical and horizontal (braking) fracture accompanied by BMO tilt (d > 0.8, p < 0.05), and more
directions that suggested the fracture site extended lumbopelvic angles
was active. (d > 0.5, p < 0.05). At BR, LBSI
bowlers displayed less contralat-
eral thoracolumbar side flexion
(d > 0.8, p < 0.05). LBSI bowlers
(2023) 15:114
had less extension of their front

hip and more ipsilateral pelvic
drop in transitions between BFC
and BR. The best logistic model
to predict LBSI included both rear
hip angle at BFC and lumbopelvic
angle at FFC, correctly classify-
ing 88% of bowlers into injured
or non-injured groups. For each
1° increment in rear hip angle
at BFC, the odds of having
a LBSI was a factor of 0.88 lower,
while a 1° increment in lum-
bopelvic angle at FFC increased
the odds of a LBSI by 1.25
Page 21 of 39
Table 2 (continued)
sample size
Taylor et al. [64] Retrospective case series. Causal- n = 38. Elite. Mean age screened Clinically relevant BMO detected Symptomatic LBSI that caused Bowlers with BMO intensity of 2.0
ity implied group 21.2 ± 3.7 (18.5–24.5) at the left and right posterior missed time from bowling (time or higher on screening MRI were
years, self-control group 19.7 vertebral arch at each vertebral loss injury) with MRI identified 1.8 times the risk of sustaining
(18.5- 24.5) years, matched- level (L1-L5) BMO with or without a fracture LBSI in the following 12 months
control group 21.0 (18.4—24.2) compared to bowlers who did
years. Male. Australia. Collected not have abnormal BMO detected
data compared to self-control on screening MRI; RR 1.8 (95% CI
group (data for same bowler 0.6–5.5; p = 0.321)
from closest eligible season)
and matched-control group
(data for a fast bowler closest

in age to screened bowler). No
reporting of injury history. Study
dates not described. No calcula-
tion of sample size
Sims et al. [59] Retrospective cohort. Causality n = 222. Youth fast bowlers Height, weight, ranges of motion MRI identified LBSI catego- 49 of the 222 bowlers sustained
(2023) 15:114
implied in elite pathway programs. Mean for ankle dorsiflexion, hip internal rised as a stress reaction (bone a LBSI. Univariate analysis: 1)
age 17.4 ± 1.1 years, age range and external rotation, trunk oedema with no cortical injured bowlers were younger
15.1–19.7 years. Male. Australia. lateral flexion. Lumbo-pelvic breach) or stress fracture (bone (p = 0.005), taller (p = 0.007),
No control group recruited, stability, Lumbar extension oedema with cortical breach) performed less efficiently on Star
but non-injured bowlers acted endurance hold time, single leg with a bowler subsequently clas- Excursion Balance Test (front foot
as controls in multivariate analy- balance range, hip abduction sified by medical staff as unavail- p = 0.006, back foot p = 0.005),
sis. July 2015 to March 2020. No and extension strength, aerobic able to train or play and on average bowled more
reporting of injury history. No fitness. Age at start of season. days per one week (p = 0.009),
calculation of sample size Number of balls bowled per day 4 weeks (p = 0.042) and 12 weeks
in training and matches. Ranges (p = 0.008); 2) no difference
of SCR and lateral flexion dur- between injured and non-injured
ing the fast-bowling action. groups in bowling technique
Bowling speed. variables. Multivariate analysis:
risk of LBSI was 2.99 times higher
for every year younger in bowlers
aged between 15 and 20 years.
Bowlers were 1.1 times more likely
to be injured for every centimetre
taller and 1.1 times more likely
for every km/hr faster the ball
was bowled. The multivariate
model was able to explain 36%
of the variance
Page 22 of 39
Table 2 (continued)
sample size
Keylock et al. [41] Prospective cohort. Causality N = 40. Recruited from profes- Height (cm). Weight (kg). Fat-free Bowlers who developed symp- Chronological age significantly
implied sional academies or schools mass (kg). Chronological age toms during study with radiolog- differed at the 0.05 alpha
and clubs with well-developed (years). Skeletal age (years). ically confirmed LBSI and asymp- level between prospectively
cricket programs. 15.5 ± 1.1 years. Skeletal maturity rating. DEXA tomatic bowlers who possessed injured and uninjured bowlers
Male. United Kingdom. No measured L3 CL BMD (g/cm2), LBSI at the end of the study. (P = 0.006), with a large effect size
control group included. Study L4 CL BMD (g/cm2), L3 vertebral LBSI defined as either stress (g = 1.396). Injured bowlers were
dates not described. Study area (cm2), L4 vertebral area reactions (evidence of BMO 1.3 years older at the beginning
duration was 2.26 ± 0.03 years (cm2). CL ankle dorsiflexion without fracture line), or LSF of the season preceding injury
after baseline. No reporting (cm). CL ankle dorsiflexion (°). (acute or chronic stress fracture than uninjured bowlers on aver-
of injury history. No calculation Sit and reach length (cm). Hip identified by evidence of incom- age although there was little
of sample size internal rotation (°). Hip external plete or complete stress fracture difference in average skel-
(2023) 15:114
rotation (°). Bent knee fall out (°). with BMO) etal age or maturation (g = 0.274
Straight leg raise (°). Total balls and 0.611, respectively, P ≥ 0.278).
bowled (n. balls). Bowling days 33% of the injured bowlers had
per week (n. days). Peak acute delayed maturation, compared
workload (n. balls). Peak medium to 13% of the uninjured bowl-
workload (n. balls) ers. Non-significant (P ≥ 0.090)
large effect sizes of increased
L3 and L4 contralateral BMD
(g ≥ 0.812) in LBSI bowlers. Hip
internal rotation of the contralat-
eral leg was non significantly
7.2 degrees less in injured fast
bowlers compared with uninjured
bowlers (32.3 versus 39.5 degrees
(g = 0.987)
BFC Back foot contact, SCR Shoulder counter rotation, BR Ball release, GRF Ground reaction forces, CT Computed Tomography, LSF Lumbar Stress Fracture, FFC Front foot contact, MRI Magnetic Resonance Imaging, QL
Quadratus Lumborum, CSA Cross sectional area, ROC Receiver operating characteristic, LBP Low Back Pain, BMI Body mass index, F/E Flexion/extension, TrA Transversus abdominis, IO Internal Oblique, EO External Oblique,
RR Risk ratio, OR Odds Ratio, MF Multifidus, SPECT Single Photon Emission Computerised Tomography, DEXA Dual Energy X-ray Absorptiometry, BMC Bone mineral content, BMD Bone mineral density, BMO Bone marrow
oedema, CL Contralateral, CI Confidence Interval
Page 23 of 39
Table 3 Summary of intrinsic variables reported in included studies

Categories of variables Intrinsic variables measured Studies
Biomechanics of fast bowling technique Shoulder and hip alignment, SCR [42, 43, 49, 53–56, 58–61, 65]
Lower limb kinematics [42, 43, 49, 53, 54, 56, 60, 65]
Trunk and lumbar rotation [49, 53, 58, 61]
Trunk and lumbar flexion/extension [49, 53, 58, 61]
Trunk and lumbar lateral flexion [49, 53, 58, 59, 61]
Ground reaction forces [49, 52–54, 56, 60]
Tibial and sacral loading [61]
Lumbo-pelvic kinetics [49]
Ball release height [42, 54, 56]
Ball release speed [53, 54, 56, 59]
Approach velocity [42, 49, 53, 54, 56]
Delivery stride length [54, 56]
Delivery stride alignment [54]
Trunk and lumbar anatomical characteristics Quadratus Lumborum asymmetry [44, 46, 47]
Multifidus CSA [50]
Abdominal muscle thickness [62]
Lumbar vertebrae BMO presence [45, 52, 64]
Lumbar disc degeneration [45]
Lumbar spine BMC/BMD [41, 63]
Age Chronological age [41, 51, 54, 59]
Skeletal age [41]
Injury history Previous LBP or lumbar injury [48, 50, 61]
Muscle strength, endurance, and function Trunk flexion/extension strength [42, 54]
Hip abduction/extension strength [59]
Hamstring/quadriceps strength [42]
Calf/single leg bridge capacity [49]
Shoulder depression/horizontal flexion strength [42]
Abdominal sit ups [42, 54, 56]
Trunk plank capacity [49]
Trunk extensor endurance [49, 57, 59]
Range of motion Sit-and-reach [41, 42, 54]
Shoulder flexibility [42]
Lumbar flexion/extension [57]
Lumbar lateral flexion [57, 59]
Straight leg raise [41, 57]
Hip extension [57]
Hip external/internal rotation [41, 49, 59]
Bent knee fall-out [41]
Ankle dorsiflexion [41, 49, 59]
Physical characteristics Skinfold levels [42, 54, 56]
Foot arch features [42, 49, 54]
Body mass [42, 54, 56, 59]
Fat free mass [41]
Body mass index [46, 47]
Segment anthropometrics [42]
Posture [42, 54]
Height [41, 59]
Aerobic capacity [42, 59]
Neuromuscular control Lumbar Reposition Error [48]
Single leg decline squat [49]
Lumbopelvic stability [49, 59]
Star Excursion Balance [59]
SCR Shoulder Counter Rotation, CSA Cross sectional area, BMO Bone marrow oedema, BMC Bone mineral content, BMD Bone mineral density, LBP Low Back Pain
variables are contained in Additional file 4. Twelve [57], extension [57], and lateral flexion in standing
studies investigated bowling technique biomechanical [57, 59], passive straight leg raise [41, 57], modified
variables [42, 43, 49, 53–56, 58–61, 65] utilising two- Thomas test for hip extension [57], hip external and
dimensional (2-D) motion analysis [42, 43, 54–56, 65], internal rotation [41, 49, 59], bent knee fall-out for
three-dimensional (3-D) motion analysis [49, 53, 58, hip flexibility [41], and ankle dorsiflexion with lunge
60], both 2-D and 3-D motion analysis [59], and inertial testing [41, 49, 59]. Physical characteristics including
measurement units (IMUs) [61]. Four studies assessed skinfold levels [42, 54, 56], foot arch features [42, 49,
trunk kinematics [55, 58, 59, 61]; whereas eight measured 54], body mass [42, 54, 56, 59], fat free mass [41], body
both trunk and lower limb kinematics[42, 43, 49, 53, 54, mass index (BMI) [46, 47], segment anthropometrics
56, 60, 65]. Seven studies quantified kinetics [42, 49, 53, [42], posture [42, 54], standing height [41, 59], and
54, 56, 60, 61]; six measured GRF with force plates/plat- aerobic capacity [42, 59] were assessed. Lumbar Repo-
forms [42, 49, 53, 54, 56, 60], and IMUs captured sacral sition Error (LRE) in neutral spine and fast bowling
and tibial rates of loading and impacts in another [61]. specific positions [48], a single leg decline squat test
Biomechanical testing environments were laboratory [49], a lumbopelvic stability test [49, 59], and a Star
based [42, 43, 53, 54, 56, 58, 60, 65], outdoors [61], labo- Excursion Balance Test (SEBT) [59] were employed as
ratory and netted [59], and not specified in two studies neuromuscular control assessments.
[43, 55]. Discrete point analysis techniques were used to
identify kinematic and kinetic variables in all biomechan- Results of individual studies
ical studies [42, 43, 49, 53–56, 58–61, 65]. Descriptive Age
variables collected included BR height [42, 54, 56], BR Prospective research reported an association between
speed [53, 54, 56, 59], approach velocity [42, 49, 53, 54], LSF and younger chronological age in professional fast
delivery stride length [54, 56], and delivery stride align- bowlers (mean age 24.87); as 74% of LSFs occurred in
ment [54]. bowlers aged under 25 years, with an annual incidence
Ten studies applied radiological investigations to assess of 4.90 LSFs per 100 bowlers aged 18 to 22 compared
trunk and lumbar anatomical characteristics [41, 44–47, to 2.46 across the entire cohort [51]. A range of asso-
50, 52, 62–64]. MRI was used to quantify Quadratus ciations between age and injury have been reported in
Lumborum (QL) muscle asymmetry [44, 46, 47], whereas adolescent cohorts [41, 54, 59]; as LBSI risk was 2.99
Ultrasound (US) was employed to measure Multifidus times higher for each year younger in bowlers aged 15
CSA [50] as well as Transversus Abdominis, Internal to 20 years [59], and bowlers with LBSI were older than
Oblique and External Oblique thickness [62]. Three stud- injury free bowlers (median 18.4 vs 16.4 years) [54],
ies utilised MRI to investigate BMO presence in lumbar whilst injured bowlers were 1.3 years older than unin-
vertebrae and its association with future injury [45, 52, 64], jured bowlers, despite no difference in average skeletal
and one examined lumbar intervertebral disc degeneration age or maturation [41].
for this purpose [45]. Dual Energy X-ray Absorptiometry
(DEXA) was used to assess lumbar spine BMC and BMD Previous lumbar injury
[41, 63], vertebral body area [41], and skeletal age was No associations were reported between incidence of pre-
assessed with DEXA of the left hand [41] and analysed by vious and future lumbar injury in two studies [48, 50].
the Tanner and Whitehouse Three method [66]. Chrono- However, previous LBP is potentially a good prognostic
logical age [41, 51, 54, 59] and a history of LBP or lumbar indicator for recurrent injury, as all bowlers who devel-
injury [48, 50, 61] were investigated as variables that may oped LBP during a prospective study reported previous
be associated with future LBP and lumbar spine injury. LBP at study commencement [61].
Strength measures included testing of maximal trunk
flexion and extension strength [42, 54], maximal hip BMC/BMD
abduction and extension strength [59], isokinetic ham- Non-significant associations were reported in two stud-
string and quadriceps muscle strength [42], calf muscle ies investigating relationships between lumbar BMD and
and single leg bridge capacity [49], and shoulder depres- injury [41, 63]. In a cross-sectional study, adult bowl-
sion/horizontal flexion strength [42]. Abdominal mus- ers with previous LSF had 3.6% and 1.7% lower BMD in
cular function was assessed with prone and side plank dominant and non-dominant sides of lumbar vertebrae
tests [49], and a 60 s sit up test [42, 54, 56], whereas respectively compared to bowlers without LSF history
trunk extensor endurance was assessed with the Biering- [63]. In contrast, prospective research reported greater
Sorensen test [49, 57, 59]. non-dominant side BMD of the L3 and L4 vertebrae by
Range of motion assessments included sit-and-reach way of larger effect sizes in adolescents who developed
[41, 42, 54], shoulder flexibility [42], lumbar flexion LBSI [41].
Trunk and lumbar muscle morphology and morphometry Reported associations between shoulder alignment and
Asymmetries presenting as increased QL volume on the lumbar spine injury are inconsistent. A front-on shoulder
bowling arm side have been associated with symptomatic alignment at back foot contact (BFC) has been associated
L4 pars lesion development [44] in adolescents. However, with LSF in adults [60], and with LSF [54], lumbar disc
subsequent research reported no significant association [54] and lower back [42] injuries in adolescents. Inter-
between QL CSA asymmetry and future LBSI in adoles- estingly, other studies have reported no association with
cents [46] and adults [47]. disc degeneration in adolescents [56] or lower back injury
Whilst Multifidus CSA on the contralateral side to the in adolescent [49, 61] or adult [53, 61] bowlers.
bowling arm at L3 and L5 was reported to be smaller in A front-on shoulder alignment at BFC has been linked
adults who developed a lumbar injury, no associations to increased SCR, which is the change between shoulder
were reported for between-sides percentage differences alignment at BFC and the minimum shoulder alignment
or asymmetry [50]. The individual and total combined during the delivery stride [60], however, the association
thicknesses of three abdominal muscles (Transversus of SCR with lumbar spine injury is inconsistent. SCR
Abdominus, Internal Oblique, External Oblique) on the has been associated with LSF [42], disc abnormalities
side opposite to the bowling arm were reported to be [56, 65], and radiological abnormalities [54] in adoles-
greater in pain-free adolescents compared to those expe- cents, and LSF in adults [60]. Subsequent studies how-
riencing LBP [62]. ever reported no association between SCR and LBP
history in elite females [58], adolescents and adults [61];
Presence of BMO or future lumbar spine injury in adolescent [49, 59, 61]
In elite bowlers, BMO at baseline MRI was associ- and adult cohorts [53, 61].
ated with symptomatic LSF development at a mean of In adults, associations between increased hip counter
10 weeks from scan time [45], and bowlers with cortical rotation and hip-shoulder separation (HSS) at BFC with
breach at baseline developed symptoms within 4 weeks, LSF and back sprain injury respectively were reported;
compared to a mean of 11 weeks for those with no corti- and a large HSS angle at BFC along with high SCR define
cal breach [45]. In adolescents who underwent six MRI a mixed technique [60]. Higher rates of radiological
scans throughout an eight-month cricket season, all par- abnormalities [54], disc degeneration [43, 56, 65], and
ticipants who sustained a symptomatic LBSI had cor- LBP [55] in adolescents, and lower back injuries in adults
responding site BMO detected in the scan immediately [60] have been associated with a mixed technique. How-
prior to diagnosis, with a mean of 96 days between initial ever, other studies reported no such associations with
BMO appearance and symptom reporting [52]. When LBP history in elite females [58] or lumbar spine injury in
results of all scans were pooled, a relative risk of 22.3 adolescent [49, 59, 61] or adult fast bowlers [53, 61].
(95% CI 1.4 to 256.6) was reported for detected BMO Conflicting results have been reported for associa-
leading to a symptomatic LBSI; with a Positive Predictive tions between lateral flexion away from the bowling arm
Value of 39.5 and a Negative Predictive Value of 100 [52]. and lumbar spine injury [49, 53, 58, 59, 61]. Thorax lat-
Elite bowlers nominated for screening by their medical eral flexion was greater during the delivery stride in elite
team with a BMO intensity ratio of ≥ 2.0 on MRI were females with LBP history [58], and at front foot contact
reportedly at 1.8 times greater risk of sustaining LBSI (FFC) and BR in adolescents who developed lumbar
in the following 12 months compared to bowlers with spine injury [49]. Injured elite males had less thoracolum-
no abnormal BMO detected; with a median of 258 days bar lateral flexion at BFC and BR, and a medium effect
between scan time and injury diagnosis [64]. size for increased lumbopelvic lateral flexion at BR [53];
whilst no association was reported for lumbopelvic lat-
Biomechanics of fast bowling eral flexion range between FFC and BR and injury else-
Biomechanical studies were prospective [42, 43, 49, 53], where [49]. Further to this, large effect sizes have been
cross-sectional [54–56], retrospective [58, 59], combined reported for increased lumbar lateral flexion at BFC in
prospective/retrospective [60, 61], and interventional adults who did not develop LBP [61], and a recent 2-D
[65] in nature. In predominantly adolescent fast bowlers, study demonstrated no relationship between trunk lat-
greater BR height was associated with lower back inju- eral flexion and LBSI in adolescents [59].
ries [42] and lumbar bone abnormalities [54], but not disc Thorax flexion and extension relative to the pelvis did
degeneration [56]. The association of BR speed and lum- not have any association with LBP history in elite females
bar spine injury is inconsistent, as studies in adults [53] [58]. Lumbopelvic flexion/extension has an inconsistent
and adolescents [54, 56] reported no associations, whereas relationship with injury; as this was not associated with
subsequent research reported LBSI risk increasing 1.1 lower back injury in adolescents [49], but in adults each
times for every km/h faster BR speed in adolescents [59]. 1° increment in the lumbopelvic extension angle at FFC
increased the odds of LBSI by 1.25 [53]. Furthermore, faster rates of peak braking and vertical force develop-
large effect sizes have been reported for greater thora- ment during FFC [60]. Large effect sizes were reported
columbar extension at BFC in adults with LBP history for reduced peak tibial Z axis acceleration and faster time
[61], and for reduced lumbar extension at BFC and FFC to peak resultant tibial acceleration at FFC in adults with
in adults who did not develop LBP [61]. LBP history [61], whereas those who did not develop LBP
Associations between LBP and lumbar spine injury and experienced higher time to peak resultant tibial accel-
rotation metrics are inconsistent [49, 53, 58, 61]. Neither eration at BFC and higher tibial loading variables at FFC
thorax rotation relative to the pelvis [58] or lumbopelvic [61]. Large effect sizes were reported for greater time-to-
rotational range [49] were associated with LBP history peak vertical and resultant acceleration at the sacrum in
in elite females [58] or lower back injury in adolescents adults who developed LBP [61]. Injured adolescents dis-
[49]. However, subsequent research reported that injured played increased peak lateral flexion power and normal-
adults had increased thoracolumbar rotation away from ised peak flexion and lateral flexion lumbar moments in
the bowling arm at the instance of BFC [53]. In ado- comparison to non-injured counterparts [49].
lescents without LBP history, large effect sizes were
reported for increased thoracic rotation away from the Physical characteristics
bowling arm at BFC and an increased range of thoracic Whilst an association was reported in adolescents
rotation between BFC and FFC [61]. In the same study, a between lower longitudinal foot arch height and LSF [42],
large effect size for reduced lumbar rotation at FFC was other research reported no such relationship with lower
observed in adults who did not develop LBP [61]. back injury [49] or radiological abnormalities [54]. An
Pelvis-shoulder separation at BFC had no association association between higher BMI and LBSI was reported
with LBP history in elite females [58] or LBSI in adults in adolescents [46], but not in adults [47]; and adoles-
[53]. Increased pelvis rotation beyond front-on at BR cents were reportedly 1.1 times more likely to sustain
was reported in adolescents who developed lower back LBSI for every centimetre taller in standing height [59].
injury [49] and increased anterior pelvic tilt at FFC and Range of motion assessments have yielded conflicting
increased ipsilateral pelvic drop in transitions between results, with sit and reach scores being lower in adoles-
BFC and BR were reported in adults who sustained cents with intervertebral disc abnormalities [54], but not
LBSI [53]. in those with disc degeneration [56] or LBSI [41]. Elite
Injured adults were reported to have more flexed rear females with LBP history had reduced lumbar lateral flex-
hip and knee angles at the instance of BFC, and the ion range to the bowling arm side [57]; however, lumbar
degree of rear hip flexion was reported to categorise LBSI lateral flexion range was not associated with LBSI in
in 76% of bowlers, with odds of injury reduced by a factor adolescent males [59]. Hip internal rotation of the non-
of 0.88 for each 1° increment in rear hip extension [53]. dominant leg was reported to be 7.2° less in adolescents
Reduced front hip flexion during FFC has been asso- who sustained an LBSI, however this was not statistically
ciated with LSF [42] and lower back injury [49] in ado- significant [41].
lescents, and LSF in adults [60]. Conversely, adults with Analyses of muscle strength and endurance have
LBSI were reported to have more flexed front hip angles reported varying associations with lumbar spine injury
at FFC and possess less front hip extension in transitions incidence [42, 49, 54, 56, 57, 59]. Greater front leg quadri-
between BFC and BR [53]. ceps and bowling arm shoulder depression and horizon-
The relevance of front knee angles to injury [42, 49, tal flexion strength have been reported in predominantly
53, 56, 60, 65] has also yielded conflicting results. Whilst adolescent bowlers with LSF and lumbar injuries respec-
predominantly adolescent bowlers who developed LSF tively [42]. Whilst reduced trunk extensor endurance was
tended to have increased front knee extension [42], and reported in adolescents who developed lower back injury
non-injured adults displayed increased front knee flexion [49]; other research reported no association between this
during FFC [60], other studies have reported no asso- and LBP history in elite females [57], or LBSI in adoles-
ciation of front knee flexion during FFC and at BR with cents [59].
lumbar spine injury in adolescents [49, 56, 65] and adults Reduced performance of the lumbopelvic stability
[53]. No associations were reported in adults between test in adolescents was reported to be associated with
LBSI and front foot and front leg plant angles at the a 1.7 times increased risk of lower back injury in one
instant of FFC [53]. study [49], but not related to LBSI in another [59]. In
GRF magnitudes at BFC and FFC have not been sig- adolescents, increased knee valgus angle during a
nificantly associated with lumbar spine injury [42, 49, single leg decline squat on both legs was reportedly
53, 54, 56, 60]; however, adults who experienced LSF dis- associated with increased lower back injury risk [49].
played tendencies for higher vertical GRF at BFC, and Whilst SEBT distance was deemed not to be significant
in multivariate analysis, adolescents who sustained participants by coaches [42, 45, 57, 58, 61], selectors
LBSI performed less efficiently on this test [59]. LRE in [47], and medical staff [64], and in another excluding
two neutral spine and six fast bowling specific positions 15 asymptomatic bowlers at study commencement due
was associated with LBP history, and LRE in two neu- to MRI findings [49]. Survivor bias may have existed in
tral positions was associated with a future lower back professional cohorts [47, 51, 57, 58, 60, 63], as previ-
injury [48]. ously injured bowlers may have become slow bowlers,
specialist batters, or no longer be playing cricket at the
Discussion elite level [57].
This systematic review reported on intrinsic factors The transparent reporting of recruitment across ado-
associated with LBP and lumbar spine injury in fast lescent, adult, amateur and professional fast bowling
bowlers. Conflicting results were reported amongst cohorts is an important first step in reducing partici-
studies investigating fast bowling biomechanics [42, 43, pation bias. Multifaceted recruitment methods incor-
49, 53–56, 58–61, 65], trunk and lumbar muscle asym- porating personal contact, social media initiatives,
metries [44, 46, 47, 50, 62], anthropometric character- and partnerships with stakeholders based on educa-
istics [42, 46, 47, 49, 54, 56, 59], muscle strength and tion and dissemination of research results will improve
endurance [42, 54, 56, 57, 59, 63], ranges of motion [41, power and representativeness of future research [68],
42, 49, 54, 57, 59], neuromuscular control [48, 49, 59], and subsequent random selection of participants from
age [41, 51, 54, 59], and lumbar BMD [41, 63]; whereas pre-established cohorts can reduce volunteer bias [69].
more consistent results were described when reporting Sample size calculations were conducted for only one
lumbar vertebra BMO and its association with subse- included study [61], and these should be considered
quent LBSI [45, 52, 64]. Inconsistencies in results may in future studies incorporating accuracy in parameter
reflect differences in study design, injury definitions, estimation, sequential testing, and Bayesian models, as
participant characteristics, measurement parameters, these approaches may improve the precision of meas-
and statistical analyses. urements and detection of small effects [70]. Moreo-
ver, the establishment of international collaborations
Risk of bias to acquire datasets of sufficient sample size and het-
Risk of bias appraisal is essential as increased bias erogeneity may improve the external validity of future
affects the internal validity of studies [37, 67] that may research [71].
inform strategies for injury prevention in fast bowlers.
Aspects of bias relating to assessed QUIPS domains and Attrition bias
how these inform directions for future research will be Apart from lowering study power, attrition threatens
discussed herein, particularly given the high overall risk both external and internal validity of results [72], as
of bias in many studies evident in Fig. 2. participants who are most impaired are more likely to
be lost to follow-up [73]. A moderate risk of attrition
bias was judged to be present in the following study
Participation bias designs that did not report participants potentially lost
Eighteen studies [41, 43, 44, 46, 48–56, 59, 60, 62, 63, to follow-up; prospective with one cricket season length
65] were classified as having a moderate risk of par- [42, 46–48, 50], prospective in elite environments over
ticipation bias, and the remaining seven [42, 45, 47, multiple seasons [45, 53], and combined retrospective/
57, 58, 61, 64] were rated as high risk. Studies with prospective [60, 61]. Prospective research not reporting
the lowest sample sizes [43, 45, 47–50, 54–58, 62, 63] dropouts in non-elite environments over multiple years
may have been inadequately powered [68], and this [43, 65] was classified as high risk, as was a study not
possibly contributed to the low replicability of results describing reasons for six participants missing from ini-
from included studies. The non-reporting of recruit- tial recruitment [49], and another with a reported drop-
ment methodologies [44, 46, 49, 62, 63] and response out rate of 45% [41].
rates to recruitment [48, 50] may reflect an absence of Reducing attrition using matching retention strategies
eligible participants and reduced study representative- to samples prior to study implementation, including care-
ness. Volunteer bias [67] may have occurred in studies ful consideration of unintended burden for participants
that recruited higher proportions of injured partici- [74] is required in future prospective research. In studies
pants [53, 62] and in research not reporting injury where attrition has occurred, bias can be reduced with
history, which was described in only four included reporting of sample size at each data collection point,
studies [44, 48, 50, 61]. Selection bias [67] may have reasons associated with loss of participants, and statis-
occurred in studies exhibiting targeted recruitment of tical analysis of dropouts versus those remaining across
demographic data, pre-test responses, and variables par- bias, and seven [41–43, 49, 53–55] were rated as high
ticular to studies [72]. risk. Increased bias was adjudged when methodologies
or reliability associated with LBP and lumbar spine injury
Prognostic factor measurement bias outcomes were not reported [42–44, 53–56, 65]. Poten-
Six studies [48, 50, 52, 58, 61, 63] were classified as hav- tial recall bias may have caused under-reporting of injury
ing a moderate risk of prognostic factor measurement incidence in studies relying on retrospective data sourced
bias, and thirteen were rated as high risk [42–44, 46, 47, from participants [48, 60, 61], or from medical records
53–56, 59, 60, 64, 65]. The use of single trials [42, 43, 48, [57, 58, 63]. Cross-sectional [55, 56, 62, 63], retrospective
53–56, 60, 65] to assess fast bowling biomechanics was [45, 54, 57–59, 61, 64], and prospective studies with one
judged to increase risk of bias, as too few trials may not cricket season follow up [42, 46–50, 52, 61] were deemed
appropriately represent long-term technique [75], and to exhibit increased bias due to missing, adverse, or oth-
individual movement patterns and movement variability erwise injury outcomes that may have occurred over a
associated with fast bowling technique fluctuate within prolonged period of observation [80].
bowling sessions [76]. Increased bias was judged when Studies that employed CT to investigate LSF presence
MRI assessments were scheduled at a time to allow bowl- [42, 54, 55] are prone to misclassification bias [67, 81],
ers further recovery [64], and when injuries pooled for as CT possesses reduced sensitivity in diagnosing stress
analysis were sustained prior to and following biome- reactions [81]. Research categorising injury on radio-
chanical testing [60], as the assumption of similar bowl- logical findings alone [43, 53–56, 65] or studies includ-
ing technique before and after injury is tenuous. ing both asymptomatic bowlers with abnormal radiology
The dichotomising of continuous variables into dis- and bowlers with symptoms [41, 49] were considered
crete categories using arbitrarily chosen or data driven to display increased risk of bias. Reported dissociations
thresholds [71] was judged to increase risk of bias [42– between lumbar symptoms and MRI [31, 52] and CT
44, 46, 47, 50, 54, 55, 58–60, 65]; as this practice discards [82] detected abnormalities support this judgement, as a
information, reduces statistical power, and is biologically proportion of fast bowlers with radiological abnormali-
implausible [77] through its assumption that all partici- ties will not experience symptomatic injuries and missed
pants within a category possess equal risk of injury [78]. playing time [31, 52, 82].
Studies not referencing the reliability of measurements Multiple injury definitions within and between stud-
were adjudged to possess increased bias risk [42, 43, ies confound the relevance of investigated variables [37],
53–56, 59–61, 65], and whilst two studies understand- and future studies should employ injury definitions that
ably employed a multicentre approach for MRI [52, 64], encompass symptoms, clinical signs, and imaging find-
inter-rater reliability for BMO detection in one of these ings, as these may better represent injury burdens in
[52] was reported as “moderate” in subsequent research fast bowling cohorts. The creation of a multidisciplinary
[79]. Studies investigating associations between QL consensus for LBP and lumbar spine injury diagnosis in
asymmetry and injury that could access images across fast bowlers may be an important step in improving the
limited vertebral levels [44, 46, 47] were deemed prone external validity of future research.
to increased bias risk, as was a study that reported bowl-
ing technique biomechanical variables for only 68% of Confounding bias
recruited participants [59]. Future studies investigating causality should carefully
The highlighting of these potential biases can guide consider the concept of confounding bias, as injury is
future researchers and approaches that include quan- the result of a complex interplay between tissue load-
tifying the number of fast bowling trials to provide a ing and a range of modifiable and non-modifiable physi-
stable estimate of key performance and biomechanical ological factors including tissue specific mechanical
variables, standardising protocols to improve inter-rater properties and adaptations that affect tissue resilience
detection of radiological abnormalities, and accounting [15, 83]. Studies implying causality that did not account
for previous injury in study designs and analyses. Fur- for confounders [43, 45, 50, 53, 55, 58, 60–62, 65] were
thermore, continuous variables should remain continu- rated as having a high risk of confounding bias; whereas
ous and be modelled appropriately [71], and the validity those that accounted for a limited number of confound-
and reliability of employed measurement tools should be ers [48, 51, 52, 63, 64] or measured confounders and did
established to limit misclassification bias [67]. not account for them in a multivariate analysis [42, 54,
56] were rated as moderate risk. Reportedly significant
Outcome measurement bias associations in these studies may have been distorted by
Nine studies [44, 48, 56–58, 60, 61, 63, 65] were classi- confounders that were related to an investigated variable
fied as having a moderate risk of outcome measurement as well as LBP or lumbar spine injury.
Future projects should incorporate directed acyclic discussion within this context of the summary of evi-
graphs (DAGs), as these can illustrate confounders to dence can inform priorities and strategies for future
include and adjust for and improve the understand- research.
ing of mediating effects and bias implications of
confounders [84, 85]. Furthermore, the effect of inves- Age
tigated variables and confounders on injury risk may Inconsistent associations of age and injury in adoles-
change over time [15, 86] due to changes in the cent populations [41, 54, 59] may be due to disparate
mechanical properties of muscle, tendon, and bone study designs and injury outcomes of included studies;
tissue [83] in response to training and match loads. as radiological abnormalities were assessed in a cross-
Whilst several included studies accounted for bowling sectional study [54], symptomatic LBSI was examined in
workloads [51, 52, 64], future research should longitu- retrospective research [59], and a combination of these
dinally account for multiple variables as time-varying outcomes was investigated prospectively [41]. The asso-
effect-measure modifiers and/or time varying con- ciation of younger age and LBSI in professional bowlers
founders [87]. [51] is supported by research reporting fast bowlers with
LBSI possessing mean age of 22.2 years [13], being pre-
Statistical analysis and reporting bias dominantly 24 years or younger [92], and demonstrat-
Studies classified as having a high risk of statistical ing 3.7 to 6.7 times greater likelihood of sustaining these
analysis and reporting bias were typified by inadequate injuries than other age groups if they are under the age of
reporting [42, 54, 55] and when the 95% Confidence 22 [20].
Intervals of risk ratios for variables reported to be sig- These findings are consistent with longitudinal meas-
nificant included 1.0 [49, 64]. Studies with reported urements of bone turnover and BMD indicating lumbar
associations based on p-values alone [43, 45, 48, 56, bone accrual continues beyond longitudinal growth ces-
57, 60, 62, 65] were rated as moderate risk, as p-values sation [93–95], with 23.1 to 24.9 years reported as the
do not provide a good measure of evidence regarding 95% Confidence Interval for attainment of peak BMD in
a hypothesis or quantify the size of an effect [88]. The males [95]. The lumbar vertebrae undergo maturation at
use of post-hoc power analyses to detect differences in secondary ossification centres in the vertebral body ring
bowlers with and without injury [46, 47] was judged to [96–98], and the mamillary, transverse and spinous pro-
increase risk of bias, as it is not conceptually valid to cesses [96] through cartilaginous, apophyseal and epi-
interpret power pertaining to observed study results physeal stages [98] that do not correlate consistently with
[89], as this should be included in study rationale and chronological age [96–99]. Furthermore, the timing and
design prior to conduct [90]. rates of growth and maturation of lumbar musculature
Low risk (and primarily more recent) studies [41, 44, are variable; as Erector Spinae and Multifidus often reach
50–53, 58, 59, 61, 63] were characterised by appropri- maximal CSA before skeletal maturity, whereas Psoas
ate interpretations of associations based on effect sizes Major and QL can continue to increase in size after skel-
[41, 50, 53, 58, 61, 63], relative risk ratios [50], predic- etal maturity [100].
tive values [52], and regression models [44, 51, 53, 59]. Previous reviews examining LBP and lumbar spine
Whilst the inclusion of these measures to accompany injury in fast bowlers have classified adolescent [26]
p-value and Confidence Interval reporting is promising, and adult [16] cohorts separately, with caution advised
further steps are required to produce more transparent in generalising injury associated factors from cricket-
and informative research. Approaches such as Bayes- ers below 18 years to adults [16, 26]. Whilst disparities
ian methods, likelihood ratios, and Bayes Factors may in spinal anatomy exist between adolescents and adults
more directly address the size and certainty of effects, [101], future research should examine neuromuscular
or whether a hypothesis is correct [71, 88]. Furthermore, [102], physiological and mechanical adaptations [83]
future researchers should report both relative and abso- as a function of training age [83, 103] and maturation
lute measures of association to draw conclusions, as status [102], as these factors may influence resilience
these may better identify minimal important differences to fast bowling [1]. Regardless, a linear relationship
in injury risk [91]. between skeletal maturity and chronological age is
disputable [104], and the rationale for classifying fast
Summary of evidence bowlers by chronological age should be re-considered.
Notwithstanding reported discrepancies, the credibility Whilst one included study [41] reported the non-signif-
of extracted results in this review are potentially com- icance of skeletal age, future studies should investigate
promised due to 23 of the 25 included studies being associations of lumbar maturation metrics and injury
assessed as having an overall high risk of bias. Regardless, outcomes.
LBP and lumbar spine injury D and collagen pathways [107], and vertebral trabecular
Irrespective of study design, the residual effects of pre- bone quality [108].
vious injury potentially distort reported associations
between investigated variables and reported outcomes Trunk and lumbar muscle morphology and morphometry
of LBP and lumbar spine injury. An index LBSI in a fast Contrasting QL asymmetry associations may be con-
bowler may be associated with recurrence at the same sequential of a limited number of images available for
site, contralaterally, or at a different lumbar level [13, analysis [44, 46, 47], and distinctive CSA [46, 47] and
105]; however, the nature of any association is unde- volumetric [44] assessments. The generation of volumes
termined, as the effects of injury on the cellular and via muscle profile templates over multiple years [44] pos-
mechanical aspects of lumbar bone are unknown. Future sibly distorted measurements, as QL CSA growth is non-
studies should clearly define the nature and site of pre- uniform during adolescence [100]. Disparities may also
vious injuries and employ statistical designs to account reflect variability in the size, number, and attachments of
for their influence on investigated variables and injury QL fascicles between individuals [109]. Whilst increases
incidence. in asymmetry have been linked to higher lumbopelvic
Comparing the significance of variables derived from lateral flexion loads in fast bowlers [110], finite element
studies that defined outcomes as varied as LBP in the modelling suggests that asymmetry may reduce lumbar
absence of radiology [48, 50, 57, 58, 61, 62], radiological loads due to the geometrical proximity of QL’s line of
abnormalities in the absence of LBP [43, 53–56, 65], or action to the centre of spinal rotation and impacted facet
a combination of LBP, abnormal radiology and missed joints during fast bowling postures [111].
playing time [42, 44–47, 51, 52, 59, 60, 63, 64] is prob- The hypothesis of modified trunk control explaining
lematic. Whilst the appearance of LBP has been reported the association between reduced non-bowling arm side
to be a common finding in fast bowlers without accom- Internal Oblique thickness and LBP [62] is problematic
panying missed playing time [9]; spondylolysis is the as bowling workloads were not accounted for as a con-
most common cause of LBP in young athletes [106], founder in this cross-sectional study. LBP-related reduc-
and LBSI should be suspected in a fast bowler present- tions in bowling volume and intensity prior to testing may
ing with LBP contralateral to their bowling arm side [12]. have influenced this finding, as repetitive fast bowling
The significance of LBP as a surrogate for lumbar spine can preferentially hypertrophy the non-bowling arm side
injury in fast bowlers is yet to be determined due to pre- Internal Oblique over the course of a cricket season [112].
viously described attrition biases in the published lit- Since fatty infiltration within trunk and lumbar muscu-
erature [41–43, 45–50, 53, 60, 61, 65], and studies being lature has been associated with LBP [113], future research
cross sectional [54–56, 62, 63], retrospective [57–61, 64], should quantify lean muscle mass. Whilst individual
or prospective with limited follow up periods [42, 46–50, muscles are postulated to influence lumbar function
52, 61]. To better understand the relationship between due to spinal and fascial attachments [114], lumbopelvic
LBP and lumbar spine injury in fast bowlers, there is a function depends on coordinated activation [115] rather
requirement for longitudinal studies that concurrently than specific muscles with unique architectural proper-
examine these outcomes over prolonged surveillance ties or mechanical advantages [116]. High levels of par-
periods. aspinal and gluteal muscle activation have been reported
around BFC and BR in injury-free fast bowlers [21], and
BMC/BMD whilst the applicability of these findings is unknown, fur-
Injury causality cannot be established in cross-sectional ther research is required to establish the role of trunk and
research that reported trends for less marked asymme- lumbopelvic musculature in LBP and lumbar spine injury
try of lumbar BMC/BMD being associated with LSF his- in fast bowlers.
tory [63]. These trends are supported by lumbar vertebral
BMC/BMD being reduced at 21 to 24 weeks post LSF in Presence of BMO
fast bowlers in comparison to baseline [105]; and a post- Distinctions in associations between BMO and future
injury delay in BMC/BMD recovery may be associated lumbar spine injury may be attributed to studies report-
with LBSI recurrences [105]. The contrasting trend for ing the significance of detected BMO [45, 52] and BMO
bowlers with greater contralateral side BMD who devel- intensity ratios [64] with p-values [45], predictive values
oped LBSI [41] suggests that LBSI risk may be some- [52], and risk ratios [52, 64]. Earlier symptom reporting
what independent of BMD. Future studies should aim with detected BMO and cortical breach in comparison
to investigate additional factors that may regulate bone to no cortical breach [45] may be indicative of bowlers
modelling and adaptation to mechanical loading such as being at a later stage of the bone stress injury continuum
vitamin D status, genetic variants associated with vitamin at study commencement [117].
Whilst excellent reliability for BMO intensity quanti- questionable, since fast bowling techniques employed
fication has been reported [64, 79]; the inter-rater reli- by these bowlers may have been influenced by existing
ability of BMO detection is uncertain, as its Kappa was or previous injury, as pain may alter muscle activity and
0.483 (95% CI 0.368–0.580) [79] in relation to one cohort mechanical behaviours at multiple levels of the motor
[52] and not reported in two others [45, 64]. The report- system [125]. Furthermore, as previous LBP or lumbar
ing of BMO intensity ratio ≥ 2.0 resulting in a 1.8 times spine injury was documented in only one biomechani-
greater risk of sustaining LBSI in the following 12 months cal study [61], the significance of biomechanical factors
should be viewed cautiously as the 95% Confidence Inter- collected from prospectively monitored cohorts that
val associated with its risk ratio included 1.0 (95% CI 0.6– did not account for this [42, 43, 49, 60, 65] may be simi-
5.5) [64]. larly affected.
Whilst a relative risk of 22.3 was reported for Precise temporal characteristics of BFC and FFC were
detected BMO leading to a symptomatic LBSI in ado- reported in only three studies [53, 58, 61], and their
lescents, 61% of all participants with BMO detected on limited reporting [42, 43, 49, 54–56, 59, 60, 65] may
one or more scans did not experience a symptomatic have caused variables across biomechanical research to
LBSI; with 37% experiencing persistent BMO and no be collected from arbitrary and inconsistent points of
symptoms, and the remaining 24% experiencing BMO the fast bowling action. Formulating precise and con-
resolution and no symptoms [52]. The undetermined sistently defined parameters for the measurement and
significance of BMO presents implications for its meas- reporting of these events is necessary to improve the
urement in future research, and in addition to BMO external validity of research. The restriction of data
detection and intensity, the quantification of lumbar analysis in all included biomechanical studies [42, 43,
intervertebral disc degeneration [118], vertebral mor- 49, 53–56, 58–61, 65] to discrete time points or joint
phometry [119], trabecular bone quality [108], paraspi- and/or segmental maxima and minima, represents a
nal muscle morphometry [120], facet orientation [121], clear limitation [126], and future research needs to
and facet degeneration [122] may be prudent, as these assess coordinated movement patterns utilising con-
variables potentially influence relationships between tinuous datasets over the entire fast bowling movement
quantified BMO and symptoms. [127]. Moreover, assessing variability in movement
may provide an improved understanding of stresses
Biomechanics of fast bowling that potentially reduce or increase cumulative loads on
Reported associations from research relating to front- internal structures [76, 128] of fast bowlers, and these
on shoulder alignment at BFC [42, 54], SCR [42, 54, detailed analyses can be achieved with time-series
56, 65] and a mixed technique [43, 54–56, 65] were based procedures such as Statistical Parametric Map-
replicated in only one [60] of six subsequent studies ping [126, 129].
[49, 53, 58–61]. Likewise, disparities exist between The threshold for SCR deemed to be “excessive” was
the reported significance of trunk and lumbar lateral inconsistent, with this being greater than 10° [54–56], 20°
flexion [49, 53, 58, 59, 61], flexion/extension [49, 53, [43, 65], 30° [53, 58, 60] or 40° [59]. 2-D studies [42, 43,
58, 61], and rotation [49, 53, 58, 61], as well as hip [42, 54, 56, 59, 65] captured kinematic data with one high-
49, 53, 60] and knee angles [42, 49, 53, 56, 60, 65] dur- speed camera positioned laterally and another over-
ing FFC. The lack of reproducibility in biomechanical head, thus introducing the risk of perspective error due
research is concerning since the modification of shoul- to the multi-planar nature of fast bowling [5]. Moreover,
der alignment, SCR, a mixed technique, trunk lateral SCR is a 2-D description of shoulder alignment in the
flexion, and lower limb kinematics are emphasised in transverse plane [60] that does not consistently repre-
contemporary injury prevention and coaching pro- sent 3-D derived fast bowling spinal kinematics [58, 130,
grams [123, 124]. 131], and bowlers classified with mixed and non-mixed
The non-consensus of predisposing or predictive bio- actions exhibited no significant differences in lower trunk
mechanical variables is understandable as these were extension, lateral flexion, and axial rotation percentages
gathered from research with disparate cohorts and utilised in the fast bowling action [130]. These findings
study designs. Biomechanical research was conducted further indicate a requirement for future research to
across adolescent [42, 43, 49, 54–56, 59, 61, 65] and investigate alternative methods of analysis and classifica-
adult [53, 57, 58, 60, 61] cohorts at club/school [42, 43, tion of fast bowling techniques.
56], high-performance/elite [53–55, 57–61, 65], and Whilst 3-D studies [49, 53, 58, 60] utilised numerous
diverse [49] skill levels. The utility of biomechanical cameras to reconstruct a three-dimensional space, they
factors from cross-sectional [54–56] and retrospective defined the thoracic and lumbar spine as singular rigid
[57–61] cohorts for injury prediction and prevention is body segments [126]. Individual thoracic and lumbar
vertebrae move in an uncorrelated manner [132, 133], during FFC [42, 60] is suggested to be a trade-off between
and the L4 and L5 posterior elements may experience improved bowling performance and heightened injury
dissimilar maximal stresses in response to an applied risk [138]; foot horizontal impulse magnitude [139], plant
physiological load [134]. Biomechanical data collected angle and strike position [140] during FFC may be more
with rigid segments should be viewed with caution [133], important determinants of knee kinematics and GRF.
and future research must explore methodologies capable The absence of consistent findings relating high GRF
of assessing multi-segmental motion of the thoracic and at FFC with injury [42, 49, 53, 54, 56, 60, 61] may reflect
lumbar regions [133] and the quantification of spinal cur- discrepancies of GRF in laboratory versus match set-
vature [126] during fast bowling. tings due to shortened run-up lengths and altered foot
The significance of excessive lateral flexion of thorax placement strategies [30]. Attainment of match intensity
[49, 58], thoracolumbar [53], lumbopelvic [49, 53], trunk bowling speeds during testing may improve the ecologi-
[59] and lumbar [61] segments in relation to injury is cal validity of future research, as reduced bowling speeds
uncertain. In studies that have reported excessive lateral may cause disproportionately large reductions in lumbar
flexion to be significant, its presence may have predated loads [141]. IMUs may contribute to the assessment of
or be consequential of LBP history [58], and it has been match intensity fast bowling kinetics in future studies, as
associated with both symptomatic and asymptomatic they can be used in a field environment and have good
bowlers [49, 53]. In described conference proceedings, measurement validity [61, 142].
fast bowlers who sustained LBSI utilised lower propor- GRF dissipation may supersede the influence of GRF
tions of available lower trunk lateral flexion range and a magnitudes since reduced force attenuation during land-
non-significantly increased amount of lower trunk exten- ing may increase stresses on more proximal structures
sion than non-injured counterparts [10]. [143, 144]. Investigating the force attenuating ability of
Increases in lumbar extension at BFC [61] and FFC the lower limbs and lumbopelvic region through eccen-
[53] deemed to elevate LBP and LBSI risk respectively tric strength [145], range of motion [146, 147], and stiff-
were coexistent with increased anterior pelvic tilt in ness [148, 149] assessments should be considered in
one study [53], and analysis of continuous datasets may future research. Whilst higher lumbar flexion and lateral
illuminate causal interactions between these variables flexion loads have been associated with injury [49], previ-
and injury. Whilst the described influences of tho- ous research has not investigated the influence of mus-
racic and lumbar rotation [49, 53, 61] are conflicting, cle forces on lumbar compressive loads [6, 49, 150], and
reported increases in thoracic rotation away from the future studies should incorporate musculoskeletal mod-
direction of delivery in bowlers without LBP history els that better simulate spinal loading [151].
[61] may inform biomechanical and physical prepara- As biomechanical research has been conducted in pri-
tion initiatives designed to reduce lumbar spine stress marily male and most likely Caucasian populations, the
during fast bowling. More detailed analyses of lateral generalisability of findings to females and other racial
flexion, extension and rotation are required as these groups may be limited. Female fast bowlers may adopt
movements have been designated as injurious due to a bowling technique where BR speed is contributed to
hypothesised stresses on posterior lumbar vertebral more by whole body angular momentum and pelvis and
elements [134, 135]. trunk rotation about the longitudinal axis in comparison
The reported association of increased rear hip flexion to their male colleagues [152]. Furthermore, during land-
at BFC instant with LBSI is proposed to be representative ings, males demonstrate greater centre of mass displace-
of poor pelvifemoral control [53], which is defined by the ment indicating a softer landing technique than females
interaction of the pelvis on the femur [136]. Whilst no reli- to absorb forces experienced during initial ground
able or valid test for this entity exists, this is associated with impact [153]. Differences in neuromuscular control strat-
perceptions amongst cricket coaches that rear leg kinemat- egies adopted during fast bowling and landing may alter
ics are important determinants of fast bowling performance the influence of extrinsic and intrinsic variables on the
[137], and future research investigating the origins and con- development of LBP and lumbar spine injury in female
sequences of observed kinematics at BFC may inform inter- fast bowlers, thus indicating a requirement for future
ventions to improve performance and reduce injury. research in female fast bowling populations.
Although reduced front hip flexion during FFC is
theorised to cause injury due to higher GRF [42, 60] Physical characteristics
and forces transmitted to the lumbar region [49]; more Conclusions from included studies investigating physical
flexed front hip angles in conjunction with increased characteristics [41, 42, 46–49, 54, 56, 57, 59] may inform
pelvic anterior tilt and ipsilateral drop are also proposed contemporary programs for injury prevention [154, 155].
to be detrimental [53]. Whilst a straighter front knee Prospective [41, 42, 46–49], cross-sectional [54, 56], and
retrospective [57, 59] designs, as well as indeterminate the exclusion of grey literature and conference proceed-
reliability of musculoskeletal screening procedures [156] ings may have contributed to this.
may have contributed to inconsistencies in results.
The reporting of a reduced lumbo-pelvic stability Conclusion
test score resulting in a 1.7 times increased risk of sus- This review has identified inconsistencies in findings
taining lower back injury should be viewed cautiously from studies investigating associations between intrinsic
as the 95% Confidence Interval associated with its variables and LBP and lumbar spine injury. These dis-
risk ratio included 1.0 (95% CI 0.78–4.10) [49]. This crepancies may be related to differences in study design,
test is based on the Sahrmann five-level core stability injury definitions, participant characteristics, measure-
test [157], which displays questionable reliability and ment parameters, and statistical analyses. LBP and lum-
validity; as abdominal activity does not sequentially bar spine injury occurrence in fast bowlers remain high,
increase during its ascending levels [158], and the ICC and this may be due to an absence of low bias studies that
for test–retest reliability is moderate (r = 0.649) [159]. have informed recommendations for their prevention.
Future research should examine methodologies to Careful study design, precise measurement, appropri-
assess lumbopelvic stability in upright positions evaluate statistical analysis, and clearly defined measurement
ating dynamic lumbar spine and pelvis control in sagit- and injury outcomes represent important strategies for
tal, frontal, and transverse planes of motion over the minimising bias and improving the representativeness
weightbearing leg [160, 161]. of findings. Future research should prioritise analysis of
The assessment of pelvifemoral stability with a single continuous datasets, models that better represent lum-
leg decline squat conceptually lacks validity, as the pres- bar kinematics and kinetics during fast bowling, and
ence of a decline alters femoral rotation and knee valgus improved quantification of previous injury, lumbar ana-
[162], displaces the body’s centre of mass posteriorly tomical features and lumbar maturation.
[163], and reduces hip strength required to control knee
alignment [162, 164]. Future assessments of hip con-
Abbreviations
trol should focus on hip muscle strength, and multipla- 2-D Two-dimensional
nar knee, femoral, pelvis and spine alignment in single 3-D Three- dimensional
leg stance [165]. Whilst reduced lumbar proprioception BFC Back foot contact
BMC Bone mineral content
may result in increased end-range lumbar loading [166], BMD Bone mineral density
assessing this at speeds more representative of fast bowl- BMI Body mass index
ing with simulated back and front foot landings may be BMO Bone marrow oedema
BR Ball release
valuable in future studies. CHARMS Checklist for critical Appraisal and data extraction for systematic
The significance of reduced lumbar extensor endurance Reviews of prediction Modelling Studies
in fast bowlers is uncertain as it was investigated in three CI Confidence Interval
CL Contralateral
studies [49, 57, 59] and associated with injury in only one CSA Cross sectional area
[49]. Future research investigating the significance of CT Computed Tomography
lumbar extensor strength and endurance should quantify DAGs Directed acyclic graphs
DEXA Dual Energy X-ray Absorptiometry
lumbar sagittal curvature and extensor muscle volume, EO External Oblique
as these factors may influence the magnitude of muscle F/E Flexion/extension
forces required for biomechanical stability of the lum- FFC Front foot contact
GRF Ground reaction forces
bopelvic region [167, 168]. HSS Hip-shoulder separation
IMUs Inertial measurement units
Limitations IO Internal Oblique
LBP Low Back Pain
The heterogeneity of investigated variables did not enable LBSI Lumbar bone stress injury
a meta-analysis to be performed, and yet to be identified LRE Lumbar Reposition Error
variables may be associated with LBP and lumbar spine LSF Lumbar stress fracture
MF Multifidus
injury. Whilst the level of agreement of risk assessments MRI Magnetic Resonance Imaging
for individual QUIPS bias domains was high, final judge- QL Quadratus Lumborum
ments were subjective to some degree. It is possible that QUIPS Quality in Prognostic Studies
ROC Receiver operating characteristic
relevant articles were not identified during the search RR Risk ratio
process, and studies published in languages other than SCR Shoulder counter rotation
English may have been overlooked. Positive publication SEBT Star Excursion Balance Test
SPECT Single Photon Emission Computerised Tomography
bias was a likely factor in the non-retrieval of studies, and US Ultrasound
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Additional File 1 Database Search Strategy
Search OVID Medline/EMBASE

#1 exp Cricket /
#2 exp * Fast Bowling /
#3 exp * Fast Bowler /
#4 1 OR 2 OR 3
#5 Risk Factor*/
#6 Risk /
#7 Factor* /
#8 Variable /
#9 Intrinsic /
# 10 Age /
# 11 Adolescent /
# 12 Young /
# 13 Adult /
# 14 Technique /
# 15 Biomechanic* /
# 16 Kinematic* /
# 17 Kinetic* /
# 18 Strength /
# 19 Flexibility /
# 20 Range of motion /
# 21 Muscle /
# 22 exp * Asymmetry /
# 23 exp *Cross Sectional Area /
# 24 exp * Volume /
# 25 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18
OR 19 20 OR 21 OR 22 OR 23 OR 24
# 26 Pain /
# 27 Injury /
# 28 Fracture /
# 29 * Stress /
# 30 exp Stress Fracture /
# 31 exp Stress Reaction /
# 32 Reaction /
# 33 Pars Interarticularis /
# 34 Pars /
# 35 Pedicle /
# 36 exp * Spondylolysis /
# 37 exp * Spondylolisthesis /
# 38 Bone /
# 39 exp Oedema /
# 40 exp Edema /
# 41 26 OR 27 OR 28 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39
40
# 42 Low Back /
# 43 Back /
# 44 Lumbar /
# 45 Lumbar spine /
# 46 42 OR 43 OR 44 OR 45
# 47 4 AND 25 AND 41 AND 46
KEY:
/ - denotes use of Medical Subject Headings (MeSH) in OVID Medline and EMTREE in EMBASE
exp - subject heading has been exploded to include narrower more specific terms
* prior to search term - subject heading has been focussed
* following search term - Truncation (search term starting with the letters preceding the asterisk)
SCOPUS search (limited to Medicine and Health Professions)
( "Cricket" OR "Fast Bowling" OR "Fast Bowler" ) AND ( "Risk Factor*" OR "Risk" OR "Factor*" OR
"Variable" OR "Intrinsic" OR "Age" OR "Adolescent" OR "Young" OR "Adult" OR "Technique" OR
"Biomechanic*" OR "Kinematic*" OR "Kinetic*" OR "Strength" OR "Flexibility" OR "Range of motion" OR
"Muscle" OR "Asymmetry" OR "Cross Sectional Area" OR "Volume" ) AND ( "Pain" OR "Injury" OR
"Fracture" OR "Stress" OR "Stress Fracture" OR "Stress Reaction" OR "Reaction" OR "Pars interarticularis"
OR "Pars" OR "Pedicle" OR "Spondylolysis" OR "Spondylolisthesis" OR "Bone" OR "Oedema" OR "Edema" )
AND ( "Low Back" OR "Back" OR "Lumbar" OR "Lumbar Spine" ) AND ( LIMIT-TO ( SUBJAREA,"MEDI"
) OR LIMIT-TO ( SUBJAREA,"HEAL" ) )
SPORTDiscus and CINAHL Search retrieval steps

( "Cricket" OR "Fast Bowling" OR "Fast Bowler" )
AND ( "Risk Factor*" OR "Risk" OR "Factor*" OR "Variable" OR "Intrinsic" OR "Age" OR
"Adolescent" OR "Young" OR "Adult" OR "Technique" OR "Biomechanic*" OR "Kinematic*"
OR "Kinetic*" OR "Strength" OR "Flexibility" OR "Range of motion" OR "Muscle" OR
"Asymmetry" OR "Cross Sectional Area" OR "Volume" )
AND ( "Pain" OR "Injury" OR "Fracture" OR "Stress" OR "Stress Fracture" OR "Stress Reaction" OR
"Reaction" OR "Pars interarticularis" OR "Pars" OR "Pedicle" OR "Spondylolysis" OR
"Spondylolisthesis" OR "Bone" OR "Oedema" OR "Edema" )
AND ( "Low Back" OR "Back" OR "Lumbar" OR "Lumbar Spine" )
Web of Science Search

(((TS=(( "Cricket" OR "Fast Bowling" OR "Fast Bowler" ))) AND TS=(( "Risk Factor*" OR "Risk" OR
"Factor*" OR "Variable" OR "Intrinsic" OR "Age" OR "Adolescent" OR "Young" OR "Adult" OR "Technique"
OR "Biomechanic*" OR "Kinematic*" OR "Kinetic*" OR "Strength" OR "Flexibility" OR "Range of motion"
OR "Muscle" OR "Asymmetry" OR "Cross Sectional Area" OR "Volume" ))) AND TS=(( "Pain" OR "Injury"
OR "Fracture" OR "Stress" OR "Stress Fracture" OR "Stress Reaction" OR "Reaction" OR "Pars
interarticularis" OR "Pars" OR "Pedicle" OR "Spondylolysis" OR "Spondylolisthesis" OR "Bone" OR
"Oedema" OR "Edema" ))) AND TS=(( "Low Back" OR "Back" OR "Lumbar" OR "Lumbar Spine" ))
Additional file 2 Defined criteria for rating of included studies with the Quality in Prognostic Studies
(QUIPS) tool
1. Study Participation
Prompting items Criteria for yes (yes, no, unclear, not reported)
Goal: To judge the risk of selection bias (likelihood that

the relationship between prognostic factors and lumbar
spine injury is different for participants and eligible
non-participants).
Optimal study or characteristics of unbiased QUIPS criterion: the study sample adequately
study represents the population of interest.
a) Adequate participation in the study by The participants should be representative of the cricket
eligible persons. fast bowling population. The involvement of
participants belonging to a single local organisation
such as a club, team, academy, school, etc. has low
generalisability and low representativeness. Teams and
single organisations differ in training methods and
strategies, competitive level of matches,
sociodemographic characteristics, as well as injury
recording personnel, procedures, and definitions. The
interpretation of representativeness is also based on the
context in the study introduction specifying the
population of interest.
b) Description of the source population or Studies should provide basic information about the
population of interest population of interest such as the estimation of the total
number and playing/skill level of participants. This is
necessary to understand the representativeness of the
sample and/or the context of applicability of the results.
Groups of fast bowlers made up of overwhelmingly
professional or adult populations may
disproportionately represent survivors, as lumbar stress
injuries appear to overly affect younger populations and
many injured young bowlers may not return to a
preinjury level of fast bowling and have an opportunity
to progress to elite high performance and professional
squads.
c) Description of the baseline study sample As a minimum, studies should report age range and
mean, gender, anthropometric characteristics and
whether all participants were of a fast bowler skill set.
More comprehensive descriptions would include
playing experience, competition level, history of low
back pain, injury history, presence of low back pain or
injury, or other injury at study commencement.
Accurately reporting time zero and clarifying the target
population for generalisability are important steps in
avoiding survivor bias. Studies with the potential to
include participants with and without the outcome
measurement at study commencement are at increased
risk of bias. Studies should report if a control group was
employed, and if so, if this was age matched, matched
in numbers, and subject to equivalent examination and
exposure. Elite performers or those in high performance
squads may have access to higher quality monitoring
and rehabilitation than fast bowlers in community-
based programs so these bowlers may not be
representative of the general fast bowling population.
These considerations are applicable when examining
cross sectional, retrospective and prospective study
designs within high performance and professional
cohorts.
d) Adequate description of the sampling Studies should report whether recruitment was on
frame and recruitment individual and/or team/organisation voluntary basis.
The sampling frame and recruitment method of fast
bowlers (newspaper or internet advertisement,
telephone interviews, questionnaires, nomination by
clubs or coaches, captured from database) should be
adequately described, including methods to identify the
sample sufficient to limit potential bias including the
number and types of recruitment used. Studies should
report whether recruitment of participants occurred
simultaneously or at different times. If recruitment was
through a process of interviews or randomisation, the
response rate should be reported to help assess level of
response and whether this is likely represents a sample
that is applicable to other groups. In prospective studies
that require recruitment through recommendation,
searching of databases, social media, internet
advertisement or telephone interviews, potential
survivor bias may exist as injured players will be less
likely to volunteer or be included in these studies, hence
reducing the representativeness of these studies. Cross
sectional studies and retrospective cohort study designs
are also subject to survivor bias in that those fast
bowlers who develop lumbar spine injuries may have
stopped bowling and not be available to be included in
these study designs, and those still bowling may
demonstrate a ‘survivor bias’, which may lead to the
underestimation of risk.
e) Adequate description of the period and Studies should specify the period of recruitment, when
place of recruitment they were conducted, and their duration. Reporting of
time of recruitment or time of testing (preseason, during
season or after season) is important. Timing of testing
during the season potentially alters levels of recruitment
and profile of risk factors based on assessment findings
derived from testing. Additionally, the place of
recruitment (setting and geographic location) should be
adequately described.
f) Adequate description of the inclusion and Studies should report inclusion and/or exclusion criteria
exclusion criteria to clarify and justify whether there were fast bowlers
excluded at study commencement, reasons for
exclusion or whether fast bowlers were included at a
later stage of the study. For prospective studies this
should include explicit diagnostic criteria or “zero time”
description that objectively decide which individuals
are included or excluded from a study. For retrospective
or case control studies, there should be definitions of
discrete groups with and without current low back pain,
history of low back pain or radiological findings. Both
types of studies ideally should include physician
diagnosis or explicit diagnostic codes.
Summary of QUIPS criteria for Study The study participation domain addresses whether the
Participation study sample is representative of the fast-bowling
population on key characteristics sufficient to limit
potential bias of the observed relationship between
prognostic factors and outcome of lumbar spine injury.
High risk: The relationship between prognostic factors
and outcome is very likely to be different for
participants and eligible nonparticipants. Moderate risk:
The relationship between prognostic factors and
outcome may be different for participants and eligible
nonparticipants. Low risk: The relationship between
prognostic factors and outcome is unlikely to be
different for participants and eligible nonparticipants.
2. Study Attrition
Goal: To judge the risk of attrition bias (likelihood that

the relationship between prognostic factors and
outcome of lumbar spine injury is different for
completing and non-completing participants).
Optimal study or characteristics of unbiased The study data available (i.e., participants not lost to
study follow-up) should adequately represent the study
sample.
a) Adequate response rate for study In prospective studies, has the study completion rate
participants and/or attrition rate been reported?
b) Description of attempts to collect Has this information been included in the methods
information on participants who dropped section? Have there been descriptions of attempts to
out collect information on participants who dropped out?
c) Reasons for loss to follow-up are Study reports information on why participants were lost
provided during the study so that the reasons for loss of
participants can be evaluated. This would specifically
refer to whether participants were lost due to random
causes or because they may have been injured. In
prospective studies, if there is no reporting of attrition
bias, or if there is no reporting as to reasons why
participants who commenced the study did not
complete a study, the representativeness of the sample
being measured may be reduced. Survivor bias can
occur in prospective studies if participants’ willingness
to remain in a longitudinal study depends on their
health and injury status, as participants who are most
impaired or injured are more likely to be lost to follow-
up, resulting in a final study sample that has excluded
the poorest faring members of the cohort.
d) Adequate description of participants lost Participants lost to follow-up are adequately described
to follow-up for key characteristics (age, sex, injury status, history of
low back pain, radiology findings).
e) There are no important differences Does any information exist that describes whether
between participants who completed the important differences exist in key characteristics (age,
study and those who did not sex, injury) and outcomes between participants who
completed the study and those who did not?
Summary of QUIPS criteria for Study The study attrition domain addresses whether
Attrition participants completing the study (i.e., with follow-up
data) represent the baseline sample. High risk: The
relationship between prognostic factors and outcome is
very likely to be different for completing and non-
completing participants and/or if there is no reporting of
attrition rate in study. Moderate risk: The relationship
between prognostic factors and outcome may be
different for completing and non-completing
participants; Low risk: The relationship between
prognostic factors and outcome is unlikely to be
different for completing and non-completing
participants
3. Prognostic Factor Measurement
Goal: To judge the risk of measurement bias related to

how prognostic factors were measured (differential
measurement of prognostic factors related to the level
of outcome of lumbar spine injury).
Optimal study or characteristics of unbiased The prognostic factor is measured in a similar way for
study all participants.
a) A clear definition or description of the A clear definition or description of the prognostic
prognostic factor is provided factors being investigated are provided with clear
specification of the method of measurement.
b) Method of prognostic factor Methods of prognostic factor measurement are
measurement is adequately valid and adequately valid and reliable to limit misclassification
reliable bias. If injury or radiological features were sustained
prior to prognostic factor measurement, then it is
possible that prior injury may have caused bowlers to
present with assessment findings during fast bowling
technique analysis or musculoskeletal screening as a
result of injury. The use of a test or procedure because
it has been used previously or has no alternative is not
considered support enough to its validity as a metric or
prognostic factor measure. Studies should present
evidence or reasonable plausibility to validate the use of
a specific prognostic factor and the metric that is
employed to measure that factor. This may include
relevant external sources regarding the validity and
reliability of testing and measurement of prognostic
factors. This may also relate to characteristics such as
blind measurement and limited reliance on recall if
questionnaires are used. The study should clearly
provide information (so that it is replicable) on how the
metric/variable was constructed. The analysis of the
kinematics and kinetics of fast bowling based on a
single or a very small number of trials is likely to lead
to inaccuracies in the measurement of prognostic
factors related to this analysis. The measurement of
kinematics of the fast-bowling action with the use of
two-dimensional (2-D) motion analysis is subject to
issues with reliability, particularly when different
members of a cohort are assessed by multiple observers.
The validity of 2-D motion analysis for fast bowling is
questionable, as the kinematics of fast bowling are
multi-planar and 2-D motion analysis is subject to
perspective error. The measurement of bone marrow
oedema and pathology with the use of MRI in
multicentre studies is prone to error as inter-rater
reliability for the detection of these variables is less
than optimal. Tests would only be considered valid and
reliable if there is literature supporting these
assumptions.
c) Continuous variables are reported, or Studies discretizing continuous variables should report
appropriate cut points are used not only how the cut points or cut offs were calculated
but also why a procedure was used and the effect of the
discretization in relation to the number of events in each
category.
d) The method and setting of measurement The devices and calculations used to measure
of prognostic factors is the same for all prognostic factors are the same for all participants.
study participants Combinations of measures derived from different
systems (e.g., 2-D vs three-dimensional motion analysis
of biomechanical factors associated with fast bowling
technique) for assessment across a single cohort is
considered inadequate 1) without evidence supporting
the aggregation coming from studies on the same
systems used in the prognostic studies or 2) without
providing sufficient data in the method sections to
support the aggregation. If prognostic factors are not
measured over a similar time span for all participants,
then this is also considered to be a source of bias.
e) Adequate proportion of the study sample An adequate proportion of the study sample (more than
has complete data for the prognostic factor 80%) had prognostic factor variables available for
analysis. A study should present the proportion of
missing data.
f) Appropriate methods of imputation are Studies using listwise deletion should present evidence
used for missing prognostic factor data or support that data were missed completely at random,
and sensitivity analysis to show the effect of
imputation. Studies using multiple imputations
(preferred method) should show the data were missed at
random, and sensitivity analysis to show the effect of
imputation. Single imputation is considered
inappropriate and justification of the single imputation
method among those available indicated. However, the
rating is increased when at least the effect of single
imputation is reported in a sensitivity analysis to show
the effect of imputation.
Summary of QUIPS criteria for Prognostic The prognostic factor measurement domain addresses
Factor Measurement adequacy of measurement of prognostic factors of
interest toward non-differential measurement related to
lumbar spine injury. High risk: The measurement of
prognostic factors is very likely to be different for
different levels of the outcome of interest. Moderate
risk: The measurement of prognostic factors may be
different for different levels of the outcome of interest.
Low risk: The measurement of the prognostic factors is
unlikely to be different for different levels of the
outcome of interest.
4. Outcome Measurement
Goal: To judge the risk of bias related to the

measurement of outcome of lumbar spine injury.
Optimal study or characteristics of unbiased The outcome of interest is measured in a similar way
study for all participants.
a) A clear definition of the outcome is A clear definition of lumbar spine injury according to
provided standardised methods (which could relate to injury
history/reported pain/clinically diagnosed
pathology/radiology findings) is provided, including
duration of follow-up and level and extent of the
outcome construct. If the definition is modified or self-
developed, the study justifies the changes and support
the validity of the new or modified definition. Studies
should also report why a particular definition was used
as an outcome to avoid that the choice can be
interpreted as a biased solution to overcome the
problem of an insufficient number of outcomes for
statistical analysis with alternative definitions. Studies
should also demonstrate the conceptual relation
between the outcome and the specific prognostic factor
unless the appropriateness of a generic outcome (e.g.,
injured/not injured vs. specific type) is supported.
b) Method of outcome measurement is The definition of lumbar spine injury employed in a
adequately valid and reliable particular study is adequately valid and reliable to limit
misclassification bias. This may include relevant
outside sources of information on measurement
properties and characteristics such as blind
measurement and confirmation of outcome with valid
and reliable tests. The study should report who
collected outcome data and the method of collection.
Reference or information to support the validity (e.g.,
accuracy) and reliability of the procedure should be
provided.
c) The method and setting of outcome The method, setting and definition of the outcome
measurement is the same for all study measurement of lumbar spine injury for the concerned
participants study is the same for all participants in that study.
Summary of QUIPS criteria for Outcome The outcome measurement domain addresses the
Measurement adequacy of lumbar spine injury outcome
measurements toward non-differential measurement
related to prognostic factors. High risk: The
measurement of the outcome is very likely to be
different related to the baseline level of prognostic
factors, Moderate risk: The measurement of the
outcome may be different related to the baseline level
of prognostic factors, Low risk: The measurement of
the outcome is unlikely to be different related to the
baseline level of prognostic factors.
5. Study Confounding
Goal: To judge the risk of bias due to confounding (i.e.,

the effect of a prognostic factor is distorted by another
factor that is related to the prognostic factor and the
outcome)
Optimal study or characteristics of unbiased Important potential confounding factors are
study appropriately accounted for
a) All important confounders are measured The study has considered and measured relevant
confounders. In this context confounders are considered
as a bias category (mixing of extraneous effects
distorting the real effect of exposure that includes true
confounders but also colliders, mediators, and effect
modifiers). These could include but not be limited to a
reasonably comprehensive set of variables/prognostic
factors potentially related to lumbar spine injury in fast
bowlers that would include but not be limited to the
biomechanics of the fast-bowling action, physical
factors such as strength and range of motion, individual
demographics (age, gender), and bowling workloads.
Confounders that should also be taken into
consideration include those attributable to professional
cricket and high-performance populations as opposed to
those resulting from preprofessional (or community
level) participation, and this could include variables
such as increased workloads, differing schedules,
differences in injury prevention and management,
standard of post injury rehabilitation, differences in
weight, age, bowling speeds, strength and conditioning
programs, and levels of monitoring. When reference to
important potential confounders is made in studies,
there is an expectation that these variables were
measured, or at least an explanation as to why these
were not measured. Within this bias category, the
manner in which a variable may influence the
associations between the prognostic factor and the
outcome should be explained (mediation, moderation,
confounder, etc.), and this explanation should be
reasonable/plausible. If the inference of the study is
causal in the reporting of the relationship between
investigated variables and lumbar spine injury
outcomes, then the absence of measurement of potential
confounders would relate to increased bias.
b) Clear definitions of the important Study should report clearly in the text the operational
confounders measured are provided definition of identified confounders.
c) Measurement of all important This information should be reported clearly in the text
confounders is adequately valid and reliable of the methodology of the study. Measurement may
include relevant outside sources of information on
measurement properties, also characteristics, such as
blind measurement and limited reliance on recall).
d) The method and setting of confounding This information should be reported clearly in the text
measurement are the same for all study of the methodology of the study.
participants
e) Appropriate methods are used if A study using listwise deletion should present evidence
imputation is used for missing confounder or support that data were missed completely at random,
data and sensitivity analysis to show the effect of
imputation. A study using multiple imputations
(preferred method) should show the data were missed at
random, and sensitivity analysis to show the effect of
imputation.
f) Important potential confounders are If important potential confounders are accounted for in
accounted for in the study design the study design (e.g., matching for key variables,
stratification, or initial assembly of comparable groups).
These should be controlled in the design or in the
analysis.
g) Important potential confounders are Important potential prognostic factors are accounted for
accounted for in the analysis in the analysis (i.e., appropriate adjustment), and these
domains of interest include but are not limited to
previous injury, anthropometric variables, the
biomechanics of the fast-bowling action, physical
factors such as strength and range of motion, individual
demographics (age, gender), and bowling workloads.
When suggesting variables as mediators, attempts to
support the role of the variable as mediator should be
provided. Also addressing (support) in a narrative way
the mediator effect was evaluated positively. Any
suggested confounder, effect modifier or moderator,
collider etc. should be considered in the analysis. If the
inference of the study is causal in the reporting of the
relationship between investigated variables and lumbar
spine injury outcomes, then the absence of potential
confounders in the analysis of results would relate to
increased bias.
Summary of QUIPS criteria for Study The study confounding domain addresses potential
Confounding confounding, or distortion of the relationship between
investigated prognostic factors and lumbar spine injury
outcomes by another factor. High risk: The observed
effect of the prognostic factor on the outcome is very
likely to be distorted by another factor related to
prognostic factor and outcome, Moderate risk: The
observed effect of the prognostic factor on outcome
may be distorted by another factor related to prognostic
factor and outcome, Low risk: The observed effect of
the prognostic factor on outcome is unlikely to be
distorted by another factor related to prognostic factor
and outcome.
6. Statistical Analysis and Reporting

Goal: To judge the risk of bias related to the statistical

analysis and presentation of results
Optimal study or characteristics of The statistical analysis is appropriate, and all primary
unbiased study outcomes are reported
a) Sufficient presentation of data to assess There is sufficient presentation of data to assess the
the adequacy of the analytic strategy adequacy of the analytic strategy. The study should
contain sufficient information and details to
understand the statistical methods used and the
calculations done, and to allow replication.
b) The strategy for model building is Studies should use the appropriate model in relation to
appropriate and is based on a conceptual the goal of the study. If findings were interpreted as
framework or model causal associations, the model should be based on a
conceptual framework or model, and any causal
assumptions should be reported. Although backward
or forward selection are not considered optimal, these
are acceptable selection methods for explorative
studies providing that results are discussed in terms of
associations, and not as causal links. Checking for and
considering collinearity is required. Selecting
variables significant in univariate analysis before
multivariate analysis is conducted is considered
inappropriate. Studies should justify the sample
(power analysis) and support it is adequate for the
analysis. Post hoc power analysis is inappropriate and
cannot be used to justify the sample used. Studies
should report information for understanding whether
there is a risk of sparse data bias (e.g., event for each
category or distribution of the outcome in relation to
the prognostic factor). Injury recurrence should be
considered.
c) The selected statistical model is Studies should report results showing the association
adequate for the design of the study of prognostic factors and lumbar spine injury (which
could relate to injury history/reported pain/clinically
diagnosed pathology/radiology findings), including
information about statistical significance. Continuous
variables are reported or (i.e., not data dependent) cut-
off points are used. Increased risks of bias for
statistical analysis are adjudged in studies that do not
include careful interpretation of statistical test
requirements in methodologies and reporting that refer
to examining the sizes of effect estimates and
confidence limits, the values of relative risk and odds
ratios, and precise P values. Additionally, lower risk
studies are characterised using multivariate analysis,
and negative and positive predictive values.
d) There is no selective reporting of results All variables (outcomes and prognostic factors) that
are described in the methods section should be
included in the results section with words or in
numbers (tables, figures). Uncertainty should be
reported for all measures of associations and
considered in the interpretation. Similarly in the
discussion, all results should be discussed without
focusing on the significant ones and acknowledging
inconsistencies and “unexpected predictor-outcome
associations” that may suggest the model in invalid
and poor generalizability. As a minimum, if there was
no explanation supporting the relevance, validity of
plausibility of a specific metric for a specific category
of injuries, the details about injury numbers and types
for each analysis and category (if a continuous
predictor is discretized) should be reported.
Summary of QUIPS criteria for Statistical The statistical analysis and reporting domain
Analysis and Reporting addresses the appropriateness of the study’s statistical
analysis and completeness of reporting. High risk: The
reported results are very likely to be spurious or
biased related to analysis or reporting. Moderate risk:
The reported results may be spurious or biased related
to analysis or reporting, Low risk: The reported results
are unlikely to be spurious or biased related to
analysis or reporting
Additional File 3 Detailed Quality in Prognostic Studies (QUIPS) assessment for evaluating risk of bias
in each study
Study ID: Foster et al. 1989 [42]
Risk of
Domain Support for judgement
bias
82 potentially high-performance fast bowlers aged 15 to 22 from an
Study
High unspecified number of club and/or school teams. Recruitment method was
participation
nomination by coaches. Injury history not specified.
Prospective study with duration of one cricket season with no reporting of
Study attrition Moderate
any attrition rates.
A single bowling trial from three deliveries used for technique analysis.
Prognostic factor Discretization of fast bowling technique analysis and no rationale for cut
High
measurement off points described. No reference to reliability of risk factor
measurements.
Clear injury definition with follow up of one cricket season. Computed
Tomography (CT) valid to assess Lumbar Bone Stress Injury (LBSI)
Outcome
High involving a cortical breach but not valid for lumbar bone stress reactions.
measurement
Methodology and reliability associated with radiology reporting not
referred to.
Large range of potential confounders identified but not included in a
Study
Moderate multivariable analysis. Causation between investigated variables and
confounding
lumbar injury outcome is implied.
Statistical
Univariate analysis referred to in methodology. Results of statistical
analysis and High
analyses not reported.
reporting
Study ID: Elliott et al. 1992 [54]
Risk of
bias
Study Sample of 20 fast bowlers (mean age 17.9 ± 1.6 years), who were members
Moderate
participation of a state association development squad. Injury history not specified.
Study attrition Low Retrospective cohort study design.
A single bowling trial from two deliveries used for technique analysis.
Prognostic factor Back and front foot kinetic data recorded from separate trials.
High
measurement Discretization of fast bowling technique data. No reference to reliability of
risk factor measurements.
CT valid to assess LBSI involving cortical breach but not for the diagnosis
Outcome
High of lumbar bone stress reactions. Methodology and reliability associated
measurement
with radiology reporting not referred to.
Study
confounding
Statistical
Univariate analysis referred to in methodology. Precise p values, effect
analysis and High
sizes or confidence intervals not reported.
reporting
Study ID: Hardcastle et al. 1992 [55]
Risk of
bias
Sample of 24 fast bowlers aged 16 to 18 years, selected for special training
Study
Moderate in a state team squad. Presence of low back pain (LBP) at study
participation
commencement referred to. Injury history not specified.
Study attrition Low Cross-sectional study.
Methods of bowling technique measurement and assessment not reported.

Prognostic factor
High Discretization of fast bowling technique data. No reference to reliability of
measurement
Radiographs and CT scans assessed by three radiologists, but no reference
Outcome to reliability of CT assessments. Magnetic Resonance Imaging (MRI)
High
measurement assessed independently. CT valid to assess LBSI involving cortical breach
but not for the diagnosis of lumbar bone stress reactions.
No confounding variables accounted for in design, conduct and analysis.
Study
High Causation between investigated variables and lumbar injury outcome is
confounding
implied.
Statistical
analysis and High Methodology and results of statistical analyses are not presented.
reporting
Study ID: Elliott et al. 1993 [56]
Risk of
bias
Study 24 bowlers of mean age 13.7 years, selected from 5 schools. Injury history
Moderate
participation not specified.
A single trial digitised for technique analysis from a total of two deliveries.
Prognostic factor
High Discretization of fast bowling technique data. No reference to reliability of
measurement
Outcome MRI scans assessed by one radiologist. No description or measurement of
Moderate
measurement the reliability of this assessment reported.
Study
confounding
Statistical Precise p values reported. Significance of a causal association reported
analysis and Moderate with p value of 0.088. No effect sizes or confidence intervals are reported.
reporting Multivariate analysis not reported in methods or results.
Study ID: Burnett et al. 1996 [43]
Risk of
bias
Study 19 bowlers of mean age 13.6 years, selected from 5 schools. Injury history
Moderate
participation not specified.
Attrition rate not reported in this prospective study of 2.7 years duration in
Study attrition High
adolescents.
A single trial from two bowling trials used for measurement of kinematics
Prognostic factor
High of fast bowling technique. Rationale for discretization of bowling technique
measurement
data not reported. No reference to reliability of risk factor measurements.
Different MRI scanners used at start and end of study. Divergent outcome
Outcome measures for different participants, as a case of pars fracture was included
High
measurement in the statistical analysis for this study analysing the relationship between
bowling technique and thoracolumbar disc degeneration.
Study
confounding
implied.
Statistical Significance level set at 0.05 and p values were reported. Effect sizes or
analysis and Moderate confidence intervals not reported. Multivariate analysis not reported in
reporting methods or results.
Study ID: Elliott & Khangure 2002 [65]
Risk of
bias
41 fast bowlers in two groups. Group 1 recruited from state cricket
Study
Moderate association development squad. Group 2 commenced study one year later,
participation
and method of recruitment not reported. Injury history not specified.
Attrition rate not reported in this intervention study of four years duration
in adolescents.
A single trial with the highest ball release speed from three bowling trials
Prognostic factor used for measurement of kinematics of fast bowling technique. Rationale
High
measurement for discretization of bowling technique data not reported. No reference to
reliability of risk factor measurements.
Each scan over the four years of the study assessed by the same blinded
Outcome
Moderate professional, but no description or measurement of the reliability of this
measurement
assessment reported.
Study
confounding
implied.
Statistical Precise p values reported. Significant main effects calculated with Tukey
analysis and Moderate post hoc testing and reported. Multivariate analysis not reported in methods
reporting or results.
Study ID: Portus et al. 2004 [60]
Risk of
bias
Homogenous group of 42 high performance adult male fast bowlers
Study
Moderate recruited from visits over a three year period to a national sports institute.
participation
Recruitment sampling rate not specified. Potential survivor bias.
Non-reporting of attrition rate in prospective portion of study. Attrition bias
not applicable in retrospective portion of study.
A single bowling trial analysed per participant. Kinematic data for different
participants measured prior to injury and post injury and in some
participants previous lumbar injury may have influenced fast bowling
Prognostic factor technique. Discretization used to classify fast bowling techniques in terms
High
measurement of hip-shoulder separation (HSS) at back foot contact (BFC), shoulder
counter rotation (SCR) and knee angles during front foot contact (FFC).
Sampling rate of three-dimensional (3-D) motion analysis varied between
50 and 100Hz. No reference to reliability of risk factor measurements.
Potential recall bias associated with retrospective injury data. Prospective
Outcome
Moderate data recorded by medical professionals external to study group over several
measurement
years.
Study
High Causation between characteristics of fast bowling technique and lumbar
confounding
injury is implied.
Statistical
Precise p values and correlation coefficients were reported. Multivariate
analysis and Moderate
analysis not reported in methods or results.
reporting
Study ID: Engstrom et al. 2007 [44]
Risk of
bias
Bowlers (n = 56) from club to national level, and a control group of
Study
Moderate swimmers (n = 20) recruited. Method of recruitment not specified. No
participation
reporting of injury history.
Seven of a total of 76 participants did not complete this prospective study.
Study attrition Low
Reasons for non-completion reported for three of the seven withdrawals.
Whilst the method of measurement and analysis of reliability of Quadratus
Lumborum (QL) asymmetry is clearly defined, muscle profile templates
Prognostic factor
High based on multiyear images were generated to overcome difficulties in
measurement
measurement. These may have distorted reported volumes. Discretization
of QL asymmetry data into quartiles.
All MRI analyses blinded with respect to injury history and participant
Outcome characteristics. Reliability of this measurement not reported. Frequency and
Moderate
measurement method of gathering injury outcome data not reported. Uneven study
durations in fast bowling and control groups.
Study
Low Causation between QL asymmetry and lumbar injury is not specifically
confounding
implied.
Statistical Precise p values and confidence intervals reported. Univariate logistic
analysis and Low regression, and area under the curve used for assessing the discriminatory
reporting power of the model to predict injury.
Study ID: Stuelcken et al. 2008 [57]
Risk of
bias
Homogenous sample of elite female fast bowlers identified as "elite" by
Study
High national team coach and recruited on this basis. Skill set and certain
participation
anthropometric characteristics reported. Potential survivor bias.
Study attrition Low Retrospective cohort study.
Assessed variables measured by two testers blinded to LBP status who
Prognostic factor underwent extensive training. Acceptable reproducibility in measurements
Low
measurement prior to study commencement. Reliability of testing procedures employed
referred to.
Whilst self-reported pain had to be verified by records kept by team
Outcome
Moderate medical support staff, there was a possibility of under reporting of
measurement
incidence of the outcome measure which was a career history of LBP.
Several confounding variables were accounted for in the design and
Study conduct, but these were not controlled for in analysis of results. Causation
Low
confounding between lumbar lateral flexion range of motion and a career history of LBP
not implied.
Statistical
P values reported with significance level of p ⩽ 0.05. Multivariate analysis
not reported in methods or results.
reporting
Study ID: Ranson et al. 2010 [45]
Risk of
bias
Study Homogenous sample of high-level fast bowlers identified by national lead
High
participation fast bowling coach.
High performance cohort monitored by team medical staff for 2 years with
no documenting of rates of completion or drop out.
All bowlers underwent MRI scans in same machine. MRI scanning and
Prognostic factor
Low reporting procedures reported to be reliable and full details reported
measurement
elsewhere by same lead author [10].
MRI scans assessed by same radiologist using reliable classification
Outcome systems. Questioning of participants at six week intervals reduces the
Low
measurement potential for recall bias with injury definition relating to absence from
cricket for seven or more days.
Study
High Causation between detected MRI findings and subsequent development of
confounding
a stress fracture is implied.
Statistical
Significance level set at 0.05 and p values reported. Multivariate analysis
reporting
Study ID: Stuelcken et al. 2010 [58]
Risk of
bias
Homogenous sample of elite female fast bowlers identified as "elite" by
Study
High national team coach and recruited on this basis. Skill set and certain
participation
anthropometric characteristics reported. Potential survivor bias.
From a total of 20 to 25 maximum speed deliveries, four bowling trials
Prognostic factor selected for kinematic analysis. Precise definition of events and
Moderate
measurement classifications in fast bowling action reported. Fast bowling technique data
discretized on basis of previous studies.
Whilst self-reported pain had to be verified by records kept by team
Outcome
Moderate medical support staff, there was a possibility of under reporting of
measurement
incidence of the outcome measure which was a career history of LBP.
Study
High Causation between characteristics of the fast-bowling technique and a
confounding
career history of LBP implied.
Statistical Independent samples t tests, effect sizes and correlation coefficients
analysis and Low reported in methods and results. Multivariate analysis not reported in
reporting methods or results.
Study ID: Kountouris et al. 2012 [46]
Risk of
bias
Study Sample of 38 junior fast bowlers aged from 12 to 17 with no description of
Moderate
participation methods of recruitment.
Non-reporting of attrition rate in this prospective study (that was part of a
larger study) over one cricket season duration.
Reference to reliability of this measurement by same author in previous
study [58]. Limited number of images available for analysis and image
Prognostic factor
High slices included for analysis were at the L3–L4 vertebral levels.
measurement
Discretization of QL cross-sectional area (CSA) magnitude of asymmetries
based on percentages (0 < 10%, 10-20%, > 20%)
When injury was suspected, radiological investigations were performed at
Outcome radiology clinics based on the referring physician’s discretion. Participants
Low
measurement injured during the study period were not necessarily assessed by the same
sports physicians or radiologists.
Moderate control for confounding with the inclusion of age, height, mass,
Study
Low and body mass index in analysis of results. Causal relationship between an
confounding
absence of QL CSA and LBSI is not implied.
Precise p values reported. Confidence intervals not reported. Multivariate
Statistical
analysis not reported in methods or results. Post hoc power analysis
performed on results to determine study power to detect differences
reporting
between injured and non-injured bowlers.
Risk of
bias
Homogenous group of 23 national and international level adult male fast
Study
High bowlers. Recruitment through identification by respective selection panels.
participation
Potential survivor bias.
High performance cohort monitored by team medical staff. No
Study attrition Moderate documenting of rates of completion in this prospective study (that was part
of a larger study) over one cricket season duration.
Reference to reliability of this measurement by same author in previous
study [58]. Only 35% of all MR images were of sufficient quality to be
Prognostic factor included for analysis and no images of sufficient quality above the L2 mid
High
measurement vertebra level and below the L4/L5 disc level. Discretization of QL CSA
magnitude of asymmetries based on percentages (0 < 10%, 10-20%, >
20%)
A variety of clinical presentations may have been referred for radiology,
Outcome and investigations ordered to confirm diagnosis were made at the discretion
Low
measurement of sports medicine physicians. A range of radiology clinics and radiologists
were involved in this study.
Moderate control for confounding with the inclusion of age, height, mass,
Study
Low and body mass index in analysis of results. Causal relationship between an
confounding
absence of QL CSA and LBSI is not implied.
Precise p values reported. Confidence intervals not reported. Multivariate
Statistical
analysis not reported in methods or results. Post hoc power analysis
performed on results to determine study power to detect differences
reporting
between injured and non-injured bowlers.
Study ID: Olivier et al. 2014 [48]
Risk of
bias
17 amateur fast bowlers participated after a process of randomisation.
Study Potentially low response rate and no reporting of mean age may affect how
Moderate
participation representative the sample is. Description of basic characteristics of
participants reported including injury history.
Non-reporting of attrition rate in this prospective study in amateur cricket
fast bowlers over one cricket season duration.
Lumbar reposition measurement described clearly. Reference made to
Prognostic factor
Moderate reliability of electro goniometer used. Only one match pace delivery used
measurement
to be representative of lumbar spine positioning in the bowling action.
Outcome Some potential for recall bias during collection of LBP history. Low
Moderate
measurement potential for bias for collection of in season data collected monthly.
Some control for confounding with inclusion of previous injury in analysis
Study
Moderate of results. Causal relationship between lumbar proprioception and LBP is
confounding
implied.
Statistical
Reporting of p values and 95% confidence intervals. Multivariate analysis
reporting
Study ID: Gray et al. 2016 [62]
Risk of
bias
Homogenous sample of high-level adolescent fast bowlers with no
Study description of method of recruitment. Nine bowlers in non-pain group and
Moderate
participation 16 in LBP group. Bowlers with pain may have been more likely to
volunteer for this study.
Detailed description of methods of measurement. Reliability of thickness
Prognostic factor measurements of abdominal musculature established elsewhere. Thickness
Low
measurement used rather than CSA as not possible to visualize the entire muscles in the
ultrasound (US) Image, but three thickness measures used for each muscle.
Low risk of classification and recall bias with reporting of LBP history that
Outcome
Low may have caused participants to miss a match or practice session in the six
measurement
weeks prior to muscle thickness assessment.
Study
High Causation between abdominal muscle thickness and current/history of LBP
confounding
implied.
Statistical
Reporting of p values. Post hoc analysis performed where appropriate.
Multivariate analysis not reported in methods or results.
reporting
Study ID: Bayne et al. 2016 [49]
Risk of
bias
15 of 46 pain-free participants excluded prior to study due to findings on
Study
Moderate MRI scan, potentially reducing representative of this sample. No
participation
description of method of participant recruitment.
31 participants in study following initial MRI. Results report 25
Study attrition High participants, but no explanation or reasons given for missing six
participants.
Four bowling trials, in which each bowler achieved their highest ball
Prognostic factor release speeds across 18 deliveries, selected for analysis. Reliability
Low
measurement reported for bowling technique analysis. Reliability for musculoskeletal
screening testing reported elsewhere [128].
Outcome Diagnostic criteria for injury outcomes not applied uniformly for all study
High
measurement participants. Radiologically detected bone stress in asymptomatic
participants employed as an outcome measure in addition to self-reported
LBP during the course of the study.
Wide range of confounders accounted for in design and analysis of results.

Study
Low Causation implied between lower back injuries and investigated variables
confounding
including physical factors and characteristics of fast bowling technique.
Reporting of p values, Pearson correlation coefficients and 95% confidence
Statistical
intervals. Reporting of association of impaired lumbo-pelvic stability with
analysis and High
injury when confidence interval crossed 1.0 (CI 0.78-410). Multivariate
reporting
Study ID: Olivier et al. 2017 [50]
Risk of
bias
26 participants from 14 cricket clubs recruited through invitations and
Study
Moderate advertisements with past injury history and playing experience described.
participation
Response rate to recruitment not described.
Non-reporting of attrition rate in this prospective study over an 8 month
duration.
Detailed description of measurement method and reference to the intra-
Prognostic factor rater reliability of this measurement. Discretization of asymmetry data
Moderate
measurement conducted to compare the injury status of bowlers with percentage
difference of 10% or > to those with percentage difference of < 10%
Outcome Incidence, body site, nature, and management of injury were captured
Low
measurement monthly by one of the researchers using a self-administered questionnaire.
Study
High Causation between reduced lumbar multifidus CSA and lower back pain
confounding
implied.
Statistical
Reporting of p values, Cohen’s d effect sizes, 95% confidence intervals and
analysis and Low
relative risk ratios. Multivariate analysis not reported in methods or results.
reporting
Study ID: Alway et al. 2019 [51]
Risk of
bias
Large cohort of 368 fast bowlers prospectively monitored over seven years.
Study Survivor bias possible as sample consisted of elite high performance fast
Moderate
participation bowlers playing in matches, thus may not be representative of broader fast
bowling population.
Whilst this was a prospective injury surveillance study that examined
bowling workload and age as variables associated with lumbar spine injury,
Study attrition Low
attrition bias was not applicable as data was extracted from a database at
the conclusion of a six year period.
Prognostic factor Age at time of injury calculated from injury date and extracted from ECB
Low
measurement injury database used to prospectively monitor injuries.
Injury outcome required symptomatic presentation and radiological
Outcome
Low evidence which resulted in a player being unavailable for match selection
measurement
and was extracted from ECB injury database in this prospective study.
Some control for confounding with the inclusion of bowling workloads in
Study
Moderate the analysis of results. Causal relationship between age at time of injury
confounding
and development of a symptomatic lumbar stress fracture implied.
Statistical Precise p values reported. Effect sizes calculated. Means, SDs and 95%
analysis and Low confidence intervals were calculated. Multivariate analysis with binary
reporting logistic regression.
Risk of
bias
Participants were from national senior or developmental squads. No
Study
Moderate explanation as to how fast bowlers were recruited. Potential survivor bias.
participation
Representativeness of sample to wider fast bowling population is uncertain.
Measurement of prognostic factor clearly described and precision of
repeatability of each analysis determined on same day testing. Bone
Prognostic factor mineral content (BMC), bone mineral density (BMD), and area of L3
Moderate
measurement vertebral body and posterior elements was measured, but this may not be
representative of the same variables at the L4 and L5 levels which appear
to be the most prevalent levels for LBSI in fast bowlers [31, 38].
Lumbar stress fracture (LSF) history potentially subject to misclassification
Outcome bias due to sourcing of injury history performed retrospectively from
Moderate
measurement existing records. Possible incidence of injury prior to bowler being
monitored by available medical records.
Some control for confounding with the inclusion of age and fat free mass
Study as covariates to control for related changes in BMD and BMC in the
Moderate
confounding analysis of results. A causal relationship between site-specific low BMD
within the lumbar spine and lumbar stress fracture is implied.
Univariate tests used to assess differences between groups with regards to
Statistical
injury and BMC/BMD. Age and fat free mass used as covariates to control
analysis and Low
for related changes in BMD and BMC. Means, SDs, effect sizes and 95%
reporting
confidence intervals were calculated.
Risk of
bias
Participants were Australian junior elite fast bowlers selected in squads
Study
Moderate preparing for and participating in a national carnival. Representativeness of
participation
sample to wider fast bowling population is uncertain.
Participants prospectively monitored in a high-performance environment
Study attrition Low with use of Athlete Management System. Six MRI scans performed in an
eight month period.
Both 1.5 and 3.0 Tesla MR scanners used. Study conducted over seven
radiology centres. Analysis of reliability for detection of bone marrow
Prognostic factor
Moderate oedema (BMO) not reported in the study, but subsequent analysis within
measurement
this cohort showed an inter-rater reliability for the clinical detection of
BMO was moderate (Kappa score of 0.483) [65].
Outcome Participants were prospectively monitored, and injury diagnosis confirmed
Low
measurement by clinical examination and subsequent radiological investigations.
Some accounting for potential confounding factors with bowling workloads
Study monitored in conjunction with MRI findings. A causal relationship between
Moderate
confounding BMO detected on MRI scanning and the development of a subsequent
LBSI is implied.
Relative risk and odds ratios of developing a symptomatic BSI in
Statistical
participants who had BMO on any of the MRI scans during the study
analysis and Low
calculated. Positive and negative predictive values calculated. A binary
reporting
logistic model with an exchangeable correlation structure used.
Study ID: Senington et al. 2020 [61]
Risk of
bias
Sample of 14 senior fast bowlers and 21 junior fast bowlers recruited
Study
High through coaches from professional cricket clubs. Reporting of injury
participation
history.
For retrospective analysis, attrition bias not applicable. For prospective
analysis over one cricket season there was no reporting of attrition rate.
Measurement of investigated variables clearly described. Repeatability of
Prognostic factor each analysis and reliability of measuring instrument not described. The
Moderate
measurement number of trials in which kinematic data was extracted from in this study
was not specified in the methodology.
Possible recall bias in the retrospective portion of the study. No clear
Outcome
Moderate reporting of compliance regarding the questionnaire relating to the
measurement
prospective portion of the study.
Study
High Causation between characteristics of the fast-bowling technique and low
confounding
back pain implied.
Univariate tests conducted to compare means of relevant data. Cohen’s d
Statistical
effect sizes calculated to provide an estimate of the magnitude or strength
analysis and Low
of certainty of the observed effect. Multivariate analysis not reported.
reporting
Sample size calculation performed and based on previous study [49].
Risk of
bias
Sample of 50 elite fast bowlers enrolled in international performance
Study pathway. Risk of survivor bias. Inclusion criteria for the uninjured group
Moderate
participation reduces the likelihood of this sample being representative of the broader
fast bowling population.
Participants prospectively monitored over multiple years, but no reference
made to drop out or completion rates for participants.
Whilst each participant bowled six deliveries, a single trial was employed
Prognostic factor
High for analysis of fast bowling biomechanical technique variables. No
measurement
reference to reliability of risk factor measurements.
LBSI determined from radiological reports solely. Possible that both
symptomatic and asymptomatic bowlers included in analysis of LBSI. The
detection of LBSI with the use of radiology alone is not adequately valid as
Outcome
High dissociation exists between radiology, symptoms, and missed playing time.
measurement
Reliability of interpretation of MRI scans not reported. Unclear as to
whether some bowlers possessed LBSI prior to technical analysis and
whether some bowlers developed LBSI post technical analysis.
Study
High Causation between characteristics of the fast-bowling technique and LBSI
confounding
implied.
Univariate analysis conducted with a significance level of 0.05. Effect sizes
Statistical
calculated for all variables. Significant variables with medium or greater
analysis and Low
effect sizes entered into binary regression model to predict key indicators
reporting
for LBSI.
Study ID: Taylor et al. 2021 [64]
Risk of
bias
Fast bowlers in screened group nominated by medical team to possibly
Study
High benefit from the screening given their perceived risk of LBSI. Elite group
participation
of fast bowlers. Risk of survivor bias.
Study attrition Low Case series study.
Timing of scan deliberate to allow bowlers an opportunity for recovery if
Prognostic factor
High indicated introduces measurement bias. Intra-rater and inter-rater reliability
measurement
> 0.80 for 10% of the scans in measurement of BMO intensity ratio.
Outcome LBSI in participants determined by a combination of clinical examination
Low
measurement and radiology at the time of consultation in a high-performance cohort.
Some control for confounding with the inclusion of bowling workloads as
Study covariates to control for related changes in scan findings in the analysis of
Moderate
confounding results. A causal relationship between detected BMO on MRI scans and
LBSI implied.
Precise p values reported. Proportions and risk ratios calculated with a 95%
Statistical
confidence interval. Reporting of association of abnormal BMO with
analysis and High
subsequent LBSI when confidence interval crossed 1.0 (CI 0.6-5.5 and CI
reporting
0.5-4.4).
Study ID: Sims et al. 2021 [59]
Risk of
bias
222 youth fast bowlers from under 17 and 19 programs from six Australian
Study states from 2015 to 2020 were included. Likelihood of survivor bias as
Moderate
participation sample made up totally of elite high performance fast bowlers, thus may
not be representative of broader fast bowling population.
No reliability analysis for bowling technique analysis from six separate
locations. 68% of participants had bowling technique variables available
for analysis. Ranges of shoulder counterrotation and trunk lateral flexion
Prognostic factor
High discretized into low (0-25 deg), moderate (25-40 deg) and high (> 40 deg)
measurement
categories. Biomechanical and musculoskeletal data from different seasons
pooled for purposes of statistical analysis. 2-D and 3-D analysis pooled to
report analysis of fast bowling biomechanics and its relationship to injury.
LBSI identified by a combination of clinical examination and radiology in
Outcome
Low high performance environments and prospectively with use of Athlete
measurement
Monitoring System.
Multiple confounding factors were identified and accounted for in a
Study
Low multivariate analysis. Causation between investigated variables and injuries
confounding
implied.
Statistical Significant variables (p < 0.05) and others based on previous research
analysis and Low thought to be relevant were included into a multivariate model involving a
reporting binary logistic regression.
Study ID: Keylock et al. 2022 [41]
Risk of
bias
40 adolescent male bowlers recruited from professional academies or
Study schools and clubs with well-developed cricket programs. No description
Moderate
participation regarding method of recruitment. Details of baseline characteristics of
bowlers provided.
22 of the original cohort of 40 fast bowlers underwent MRI and Dual
Energy X-ray Absorptiometry (DEXA) assessment at study conclusion.
Attrition rate of 45%. Reasons given for participants who dropped out are
reported.
DXA used to assess BMC, BMD, and skeletal maturity. A musculoskeletal
Prognostic factor
Low assessment protocol employed prior to bowling and found to be
measurement
reproducible in a preliminary reliability study (ICC ≥ 0.946).
Outcome Asymptomatic and symptomatic cases that presented with changes on MRI
High
measurement classified as LBSI cases.
A wide range of confounding variables accounted for in design, conduct
Study
Low and analysis. Causation between investigated variables and LBSI measure
confounding
is implied.
Statistical
P values and corrected Hedges’ g effect sizes reported. Multivariate
analysis and Low
reporting
Additional File 4 Definitions for Intrinsic Variables
Age
• Chronological age - the age of a person expressed in years as measured from birth to a given date.
• Skeletal age - the age of a person expressed in years that corresponds to the level of maturation of the
skeleton, with this determination based on the presence of centres of bone formation as well as the
dimension and structure of bones.
Injury history
• History of low back pain (LBP) - previous incidence of LBP determined by subjective examination or
questionnaire.
• History of lumbar injury - previous incidence of lumbar spine injury determined by subjective examination,
questionnaire, or sourcing of medical records and databases.
Trunk and lumbar anatomical characteristics

• Quadratus Lumborum asymmetry - percentage asymmetry derived by comparing bilateral Quadratus
Lumborum Cross Sectional Area (CSA) or Volume as measured by MRI with participant positioned in
supine.
• Multifidus CSA - Ultrasound measurement of the Lumbar Multifidus muscle CSA in square
centimetres with participant positioned in prone with lumbar spine within 10° of horizontal.
• Abdominal muscle thickness - thickness in centimetres of the Internal Oblique, External Oblique, and
Transversus Abdominus muscles measured by Ultrasound at the end of a normal quiet expiration with
participant positioned in supine with the hips flexed to 45° and knees flexed to 90°.
Lumbar spine radiological variables

• Bone Mineral Content (BMC) - a measurement of bone mineral found in a specific area that is measured in
grams.
• Vertebral body area - a measurement of the area in square centimetres of the vertebral body which is the
thick, cylindrical, anterior and weight bearing portion of a vertebra that articulates with an adjacent
vertebral body by an intervertebral disc.
• Bone Mineral Density (BMD) - a measurement of the amount of bone mineral contained in an area of bone
that is derived by dividing the BMC by bone area and is normally expressed in grams/square centimetre.
• Lumbar disc degeneration - degenerative changes in the lumbar intervertebral disc related to a loss of disc
height and disc hydration.
• Bone Marrow Oedema (BMO) - the presence of abnormal fluid signal seen within the bone marrow as
detected by MRI.
• BMO Intensity Ratio - the ratio of the mean BMO intensity in the area with the highest signal intensity (in
the pars interarticularis or pedicle region) divided by the mean BMO intensity in the largest possible area of
the vertebral body. BMO intensity is measured by the elliptical region of interest tool in imaging software.
Biomechanics of fast bowling technique

• Ball release height - the vertical distance from the central core of the cricket ball to the ground at the instant
that a cricket ball is released from the bowler’s hand during the fast bowling action.
• Ball release speed - the speed of release of a cricket ball at the instant that it is released from the bowler’s
hand during the fast bowling action.
• Approach velocity - the mean horizontal velocity of a fast bowler during the run up (the bowler’s running
approach to the wicket prior to the delivery stride) of the fast bowling action.
• Back foot contact (BFC) - the initial point when the back foot (the foot ipsilateral to the dominant arm) is in
contact with the ground at the commencement of the delivery stride.
• Front foot contact (FFC) - the initial point when the front foot (the foot contralateral to the dominant arm) is
in contact with the ground at the conclusion of the delivery stride.
• Delivery stride length - the calculated distance from back foot contact to front foot contact in the fast
bowling action.
• Delivery stride alignment - the angle formed between back foot contact, front foot contact and a line
representing the direction of ball travel.
• Shoulder alignment - the angle of the line represented by a line joining the acromion processes in the
transverse plane in relation to the direction of ball travel. A front-on shoulder alignment is categorised if the
shoulder alignment of greater than 200° is present in relation to the direction of ball travel, as per the
graphical representation defining hip and shoulder alignment [169]
• Hip alignment - the angle of the line represented by a line joining the hip joints in the transverse plane in
relation to the direction of ball travel, as per the graphical representation defining hip and shoulder
alignment [169]
Graphical representation defining hip and shoulder alignment [169]
• Shoulder counter-rotation - the change between shoulder alignment at back foot contact and the minimum
shoulder alignment during the delivery stride. This is calculated by subtracting the alignment of the
shoulders when they are in their most side-on position (normally just prior to front foot contact), from the
shoulder alignment at back foot contact.
• Hip counter rotation - the change between hip alignment at back foot contact and hip alignment during the
delivery stride.
• Hip-shoulder separation - the angle that is calculated by subtracting the hip alignment angle from the
shoulder alignment angle. A positive separation angle refers to the shoulders being in a more front-on
alignment than the hip segment, a negative separation angle refers to the hip segment being more front-on
than the shoulder segment.
• Front-on bowling technique - Mixed technique - a hip-shoulder separation angle equal to or greater than 30°
at back foot contact, or shoulder counter rotation equal to or greater than 30°
• Side-on bowling technique – a shoulder segment angle less than 210° at back foot contact, a hip-shoulder
separation angle less than 30° at back foot contact, and shoulder counter-rotation less than 30°
• Semi-open technique – a shoulder segment angle from 210 to 240° at back foot contact, a hip-shoulder
separation angle less than 30° at back foot contact, and shoulder counter-rotation less than 30°.
• Mixed technique - a hip-shoulder separation angle equal to or greater than 30° at back foot contact, or
shoulder counter rotation equal to or greater than 30°.
• Pelvis alignment – the angle of the pelvis in the transverse plane in a 3-D motion analysis model in relation
to the direction of ball travel.
• Pelvis-shoulder separation - the angle that is calculated by subtracting the pelvis alignment angle from the
shoulder alignment angle.
• Lateral flexion - the degree of lateral flexion (frontal plane motion) of either the trunk, thorax,
thoracolumbar segment or lumbopelvic segment towards the non-bowling side.
• Rear hip angle - the degree of flexion or extension of the hip that is ipsilateral to the bowling arm and is
normally measured during the back foot contact phase of the fast bowling action.
• Rear knee angle - the degree of knee flexion or extension of the knee that is ipsilateral to the bowling arm
and is normally measured during the back foot contact phase of the fast bowling action.
• Front hip angle- the degree of flexion or extension of the hip that is contralateral to the bowling arm and is
normally measured during the back foot contact phase of the fast bowling action.
• Front knee angle- the degree of flexion or extension of the knee that is contralateral to the bowling arm and
is normally measured during the back foot contact phase of the fast bowling action.
• Flexion/extension - the degree of flexion/extension (sagittal plane motion) of the trunk, thorax,
thoracolumbar segment or lumbopelvic segment
• Rotation - the degree of rotation (transverse plane motion) of either the trunk, thorax, thoracolumbar
segment or lumbopelvic segment
• Front foot plant angle - the tilt orientation of the front foot at front foot contact that is represented by the
angle between the global y-axis (the line pointing down the wicket) and a line joining a projection of the
ankle and metatarsophalangeal joint centres onto a vertical global plane.
• Front leg plant angle - the tilt orientation of the front leg at front foot contact that is calculated by projecting
the hip and ankle joint centres onto a vertical plane and represented by the angle between the downwards
vertical and a line joining these two projected points.
• Ground Reaction Force - the force exerted by the ground on a body in contact with it.
• Tibial and sacrum acceleration - a proxy measurement for the impact forces experienced at the tibia and
sacrum respectively, commonly measured with a segment mounted accelerometer.
• Peak resultant acceleration - the square root of the sum of squared accelerations along all three axes
Physical testing
• Sit-and-reach - a field test used to measure hamstring and low back flexibility, involving a participant
sitting with feet approximately hip-wide against a testing box and slowly reaching forward as far as
possible by sliding hands along a measuring board whilst knees remain extended.
• Straight leg raise - a test for hamstring flexibility which assesses the range of hip flexion whilst the knee is
held in extension.
• Modified Thomas test - a test to assess hip extensibility and the presence of a hip flexion contracture.
• Bent knee fall-out - a test designed to measure hip and adductor muscle flexibility, involving a participant
to allow their knee to ‘fallout’ into hip abduction and external rotation whilst in supine.
• Lunge test - a test involving a participant standing and lunging forward with the subtalar joint remaining in
neutral and achieving maximal ankle dorsiflexion.
• Calf capacity - a test of calf endurance measured the maximum number of repeated maximal height single
leg calf rises performed in knee extension.
• Single leg bridge capacity - a test of the ability to maintain a single leg bridge position in supine for the
maximal length of time without lowering the hips, tilting the pelvis or arching the lumbar spine.
• Prone plank test - a test of the ability to maintain neutral spinal and pelvis alignment for the maximal length
of time in a prone position with elbows flexed at 90° whilst resting on forearms and toes with the trunk
raised off floor.
• Side plank test - a test of the ability to maintain neutral spinal and pelvis alignment for the maximal length
of time in a side-lying position supported on one elbow flexed at 90°, whilst resting on one forearm and
side of one foot with the trunk raised off floor.
• Biering-Sorensen test - a test for trunk extensor endurance assessing the maximal time the trunk can be
actively held in a neutral position with a participant in prone and fixed to the testing table at the ankles,
knees, and hips.
• Lumbar Reposition Error - the absolute difference between actual and participant replicated target positions
in the assessment of lumbar proprioception impairment.
• Single leg decline squat - a test that involves a participant squatting to 90° of knee flexion with the trunk
upright in in single leg stance on a board with 25° decline.
• Lumbopelvic stability test - a test that examines the ability to maintain neutral alignment of the lumbar
spine and pelvis whilst performing staged lower limb movements.
• Star Excursion Balance – a test used to assess deficits in dynamic postural-control as assessed by a series of
single-limb squats using the non-stance limb to reach maximally to touch a point along 1 of 8 designated
lines on the ground.

Farhart - Intrinsic Variables Associated With Low Back Pain and Lumbar Spine Injury in Fast Bowlers in Cricket A Systematic Review, BMCSSMR 2023

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Farhart et al.

BMC Sports Science,

RESEARCH Open Access

Intrinsic variables associated with low back

Background associated with injury [15]. Identifying intrinsic vari-

Fig. 1 PRISMA flow diagram of search and included studies

Table 1 Results of quality assessment of studies using the QUIPS tool

Study characteristics Participants

Bowling kinetics (GRF) zontal GRF during FFC and back

ment > 240° at BFC (p < 0.05).

cal features, in contrast to those

vs 110% in non-injured bowl-

or front-on technique recorded

eration (12.5%) when compared

from 35.4° at the commence-

tion angle than the no injury

injured group, but this was statisti-

Reporting of injury history

ing arm relative to the pelvis

When LBSI group was compared

bar bone stress at baseline, and all

side (post hoc—p = 0.03), but simi-

side in no pain group (post

lateral flexion power (25.8 ± 16.2

in bowlers with/without asym-

reported. No calculation of sam- vertebra and LSF history on BMC

peak resultant tibial acceleration

had less extension of their front

(data for a fast bowler closest

Table 3 Summary of intrinsic variables reported in included studies

Search OVID Medline/EMBASE

SPORTDiscus and CINAHL Search retrieval steps

Web of Science Search

Goal: To judge the risk of selection bias (likelihood that

Goal: To judge the risk of attrition bias (likelihood that

Goal: To judge the risk of measurement bias related to

Goal: To judge the risk of bias related to the

Goal: To judge the risk of bias due to confounding (i.e.,

6. Statistical Analysis and Reporting

Goal: To judge the risk of bias related to the statistical

Methods of bowling technique measurement and assessment not reported.

Wide range of confounders accounted for in design and analysis of results.

Trunk and lumbar anatomical characteristics

Lumbar spine radiological variables

Biomechanics of fast bowling technique

Graphical representation defining hip and shoulder alignment [169]

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