Low Back Pain in female high school athletes lumbar spondylosis
Ross A. Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C
Low Back Pain in female high school athletes. A look at lumbar spondylosis
In this article, we are going to talk about your daughter, her sports, and her back pain. If you are reading this article it is likely that your daughter has been diagnosed with lumbar spondylolysis, which is a stress fracture or cracks in her vertebrae that is causing her pain and preventing her from playing sports or from being a happy teenager. We will also explore the various treatments that may work and treatments that may accelerate healing and get her back to her game perhaps a little faster including a regenerative injection program to strengthen the core spinal ligaments.
We often get emails from the parents of young athletes who need to register their daughter for an upcoming spring or fall sport event or team. Their great concern is that their daughter has significant back pain and they do not know if she can play. A typical story is one like this:
- Your daughter is complaining of continued dull back pain. Sometimes she suffers a very unsettling acute flare-up that causes you distress and great concern.
- You took her to a spine specialist where an x-ray and MRI showed spondylosis, a crack in the vertebrae segment of the facet joint called the pars interarticularis.
- This probably frightened you because your daughter has a “fractured spine.”
- Your doctor tried to reassure you that this was a common injury in adolescent athletes and that time should be taken to allow the fracture(s) to heal.
- You got a couple of prescriptions for anti-inflammatories, (to help with the swelling or edema in the bone marrow) and were told to come back after 2 to 3 months to check your daughter’s healing progress.
- Over time your daughter’s back felt better, the pain went away, it was now time to get back to the field. For many of you, that very same day, once on the field, your daughter’s back pain returned. “Nothing had healed.”
- In some instances, depending on the fracture, your daughter may have been placed in a hard back brace for 6 weeks and then converted over a soft brace. Typically the brace would be more common for girls who compete in gymnastics, cheerleading, or dance where bending the spine backward would be more stressful than say basketball, soccer, volleyball, or running impact sports. The more stress, the worse the fracture.
Now after another 2-3 months, if your daughter’s back pain finally went away, you are probably not reading this article. You are probably here because her back pain did not go away.
- While your daughter’s back pain has lessened, it is still there and at this time she has not resumed sports.
- Your follow up visit with the spine doctor has been disheartening as he/she has told you nothing more can be done other than more rest.
You did your research and you may have hit upon something. Physical therapy. Perhaps if you can get your daughter into an extensive PT program they can help strengthen her core muscles and provide stability that will help her heal faster. So you had the doctor, if he/she was agreeable, write you a prescription for PT and you and your daughter went with great optimism.
Now if you had the 2 – 3 months of PT and your daughter’s back pain was alleviated and she was able to return to her sport, you are not here reading this article. If you are reading this article, you are still looking for answers.
For some, conservative care will fail and it is at this time that athletes, doctors, and parents start to consider surgery. However, non-surgical treatment is effective in almost 90% of competitive athletes
Later in this article, we are going to present non-surgical options including the use of regenerative medicine injections to strengthen the core spinal ligaments. In this segment, we will discuss the surgical options as presented by surgeons at leading medical centers.
According to the research, we are going to present below, for most adolescent athletes, conservative care will help them. For some, conservative care will fail and it is at this time that athletes, doctors, and parents start to consider surgery. For some patients surgery will be the answer, however, surgeons warn, it is not the answer for every patient.
Doctors in Poland at the Poznan University of Medical Sciences, (1) offer these observations on surgery for the young elite athlete with spondylolysis: These findings were published in the European Journal of Orthopaedic Surgery and Traumatology.
- About 15% of young elite athletes will suffer from spondylolysis
- Non-surgical treatment is effective in almost 90% of competitive athletes
- In those were non-surgical treatment has failed, pain associated with spondylolysis can significantly interfere with playing ability, if play can be maintained at all.
Low-intensity pulsed ultrasound: Fracture healing and spinal instability
One conservative treatment that many have tried, and some successfully, is Low-intensity pulsed ultrasound. This treatment addresses the fractures and not the specific cause of how the fracture occurred. In many young athletes, as we will discuss below, the cause of the fractures can be from prolonged or unhealed ligament injury, more commonly known as a back sprain. Low-intensity pulsed ultrasound does not address this problem but can in some instances be used in conjunction with treatment.
This was suggested in a July 2019 study in the Clinical Journal of Sports Medicine (2). Here researchers looked at 82 patients, average age 15. Patients received either standard conservative treatment combined with Low-intensity pulsed ultrasound (LIPUS) without LIPUS. The standard conservative treatment included thoracolumbosacral brace, sports modification, and therapeutic exercise.
Main outcome measures: The time required to return to previous sports activities:
- The average time to return to previous sports activities was 61 days in the group treated with LIPUS, which was significantly shorter than that of the group treated without LIPUS (167 days). These results suggest that LIPUS combined with conservative treatment for early-stage lumbar spondylolysis in young athletes could be a useful therapy for quick return to playing sports.
Surgical problem: damaging soft tissue, muscle atrophy, and scar tissue
- A great disadvantage of surgery is the need for muscle dissection from the vertebral lamina to the facet joint. This causes considerable tissue damage which, combined with a scar generated in the subcutaneous tissues, may limit the optimum functionality of the back muscles. This is particularly undesirable in professional athletes, where even the slightest change in the functionality of tissues may affect the results achieved in sport.
What jumped out at you in that observation was muscle damage, scar tissue, reduced ability. Let’s point out that the researchers of this study were suggesting a “Buck’s fusion,” or “Buck’s surgery,” a technique that would limit the soft tissue damage by addressing the fracture with the micro-surgical implant of a screw as a means of “Direct surgical repair of spondylolysis in athletes.”
In a paper titled, “Direct surgical repair of spondylolysis in athletes,” published in the journal Neurosurgical Focus, (3) doctors at the Department of Neurosurgery, Cedars-Sinai Medical Center, in Los Angeles, suggested:
- “For a young athlete with a symptomatic pars defect, any (surgical) techniques of repair would probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years with minimal or no listhesis (the unnatural slippage of one vertebra on top of another) and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively.”
Of course, what would stand out to you is, it is 5 to 12 more months of recovery on top of the time invested already in healing.
This downtime was also suggested by a 2018 review study (4) which cited research on 59 professional and Olympic athletes undergoing lumbar microdiscectomy, The review study found that 88% of patients returned to active sport at an average period of 5.2 months following surgery. However, there was no performance-based outcome assessed in this study. The authors highlighted the role of trunk stabilization and strengthening exercises for athletes to be able to return to their respective sports.
More surgical clues that the answer may not be in surgery but in injections that create stability – addressing the lumbar sprain
Above we spoke about the lumbar sprain, spinal ligament injury as the cause of spondylosis. At this point of our article, we are going to start presenting evidence that the research the surgeons are giving us on post-operative results can make a good case for non-surgical regenerative injections. We will present the evidence in the forms of clues.
Again, in our clinics, we see the young athlete in our office with problems of stress fractures of the vertebrae, herniated disc, and spondylosis. The young athlete may have been in a back brace, may have been to physical therapy, may have taken an entire season off, yet here she is with pain. She is here because her parents may have explored a surgical option and are trying one last attempt to avoid it and one more attempt to help their daughter get back to the game she loves.
How can we help her do this? Can we help her do this?
A clue that we can help: Core spinal ligament weakness and spinal curvature
You went to physical therapy with the idea that your daughter would be able to build up her core muscles and this would provide stability to the spine and cause her less pain. This did not happen. Why? Because physical therapy can not strengthen ligaments, those small connective tissue “rubber bands,” that hold the vertebrae in place. Why? Because physical therapy focuses on muscles and tendons.
Ligaments are a different tissue then tendons. While both are strong connective tissue, tendons have an ample supply of blood that flows to them, ligaments do not. When compromised or damaged, tendons tend to heal quickly, ligaments because they do not have direct blood circulation to them, do not heal well. This is why in the most famous sports surgeries, ligaments are replaced with a tendon, for example, the UCL in Tommy John surgery or the ACL in the knee. Tendons heal better.
So when this young athlete comes into our office, we look for spinal ligament damage and spinal instability by examining the curvature of the spine and by locating the pain triggers. Here we can identify the area of the fracture and apply treatments. We can not replace the ligaments with tendons, what we can do is direct injection treatments. Let’s look at some research first on the importance of spinal stability in treating lumbar spondylosis.
In May 2018, doctors at the Hospital for Special Surgery (5) published research in which they were looking for a connection between abnormal sacropelvic orientation (tilted pelvis, abnormal spinal curve) and both spondylolysis and spondylolisthesis (the moving forward of the vertebrae on top of the vertebrae below it causing abnormal spinal curvature as we mentioned above). The research appears in PM & R: the journal of injury, function, and rehabilitation.
What did they find?
- A wear and tear stress vertebrae fracture is not something that occurs all by itself as an isolated injury.
- For this stress factor to occur, in many athletes, the proper inter-relationship between pelvic stability and spinal stability has been broken.
- This has caused hypermobility in the spine, sacrum, pelvic region and has caused misalignment and misconfiguration of the lumbar lordosis or curve.
This is the concluding statement: “Sacral slope may be an important variable for clinicians to consider when caring for young athletes with low back pain, particularly when the index of suspicion for spondylolysis is high.”
Let’s take these few brief sentences in.
- Your daughter can have spinal instability causing unnatural pressure on her spine causing stress fracture.
- This fracture causing pressure is coming from a spine that is hypermobile, causing the vertebrae to move out of place.
- The spinal instability is putting pressure on the sacrum and pelvic region and causing the spine to loss or gain too much curvature, adding more pressure.
- When you put a surgical screw into the vertabrae, you are only fixing the crack, you are not fixing what caused the crack or what will likely cause another crack to occur.
The connection between spinal curvature, spinal instability, and your daughter’s spondylolysis
In June 2018, a study from Department of Orthopaedic Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, at the University of Southern California, provided these two simple observations in the medical journal Spine,(6) about lumbar lordosis, the lower curvature of the back, and vertebral cross-sectional area (the measure of how much axial or mechanical load is on a specific part of the vertebrae.)
- Analyses indicate that the cross-sectional area of the vertebral body was negatively associated with lumbar lordosis angle and an independent predictor of the presence of spondylolysis.
- This provides evidence that patients with spondylolysis have increased lumbar lordosis and smaller vertebral cross-sectional area of the vertebral body.
What does this mean to you and your daughter?
- Spinal instability has caused a shift in the vertebrae so less of the vertebrae (the cross-sectional area) is actually supporting the weight of the spine.
- This is causing pressure on the smaller, weight-bearing area of the vertebrae
- This is also causing the spine to curve unnaturally
- The pressure of the curving spine, the less weight-bearing area of the vertebrae, is causing the stress fracturing and cracks.
In our opinion how is a screw going to fix all this?
Prolotherapy injections for low back pain in female high school athletes lumbar spondylosis
There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.
University of Manitoba, Winnipeg, Manitoba, Canada. The Journal of Alternative and Complementary Medicine. (7)
- One hundred and ninety (190) patients were treated between, June 1999-May 2006.
- Both pain and Quality of Life scores were significantly improved at least 1 year after the last treatment.
- This study suggests that prolotherapy using a variety of proliferants can be an effective treatment for low back pain from instability from ligament dysfunction for some patients when performed by a skilled practitioner.
Citing our own Caring Medical and Rehabilitation Services published research (8) in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy, but the mental aspect of treatment as well.
- In our study, 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option.
- In these 145 low backs,
- pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability
- 75% percent were able to completely stop taking pain medications.
If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.
The first step in determining whether Prolotherapy will be an effective treatment for you
The first step in determining whether Prolotherapy will be an effective treatment for the patient is to determine the extent of ligament laxity or instability in the lower back by physical examination. The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain. Pain here is an indicator that Prolotherapy can be very effective for the patient.
If this article has helped you understand problems of lumbar spondylosis and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
1 Bartochowski Ł, Jurasz W, Kruczyński J. A minimal soft tissue damage approach of spondylolysis repair in athletes: a preliminary report. European Journal of Orthopaedic Surgery & Traumatology. 2017 Oct 1;27(7):1011-7. [Google Scholar]
2 Tsukada M, Takiuchi T, Watanabe K. Low-intensity pulsed ultrasound for early-stage lumbar spondylolysis in young athletes. Clinical Journal of Sport Medicine. 2019 Jul 1;29(4):262-6. [Google Scholar]
3 Drazin D, Shirzadi A, Jeswani S, Ching H, Rosner J, Rasouli A, Kim T, Pashman R, Johnson JP. Direct surgical repair of spondylolysis in athletes: indications, techniques, and outcomes. Neurosurgical focus. 2011 Nov 1;31(5):E9. [Google Scholar]
4 Gadia A, Shah K, Nene A. Outcomes of Various Treatment Modalities for Lumbar Spinal Ailments in Elite Athletes: A Literature Review. Asian Spine J. 2018 Aug;12(4):754-764. doi: 10.31616/asj.2018.12.4.754. Epub 2018 Jul 27. [Google Scholar]
5 Hanke LF, Tuakli-Wosornu YA, Harrison JR, Moley PJ. The relationship between sacral slope and symptomatic isthmic spondylolysis in a cohort of high school athletes: a retrospective analysis. PM&R. 2018 May 1;10(5):501-6. [Google Scholar]
6 Wren TA, Ponrartana S, Aggabao PC, Poorghasamians E, Skaggs DL, Gilsanz V. Increased Lumbar Lordosis and Smaller Vertebral Cross-Sectional Area Are Associated With Spondylolysis. Spine. 2018 Jun 15;43(12):833-8. [Google Scholar]
7 Watson JD, Shay BL. Treatment of chronic low-back pain: a 1-year or greater follow-up. J Altern Complement Med. 2010 Sep;16(9):951-8. doi: 10.1089/acm.2009.0719. [Google Scholar]
8. Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155. [Google Scholar]