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)}.

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.

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.

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)}.

Book and Appointment

Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

We have Pure Physiotherapy clinics across the country including Norwich, Great Yarmouth, Manchester, Stockport, Sheffield and Rotherham. Please view our clinics to find the closest physiotherapy clinic for you.