Physical Therapy for Spondylolysis in Teens
Spondylolysis is a lumbar stress fracture in the pars interarticularis, the bony bridge that connects the upper and lower facet joints of the vertebrae. Spondylolysis is a common cause of low back pain in adolescent athletes, caused by repetitive loading, backward bending, and twisting of the lower back. Physical therapy can successfully manage spondylolysis in adolescent athletes, helping to reduce pain, improve strength and function in the low back, and safely return athletes to sports competition.
Anatomy of the Lumbar Spine
The spine is comprised of a column of 24 vertebrae, divided into 7 cervical, 12 thoracic, and 5 lumbar vertebral bodies stacked on top of one another. The lumbar spine is made up of five vertebrae in the lower part of the spine, between the ribs and the pelvis. The lumbar spine supports and stabilizes the upper body, allows movement of the trunk, protects the spinal cord, and controls leg movements.
The spinal column protects the spinal cord which is made up of bundles of nerves that send and receive messages between the body and the brain. Each vertebra consists of the body (round front portion), a central ring-shaped opening (spinal canal), a flat bony area (facet joints) where one vertebra meets the vertebrae above and below it, and a bony section along the sides and back of the vertebral body. Between each vertebra is a flat, round pad called an intervertebral disc that serves as a shock absorber.
The pars interarticularis is an important part of this structure, acting as the bony bridge that joins these two upper and lower facets in the back of the spine. The pars interarticularis is a weak area of bone, especially in patients that are not skeletally mature.
What is Spondylolysis?
Spondylolysis involves a lumbar stress fracture, most often of the L5 vertebra, in which a small break occurs in the par interarticularis (the area of the spine between the facets). Spondylolysis most often affects 11–18-year-old athletes, occurring during puberty and growth spurts. It affects up to 11.5% of the general population with a higher prevalence among adolescent athletes and impacts male adolescent athletes at a much higher rate than female adolescent athletes.
Spondylolysis is most likely to affect highly active teen athletes who lift heavy loads and engage in repeated backward bending or twisting of the trunk, such as in football, hockey, gymnastics, cheerleading, and dance. Overstretching or overextending the spine by bending backward can lead to small cracks in the vertebrae.
The stress fracture occurs because the mechanisms of repair of the vertebrae fail to keep up with the damage caused by the repetitive force of lifting, bending backward, or twisting the trunk. The pars interarticularis is particularly vulnerable to these loads on the back, as it is the bony bridge that connects the weight-bearing lower and upper facet joints of the vertebrae. Minor stress and fatigue fractures can progress to worse, more significant cracks and even complete fractures with a vertebral slip (known as spondylolisthesis).
Spondylolysis typically presents as low back pain that worsens with activity and back extension movements. Symptoms of spondylolysis include:
Low back pain with or without radiating pain through the buttocks or leg. If leg pain is present, pain is felt in the thigh.
Muscle spasms in low back, buttocks, and thighs
Difficulty or pain walking or standing for a long period of time
Symptoms that are relieved by sitting, slouching, or bending forward
Pain with sports or manual labor
Pain when bending backward, twisting the spine, or when throwing
Decreased flexibility of leg muscles, particularly tight hamstrings
Children and teens that are treated for spondylolysis should be examined annually until they are 16, even if treatment relieves symptoms. Spinal bones continue to grow until puberty and symptoms of a stress fracture can reappear during a teen growth spurt.
Physical Therapy for Spondylolysis
Early detection and proper diagnosis are essential for optimal healing and a safe return to sport. Surgery is rare and is only recommended after 6 months if conservative treatment has failed and symptoms persist.
Initially, the therapist conducts a thorough assessment to evaluate the degree and cause of the injury, testing walking gait, spine and leg flexibility, and core strength and assessing the patient’s level of pain. The therapist also works with a primary care physician to coordinate any imaging testing, such as an X-ray or MRI to determine the extent of the lumbar spine stress fracture. Generally, physical therapy is recommended for 6-12 weeks, with the therapist completing a 6-week re-evaluation to assess the athlete’s progress.
Physical therapy treatment for spondylolysis can include:
Patient Education regarding the type and amount of exercise the patient does and assessing aggravating sports activities and the surfaces on which the patient plays which may contribute to symptoms
Pain management using ice, heat, and electrical stimulation, which gently targets nerve fibers that send pain signals to the brain, to minimize pain
Body mechanic instruction to improve body movement for optimal alignment and posture during daily activities and sports
Manual therapy using soft tissue release and massage to address tight and sore muscle groups in the back to promote normal movement and reduce pain
Stretching of tight muscles in the back and lower extremities to improve mobility and decrease stress on the lumbar spine. Physical therapists often target the hamstrings, as many with spondylolysis have tight hamstrings.
Targeted strengthening of muscles of the lumbar spine, pelvis, hips, core, and buttocks for greater stability and to reduce strain on the low back.
Functional training to learn safe, controlled movements for daily activity as well as sport-specific movements to minimize the risk of re-injury
A recent systematic review found that with non-surgical treatment, consisting of activity restriction, rest, and physical therapy, 92% of individuals were able to return to sport with little to no pain within six months. Research on spondylolysis treatment suggests that targeted strengthening of the transversus abdominis and lumbar multifidus as well as motor control training and dynamic lumbar stabilization exercises are effective to reduce pain and improve spinal stability.
To prevent spondylolysis, limit your child or teen’s participation to one high-risk sport at a time during a season as well as participating in one team at a time during a season. Ensure your child rests 1-2 days from training per week. It’s important to gradually increase the volume, intensity, and frequency of training to reduce the risk of stress fractures. Maintain good strength and conditioning in the back and hamstring muscles and refrain from one-sport specializations or playing back-to-back sports year-round without sufficient rest, as this places the child at a higher risk of overuse and stress fractures.
Developing spondylolysis not only causes persistent low back pain in adolescents but also can limit their participation in daily activities and sports. Work with a physical therapist to address spondylolysis, safely heal, and return to sport!
