Spondylolysis (Back Stress Fracture)
Stress Fracture Back
What is Spondylolysis?
A stress fracture in your spine is known as spondylolysis. Spondylolysis is a non-displaced stress fracture of a spinal vertebra, also known as a pars stress fracture. It is a common cause of structural back pain in children, adolescents and active young adults.
A spondylolysis in a child or adolescent most commonly results from a defect or stress fracture in the vertebra’s pars interarticularis. 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 nonunion fracture cases, 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. This vertebrae slippage occurs in about 50% of cases and is known as spondylolisthesis. A spondylolisthesis is more common in individuals with bilateral spondylolysis, mechanical instability and females. (Spinelli and Rainville., 2008)
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 the 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
- Butterfly swimming
- Ballet & Dance
- Ice skating
- Track and field throwers, e.g. javelin
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:
- Early childhood, as a child, is learning to stand or walk.
- 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.
Bone scintigraphy differentiates an acute stress reaction (spondylolysis) from a chronic defect. 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.
The most common physical examination finding 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 in the leg.
For specific advice, please consult your spinal physiotherapist or sports 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 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 (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.
Bracing is controversial. An anti-lordotic brace prescription occurs in patients unable to settle their pain quickly or have instability. Your physiotherapist will guide you. Peer & Fascione (2007).
Relaxed freestyle or hydrotherapy exercises are beneficial in early injury repair due to lesser body weight in water buoyancy. This activity allows more movement without causing pain. Water running may also be helpful to maintain your cardiovascular fitness.
Restoring Normal Joint Motion & Posture
Stiff joints adjacent to the spondylolysis often require mobilising to unload the pars interarticularis stress. As your pain and inflammation settle, your physiotherapist will turn their attention to restoring your joint health, range of motion and posture. 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 help their spondylolysis patients regain reasonable core muscle control. Your physiotherapist will assess your core muscle recruitment pattern and prescribe the best exercises 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 appears as a good 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 that 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, recurrence potential 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 is 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 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.
Exercise is like cleaning your teeth. Exercise prevents problems.
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.
Common Lower Back Pain Causes
The following conditions may cause lower back pain.
- Back Cramps
- Back Muscle Pain
- Core Stability Deficiency
- DOMS - Delayed Onset Muscle Soreness
- Side Strain
- Back Stress Fracture
- Scheuermann's Disease
- Spinal Stenosis
- Stress Fracture Spine (Cricket Bowlers)
Back Joint Injuries
Youth Spinal Pain
Teenager Neck & Back Pain
Teenagers 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 fitness and core stability control are less prone to spine injury and problems due to the strength and flexibility of supporting structures. 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. Your physiotherapist can assist in the resolution of any deficits in this area.
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 types 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)
For specific advice regarding youth neck or back pain, please seek the professional advice of your trusted spinal physiotherapist or doctor.