Spondylolysis (Back Stress Fracture)

Article by John Miller

What is Spondylolysis?

spondylolysis

Spondylolysis is a back stress fracture. It is a common causes of structural back pain in children, adolescents and active young adults. Spondylolysis is a non-displaced stress fracture of a spinal vertebra, also known as a pars stress fracture.

A spondylolysis in a child or adolescent most commonly results from a defect or stress fracture in the pars interarticularis of the vertebra. The pars interarticularis is the part of the vertebra between the superior and inferior facets. 

Approximately 90-95% of cases of spondylolysis occur at the L5 vertebral level. The stress lesion usually completely heals. In about 25% of cases where fracture nonunion occurs, a fibrous mesh connective tissue is laid down rather than bone.

Spondylolysis is classified as dysplasic (congenital - born with eg spina bifida occulta), isthmic (stress fracture from sport), degenerative (older adults - arthritis related), or traumatic. The majority are isthmic.

If your spondylolysis deteriorates and allows the vertebral body to slip forwards, it is known as a spondylolisthesis. This occurs in about 50% of cases. A spondylolisthesis is more common in individuals with bilateral spondylolysis, mechanical instability and females.

What are the Symptoms of Spondylolysis?

Spondylolysis sufferers usually report:

  • Spontaneous onset, unilateral back pain - at beltline. Initially sharp. Dull later.
  • Aggravated by arching, standing or pars “stress” activities, especially with increased training.
  • Pain may radiate to buttock or thigh.
  • Normal neurological signs.
  • Pain eased by rest.
  • The patient will often have an exaggerated back arch and tight hamstrings - 80%.

What Causes Spondylolysis?

  • Activities that overstress the pars interarticularis can cause stress fractures.
  • Activities that require repetitive rotation and/or hyperextension can cause stress fractures.

Sports that have been identified with a high incidence of spondylolysis include:

  • Cricket bowlers
  • Gymnastics
  • Weightlifting
  • Wrestling
  • Diving
  • Butterfly swimming
  • Ballet dancing
  • Ice skating
  • Track and field throwers eg javelin
  • Golf
  • Gridiron

Merlino & Perlisa (2012) studied 4200 young athletes with back pain - 13.9% had spondylolysis identified radiologically.

What Age Does Spondylolysis Occur?

Spondylolysis tends to occur in two distinct stages of your skeletal development:

  1. Early childhood - when a child is learning to stand or walk.
  2. Early adolescence - high risk active sportspeople with immature bone structure.

The condition is more common in males; 2:1.

How is Spondylolysis Diagnosed?

The diagnosis of spondylolysis is made based on your back symptoms, a physical examination, as well as X-rays of the spine. Oblique X-rays of the lumbar spine are often obtained to evaluate for possible spondylolysis or spondylolisthesis. 

SPECT bone scan appears to be the most sensitive investigation to pick up active spondylolysis. CT scan and MRI scan can be used to assess for a possible spondylolysis. A bone scintigraphy can also be useful in differentiating an acute stress reaction (spondylolysis) from a chronic defect.

The most common finding on physical examination is low back pain and pain with extension of the lumbar spine. Hamstring tightness is another very common finding in patients with spondylolysis. 

Most patients will not have neurological symptoms or referred pain to the leg.

What is Spondylolysis Treatment?

The treatment for spondylolysis is initially conservative and aims to reduce your pain and facilitate healing.

Managing Your Pain & Inflammation

Pain is the main reason that spondylolysis sufferers seek treatment. Pars inflammation is thought to be the main reason why you experience pain, so managing your inflammation is important in the early phase.

Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include: ice, tens machine, acupuncture, de-loading taping techniques, soft tissue massage and temporary use of a supportive brace to off-load the injury site.

You can reduce your inflammation by avoiding the activities that cause your pain (eg extension) and using ice therapy and treatment techniques or exercises that unload the inflammed structures. You may be prescribed non-steroidal anti-inflammatory medication such as ibuprofen to assist your inflammation reduction.

Back Brace

Bracing is controversial. An anti-lordotic brace is sometimes recommended in patients unable to quickly settle their pain. Peer & Fascione (2007). Your physiotherapist will guide you.

Hydrotherapy

Relaxed freestyle or hydrotherapy exercises are beneficial in early injury repair due to lesser body-weight in the buoyancy of water. This allows more movement without causing pain. Water running may also be helpful to maintain your cardiovascular fitness.

Restoring Normal Joint Motion & Posture

As your pain and inflammation settles, your physiotherapist will turn their attention to restoring your normal back joint range of motion and posture. Stiff joints adjacent to the spondylolysis often require mobilising to deload the pars interarticularis stress. Samsell (2010).

Normalise Muscle Flexibility

Tight leg and back muscles will need to be assessed and stretched to allow full and normal movement of your legs and back. Your leg and buttock muscle groups are often tight and shortened. Myofascial massage is helpful. Standaert (2011).

Restore Normal Muscle Strength & Coordination

Back pain researchers have discovered the importance of your deep abdominal core muscle recruitment patterns with a normal order of: deep, then intermediate and finally superficial abdominal muscle firing patterns in normal pain-free backs. Standaert (2011).

PhysioWorks has developed a Back Pain Core Stabilisation Program to assist their spondylolysis patients to regain normal core muscle control. Your physiotherapist will assess your core muscle recruitment pattern and prescribe the best exercises for you specific to your needs. They may recommend that you undertake an ultrasound guided exercise program where you can view your deep core muscle contractions on a TV monitor.

Pilates

Pilates appears a useful exercise regime. Peer and Fascione (2007). Instruction from a physiotherapist with knowledge of what pilates postures could exacerbate your spondylolysis is preferred.

Graded Return to Sport

The next stage of your rehabilitation is aimed at safely returning you to your desired activities. Everyone has different demands will determine what specific treatment goals you need to achieve. 

Due to the cause of spondylolysis being predominantly caused by sport, ideally your sports physiotherapist should use their knowledge of biomechanics and the demands of your sport to guide your return to sport.
They may adjust your technique and develop a safe training and competitive workload schedule.
Return to sport may take 12 weeks or longer. Sampsell (2010).

Your physiotherapist will tailor your spondylolysis and spondylolisthesis rehabilitation to help you achieve your own functional goals.

What is the Prognosis for Spondylolysis?

The treatment results for spondylolysis is based on your history and symptoms. In most cases, spondylolysis symptoms will resolve within 6 to 12 weeks.

Non-surgical conservative treatments successfully relieve pain in approximately 80-85% of children and adolescents with acute spondylolysis. However, the potential for recurrence is high in individuals who do not address the risk factors that led to the initial injury. Stanitski (2006).

Preventing a Recurrence

Spondylolysis is a condition that will recur if you overstress your lower back. The main reason it is thought to recur is due to poor muscle control or insufficient rehabilitation. Fine tuning your back mobility and core control and learning self-management techniques will ultimately help you to achieve your goal of safely returning to your previous sporting or leisure activities without back pain or sciatica that is commonly associated with spondylolysis and spondylolisthesis.

Exercises

Exercise is like cleaning your teeth. Exercise prevents problems.

Spinal Surgery

Surgery for spondylolysis is extremely rare if you are suffering back pain without any neurological signs.

More Information

Please consult your physiotherapist or doctor for their professional opinion on how best to manage your spondylolysis.

Contact PhysioWorks Book Online

Spondylolysis Treatment Options

  • Bed Rest
  • Early Injury Treatment
  • Avoid the HARM Factors
  • Soft Tissue Injury? What are the Healing Phases?
  • Acupuncture and Dry Needling
  • Core Exercises
  • Biomechanical Analysis
  • Proprioception & Balance Exercises
  • Agility & Sport-Specific Exercises
  • Medications?
  • Real Time Ultrasound Physiotherapy
  • Soft Tissue Massage
  • Brace or Support
  • Electrotherapy & Local Modalities
  • Heat Packs
  • Joint Mobilisation Techniques
  • Kinesiology Tape
  • Neurodynamics
  • Prehabilitation
  • Strength Exercises
  • Stretching Exercises
  • Video Analysis
  • Yoga
  • Spondylolysis FAQs

  • Common Physiotherapy Treatment Techniques
  • What Causes Back Pain?
  • What is Pain?
  • Physiotherapy & Exercise
  • When Should Diagnostic Tests Be Performed?
  • How Does Kinesiology Tape Reduce Swelling?
  • The Best Core Exercises
  • Heat Packs. Why do they feel so good?
  • How Does an Exercise Ball Help Back Pain?
  • How Much Treatment Will You Need?
  • What are the Benefits of Good Posture?
  • What are the Common Adolescent Spinal Injuries?
  • What are the Common Massage Therapy Techniques?
  • What are the Early Warning Signs of an Injury?
  • What are the Healthiest Sleeping Postures?
  • What are the Signs of an Unsupportive Pillow?
  • What Can You Do To Help Arthritis?
  • What Causes Repeat Low Back Strains & Sprains?
  • What is a TENS Machine?
  • What is Chronic Pain?
  • What is Nerve Pain?
  • What is Sports Physiotherapy?
  • What is the Correct Posture Standing?
  • What is the Correct Way to Sit?
  • What to do when you suffer back pain?
  • What's the Benefit of Stretching Exercises?
  • What's Your Core Stability Score?
  • When Can You Return to Sport?
  • Which are the Deep Core Stability Muscles?
  • Why are Sprains and Strains of the Low Back Common?
  • Why are Your Deep Core Muscles Important?
  • Why does Back Pain Recur?
  • Contact PhysioWorks Book Online

    Spondylolysis Related Products

    Spondylolisthesis

    Related Conditions

  • Ankylosing Spondylitis
  • Back Muscle Pain
  • Bulging Disc
  • Core Stability Deficiency
  • Degenerative Disc Disease
  • Facet Joint Pain
  • Fibromyalgia
  • Muscle Strain (Muscle Pain)
  • Pinched Nerve
  • Piriformis Syndrome
  • Pregnancy Back Pain
  • Sacroiliac Joint Pain
  • Scheuermann's Disease
  • Sciatica
  • Scoliosis
  • Spinal Stenosis
  • Spondylolisthesis
  • Spondylolysis (Back Stress Fracture)
  • Spondylosis (Spine Arthritis)
  • Stress Fracture

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    Last updated 12-May-2014 08:10 PM

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