Spondylolysis (Stress Fracture Back)

Spondylolysis (Back Stress Fracture)

Article by J.Miller, Z.Russell

back-pain

Spondylolysis

Stress Fracture Back

What is Spondylolysis?

A stress fracture in your spine is known as spondylolysis. It is a common cause 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 wholly heals. In about 25% of cases where fracture nonunion occurs, a fibrous mesh connective tissue is laid down rather than bone.

Spondylolysis classifications include dysplasic (congenital – born with, e.g. spina bifida occulta), isthmic (stress fracture from sport), degenerative (older adults – arthritis-related), or traumatic. The majority are isthmic.

If your spondylolysis deteriorates, the vertebral body may slip forwards. It is known as spondylolisthesis. This slippage occurs in about 50% of cases. A spondylolisthesis is more common in individuals with bilateral spondylolysis, mechanical instability and females. (Spinelli and Rainville., 2008)

Spondylolysis Symptoms

stress fracture back

Spondylolysis sufferers usually report:

  • Spontaneous onset, unilateral back pain – at the 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.
  • The 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 or hyperextension can cause stress fractures.

Sports with a high incidence of spondylolysis include:

  • Cricket bowlers
  • Gymnastics
  • Weightlifting
  • Wrestling
  • Diving
  • Butterfly swimming
  • Ballet dancing
  • Ice skating
  • Track and field throwers, e.g. 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, as a child is learning to stand or walk.
  2. Early adolescence. High-risk active sportspeople with an immature bone structure.

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

How is Spondylolysis Diagnosed?

Diagnostic scans of your spine confirm spondylolysis. Oblique X-rays of the lumbar spine may 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 assess for a possible spondylolysis. Bone scintigraphy differentiates 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 common finding in patients with spondylolysis.

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

For specific advice, please consult your spinal physiotherapist or doctor.

What is Spondylolysis Treatment?

The treatment for spondylolysis is initially conservative and aims to reduce your pain and facilitate healing. Treatment then safely progresses into an exercise-based strengthening of your abdominal and hip core muscles as a minimum. Please seek the specific advice of your trusted back physiotherapist who will tailor an exercise program safely and specific to your needs.

Managing Your Pain & Inflammation

Pain is the main reason that a spondylolysis sufferer seeks treatment. Bone marrow inflammation is potentially the main reason why you experience pain, so managing the reason for your inflammation is essential in the early phase.

Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include ice, tens machineacupuncture, 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 (e.g. extension) and using ice therapy and treatment techniques or exercises that unload the inflamed 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 prescription occurs in patients unable to settle their pain quickly or have instability. 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 activity 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 settle, your physiotherapist will turn their attention to restoring your joint health, range of motion and posture. Stiff joints adjacent to the spondylolysis often require mobilising to unload the pars interarticularis stress. Samsell (2010).

Normalise Muscle Flexibility

Tight leg and back muscles require assessment and stretched to allow full and healthy movement of your legs and back. Your leg and buttock muscle groups are often uncomfortable 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 standard order of deep, then intermediate and finally, superficial abdominal muscle firing patterns in healthy pain-free backs. Standaert (2011).

PhysioWorks has developed a Back Pain Core Stabilisation Program to assist their spondylolysis patients in regaining reasonable 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 as a useful exercise regime. Peer and Fascione (2007). Personalised pilates instruction from a knowledgeably spinal care practitioner, such as your physiotherapist, is preferred.

Graded Return to Sport

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

The cause of spondylolysis from sport beckons a review of your spinal control and biomechanics. Ideally, your sports physiotherapist should use their knowledge of biomechanics and the demands of your competition to guide your return to activity.

They may adjust your technique and develop a safe training and competitive workload schedule.

Return to your sport may take 12 weeks or longer. Sampsell (2010).

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

What is the Prognosis for Spondylolysis?

In most cases, spondylolysis symptoms will resolve within 6 to 12 weeks. But, many can take longer.

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 leading reason practitioners think stress fractures reappear due to poor muscle control or insufficient rehabilitation. Fine-tuning your back mobility and core control is critical. Learning self-management techniques will ultimately help you to achieve your goal of safely returning to your previous sporting or leisure activities. Ideally, without back pain or sciatica, that can be 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.

Please consult your back physiotherapist or a spinal surgeon for individualised advice.

Nerve Pain

Nerve pain is pain that is caused by damage or disease that affects the nervous system of the body. It is also known as neuropathic pain or neuralgia. Nerve pain is a pain that comes from problems with signals from the nerves. It is different to the common type of pain that is due to an injury. This is known as nociceptive pain.

What Causes Nerve Pain?

nerve painNeuropathic pain is caused by a problem with your nerves themselves, which sends pain messages to the brain.

What is Nerve Pain Symptoms?

Nerve pain is often described as burning, stabbing, shooting, aching, or like an electric shock.

What Causes Nerve Pain?

Various conditions can affect your nerves and cause nerve pain. Common sources of nerve pain include:
  • Shingles (post-herpetic neuralgia).
  • Trigeminal neuralgia.
  • Diabetic neuropathy.
  • Phantom limb pain following an amputation.
  • Cancer.
  • Multiple sclerosis.
  • Chemotherapy.
  • HIV infection.
  • Alcoholism.
  • Other nerve disorders.

Nerve Pain & Nociceptive Pain

You can suffer both nerve pain and nociceptive pain simultaneously. Both pain types can be caused by the same condition.

Nerve Pain Treatment

Nerve pain is less likely than nociceptive pain to be helped by traditional painkillers such as paracetamol, anti-inflammatories and codeine.  However, other types of medicines often work well to ease the pain. Nerve pain is often eased by anti-depressant or anti-epileptic medicines. Please ask your doctor for more advice.

Pain Links

Pain & Injury

Tens Machine

What is a TENS Machine?

Pins and Needles - Paraesthesia

What Causes Pins & Needles?

A moderately pinched nerve is the most common cause of "pins and needles". Pins and needles are referred to as "paraesthesia" in the medical community. Did you know that feeling "pins and needles" can be a worse sign than having pain in your arm or leg? The reason is that you can't even feel pain anymore when you significantly squash the nerve.

Even worse than "pins and needles" is "numbness" or "anaesthesia", which is a total lack of sensation. You will experience anaesthesia when there is severe nerve compression. Anaesthesia or numbness that persists for more than a few hours can be a sign of permanent nerve compression. Please seek prompt medical attention to prevent the nerve from permanent damage and the muscles it innervates to weaken drastically.

The majority of pinched nerves and nerve compressions are only transient and quickly reversed with early treatment. However, neglect can lead to permanent nerve compression injuries, which may never recover.

Common Causes of Pinched Nerves

The most common forms of nerve compression are in the spinal joints where either a disc bulge or a bony arthritic spur can irritate and compress the nerve. Compressions can also occur as the nerve passes through or around muscles. Your physiotherapist will know where to look.

How Can You Fix "Pins and Needles"?

If you know of someone who is experiencing chronic or permanent "pins and needles", "numbness" or "muscle weakness", please encourage them to seek urgent professional advice. The secret to quick success is the correct diagnosis. A highly trained health practitioner such as your physiotherapist or doctor is your best port of call.

More info

Youth Spinal Pain

Teenager Neck & Back Pain

teenager back painTeenagers can be particularly vulnerable to back pain, mainly due to a combination of high flexibility and low muscle strength and posture control. The competitive athlete and most individuals who exercise regularly or maintain a level of fitness and core stability control are less prone to spine injury and problems due to the strength and flexibility of supporting structures. Your physiotherapist can assist the resolution of any deficits in this area. Luckily, issues involving the lower lumbar spine are rare in athletes and account for less than 10% of sports-related injuries. Injuries do occur in contact sports and with repetitive strain sports.Sports such as gymnastics, cricket fast bowlers, and tennis have a higher incidence of associated lumbar spine problems related to repetitive twisting and hyper-bending motions.Spondylolisthesis is a significant concern and needs to be appropriately treated by a physiotherapist with a particular interest in these type of injuries. Luckily, most injuries are minor, self-limited, and respond quickly to physiotherapy treatment.

Common Adolescent Spinal Injuries

Lower Back (Lumbar Spine)

Midback (Thoracic Spine)

Neck (Cervical Spine)

Pelvis

For specific advice regarding youth neck or back pain, please seek the professional advice of your trusted spinal physiotherapist or doctor.Common Youth & Teenager Sports InjuriesCommon Youth Leg InjuriesCommon Youth Arm Injuries

Back Muscle Strains

Back muscle injuries are the most common form of back injury. Muscle fatigue, excessive loads or poor lifting postures are the most common problems. Inefficient back muscles can lead to poor joint stabilisation and subsequent injury.More info: Back Muscle Pain

Ligament Sprains

Ligaments are the strong fibrous bands that limit the amount of movement available at each spinal level. Stretching ligaments too far or too quickly will tear them with subsequent bleeding into the surrounding tissues, causing swelling and pain. Awkward lifting, sports injuries, and motor vehicle accidents are very common causes. Just as in other regions of the body, physiotherapy hastens ligament healing and relieves pain so that you can enjoy life again as soon as possible.More info: Back Ligament Sprains

Bulging Discs

A bulging disc injury is a common spine injury sustained to your spine's intervertebral disc. Spinal discs are the shock-absorbing rings of fibrocartilage and glycoprotein that separate your bony vertebral bodies while allowing movement at each spinal level, and enough room for the major spinal nerves to exit from the spinal canal and travel to your limbs.The annulus is the outer section of the spinal disc, consisting of several layers of multi-directional fibrocartilaginous fibres all densely packed to create a wall around the glycoprotein filled jelly-like disc nucleus. A disc bulge (commonly referred to as a slipped disc), can potentially press against or irritate the nerve where it exits from the spine. This nerve pinch can cause back pain, spasms, cramping, numbness, pins and needles, or pain in your legs.More info: Bulging Discs

Bone Injuries

You can also fracture your spine if the force involved is highly traumatic or you have a low bone density (e.g. osteoporosis).More info: Osteoporosis

Poor Posture

Poor posture when sitting, standing or lifting at work can place unnecessary stress on your spine. Muscles fatigue, ligaments overstretch, discs stretch and this places spinal joints and nerves under pain-causing pressure.More info: Poor Posture

What Can Cause Severe Low Back Pain?

A sudden injury most often causes acute low back pain. The most common injury sources are the muscles and ligaments supporting the back. The pain may be caused by muscle spasms or a strain or tear in the muscles and ligaments. But occasionally, it can have a more sinister cause.

Warning Signs of a More Serious Back Injury?

In these instances of neurological deficit, please urgently consult your nearest hospital, doctor or physiotherapist. The following neurological signs warrant prompt assessment:
  • pins and needles (paraesthesia),
  • numbness (anaesthesia),
  • leg muscle weakness,
  • altered reflexes,
  • difficulty walking,
  • loss of control of bladder or bowels.

Non-Musculoskeletal Causes of Low Back Pain

Although most low back pain is musculoskeletal in origin, other health conditions can cause low back pain.
  • Abdominal aortic aneurysm
  • Infection of the spine (osteomyelitis, discitis)
  • Kidney infection or kidney stones
  • Spondyloarthropathies: e.g. rheumatoid arthritis, psoriatic arthritis.
  • Female reproductive organs: e.g. pregnancy complications, ovarian cysts or cancer, endometriosis
Please seek the professional advice of your trusted and experienced healthcare practitioner to diagnose the cause of your lower back pain.

What Causes Lower Back Pain?

Researchers and spinal health care practitioners categorise lower back bain into the following categories:1. Specific Spinal Pathologies  (<1%)2. Radicular Syndromes (5-10%) 3. Non-Specific Lower Back Pain (NSLBP) (Bardin et al., 2017)

Specific Spinal Pathologies

Some conditions that cause back pain do require an urgent and specific referral and treatment. These conditions include: These conditions do require early diagnosis and prompt referral to the appropriate medical specialist.  Luckily these conditions account for less than 1% of back pain sufferers, but you don't want them missed.Some referrals should be IMMEDIATE!

Radicular Syndromes

Lower back pain can result from structural damage that can irritate or pinch a nerve. Researchers believe that radicular syndrome causes 5-10% of the presentations of back pain to general practitioners.

Radicular pain (e.g. sciatica)

The most common pinched nerve in the lower back is your sciatic nerve. You may be diagnosed with sciatica if you are suffering radicular pain down your leg due to a back injury. While the sciatic nerve is the most common nerve that can be affected by a spinal injury, you can modify any spinal nerve function (e.g. femoral nerve).The following back injuries may cause radicular pain: Pain is due to swelling or space-occupying material adjacent to the spinal nerve. The affected nerve may be simply irritated, resulting in radicular pain. Or, even worse, become pinched or compressed, resulting in radiculopathy.

Radiculopathy

Lumbar radiculopathy can result in functionally disabling conditions such as foot drop, foot slap or eversion muscle weakness that can affect your ability to walk.

Spinal Stenosis

Spinal stenosis is a slightly different condition and relates to the narrowing of the spinal canal. Spinal stenosis is usually more prevalent as you age.

Non-Specific Lower Back Pain (NSLBP)

Non-Specific Lower Back Pain (NSLBP) is the diagnostic term used to classify sufferers of lower back pain with no specific structure injured. It is a diagnosis of exclusion. In other words, your spinal health care practitioner has excluded specific spinal pathologies and any of the radicular syndromes mentioned above as the cause of your back pain or symptoms.Fortunately, these conditions account for approximately 90-95% of lower back pain and can nearly always successfully rehabilitate without the need for surgery. Most improve within two to six weeks. They can be fast-tracked with pain relief and physiotherapy techniques such as manual therapy and back exercises.

NSLBP Causes

 The causes of NSLBP are numerous but roughly fall into either a sudden (traumatic) or sustained overstress injuries.Most people can relate to traumatic injury such as bending awkwardly to lift a heavy load that tears or damages structures. However, sustained overstress injuries (e.g. poor posture) are probably more common but also more straightforward to prevent. In these cases, positional stress or postural fatigue creates an accumulated microtrauma that overloads your lower back structures over an extended period to cause injury and back pain.Most commonly, NSLBP causes include back muscle strain or back ligament sprain. Other chronic back conditions such as degenerative disc disease may underly your acute disc health and predispose you to the severe pain.The good news is that you can take measures to prevent or lessen most back pain episodes. Early diagnosis and specific individualised treatment is the easiest way to recover quickly from lower back pain and to prevent a recurrence.

What is Back Muscle Pain?

Back muscle pain or its aliases: pulled back muscle, back muscle spasm, torn back muscle or back muscle strain, is very common. Back muscle pain is the most common source of back pain. The good news is that it is also one of the quickest to heal and rehabilitate.

What Causes Back Muscle Pain?

Most causes of low back pain are muscle, ligament or joint-related. Commonly, these muscular strains, ligament sprains and joint dysfunction arises suddenly during or following physical loading of your spine. Muscle fatigue, excessive loads, high speeds or poor lifting postures are the most common causes.The causes of pure back pain are numerous but roughly fall into the following categories.

Back Muscle Strains

Muscle pain is the most common source of back pain. Muscle fatigue, excessive loads or poor lifting or sitting postures are the most common problems.Inefficient, weak, or back muscles that lack endurance or normal contraction timing can lead to reduced joint stabilisation and subsequent injury to your back muscles, ligaments, joints or even spinal discs.

Poor Posture

Poor posture, when sitting, standing and lifting at work, can place unnecessary stress upon your spine. With muscle fatigue or overstretching, your ligaments and discs can stretch, and this puts spinal joint muscles and nerves under pain-causing pressure or strain, that results in back pain.

Ligament Sprains

Ligaments are the durable, fibrous bands that limit the amount of movement available at each spinal level. Stretching ligaments too far or too quickly will tear them with subsequent bleeding into the surrounding tissues, causing swelling, muscular spasm and pain.Awkward lifting, sports injuries and motor vehicle accidents are prevalent causes. Just as in other regions of the body, physiotherapy hastens ligament healing and relieves pain so that you can enjoy life again as soon as possible.

What are the Symptoms of Back Muscle Pain?

Back muscle pain symptoms may range from a mild ache to sudden debilitating back pain.Typical back muscle pain symptoms include:
  • Localised back pain, with no radiation into your buttock or leg.
  • Back muscle tenderness and spasm.
  • Protective back stiffness.
  • Sudden back pain onset.
You will usually feel better when resting and may find a change of position painful, e.g. sit to stand, rolling in bed, walking or bending.

How is Back Muscle Pain Diagnosed?

Differentiating a back muscle strain from a ligament sprain can be difficult, as both injuries will show similar symptoms. In general, it doesn't significantly matter what you call the problem because the treatment and prognosis for both back muscular strains and ligament sprains are similar. Most spinal practitioners refer to both injuries as a category called a "Back Strain" or "Musculoligamentous Strain".X-rays and CT scans do not identify muscle or ligament injury. MRI scan is probably the best diagnostic test to determine the muscle or ligament structures injured.

What is Back Muscle Pain Treatment?

Seek a Professional Diagnosis!

A spinal healthcare practitioner, such as your physiotherapist, should thoroughly; examine you to exclude more severe sources of back pain.Numerous injuries can cause back pain, and the treatment does vary significantly depending on your diagnosis. Physiotherapy treatment aims to protect your damaged tissue while hastening your muscle and ligament healing and then look at strategies to prevent a recurrence.Your physiotherapist has some nifty tricks for quickly relieving your back pain so that you can enjoy life again as soon as possible.

Back Strain Causes

We do know that some people are vulnerable to repeated lower back sprains and strains. While it is easier to understand that lifting a heavy load in an awkward position can cause back pain, it's harder to comprehend how a simple movement can hurt your back. Yes, it can happen by merely leaning forwards to pick up your teacup or when bending to brush your teeth!The reason is poor local joint control. The main reason for this is inadequate or non-existent muscle activation of the deep core stability muscles. These muscles are small but are right next to the joint to control excessive slides and glides. When they don't work correctly, the joint can slide too far and strain its supporting ligaments. Ouch! That hurts.The good news is poor core stability can be easily corrected to prevent back pain. Please contact your physio for more information or to have your core activation accurately assessed.High-risk factors of back pain include:
  • sudden forceful movement
  • lifting a heavy object
  • twisting the back
  • coughing or sneezing
  • prolonged sitting with poor posture
More information about Back PainMore information about Deep Core Stability