Jan 29, 2015Back in Trouble
If an athlete’s lumbar pain won’t go away with time, the cause might be a serious spinal condition called spondylolysis. This article explains what it is and how to manage it.
By Chris Gellert
Chris Gellert, PT, MPT, CSCS, CPT, is the President of Pinnacle Training & Consulting Systems, based in Germantown, Md., and the author of Synergy of Human Movement, an advanced continuing education program for personal trainers. He can be reached through his Web site at: www.pinnacle-tcs.com.
If you’ve worked with competitive athletes for any length of time, you have probably heard complaints of back pain. Repetitive, overloading compressive forces and extension movements are a regular part of training and competition in most sports, making some degree of back pain almost inevitable for many athletes.
However, not all back pain is the same. Sometimes it’s a simple case of sore muscles or a sprain that resolves on its own in a few days. Other times, a more serious orthopedic problem is to blame. Spondylolysis is a type of back injury that will not simply resolve itself without intervention. It’s caused by a specific injury or defect in the spine, and young athletes are especially at risk since it is often caused by damage to growth cartilage–the weakest link in the musculoskeletal system from childhood through adolescence.
Awareness is key to helping athletes deal with spondylolysis and to preventing it in the first place. If you understand why the condition occurs, how to identify it, and what types of intervention have been proven successful by research, you can reduce athletes’ back pain, cut time lost to injury, and help promote long-term spinal health.
DEFECT IN VERTEBRA
Surveys of athletes across all sports have found that as many as 30 percent suffer from some type of back pain. Not surprisingly, the highest rates of pain are clustered in sports that place the greatest stress on the lumbar region, such as football, wrestling, gymnastics, and weightlifting. When the pain is temporary, it is frequently diagnosed as a self-limited back sprain or back strain, and standard treatment protocols can be used.
Chronic back pain, however, often has a more serious cause. For some athletes, the problem is spondylolysis, a defect in part of one or more vertebrae known as the pars interarticularis. This defect can occur naturally (it is sometimes even present at birth), but in athletes it is most often the result of a stress fracture. The most common site of spondylolysis is the fifth lumbar vertebra, but it can also occur in the fourth lumbar vertebra, and occasionally elsewhere in the spinal column.
How does an athlete sustain such a stress fracture? Overworking the lumbar region is a common cause among football players, wrestlers, weightlifters, and other athletes in traditional “power sports.” Gymnasts, soccer players, volleyball players, and dancers may place excessive stress on the spine through repetitive hyperextension and movements such as extension with side bending.
An acute trauma can also lead to a spondylolysis fracture, such as when a wrestler lands on his or her side in a twisted position or when a football player suffers a direct blow to the spine. Adolescents are especially susceptible, because the pars interarticularis of their vertebrae have not yet fully matured.
The most common symptom of spondylolysis is lower back pain that does not resolve in the normal healing time for a back sprain or strain. The pain is often described as a dull aching and cramping sensation in the lower back region, and it is typically aggravated during standing, trunk extension, and trunk rotation. Spondylolytic athletes also may stand with their hips and knees flexed, tilting their pelvis posteriorly (backward) and demonstrating a classic “swayback” posture.
If the stress fracture weakens a vertebra so much that it shifts out of place, the result is a condition called spondylolisthesis. This occurs only in a minority of individuals who suffer from spondylolysis, and its most common symptoms are stiffness and an increase in back pain. If too much slippage occurs, the vertebra may begin to press against nerves, and surgery may be necessary to correct the displacement.
A physician can perform a variety of movement tests to help identify spondylolysis and spondylolisthesis, but the most reliable method of diagnosis is an x-ray of the lumbar spine. Sometimes, a specific type of radiography called a SPECT (single-photon emission computed tomography) image is used for a clearer picture of the lumbar region.
When an athlete is diagnosed with spondylolysis, the most immediate concern is usually managing the pain and reducing inflammation. A physician will often prescribe NSAIDs and acetaminophen, and the athlete is typically told to avoid extension and twisting motions to reduce compression and shearing forces in the injured area. Hyperextension bracing and restriction of activity are also usually called for by a physician. Sometimes, immobilization using a specific type of brace called a thoracolumbosacral orthosis (TLSO) is prescribed.
Spondylolysis fractures can most often heal with time. One recent study of 28 athletes with subtle fatigue fractures of the pars interarticularis found that conservative bracing allowed the injury to heal in the majority of cases, especially when the actual lesion on the vertebra was not severe. Ninety-two percent of participants in the study rated their outcome as good or excellent, and 89 percent were able to return to competitive athletics in an average of five and a half months after beginning treatment. Other research also supports the finding that bracing and cessation of activity usually result in successful healing.
Sometimes, however, bracing and activity restriction do not result in a positive resolution. This is especially likely in severe cases where spondylolisthesis is present. For these athletes, a doctor may recommend surgery to repair the injured vertebra or vertebrae and to prevent interference with other parts of the spinal column.
For the rare cases when an athlete requires surgery for spondylolysis, the two most common procedures are a laminectomy and a posterior lumbar fusion. In a laminectomy, a small portion of bone is removed from the vertebral arch to relieve pressure on nearby nerve tissue. In a posterior lumbar fusion, used mostly in cases of spondylolisthesis, loose or unstable vertebrae are fused together, typically with the help of bone grafts and sometimes plates or screws.
REHAB & PREVENTION
For both surgical and non-surgical cases of spondylolysis, an important first step in rehab is addressing postural issues that may have contributed to the injury. In particular, maintaining a neutral spine during exercise can prevent unnecessary stress to the lumbar region.
Many athletes don’t know exactly what a neutral spine looks or feels like, so here’s an easy way to show them: Have the individual lie on their back with their knees bent, tilting the ASIS (anterior superior iliac spine) toward them and then away from them in a rocking motion. A neutral spine exists when the ASIS is “balanced,” as if you could balance a book on the athlete’s pelvic girdle.
Athletes can then work on maintaining a neutral spine through lumbo-pelvic stabilization exercises, during which proper technique and repetition are essential. A quadruped alternating opposite arm and leg lift is one exercise that can be used for this type of training. Once the athlete can maintain a neutral spine statically, dynamic lumbar stabilization exercises such as the quadruped alternate leg raise can be introduced.
Progression from static to dynamic lumbar stabilization work should occur when the athlete demonstrates proper form and can increase the number of reps as they build muscle endurance. From there, athletes should progress to more complex dynamic lumbar stabilization movements to develop synergistic control of the core and lumbo-pelvic junction.
As a former physical therapy patient, I know from experience that learning and practicing proper lumbo-pelvic stabilization not only helped me regain function, but also provided a sense of normalcy in my everyday movements. In addition to being a physical therapist, I am also an avid mountain biker and adventurer, and stabilization exercises were a key component in my recovery. Two good examples are the prone alternating arm and leg lift and the single-leg bridge, both performed using a stability ball.
Once stabilization has been addressed, the later phases of a typical spondylolysis rehab involve light progressive resistance exercises for the upper body to strengthen the rhomboids, latissimus dorsi, lower trapezius, and upper trunk/posterior muscle groups. Research has shown that these muscles in particular are often weaker than the surrounding musculature, and these strength imbalances could leave an athlete at risk for re-injury. The specific exercises and intensity levels for this resistance work should vary depending on the athlete’s progress, level of pain, and sport-specific demands.
Of course, the best scenario is for an athlete to avoid suffering a spondylolysis injury in the first place. While there is no single surefire way to prevent this condition, a program based around athlete education, adaptation to sport-specific demands, and adequate attention to lumbo-pelvic stabilization training and periodized individual programming provides the best approach.
In my experience, cross training is very valuable for preventing back injuries of all types, including spondylolysis. The activities don’t have to be complicated–in fact, one of my favorites is hiking. A challenging hike requires the synergistic use and control of the trunk, the abdominal muscles, and the core, providing a truly effective workout. Swimming is another excellent exercise that strengthens the entire body, including key connective tissues and supportive spinal musculature that can help promote sound movement patterns and protect athletes from unnecessary lumbar stress.
BACK TO ACTION
Return-to-play decisions for athletes coming back from spondylolysis should depend on several factors. Once the symptoms, in particular back pain, have fully resolved, athletes are typically eager to return to full activity. As with any recovery from a bone fracture, a physician should decide when the athlete is ready to resume normal activity, and follow-up x-rays may be necessary to assess vertebral healing.
Before engaging in activity that may re-aggravate the injury site, particularly in high-extension sports like gymnastics and volleyball and high-impact sports like football and wrestling, athletes should be able to demonstrate pain-free range of motion with no sign of biomechanical compensation. They should also be able to perform sport-related skills without pain. Research has consistently shown that most cases of spondylolysis can be completely resolved within six months of the original diagnosis.
Having successfully helped hundreds of spinal patients over the years, I know there is no universal template for bringing a spondylolytic athlete back to health. However, a full understanding of the condition and knowledge of the relevant research, rehab strategies, and prevention techniques can be the keys to minimizing your athletes’ risk of back pain and injury.
To view references for the research discussed in this article, go to: www.Training-Conditioning.com/references.
This article discusses spondylolysis, a defect in a specific part of one or more vertebrae, often caused by a stress fracture and associated with chronic low back pain. Spondylolysis should not be confused with these other, similar-sounding conditions, all of which derive from the same Latin and Greek root words for vertebra:
• Spondylosis, also known as cervical spondylosis or cervical osteoarthritis, refers to changes in the vertebrae, discs, and joints of the back in aging populations. It is not typically seen in competitive athletes.
• Spondylitis is a general term for inflammatory conditions that primarily affect the spine. Ankylosing spondylitis is a form of chronic arthritis that may occur in young individuals (typical onset is before age 35) and is usually linked to a specific inherited trait.
• Spondylolisthesis, described briefly in this article, occurs when one or more vertebrae actually slip out of place in the spinal column.