Spondylolysis (stress fracture) & Spondylolisthesis (slippage)

The lumbar spine is commonly referred to as the low back. The lumbar spine consists of 5 bony vertebrae. In the young athlete the most common cause of low back pain is a stress fracture of one of the lumbar vertebrae. This most commonly occurs in the lower two vertebrae i.e. the fourth and fifth lumbar vertebrae. Technically this condition is called spondylolysis. It is very common in those athletes who’s sport involves hyperextension and rotation of their back e.g. fast bowlers in cricket, gymnasts. The fracture usually occurs on the opposite side to the one performing the activity i.e. a right handed bowler would get a left sided fracture.

If the stress fracture weakens the vertebrae so much that it is unable to maintain its normal position slippage of the vertebrae forward on the one below it can occur. This is technically known as spondylolisthesis. In adults this condition is usually caused by degeneration of the intervertebral discs.
Spondylolisthesis can be graded from I to IV depending on the percentage of how much of the vertebrae as slipped over the body of the vertebrae below it:

•    I – less that 25 % slip
•    II – 25 % slip
•    III – 50 % slip
•    IV – greater than 75% slip

Symptoms of Spondylolysis & Spondylolisthesis

•    Spondylolysis:

o    the pain is one sided (side of the fracture)
o    there may be some pain into the buttocks
o    pain is aggravated by hyperextension (straightening past neutral)
o    muscle spasm in the hamstring muscles
o    tenderness on the side of the fracture

•    Spondylolisthesis

o    grade I slips are usually asymptomatic
o    grade II –IV – low back pain with or without leg pai
o    in a significant slip the vertebrae can narrow the spinal column resulting in pressure on the spinal nerves – this may cause leg symptoms such as pins and needles, numbness, pain and weakness.
o    Soft tissue abnormalities e.g. overactive hamstrings
o    Pain increases with extension (straightening)
o    There may be a palpable dip in the lumbar spine

Diagnosis

In the case of a spondylolysis the stress fracture is only usually seen on x-ray in longer standing cases. If the condition is in its early stages and the x-ray is normal then other imaging techniques will be use to confirm the presence of a stress fracture. An x-ray however will clearly show a spondylolisthesis.

Physiotherapy

Spondylolysis

Initially the athlete needs to rest from their sport and aggravating activities. Initial physiotherapy management would involve reducing pain and inflammation through the use of electrotherapeutic modalities and gentle soft tissue techniques. Your physiotherapist will also re-educate you about posture and provide a progressive exercise program that would include such things as stretches (hamstrings) and strengthening exercises (e.g. muscle corset for support of your low back).

Once aggravating manoeuvres i.e. extension are pain free and there is no more local tenderness a gradual progressive return to sport over a 4-6 week period can be commenced, with pain as the guide for progression. As this condition is an overuse injury it will also be important to identify the causes and correct them if possible (e.g. poor bowling action).

Spondylolisthesis

Grade I and II slips involve the patient resting form aggravating activities. Initial physiotherapy management would involve reducing pain and inflammation through the use of electrotherapeutic modalities and gentle soft tissue techniques. If there is stiffness of adjacent joints these will be mobilized and if there is muscle imbalances these will be corrected. For example the hamstrings often get tight and require stretching. An important part of treatment will include the re-education and strengthening of the muscle corset that provides stability to your lumbar spine. Patients can commence a gradual return to sport once they are pain free with extension and once they have good stabilization of their spine through the use of their muscle corset.

Athletes with grade III and IV slips should avoid high speed and contact sports. Physiotherapy treatment for this would be symptomatic and similar to that of I and II slips. If there continues to be progression of the slip surgery to fuse the vertebrae may be performed.