Spondylolisthesis in the athlete Vertebrae misalignment due to ligament weakness

Ross Hauser, MD

Spondylolisthesis in the athlete Vertebrae misalignment due to ligament weakness

Spondylolisthesis occurs when a weak area of bone, in conjunction with stretched ligaments, allow vertebrae to slip and pinch a nerve, resulting in terrible back pain and radiating pain down the leg. Spinal instability and secondary muscle weakness can also predispose the spine to osteoarthritis. In this article, we will explain how Prolotherapy strengthens the weakened areas, relieving the pinched nerve and eliminates the chronic pain.

There are many reasons a young athlete can develop Spondylolisthesis.

Doctors writing in the medical journal World neurosurgery write the facet angle tropism (the mild to extreme rotation of the vertebrae to compensate for spinal instability) is seen in a high proportion of patients with Isthmic Spondylolisthesis (where a bone has chipped off the vertebrae) and seems to be a predisposing factor in the etiology of Isthmic Spondylolisthesis.1 In other words the progression is, spinal instability, vertebral rotation, bone chip, Isthmic Spondylolisthesis.

Genetics can play a large role as thin vertebral bone points to a precondition for the disease and bone fragments. Other causes include:

Conventional treatments may include physical therapy, nonsteroidal anti-inflammatories and surgery.

Doctors in Greece writing in the European journal of orthopaedic surgery & traumatology report that conservative treatment including physiotherapy and bracing is the mainstay in the treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in fine athletes. If consequent treatment fails, the operative treatment (pars repair and short fusion) is decided. Return to play following surgery varies from 6 to 12 months with prohibition in collision sports. Return to play is mostly depended on specific sport activity.2

We have found in our young athletes that a recommended back brace or a body cast for up to six months is a very unpopular treatment. We have also found that immobility and casting are tremendously detrimental to ligament healing.

In fact, ligament laxity, pre-strain, can account for significant altered spinal biomechanical movement and spinal instability.3 The casting/brace process can then be seen as making spinal instability worse.

Return to play after surgery, recovery and rehabilitation

Doctors at the Joint Reconstruction Research Center, Tehran University of Medical Sciences, have released their findings in the Asian Journal of Sports Medicine on treatment options for athletes with low back pain.

Here is the summary of their research:

Although most athletes, with low back pain whether resulting of degenerative disc disease or spondylolysis respond well to conservative treatment, when conservative treatment fails, surgical treatment is indicated.

On the other hand, intractable pain, progressive listhesis in spite of conservative treatment, or development of neurologic deficit, especially if it is progressive, are the surgical indications in athletes.

There are different kinds of surgical technique, including spinal  fusion. Recently minimally invasive spinal surgery techniques instead of conventional techniques are developing fastly, which might have benefits for athletes to return to play earlier in comparison to conventional techniques.

It should be emphasized that with any kind of surgical technique the patients need time for fusion and healing, which is a year.

The major concern in athletes with low back pain is return to play and previous level of their activity after treatment. There is insufficient data regarding this issue in literature to define the optimal time to return to play following treatment.4

For patients who underwent fusion whether due to degenerative disc disease or spondylolysis, with any kind of surgical technique, either conventional or new minimally invasive techniques, Return to Play recommend waiting time of at least one year before return to play.5

Prolotherapy for spondylolisthesis


Prolotherapy is an excellent treatment for spondylolisthesis because it strengthens the ligaments surrounding the slipped vertebrae causing proper alignment to be restored.

Prolotherapy is given to the ligaments on the back of the spine.  By tightening the ligaments in the back of the spine Prolotherapy helps stabilize the area thereby giving pain relief and allowing for other structures to heal. Typically a patient will require 3-6 visits, although some patients require more visits depending on their overall health status and the extent of their injury.

Unilateral vs. Bilateral Spondylolysis?

In new research, doctors at the Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, South Australia compared surgical versus non-surgical treatments for Spondylolisthesis.3

Historically, spondylolysis injuries were thought to be mostly bilateral (both sides of vertebrae) ; however advances in lumbar spine imaging have shown that in certain athlete groups, unilateral spondylolysis is highly prevalent.

Here is another term to describe what is going on in the back. In the Spondylolysis patient. as mentioned above) a defect in the segment of bone joining the facet joints of the spine is called the  pars interarticularis defect (pars fracture) and it can be on one side of the spine (unilateral) or both sides (bilateral). You can also add anterior spondylolisthesis, a fracture towards the back of the vertebrae.

In the study, the doctors examined previously published papers researching athletes with symptomatic unilateral spondylolysis of the lumbar spine who had spondylolisthesis surgery which attempted a direct repair of the pars interarticularis, compared to conservative management.

What they were really looking for was what got the athlete back to the sport quickly. The effectiveness of surgery on pain and overall function were secondary outcomes of interest.

Five studies reporting results for the outcomes of interest were critically appraised and included in the review. The limited evidence on the effectiveness of surgical treatment versus conservative treatment for unilateral spondylolysis in athletes does not allow any conclusions to be drawn about the relative effectiveness of surgery versus conservative treatment for facilitating rapid return to sport or a high level of post injury sporting level/performance.

It does suggest, however, that for adult athletes for whom conservative treatment has not been successful, surgery is likely to enable return to sport, reduce pain and promote overall function.

References for this article.

1 Eroglu A. The Role of the Features of Facet Joint Angle in the Development of Isthmic Spondylolisthesis in Young Male Patients with L5-S1 Isthmic Spondylolisthesis. World Neurosurgery. 2017 May 23. [Pubmed] [Google Scholar]

2 Bouras T, Korovessis P. Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review. European Journal of Orthopaedic Surgery & Traumatology. 2015 Jul 1;25(1):167-75. [Pubmed] [Google Scholar]

3. Robertson DJ, Von Forell GA, Alsup J, Bowden AE. Thoracolumbar spinal ligaments exhibit negative and transverse pre-strain. J Mech Behav Biomed Mater. 2013 Jul;23C:44-52. doi: 10.1016/j.jmbbm.2013.04.004. Epub 2013 Apr 17. [Pubmed] [Google Scholar]

4. Mortazavi J, Zebardast J, Mirzashahi B. Low Back Pain in Athletes. Asian Journal of Sports Medicine. 2015;6(2):e24718. doi:10.5812/asjsm.6(2)2015.24718. [Pubmed]

5 Scheepers MS, Streak Gomersall J, Munn Z. The effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review. JBI Database System Rev Implement Rep. 2015 Apr 17;13(3):137-73. [Pubmed]


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