By Michael Lucido, PT
The human spine is capable of producing large amounts of torque and power during athletic competition. Young athletes, participating in sports such as gymnastics, swimming, and wrestling are susceptible to stresses that can lead to low back pain. Low back pain in young athletes can be persistent and difficult to resolve leading to frustration for the young athlete and for his or her parents.
One condition that can lead to significant impairment and slow return to competition is lumbar spondylolysis. Spondylolysis, is a fatigue or stress fracture located at the pars interarticularis. Mechanical stresses that are produced by rapid and repetitive lumbar extension are believed to be the cause of this abnormality. This paper addresses the pathology, examination and evidence based physical therapy treatment of spondylolysis that can lead to the successful return the young athlete to full competition.
Low back pain is the most costly musculoskeletal condition that affects industrialized countries. One of the reasons that low back pain is costly is because the exact pain generator is difficult to identify. In young athletes, low back pain can also be difficult to identify. Fortunately, advances in examination and imaging can identify a pain generator in young athletes know as lumbar “spondylolysis”, that when identified can be treated successfully.
Young athletes become susceptible to low back complications when participating in sports during a time of skeletal growth and adolescence, Sairyo, et al. (2001). Batt, Skattum, Chong & Tanji, (1996) state that adolescence with low back pain are clinically unique in that their pain is likely coming from the posterior elements, not from disc related problems like adults have.
According to Bogduk and Twomey (1997) the function of the posterior elements are very specific “… the various posterior elements are specially adapted to receive and transfer the different forces that act on a vertebra”(p.7 ). The zone of the posterior elements that is most susceptible to injury is the pars interarticularis or isthmus. (fig. 1). Bellah, Summerville, Treves & Micheli, (1991) state that this area is most susceptible to microfractures, fatigue fractures, and stress reactions due to mechanical stresses produced by lumbar extension.
Diagnostically, there are three stages of spondylolysis that are considered when interpreting plain radiographic films. The classic finding of the “Scotty dog with a collar” is evident in two of three radiographs (fig. 2). Stage 1 shows a small break in the bone between the inferior and superior articulating surfaces. Stage 2 exhibits a “frank” fracture line with small separation and stage 3 shows that the fracture line is beginning to ossify and heal. Bellah, et al. (1991) stated that such abnormalities may not be apparent on plain radiographs and specialized imaging such has the SPECT (single proton emission computerized tomography) is more specific for this condition.
In some case spondylolyis can progress to further abnormalilties such as spondylolisthesis or wedging of the vertebra. Saraste, (1993) reported that approximately 80% of patients with spondylolyis showed radiographic evidence of spondylolisthesis. In children and adolescence there is a growth plate between the vertebral body and the apophyseal ring. According to Farfan, et al. (1996) the growth plate is the weakest link to anterior shear forces thus it is more prevalent to develop spondylolisthesis during the growth period.
Typically the patient has full range of motion in all the cardinal planes of the lumbar spine with pain at end range of extension. Some physicians and spine specialist such as Drew Dossett, MD, team physician for the Dallas Cowboys, uses a provocative test for spondylolysis by having the athlete grab one of their knees with both hands then extending their lumbar spine. (personal communication, May 15, 2008). Neurological exam is typically negative as well has provocation of the sacroiliac joint in supine.
During straight leg raising false positive are common when the hip reaches about 70 degrees due to motion arriving at the lumbo – sacral junction. Cyriax (1991) described a clinical test in supine of resisting the hip flexors. If resisting the hip flexors reproduces low back pain he stated that this is indicative of spondylolisthesis, spondylolysis, sacroilitis or spinal fracture.
Examination in supine might also show a short leg on that side due to the hypertonicity of the quadratus lumborum or muscle imbalance. Prone examination can indicate reflex contractures when posterior/anterior pressure is applied over the corresponding spinal segment. Resisting hip flexion in a prone position with the hip extending and knee flexed can further sensitize the contractile test if the supine resisted hip flexion test was negative.
Evidence Based Practice
The vast majority of young athletes respond successfully to non-operative treatment of lumbar spondylolysis however, Barker, Shamley, & Jackson, (2004) reported that with chronic low back pain it is common to develop atrophy of the multifidus muscle and ipsilateral psoas muscle. O”Sullivan, Twomey & Allison, (1997) examined a specific exercise program to address this muscle insufficiency.
The conclusion of their research showed that with a specific exercise program, individuals with spondylolyis and spondylolisthesis reported significant reducation in pain as compared to the control group. The last phase of rehabilitation is functional movement patterns and slowly getting the athlete back on the practice field with the goal of practicing at full speed and full contact.
Persistent low back pain in young athletes can be a challenging orthopedic condition. Young athletes that play specific sports have a higher incidence of low back pain as compared to adolescence who do not engage in those activities. If gone undetected, spondylolysis can lead to further impairments and perhaps chronic back pain as the young athlete heads into adulthood. Once identified as a pain generator, the fracture site associated with spondylolysis eventually heals and with proper rehabilitation the young athlete returns to his or her level of competition.
Barker, K. Shamley. D.R., & Jackson, D. (2004). Changes in the Cross-Sectional area of Multifidus and Psoas in patients with unilateral back pain. Spine (29), p. 515–519. Retrieved May 17, 2008 from Medline.
Batt, M., Skattum, N., Chong, B.,Tanji, B.J. (1996). Posterior element pain in an adolescent
schoolgirl: A case report. British Journal of Sports Medicine. (30). p.356-358.
Bellah,R.D., Summerville, D.A., Treves, T., Micheli, L.J. (1991) Low-Back Pain in adolescent athletes: Detection of stress injury to the pars interarticularis with SPECT. Radiology, 80. p. 509 – 512. Retrieved May 26, 2008, from Ovid.
Bogduk, N. & Twomey, L.T. (1997). Clinical Anatomy of the Lumbar Spine. New York:
Bono, C.M. (2004). Low back pain in athletes. The Journal of Bone & Joint Surgery. (86-A)
p. 382 – 396. Retrieved May 17, 2008 from Medline.
Cyriax, J. (1991). Textbook of Orthopaedic Medicine: Volume 1 diagnosis of soft tissue lesions.
London: Bailliere Tindall.
Farfan, H.F., Osteria, V., & Lamy, C. (1976). The mechanical etiology of spondylolysis and
spondylolisthesis. Clinical Orthopedics (117). p. 40 -55.
O’Sullivan, P., Twomey, L., & Allison, G. (1997) Evaluation of specific stabilizing exercises in the
treatment of chronic low back pain with radiographic diagnosis of spondylolysis or spondylolisthesis. Spine, 22. p. 2959 – 2967. Retrieved May 22, 2008. from Medline.
Sairyo, K., Shinsuke, K., Takaaki, I., Koji, F., Kiyshi, K., & Goel, V. (2001). Development of
spondylolytic olisthesis in adolescents. The Spine Journal, (1) p. 171 – 175.
Saraste, H. (1993) Spondylolysis and spondylolisthesis. Archives of Orthopedic Scandinavian. (251) p. 84 – 86.