Lumbar Spondylolysis
Where is it painful for a client with Lumbar Spondylolysis?
Classical patient features for Lumbar Spondylolysis
Age: Younger athletes participating in high-risk activities (accounts for up to 47% of athletes presenting with back pain)
Gender: males more prevalent than females 2:1. However high prevalence in female athletes with poor bone health (special questions for menstrual disturbance or relative energy deficiency in sport)
sport: cricket, tennis, ballet, divers, gymnastics, soccer, volleyball
Area of symptoms for Lumbar Spondylolysis
– Localised unilateral back pain
– Can refer in the buttock and leg but uncommon
– If crosses the midline consider other differentials
– if persistent pain and bilateral may provide evidence for Spondylysthesis
Characteristics of symptoms of a client with Lumbar Spondylolysis
– Sharp, catching pain with an extension activity
– dull aching with sustained positions of aggravation
– intermittent pain but persistently bought on by aggravating activities
Typical activity capability/restriction for Lumbar Spondylolysis
– Insidious: patient often still high activity and often have not changed their participation in sport
– Acute: ie fracture pain will be intense enough for the participant to be removed from the activity
– will progressively reduce sporting performance as symptoms are provoked due to the worsening nature
– stress response at the bone will accumulate over time or throughout a season
Behaviour of symptoms for Lumbar Spondylolysis
Ease: rest and avoidance or alterations to aggravating activities (can be in the form of activity modification or general factors such as technique changes ie fast bowler)
Agg: lumbar extension, combined movements, repeated movements, fast movements especially if at the end of rance
24-hour pattern: activity dependant
Typical history for a client with Lumbar Spondylolysis
– Participation in activities with bending forces that have a unilateral bias (rotation or side-flexion)
– can have hyperextension incident with acute onset (more likely fracture)
– can have insidious onset (more likely in the earlier stages of a bone stress injury)
– will get worse with activity (no warm-up effect)
– can be brought on by an increase in load (training or gameplay secondary to demographic)
Pathobiological mechanisms underlying Lumbar Spondylolysis
– Nociceptive with acute presentations.
– The longer the symptoms have been evident, especially if long term rehabilitation is required, the patient may have an increase in nociplastic pain
Proposed pathology for Lumbar Spondylolysis
– Most commonly affects the pars interarticularis in the region of the posterior vertebral arch
– The term includes a range of bony lesions that occur at this site of injury
– Imaging has shown that the injury commonly involves the adjoining pedicle and lamina
Physical impairments & associated structure/tissue sources (ie P/E findings)
Local
– pain with lumbar extension
– increased pain with lumbar combine movements (extension + unilateral bias)
– pain with unilateral lumbar PAIVM
– increased lumbar lordosis // if adaptive might have a reduced lordosis
– reduced motor control // assess with normal activities and at end of the range
– reduced lumbar body schema // worse if the pain has been around for a long period of time, evidence for nociplastic influences
– hip flexor and hamstring tightness
– abdominal and glute weakness
– hypermobility in the Lx
Remote
– reduced extension range in thoracic spine and/or hips
– reduced independent control into extension in spine and hips
General
– poor dynamic control at the end of range
– excessive extension moments
– bracing
Typical contributing factors for Lumbar Spondylolysis
– participation in high-risk activities
– Weight
– Genetics
– hypermobility in the lumbar spine
– REDS
– menstrual disturbance
– malnutrition
Relevant precautions/ contraindications to P/E and treatment
– with acute onset could have a fracture with nonunion // if suspect this need to send to hospital for imagining ASAP
– if the patient has neuro symptoms // referral straight away
– if the patient has a suspected stress fracture// imaging is required and referral to a sports physician for medical management to align with rehabilitation
Relevant diagnostic imaging for Lumbar Spondylolysis
X-ray: may pick up a larger defect however little diagnostic accuracy and can not rule out the presence of pathology, therefore not recommended
CT: will identify stress fracture however is likely to provide sufficient detail to identify a stress response in the early stages
MRI: Gold standard, will alert to stress injuries in early stages as well as fractures
Note: may need scans throughout rehab period to determine healing response prior to progression // especially with contact sports
Typical prognosis for Lumbar Spondylolysis
– 92% return to sport with conservative management
– for boney stress and united stress fractures return to sport timeframe is between 3-6 months
– for complex stress fractures and when there is non-union, return to sport can take up to 12 months
Management/treatment selection for Lumbar Spondylolysis
Phases of rehabilitation
– stage 1: protection and fracture healing (~0=8 weeks)
– stage 2: reloading phase (~ 9-16 weeks)
– stage 3: return to full function and sport (~17 weeks onwards)
Note: the stage of pathology will determine the speed of rehabilitation
Relative load reduction (high-level evidence)
– period of rest from the aggravating activity indicated in pain dominant presentations // non-negotiable if fracture present
Immobilization
– low levels of evidence for both taping and bracing
– need to provide clear instructions to restrictions in spine loading in conjunction with other members of the medical team
Rehabilitation objectives:
Local (no evidence)
– mobility into flexion
– muscles control and performance safe to begin in the non-provocative inner range
– progress loading progressively with strengthening, especially at the end-stage when moving into extension
Remote
– Abdominal strengthening ( mid-level evidence for TA activation)
– (early stage) remove the extension from the lumbar spine (increase extension at thoracic and hips)
– (early stage) muscles control and performance safe to begin in the non-provocative inner range
General
– consider biomechanics and technique // are we able to redistribute the load somewhere else
– posture
– address contributing factors and cardiovascular fitness
Surgical
– with failed conservative treatment surgery is indicated in ~9% of cases
High evidence in the back pain world for ensuring the use a biopsychosocial approach when planning for optimal rehabilitation
Differential diagnosis for Lumbar Spondylolysis
Spondylolisthesis // bilateral pain, neurological symptoms
Disc pathology// flexion pattern and pain that crosses the midline
Spinal cord injuries // positive neurological or neurological symptoms
Cord equina // B&B, saddle anesthesia, bilateral symptoms
Muscle strains // dynamic assessment
Central canal stenosis // neurological symptoms, bilateral symptoms
Nerve root // positive neurological or neurodynamic findings
Cancer // subjective special questions
Ankylosing spondylitis // inflammatory special questions
References
Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.
Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.
Garet, M., Reiman, M.P., Mathers, J. and Sylvain, J., 2013. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Sports health, 5(3), pp.225-232.
Leone, A., Cianfoni, A., Cerase, A., Magarelli, N. and Bonomo, L., 2011. Lumbar spondylolysis: a review. Skeletal radiology, 40(6), pp.683-700.
McNeely, M.L., Torrance, G. and Magee, D.J., 2003. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual therapy, 8(2), pp.80-91.
Peer, K.S. and Fascione, J.M., 2007. Spondylolysis: a review and treatment approach. Orthopaedic Nursing, 26(2), pp.104-111.
Standaert, C.J. and Herring, S.A., 2000. Spondylolysis: a critical review. British journal of sports medicine, 34(6), pp.415-422.
Lawrence, K.J., Elser, T. and Stromberg, R., 2016. Lumbar spondylolysis in the adolescent athlete. Physical Therapy in Sport, 20, pp.56-60.