Spondylolisthesis in the athlete Vertebrae misalignment due to ligament weakness
Ross Hauser, MD
Spondylolisthesis occurs when a weak area of bone, in conjunction with stretched ligaments, allows 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 conservative and surgical care treatments for lumbar spondylolysis in adolescent athletes.
Treatment of spondylolisthesis is controversial
Conservative care treatment for spondylolisthesis is controversial because there is no standard of care. In the below research evidence is given that surgery should only be offered in certain cases.
An April 2022 paper in the Spine Journal (1) comes to us from the University of California, Irvine; Department of Orthopaedic Surgery. In this paper, a contemporary account of the understanding of the difficulties in treating Lumbar Spondylolysis in the adolescent athlete is given.
“Spondylolysis is a defect of the pars interarticularis of vertebrae, most commonly seen at L5 and L4. The etiology of spondylolysis and isthmic spondylolisthesis is generally considered to be a result of repetitive mechanical stress to the weak portion of the vertebrae. A higher incidence of spondylolysis is observed in young athletes. Symptomatic spondylolysis can be successfully treated conservatively, but there is currently a limited consensus on treatment modalities and a lack of large scale clinical trials.”
Understanding this, the study authors then set about to investigate the optimal treatment program for symptomatic spondylolysis in adolescent athletes and “evaluate the functional outcomes of those undergoing the non-operative treatment.”
- The study examined 201 adolescent patients (62 females and 139 males) ranging from age 10-19 involved in athletics
- All patients were treated conservatively with rest (NO sports activity), thoracolumbosacral (TLSO) orthosis (a back brace), and an external bone stimulator for three months after diagnosis.
- Subsequently, the patients received six weeks of rehabilitation focused on core strengthening. Symptomatic patients after the treatment were referred for steroid injections and continued with the rehabilitation protocol.
- The most common age of injury was 15 years old.
- The most commonly played sport was football, followed by baseball/softball.
- The primary cause of injury was weight training closely followed by a football injury.
- 152 athletes reported using bone stimulators as prescribed. These patients showed a significantly higher rate of bony healing on follow-up CT scans than those who did not use bone stimulators.
- 197 patients (98%) returned to sports or similar levels of activities.
- 37 patients (18%) received facet or epidural steroid injections due to continued pain and one patient underwent a surgical procedure.
- Follow-up CT scans showed 49.8% bony healing.
Conclusions: Conservative treatment of spondylolysis in adolescent athletes was associated with excellent outcomes in terms of return to sports.
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. The casting/brace process can then be seen as making spinal instability worse.
Dancers and female athletes
An April 2016 paper in PM & R: The Journal of Injury, Function, and Rehabilitation (8) noted that the most common skeletal injury among pediatric dance injuries was a par stress reaction/spondylolysis. A 2000 paper in Clinical Orthopaedics and Related Research (9) writes: “spondylolysis or a stress fracture of the posterior vertebral elements can be a common cause of back pain in an athlete. In many sports that are dominated by females (gymnastics, dancing, figure skating), the athletes carry a high risk of having spondylolysis or a stress fracture. Knowing the risk factors permits precise diagnosis and appropriate treatment. Treatment options include the use of a brace and surgery.”
This 2000 research paper was cited in 2022 research published in the Orthopaedic Journal of Sports Medicine (10) examining injuries in cheerleaders. Here the authors write: The lower back is susceptible to muscle strains and pars interarticularis stress reactions, progressing to spondylolysis with or without spondylolisthesis, from the repetitive flexion, hyperextension, rotation, and compressive loading involved in tumbling and basing stunts.”
Lumbar spondylolysis recurrence after conservative treatment.
A March 2022 paper (2) from the Department of Orthopaedic Surgery and Sports Medicine, Tsukuba University Hospital in the journal Scientific Reports found: Occasionally lumbar spondylolysis in adolescents will recur after conservative treatment. The goal of this study was to retrospectively review the conditions in which recurrence transpired in a subset of adolescent patients diagnosed with acute lumbar spondylolysis.
- A retrospective survey was conducted in 141 patients who had been treated for spondylolysis and had obtained bone union.
- Twenty patients were selected who had recurrent lumbar spondylolysis after returning to sports activity following the initial spondylolysis treatment.
- There were 18 males and two females with an average age at the time of the initial visit of 13.3 years old and 14.1 years old at the time of recurrence.
- The average period of initial treatment was 101 days, and the average time to recurrence after healing was 149 days.
- In this study, the recurrence rate was 13.2%. Eighty percent of cases had recurrence within six months after healing. After recurrence, 20% of the cases reached pseudoarthrosis (failed spinal fusion). It is useful to take regular MRI images to detect recurrence within six months after returning to sports.
There are many reasons a young athlete can develop Spondylolisthesis.
A January 2022 update to the United States Library of Congress’ medical publication STAT PEARLS (3) writes: “Pars interarticularis defect (spondylolysis) represents a common cause of axial back pain in adolescents, especially in the case of young athletes. . . The definition of pars interarticularis defect is a unilateral (one-sided) or bilateral (both sides) overuse or fatigue stress fracture involving the pars interarticularis of the posterior (rear) vertebral arch. This injury occurs almost exclusively in the lower lumbar region, most often at L5. Though history can be suggestive (it sounds like spondylolysis), especially in the case of young athletes involved in higher-risk sports, (Gymnastics, weight lifting, and football, as well as other sports that put pressure on the lower back, can also be a catalyst. In addition, the constant hyperextension of the spine required in these sports can be very hard on the bones.) diagnosis is made radiographically by the presence of fracture through the pars interarticularis. . . (a) common presentation is an adolescent athlete involved in a sport requiring repetitive lumbar loading in extension and rotation, presenting with acute or insidious onset low back pain that is aggravated by continued lumbar loading.” Conventional treatments may include physical therapy, nonsteroidal anti-inflammatories, and surgery.
Physical therapy that conforms to the player’s sport has higher success rate of returning players to the sport.
Before we go back to the medical publications, let’s stop here for a brief discussion of physical therapy. The goal of physical therapy in the treatment of spondylolisthesis is to strengthen core muscles. Many young athletes find physical therapy to be very beneficial. These are typically not the people we see at our center. We see the people, young and old, who did not respond to physical therapy and exercise. A reason why physical therapy may not be successful is that the ligament and tendon attachments that allow the resistance necessary for muscles to grow and strengthen are too weak to provide that needed resistance. This is a long subject that is covered in our comprehensive article: Why physical therapy and yoga did not help your low back pain.
A Case history presented in the International Journal of Sports Physical Therapy (4) December 2020 presents the case of an 18-year-old lacrosse player. Here is what the attending physicians reported: “The purpose of this case report is to present a program where demands of sport (in this case Lacrosse) were considered and allowed successful return to sport for a (patient) with recalcitrant symptomatic spondylolysis that had failed to respond to prior treatment.”
The patient was an 18-year-old lacrosse player with a history of recalcitrant symptomatic spondylolysis that failed three courses of conservative treatment and had been unsuccessful in returning to sport. A multi-phase program with a focus on multi-planar and full kinetic chain activities (the movements that a lacrosse player would need in a game) that addressed the nature of the sport’s demands was designed.
The patient was able to successfully return to sport after 10 weeks of physical therapy and complete the remaining few months of his lacrosse season without reinjury. Range of motion and strength testing was markedly improved upon discharge. The authors concluded: “Although the return to sport rates following spondylolysis in young athletes is high, this case report demonstrates that a consideration of sport demands may increase return to sport rates in athletes that do not respond to standard care and prevent surgical intervention.”
Return to play following surgery varies from 6 to 12 months with prohibition in collision sports
In 2015, doctors in Greece writing in the European Journal of Orthopaedic Surgery & Traumatology (5) 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 dependent on specific sports activity.
Unilateral vs. Bilateral Spondylolysis?
In recent 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. (11)
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.
Surgical intervention is rarely necessary
In 2022, this research was built on a study in the journal Current Reviews in Musculoskeletal Medicine. (6) Here researcher again noted that “Spondylolysis remains one of the most common causes of lower back pain in the pediatric and adolescent populations and is particularly prevalent in young sporting individuals. Despite this, approaches to diagnostic imaging and both conservative and surgical treatment vary widely among surgeons. . . While the exact cause of spondylolysis remains unclear, there is a growing understanding of the behavioral, genetic, and biomechanical risk factors (overuse and poor training) that predispose individuals to the condition. . . Conservative treatment remains the first step in management due to excellent outcomes in most patients, with surgical intervention rarely necessary.”
Return to play after surgery, recovery, and rehabilitation
In 2015, doctors at the Joint Reconstruction Research Center, Tehran University of Medical Sciences, released their findings in the Asian Journal of Sports Medicine on treatment options for athletes with low back pain. (7)
Here is the summary of their research:
- Low back pain in athletes is common and has a broad spectrum of differential diagnoses that must be taken into account when a clinician approaches the patient. We discussed that above.
- The physicians should take into account spinal and extra-spinal causes of low back pain in athletes. The two most common causes of low back pain arising from the spine, in athletes are degenerative disc disease and spondylolysis with or without listhesis (the slippage of the vertebra over another).
Although most athletes, with low back pain whether resulting from 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 fast, 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. 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 recommends a waiting time of at least one year before return to play.
Prolotherapy for spondylolisthesis
Prolotherapy is an excellent treatment for spondylolisthesis because it strengthens the ligaments surrounding the slipped vertebrae causing the 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.
- Please see our article Spondylolisthesis | Spondylolysis | Spondylisis Fusion Alternatives
- If you have questions about Spondylolisthesis, get help and information from Caring Medical
References for this article.
1 Choi JH, Ochoa JK, Lubinus A, Timon S, Lee YP, Bhatia NN. Management of Lumbar Spondylolysis in the Adolescent Athlete: A Review of over 200 cases. The Spine Journal. 2022 Apr 30. [Google Scholar]
2 Tatsumura M, Gamada H, Okuwaki S, Eto F, Nagashima K, Mammoto T, Hirano A, Funayama T, Yamazaki M. Characteristics of recurrent cases after conservative therapy in adolescent lumbar spondylolysis. Scientific Reports. 2022 Mar 7;12(1):1-6. [Google Scholar]
3 Mansfield JT, Wroten M. Pars interarticularis defect. InStatPearls [Internet] 2020 Aug 13. StatPearls Publishing. [Google Scholar]
4 Murray MK, Maxwell J. CONSIDERATION OF SPORT DEMANDS FOR AN 18-YEAR-OLD LACROSSE PLAYER WITH RECALCITRANT SYMPTOMATIC SPONDYLOLYSIS: A CASE REPORT. International Journal of Sports Physical Therapy. 2020 Dec;15(6):1196. [Google Scholar]
5 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. [Google Scholar]
6 Linton AA, Hsu WK. A Review of Treatment for Acute and Chronic Pars Fractures in the Lumbar Spine. Curr Rev Musculoskelet Med. 2022 May 2. doi: 10.1007/s12178-022-09760-9. Epub ahead of print. PMID: 35499747.
7 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. [Google Scholar]
8 Yin AX, Sugimoto D, Martin DJ, Stracciolini A. Pediatric dance injuries: a cross-sectional epidemiological study. PM&R. 2016 Apr 1;8(4):348-55. [Google Scholar]
9 Omey ML, Micheli LJ, Gerbino PG. Idiopathic scoliosis and spondylolysis in the female athlete: tips for treatment. Clinical Orthopaedics and Related Research®. 2000 Mar 1;372:74-84. [Google Scholar]
10 Xu AL, Beck JJ, Sweeney EA, Severson MN, Page AS, Lee RJ. Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature. Orthopaedic Journal of Sports Medicine. 2022 Jan 13;10(1):23259671211067222. [Google Scholar]
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]