Spondylolysis (spon-dee-low-lye-sis) is a stress fracture of a section of the lumbar spine; most frequently the fifth vertebrae. The injury can occur on the left, the right, or both sides of the vertebrae. Spondylolysis occurs in up to 11.5% of the general population in the United States, and is most frequently seen in young males. Spondylolysis is a common cause of low back pain experienced in late childhood and adolescence. Highly active teens, both boys and girls who engage in activities that require lifting heavy loads, repeated backward bending of the back, or twisting of the trunk, are most at risk for spondylolysis, including athletes participating in activities like football, hockey, gymnastics, or dance. Only a small percentage of cases of spondylolysis require surgery, and 85% to 90% of young patients recover in 3 to 6 months with proper treatment.
Spondylolisthesis (spon-dee-low-lis-thee-sis) describes the forward slippage of a vertebrae over the vertebrae beneath it. Because the mechanism of injury, age of the patient, symptoms, and treatment are similar for both conditions, spondylolysis and spondylolesthesis are often described together.
Physical therapists provide education, pain reduction, activity modification, and cross-training to aid healing for patients with these conditions. A physical therapist can help you increase your spine and leg flexibility, strengthen your core muscles, and return to your sport, work, and recreational activities without a recurrence of symptoms.
What are Stress Fractures of the Lumbar Spine?
Spondylolysis is a stress fracture of the pars interarticularis, part of the bony ring that connects the front part of the spinal column to its back portion. Specifically, the fracture occurs between the spinous process (bony protrusion that sticks out the back of the spine) and the transverse process (bony protrusion that sticks out of the side of the spine). Excessive strain on the lumbar vertebrae due to repetitive activities in a growing child can cause injury to the vertebrae, resulting in low back pain.
Spondylolisthesis is the forward slip of a defective, unstable vertebrae. There are five grades of slips, with grade I being the smallest amount of slip and grade V being a slip of 100%. Nonsurgical management is most successful with patients who have a defect on only 1 side of the vertebrae and those patients with a grade II or less slip. Young athletes whose adolescent growth spurt has not yet occurred are at greater risk for continued slippage and are monitored until they stop growing.
Key points to understand about spondylolysis and spondylolisthesis:
Early detection and proper diagnosis of these conditions is important because return to sport or an active lifestyle can occur within 3 to 6 months with early diagnosis. With prolonged symptoms and a delayed diagnosis, healing may take up to a year.
The majority of symptoms resolve with rest, with or without the use of a back brace or activity modifications.
Surgery may be indicated when conservative treatment of greater than 6 months fails and debilitating symptoms persist.
Spondylolysis and spondylolisthesis need to be ruled out in a young athlete who is experiencing low back pain for more than a few weeks. Active young athletes who participate in sports, such as football, hockey, gymnastics, and dance are at the greatest risk of developing the conditions, especially while growing.
A negative x-ray reading requires additional imaging to rule out early injury to the vertebrae if clinical exam findings suggest a high probability of spondylolysis.
Spondylolysis and spondylolisthesis are not a major cause of low back pain in adults, except in high-level athletes engaging in high-risk sports.
Signs and Symptoms
Spondylolysis may be present if you are experiencing:
Low back pain with or without buttock or leg pain (If leg pain is present, it radiates into the thigh, but generally not below the knee.)
Muscle spasms in your low back, buttocks, and thighs
Difficulty or pain with walking or prolonged standing
Symptoms that are relieved by sitting, slouching, or bending forward
Pain with sports or manual labor
Pain with bending backwards, twisting the spine, or with throwing
Decreased flexibility of the leg muscles
How Is It Diagnosed?
Your physical therapist will conduct a thorough evaluation that includes taking your health history. Your therapist may ask:
How long you have had the pain, and whether it came on suddenly or gradually
If the pain occurs with activity or at rest, or during the day or night
What activities or positions make the pain better or worse
If you engage in high-risk activities that may cause injury to your vertebrae
If you can point with 1 finger to the area on your back that is painful
If you are having any other symptoms, such as fever, chills, or night sweats
If you have difficulty maintaining control over your bowel and bladder
Additionally, your physical therapist will perform objective tests and measures to identify movement, flexibility, or strength factors that may be contributing to your pain. Specifically, the therapist may watch you walk, have you bend forward to touch your toes, bend back as far as you can, stand on 1 leg and bend back, and turn your trunk from side to side. Your physical therapist will assess your leg and spine flexibility as well as your core strength, and ask you if the testing changes your symptoms. Your therapist may gently press areas of your back to see if they are painful. All the information gathered helps determine the cause of your pain and the best treatment to resolve your symptoms.
Diagnosing spondylolysis and spondylolisthesis can be challenging. If stress fracture is suspected, your therapist will refer you to an orthopedist or sports medicine physician familiar with back injuries. The physician may order further imaging tests to confirm the diagnosis and rule out other spine conditions.
How Can a Physical Therapist Help?
In the beginning, when you are in pain and having difficulty performing your normal daily routine, your physical therapist can:
Show you how to rest the injured vertebrae, use lumbar bracing, modify your activities, and avoid painful movements
Help you reduce and manage your pain symptoms
Help you maintain fitness while healing, through pain-free cross-training, such as aquatic therapy
Initiate symptom-free hamstring stretching and activation of your core muscles, either in or out of a back brace
When you are pain free, and the healing of your injured structures has begun, your physical therapist can help you:
Improve the flexibility of your hip and leg muscles
Improve your core and leg strength
Improve your spine flexibility
Prepare for a return to sport or work activities by improving your overall fitness levels
Begin a gradual progression of higher-risk movements, such as back extension and trunk rotation to reduce the chance of reinjury
Can this Injury or Condition be Prevented?
Spondylolysis and some types of spondylolisthesis may be preventable by educating individuals who are at higher risk of acquiring an injury on how it can be prevented.
For the growing young athlete, monitoring exercise volume, intensity, and frequency is necessary. Coaches or parents should:
Limit participation to 1 high-risk sport at a time during a season
Limit participation to 1 team at a time during a season
Enforce 1 to 2 days of rest from training per week
Gradually increase training volume, intensity, and frequency when starting out
Additionally, bone health and overall well-being are improved by ensuring proper rest, nutrition, and hydration while participating in high levels of activity.
Real Life Experiences
Jake is a 15-year-old athlete who plays shortstop on his high school baseball team. One day while batting, Jake feels pain in his lower back. Gradually, as the season progresses, Jake’s back pain worsens; the pain is now constant and present even when he is not playing baseball. Jake’s father takes him to see a physical therapist.
During the evaluation, Jake’s father notes that Jake has grown 4 inches in the past year, and during last weekend’s 2-day baseball tournament, Jake’s pain was so bad, he was unable to participate in the final game.
Jake’s physical therapist notes that he bends slightly forward over his legs when he walks. When he’s asked to bend forward and touch his toes, Jake reports a reduction in his symptoms. When he stands up straight and bends backwards, he reports an increase in pain in his left lower back and buttocks. Jake explains that twisting his trunk when he is batting is really painful, and rates it a 7 out of 10 on the pain scale. Jake is unable to lie on his stomach without his symptoms increasing. His physical therapist is concerned that he may have a lumbar stress fracture.
She refers Jake to a sports medicine physician who treats young athletes. Multiple x-rays are taken and show a stress fracture on the left pars interarticularis. Spondylolysis is diagnosed. The doctor recommends that Jake wear a hard-shell brace for 3 months.
Several weeks later, Jake is pain free and is referred back to physical therapy for rehabilitation. His physical therapist helps him gradually remove his brace without experiencing a return of symptoms. She teaches him gentle hamstring-stretching and core-strengthening exercises. He begins improving his cardiovascular conditioning with interval stationary bike riding. He continues to be pain free as harder, more dynamic and challenging core exercises are introduced. Jake begins a running program, and practices simulated batting and throwing movements. After a few months, he is allowed to return to baseball practice for 1 hour every other day. With the continuation of pain-free practice, Jake increases his practice volume and intensity weekly. By the end of 5 months, Jake has returned to playing baseball without pain or restrictions. He can now bend his back in any direction without pain, and feels “more athletic.” Jake looks forward to full participation in next year’s baseball season!