Spondylolysis
1. Introduction
Stress fractures of the pars interarticularis are defined as an injury to the bony bridge at the back of the vertebra which causes pain felt in the centre, or just off centre, of the lower back (1, 2) but can also cause pain in the buttock and back of the leg to the knee. This is often referred to as spondylolysis.
Each vertebra has two pars interarticularis, one on each side of the vertebra, and damage can occur on just one side or both (9). Symptoms can occur gradually over time or after a one-off movement (1, 6). Stress fractures of the pars interarticularis are present in around 5%-10% of the general population and are up to 20% higher in the athletic population under 20 (1, 2, 8).
There are different grades of injury:
- A stress response which is like a precursor to a fracture – the most minor.
- A stress fracture involving less than 50% of the thickness of the pars.
- A stress fracture where greater than 50% of pars is fractured, up to a complete fracture (1, 2, 8, 9) – the most severe injury.
All can cause pain and if pain is present for 2 weeks or more you should seek advice (1, 2, 3, 6).
Frequently Asked Questions
- This injury occurs due to a stress fracture through part of a vertebra(e) known as the pars interarticularis of the lumbar vertebrae (located in the lower back). The pars interarticularis is a thin bone segment joining two vertebrae.
- This condition is common in the first two decades of life (1).
- 20% more likely to occur in an active population of adolescents and young adults, particularly in sports that require repetitive rotation and extension (backwards bending) of the lower spine (4).
- Stress fractures in the lumbar spine are present in 3%-10% of the adult population, but not all cause pain (3, 6, 9).
- Up to 95% of stress fractures of the pars interarticularis occur at the junction between the lumbar and sacral spine (9).
- No.
- When diagnosed in an appropriate time frame most stress fractures of the pars interarticularis can be managed without need for surgery (1,2).
- Back pain in an adolescent lasting more than 2 weeks should be assessed by a physiotherapist (1, 8).
- Males are twice likely to suffer from this condition.
- Those with a family history of low bone density.
- More common in those aged below 25.
- More common in Caucasians.
- More common in sports where you arch your back such as tennis, gymnastics, dance, football and rugby.
- Those who have had sudden increases in training load (returning to sport after injury, start of pre-season).
- Pain onset that can be acute or gradual, after intense sporting activity (1).
- Direct contact to that part of the spine (1).
- Aching in the centre of the spine or just to the side.
- Referral of pain into the buttock or back of the leg (5).
- Morning stiffness that takes 30-60 minutes to settle.
- Pain when arching the back backwards or twisting (6).
- Rest usually relieves the symptoms (2).
- Intense pain that restricts activities of daily living or sporting performance (6, 7).
- Activity modification – initially this may mean total rest or using crutches, depending on the severity of injury (3).
- Physiotherapy – after the initial period of rest, exercise can help strengthen the muscles around the spine (2).
- Seek input from a musculoskeletal specialist who might suggest investigations and medication (2, 3).
- This will depend upon several factors including, but not limited to, the severity of the injury and bone density (8).
- Most stress fractures of the pars interarticularis take between 3-4 months to heal (2).
- More severe cases can take 4-6 months to heal and return to sport (6).
- In rare cases, if symptoms persist for 6 months without improvement with good conservative management, then referral for surgical opinion is warranted (1, 3, 8).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
- Pain onset, that can be acute or gradual, after intense sporting activity (1).
- Direct contact to that part of the spine (1).
- Aching in the centre of the spine or just to the side.
- Referral of pain into the buttock or back of the leg (5).
- Morning stiffness that takes 30-60 minutes to settle.
- Pain when arching the back backwards or twisting (6).
- Rest usually relieves the symptoms (2).
- Intense pain that restricts activities of daily living or sporting performance (6, 7).
3. Causes
This condition tends to affect young people in the first two decades of life (1, 3, 5). Activities that require extending the back (such as dance and gymnastics), twisting of the back (such as tennis or golf) or sports that require fast change of direction (such as football, rugby or basketball) (1, 6, 8) might contribute to the development of this condition. These activities place a lot of force across the bony bridge and can cause damage to the bone structure (8, 9).
As we grow and develop, our bones grow and our soft tissues, such as muscles and ligaments, adjust to this development. Due to this period of development our soft tissues are less efficient at supporting the spine in taking the load of activity and this causes our spine to take too much load around the pars interarticularis and cause injury (1, 6).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing spondylolysis. It does not mean everyone with these risk factors will develop symptoms (1, 2, 3, 5, 7).
- Males are twice as likely to suffer this condition as females.
- Caucasians are more likely than other ethnic groups to suffer stress fractures.
- Adolescents and young adults who engage in sports that require extension and rotation, e.g. ballet, gymnastics, golf, tennis, football and rugby.
- Adolescents experiencing accelerated growth between 12-19 are more susceptible.
- Those with low levels of vitamin D or poor diet.
- Girls who have delayed start to their periods.
- Family history of osteoporosis and those who engage in high-impact sports are at the greatest risk.
5. Prevalence
Stress fractures of the pars interarticularis are present in around 5%-10% of the general population and up to 12% of the athletic population under 20 (1, 2, 7, 8). Most of the injuries occur as a younger child and then become symptomatic as we continue to load the spine as an adolescent or young adult (3, 5, 7). After the age of 20, a new stress fracture of the pars interarticularis is significantly less likely.
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.
Further investigations or imaging may include assessment of vitamin D levels; this is in the form of a blood test that will give an indication of bone health. If your symptoms have not resolved in sufficient time, you might be referred for further investigations such as X-ray, magnetic resonance imaging (MRI) or CT Scan to get a definitive diagnosis of the problem and help to decide the best treatment options. If you have had previous stress fractures and another one is suspected, you may be sent for a DEXA (dual energy X-ray absorptiometry) scan that will give an indication of your overall bone health.
7. Self-Management
Initial self-management includes activity modification and resting from aggravating activities for two weeks. If pain settles, then gently resume exercise. If pain returns or never subsides, seek further assessment from a musculoskeletal specialist.
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your patellar tendinopathy. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
This will depend entirely on your symptoms and the outcome of any imaging that may be requested.
- For those with mild symptoms – a 4-week period of rest from all activities followed by a 4-week build-up back to normal activities, including leg and trunk strengthening activities as outlined below (1, 3, 8).
- For moderate symptoms – rest from all activities for 4 weeks, followed by 4 weeks of progressive loading with trunk strengthening and non-impact activities like swimming and cycling. Over a further 4 weeks you will be allowed to progress towards normal activities for your sport (1, 3, 8).
- For severe symptoms or after surgery – rehabilitation will be similar to moderate injury but the first 2 stages usually last for 6 weeks.
For all grades of injury your physiotherapist will work with you to progress toward your goals of rehabilitation that you have agreed. Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing stress fractures of the pars interarticularis. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Spondylolysis
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme will begin the process of increasing the strength of the muscles around the lower back, abdomen and pelvis. It should be performed regularly as the level of exercise is quite light. This should not exceed any more than 3/10 on your perceived pain scale.
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Here the exercises progress to more challenging positions and increased effort level. This is with the aim of increasing the strength in the area. This should not exceed any more than 3/10 on your perceived pain scale.
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In this stage, we add more challenging exercises and more whole-body movements to further increase strength and to prepare the back towards a return to normal activity. This should not exceed any more than 3/10 on your perceived pain scale.
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10. Return to Sport / Normal life
Returning to sport after stress fracture of the pars interarticularis is a gradual process of slowly increasing the difficulty of strengthening exercises and reintroduction to preferred sporting activities (1, 3, 8).
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence (1, 6, 8).
A small percentage of adolescents and young adults do no heal and if, after 6 months of appropriate conservative management, things are not improving, you may be referred to a specialist orthopaedic consultant where surgery may be considered (1, 5).
11. Other Treatment Options
Specific treatment methods such as some electrotherapies and supplements, such as vitamin D, have been found to help with the healing process and may be included in your rehabilitation if appropriate.
For those who do not recover with activity modification, exercises and other comprehensive treatments, the next option is often surgical (1, 6, 8).
- Surgical pinning – here a small incision is made in the back and using a live CT scan of the lumbar spine a screw is placed across the fracture site to bring the two bone ends together. A special protein is then injected around the fracture site that stimulates the bone to heal (6).
- Bisphosphonates – a medication that helps suppress the cells in the body that reabsorb bone, thus providing a good environment within the bone for healing. They can have associated side-effects so it is worth reading up on them before deciding to use them.
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References
- Astur, D.C., Zanatta, F., Arliani, G.G., Moraes, E.R., Pochini, A.D.C. & Ejnisman, B. (2016). Stress fractures: definition, diagnosis and treatment. Revista brasileira de ortopedia, 51(1), 3-10.
- Leone, A., Cianfoni, A., Cerase, A., Magarelli, N. & Bonomo, L. (2011). Lumbar spondylolysis: a review. Skeletal radiology, 40(6), 683-700.
- Ruiz-Cotorro, A., Balius-Matas, R., Estruch-Massana, A.E. & Angulo, J.V. (2006). Spondylolysis in young tennis players. British journal of sports medicine, 40(5), 441-446.
- Field, A.E., Gordon, C.M., Pierce, L.M., Ramappa, A. & Kocher, M.S. (2011). Prospective study of physical activity and risk of developing a stress fracture among preadolescent and adolescent girls. Archives of paediatrics & adolescent medicine, 165(8), 723-728.
- Cavalier, R., Herman, M.J., Cheung, E.V. & Pizzutillo, P.D. (2006). Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 14(7), 417-424.
- Robberecht J. Stevens N. & Sys J. (2016). Treatment of Acute Spondylolysis in elite Athletes. Literature Review and Presentation of a new Percutaneous Grafting Technique Open Access Journal of Neurology and Neurosurgery, 1(4), 1-6.
- Depalma M. (2011). iSpine: Evidence-based interventional spine care, Demos Medical Publishing p. 156-157. (Level of evidence: 5).
- Haun D. & Kettner N. (2005). Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis, and conservative management. Journal of chiropractic medicine 4(4): 206–217 https://doi.org/10.1016/S0899-3467(07)60153-0.
- Ruff, A.N., Cornelson, S.M., Wells, C.B. & Kettner, N.W. (2019). Neural Arch Bone Marrow Edema and Spondylolysis in Adolescent Cheerleaders: A Case Series. Journal of Chiropractic Medicine, 18(4), 335-342.
Other Conditions in
Lower Back, Orthopaedics, Paediatrics
Spondylolisthesis
A term to describe a slight change in position (usually further forward) of one vertebra relative to the vertebrae below.
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Mechanical Back Pain
Lower back pain caused by structures in the back, such as joints, bones and soft tissues.
Lumbar Spinal Stenosis
Narrowing of the spaces though which lower back spinal nerves travel which can result in weakness, pain and reduced function.
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Deep Gluteal/Piriformis Syndrome
A presentation where the sciatic nerve is irritated in the buttock and can cause sciatica symptoms in the leg.
Cauda Equina Syndrome
A rare but serious condition as a result of compression of the nerves at the base of your spine.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Ankylosing Spondylitis
A rare condition that can cause joint stiffness and pain, often worse at night and when resting.