Spondylolysis: Causes, Symptoms, Prevention and Reconditioning

Abstract

Spondylolysis is the leading causing of back pain in minors, being more common in athletes than in nonathletes. Spondylolysis is a stress fracture, usually occurring in the lumbar portion of the spine. This condition is more prevalent in American football athletes than in other sports and the injury can lead to months of missed playing time in order to heal. The increase in this specific sport is may be due to the spine loading essential in football, but it is likely increased by other factors such as poor hip strength, high pelvic incidence, trauma, etc. This paper will describe what a spondylolysis is in detail, discuss the mechanisms of injury, factors relating to adolescents, elderly, and American football players, discuss specific activities that may help offset anatomical alignments that play a role in development of this condition, and finish with a variety of prevention exercises for spondylolysis.

 Keywords: spondylolysis, stress fracture, pelvic incidence,

Introduction

 Lower back pain is a common complaint among most people, being most prevalent in adolescent athletes, affecting up to 36% per year (Olsen et. Al, 1992). One of the most common causes of lower back pain is spondylolysis, which Micheli (1995) states is a fracture of the pars interarticularis; an area on the posterior aspect of the vertebrae between the facet joints. A popular study by Micheli and Wood (1995) shows that 47 out of 100 young patients that complained of lower back pain did indeed have spondylolysis. This paper will continue to describe the signs and symptoms related to a spondylolysis and describe in detail the specific spinal composition that is more susceptible to a spondylolysis.

Description

 When discussing the spine, it is usually divided into two sections: the anterior and posterior columns. The anterior column is composed of the vertebral body, intervertebral disc, and anterior and posterior longitudinal ligaments. In this paper, the posterior column is the focus and it includes the pedicles, lamina, spinous and transverse processes, and the facet joints. The pedicles and lamina form the neural arch. The pars interarticularis is a narrow region of the neural arch between the facet joints. Spondylolysis, a stress fracture, is a common deficiency in this area of the posterior column. The pars interarticularis is the weakest part of the arch and is at a significant risk to injury in younger children, due to their bones not being fully mature. Individuals who have not yet reached skeletal maturity have areas of growth cartilage and ossification centers in the spine, including one on each mammillary and transverse process (Humphries,1970). These areas are known as the “weakest links” in fore transfer because they are the most prone to torsion, compression, and traction than the bones surrounding them (Micheli & Curtis, 2006/01). The posterior column is usually not fully ossified until around age 25. Almost 90% of defects in the pars interarticularis occur in the fifth lumbar vertebra, the fourth being a close second (Micheli & Curtis, 2006/01). The irregularly high rate of defects relating to spondylolysis at L5 is due to its interaction with the sacrum. The steep sagittal angulation of the sacrum causes anterior shear forces across the L5 neural arch (Micheli & Curtis 2006/01). According to Bugg et. Al (2011), compression on the pars interarticularis when the inferior facets of L4 contact it during full extension, L5 is likely to fail as a result of this “nutcracker” mechanism.

Etiology

Individuals with a high pelvic incidence are more likely to develop spondylolysis. Pelvic incidence is the sum of sacral slope and pelvic tilt (Legaye,1998; Roussouly 2006). Been & Kalichman (2014) say that compressive forces along the posterior column of the vertebra increase when there is lumbar lordosis, an abnormal anterior convexity of the lumbar spine, correlating with the pelvic incidence. There several techniques used to measure lumbar lordosis but the most popular is Cobb’s method. Cobb’s method is a measure of the angulation between the superior endplates of the first lumbar vertebra and the sacrum(Been & Kalichman, 2014). This method shows, in the adolescent population, a mean value of 54 to 60 degrees, with some studies even showing pain with a value above 60 degrees. (Been & Kalichman, 2014; Lee & Yoo; 2012) A study by Tallarico et. al demonstrates changes in the sacrum after the fracture showing a potential anatomical change that formed due to the fracture( Tallarico, Fredrickson, Whitesides, & Lavelle, 2015). Whether or not the sacrum changed occurred before or after the fracture, the sacral angulation could not be a factor that is impacted upon training. There are other imminent anatomical traits that have been involved in spondylolysis development and spondylothesis development such as, larger vertebral canals, abnormal orientation of the facet joints, and structure of the pelvis (Cinotti,1997; Masharawi, 2012).

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None of these anatomical factors can have much impact from training, however, the role of the pelvic tilt (lumbar lordosis) and its many factors is important to the strength and conditioning specialist.  A hyperlordotic curvature of the lumbar spine is caused by an anterior tilt of the pelvis, which results in the compression of the posterior aspects of the lumbar spine (Been & Kalichman, 2014; Youdas, 2000). This tilting can be a result of spinal extensors being stronger than spinal flexors. Some authors have suggested that lower extensor strength can be a risk factor of lower back pain, even though over development of these extensors can lead to compression of the posterior aspect of the lumbar vertebrae.

Cyclic loading in the lumbar spine, specifically L5, has shown that is a primary cause of injury relating to spondylolysis. Movements such as full flexion and extension, repeated hyperextension, and repetitive trunk rotation are common movements within the causes of injury (Donatelli, 2012; Kim & Green, 2011). These movements are used frequently in young children and adolescents as part of their training, more importantly they are used when their neural arch is not fully ossified, and their pars is thin, it is no surprise that they are among the most susceptible and common in athletes who suffer from spondylolysis.

According to authors Baranto et. Al and Haus & Micheli (2012),along with sports movements, a growth spurt can give rise to the injury when sudden increase in bone growth leads to muscular tightness around the joints of the lumbar spine. Specifically, tightness of the iliopsoas and thoracolumbar fascia can both cause increased lumbar lordosis. In addition to causing a compressive load on the lumbar vertebrae, the iliopsoas causes an anterior force owing to its course in front of the pubis on its way to the lesser trochanter of the femur. Other contributors to increased lordosis are weakness in the rectus abdominis and internal and external obliques, all flex the spine and produce a posterior pelvic tilt. This is more likely in the presence of stiffness of the rectus femoris or tensor fasciae latae, both of which originate on the pelvis, insert onto the tibia, and can produce an anterior pelvic tilt resulting in lumbar lordosis (Sahrmann, 2002). Iliopsoas can cause an anterior pelvic tilt resulting in tightness of the hip flexors, which has been closely related to lower back pain. Overdevelopment or stiffness of the erector spinae group can also be a cause of pelvic tilt. Haus and Micheli (2012)says that the latissimus dorsi can cause lumbar hyperextension and anterior pelvic tilt, through its origin on the thoracolumbar fascia. This tilting is resisted by the rectus abdominis, obliques, and the hamstrings. The finding of tight hamstrings in spondylolysis patients is likely due to the chronic stretch which is produced by the pelvic tilt.

Signs, Symptoms, and Outcomes

Athletes that suffer from spondylolysis usually complain of lower back pain with no memory of any specific cause of injury. They state that little activity, rest, and lying down decreases the pain but activity seemed to be the man cause of increased pain. The pain tends to diverge into the buttocks and posterior thigh and is aggravated by lumbar hyperextension, specifically with a single-leg stance (McCleary & Congeni 2007). Neurologic symptoms, such as tingling or burning pain along a dermatome, or lower extremity weakness are unusual. Spondylolysis is bilateral and could cause the athlete to develop spondylothesis, which is an anterior translation of the vertebrae relating to the inferior vertebral segment. (Micheli & Curtis,2005)

Once an athlete has been diagnosed with a spondylolysis, they usually react positively to treatment. McCleary and Congeni (2007)says that surgery may be considered if pain does not resolve after 9–12 months of conservative treatment or if there has been a slippage (spondylolisthesis) of greater than 50% of the superior vertebral body over the inferior vertebrae. There is some dispute over the use of bracing with conservative treatment, some support the idea of using the Boston brace to limit movement (Mcneely, Torrance, &Magee,2003). The Boston brace is a brace worn for 23 hours a day for 3-4 months and can result in wearing it for a longer period after if it shows evidence of bony healing. Some authors believe that the brace isn’t the main reason for bony healing or spine stabilization and that it mostly restricts activity, bony healing has been shown without the brace (Standaert & Herring, 2007). Bracing or not, rest is the most important procedure when trying to heal a spondylolysis. Those who stopped any type of sports activity for 3 months were 16 times more likely to return to normal sports participation with no pain than those who did not take the same amount of time to rest (Rassi, Takemitsus, Glutting & Shah,2013).  After the proper amount of rest, the athlete then will move to physical therapy for about 2-4 months depending on the progress. Once athletes have demonstrated full range of motion with no pain, the appropriate sport conditioning, and no pain while performing the specific sport movements, they will be permitted to return to play. Normal return to play is in 5-7 months. (Standaert & Herring, 2007)

    Some evidence shows that those suffering from lower back pain and back injuries caused by overuse can recur in 26% of male athletes (Taimela, Kujala, Salminen  & Viljanen). For athletes with hopes of playing at the highest level, a recent study by Schroeder et al. (2015) suggests that football players with a lumbar spine diagnosis, including spondylolysis or spondylolisthesis, were less likely to be drafted and had shorter playing careers in the National Football League (NFL) than matched controls. Brophy et al. (2009) found that spondylolysis reduced the likelihood of running backs playing in the NFL and a resulted in fewer receivers with the diagnosis playing in the league. An important note to take into consideration is that studies show collegiate football players playing careers are not affected by studies and finding on spondylolysis.

Healing through Strength and Conditioning

A spondylitic fracture is caused by numerous factors. When it comes to strength and conditioning of someone with a spondylolysis, it is important to remember that hyperlordosis is high contributing factor. A strength and conditioning coach could help prevent the development of a spondylolysis in an athlete which could lessen the severity of anterior pelvic tilt. This can be done by including core workouts and static stretching.  A recent study by Lee and McGill (2015) demonstrated that isometric exercises were more effective at producing stiffness of the torso when compared with dynamic exercises over a 6-week training period. When it concerns cyclic movements of the spine (such as flexion, extension, and rotation) the thing that seems to bring the most benefit of increased core endurance, without adding spinal stresses, is isometric exercises. In addition, Lee and McGill argue that low loads on the spine experienced during isometric exercises allow performance of the exercises almost daily. When it comes to the relationship of  muscular endurance and the amount of training, it is expected that a higher volume of work could give more protective benefits.

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The best and most effective way to help increase range of motion and relieve back pain in young athletes is through myofascial release through foam rolling. The exact cause for this increase in range of motion is unknown, some supposed that it might be due to a combination of decreased viscosity of the fascia, increased blood flow to the muscle, and decreased adhesions between layers of fascia (Fledbauer, Smith & Lunen, 2015). When foam rolling is accompanied by static stretching, the increase in range of motion seems to be greater. Studies by Bradbury et. Al (2015) and MacDonald et. A (2013)have shown that, in addition to increased range of motion, there were also effects on increased vertical jump height and muscular force were also shown; as well reduction in fatigue when an athlete participated in foam rolling. But there were no studies that showed foam rolling improved enhanced power, agility, or range of motion. Static stretching can improve range of motion but too much static stretching can decrease muscular strength and power. Considering the disadvantages of static stretching, it is no surprise to see how too much static stretching can negatively affect spondylolysis when the muscles are not strong enough to protect the spine from further injury. A review article by Kay & Blazevich (2012) determined that the negative effects of static stretching are limited to longer-duration stretches of more than 60 seconds, but it seems well advised to incorporate foam rolling into the pre-exercise routine in order to increase range of motion. Because many results with foam rolling and static stretching are beneficial to range of motion is important to incorporate both to a post workout routine. More importantly, foam rolling is shown to improve muscle soreness, purposeful for recovery.

Stretching

 Static stretching is important to post workout routine and a vital role in preventing spondylolysis. Static stretching should be preformed after workouts and each stretch should be preformed three times for 30 seconds.

 Latissimus Dorsi. This muscle stretch can be performed with a stability ball. The steps for this stretch are as followed: the athlete will begin with kneeling while facing the ball and then touch its top while in a position of a karate chop. Breath out then bow while sitting on your heels and pushing away on the ball. The athlete will hold the position and take two deep breaths before returning to original position. Repeat the exercise 8-10 times on each side.

Tensor fasciae latae. The athlete will stand next to a wall and place their arm closest to the wall against it for support. An athlete then puts their leg closest to the wall behind the contralateral leg and leans the hips toward the wall. The athlete counters this movement by laterally flexing the trunk away from the wall.

Conclusion

While anatomical characteristics of an athlete like sacral slope and vertebral configuration play a major role in the development of spondylolysis, hyper lordosis has also been closely related to the cause of spondylolysis. By adding foam rolling, static stretching, exercise for pelvic stabilization, a strength and conditioning professional could aid in the role of preventing development of spondylolysis by decreasing anterior tilt of the pelvis and hyper lordosis. As a result of these exercises, athletes should see a result in decreased risk of developing spondylolysis. The commitment is quite a toll on an athlete with so many commitments, but the preventative actions show that it can have increased beneficial results and a longer time participating in sports-even higher-level sports. Keeping players on the field and healthy is the main goal of any specialist and the amount of research done is substantial evidence that should be considered and followed to prevent spondylolysis.

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