Spondylolysis and the Athlete

Spondylolysis and the Athlete

Tracy Ray and Chad Carlson

Introduction

Lower back pain is a very common complaint amongst many types of athletes. While certain types of pain could simply be muscle soreness from activity, others can be more concerning and require treatment. Carlson and Ray (2007) show that spondylolysis is a common cause of pathological low back pain, especially for athletes who perform repetitive hyperextension of the lumbar spine. The lumbar spine can handle the weight of our upper body very well and provides mobility of the torso (Biel, 2014). Spondylolysis refers to a stress fracture (unilateral or bilateral) of the pars interarticularis (Carlson & Ray, 2007). This becomes even more concerning given that this fracture can lead to rotational or anterior displacement of the affected vertebrae, called “spondylolisthesis.” 

Purpose

The purpose of this article is to bring awareness to athletic trainers, personal trainers, physical therapists and other professionals dealing with athletes. The article highlights the sports that have the highest prevalence of spondylolysis so that coaches and trainers can help with prevention. This article also discusses proper diagnosis for medical professionals and even treatment suggestions for athletes suffering from this stress fracture. 

Incidence

Carlson and Ray (2007) suggest that the overall incidence of spondylolysis in the general Caucasian population is about 6%. Males are about twice as likely as females to have this fracture. There also appears to be a genetic component that contributes to incidence since it is seen as high as 35-50% among affected family members. Some sports are listed with higher incidence rates due to the amount of hyperextension of the lumbar spine. Female Gymnastic shows an 11% incidence rate, 15-36% for Heavyweight lifting, 15-33% for Wrestling and 15% for Football (Carlson & Ray, 2007). Although the rates are higher in these sports, the authors reference an article by Muschik et al. (1996) that suggests, “Progression of spondylolisthesis probably relates more to heightened muscle tension associated with rapid growth than participation in sport.” 

Diagnosis

Some of the diagnosis techniques mentioned are beyond my scope of practice, but a brief overview is still valuable. Carlson and Ray (2007) say that many times spondylolysis is diagnosed incidentally when radiographs of the back are obtained for some other reason. The paralumbar muscles will spasm during examination and there will be pain during motion through the facets. There are many manual methods of testing listed that a physician or physical therapist could perform to gain positive feedback, mainly by increasing lumbar lordosis. Carlson and Ray (2007) seem to place increasing value on imaging in this order: x-ray, SPECT scan, CT scan then MRI scanning. Although it is mentioned that MRI scanning is so sensitive that it could lead to false positives. 

Treatment/Discussion

Carlson and Ray (2007) suggest some treatment options that I believe can also be used for prevention. They suggest increasing lower extremity flexibility. Doing this will protect the lumbar spine from being over-utilized due to muscle motion restriction at the hips. The hamstrings of an affected athlete can be especially tight due to compensation while trying to decrease lumbar lordosis. Building strength of the abdominals as antagonists to the extensors of the spine can help with prevention and rehabilitation. If the athlete has healing potential, its suggested that all sport activity be terminated and rigid bracing be implemented until healed (Carlson & Ray, 2007). This takes about 2.65 months on average, but as long as 6 months. Carlson and Ray (2007) also note that recurrence is high. About 44% of patients will experience slip progression after diagnosis. Surgery is suggested for a forward slip greater than 50% and for those who fail to find relief from physical therapy. 

Application

I work in an industry that is shown to have the highest incidence percentages, and I participate in weightlifting as well. I have noticed that it has become particularly trendy to hyperextend the lumbar spine during that last phase of a deadlift. I’m not sure if people are trying to emphasize their gluteus activation or if others are being cued to drive their hips to the bar, leading to hyperextension. We should cue the athlete to bring their hips to the neutral position but to avoid hyperextension to decrease risk of spondylolysis. Another risky motion that I try to watch for is the hyperextension during the log press (a strongman event). Many athletes will overly hyperextend their lower back while trying to press the log overhead in an attempt to recruit more pectoralis vs. deltoids. The extremely heavy weight of the log only increases the risk of spondylolysis during the motion. The article has also highlighted ways to prevent the injury through abdominal muscle strengthening and mobility of lower extremity muscles. Being more aware of this injury will also help me to move a client to the right care when lower back pain is reported. 

Questions

Which exercises would be most effective for strengthening the flexors of the spine, specifically for spondylolysis prevention?

Which movements would you consider to be the most “at-risk” for spondylolysis in your sport? 

Which cues would you implement for an athlete in one of the more incidence prevalent sports?

Would you suggest that a deadlifter that displays excessive lordosis stop pelvic thrust sooner than one who has normal lordosis?

References

Carlson, C. T., Ray, T. (2007). Spondylolysis and the athlete. Athletic Therapy Today 12(4), 37-39.

Muschik, M. (1996). Competitive sports and the progression of spondylolisthesis. Journal of Pediatric Orthopedics 16, 364-369.

Biel, A. (2014).Trail Guide to the Body(5^thed., pp. 170). Boulder, CO: Books of Discovery.