A deep dive on spondylolysis
“My back hurts when I bend backwards and when I rotate.”
If your kid/teen tells you this, sirens need to go off in your head.
It’s not usually a big deal for you, as a grown adult, to have back pain flare ups. But, your kid? That’s a different ball game.
It is not normal for adolescents to have back pain.
Today, I want to talk about what I believe to be the most missed diagnosis in all of youth sports: spinal stress fractures.
Wait, did you say fractured spine?
If your athlete has pain with bending backwards (extension) and rotating, a stress fracture needs to jump to the front of your mind.
This stress fracture, which goes through a part of the vertebrae called the pars interarticularis, is called a spondylolysis (spondy).
Extending and rotating your spine causes the spinal facet joints to go to end range and jam together. This transfers force into the pars.
If you extend and rotate aggressively and repeatedly, like swinging a softball bat, then this area can get worn down. Eventually, it breaks.
It’s a process
If you tear your ACL, it usually happens all at once. Your ACL was healthy, then you made that awkward cut, then your ACL was torn. It went from healthy to unhealthy in one movement.
Spondys aren’t like that. This isn’t a “one swing” or “one lift” type of injury.
Spondys are the result of prolonged trauma. Your pain might skyrocket with one particular swing, but it’s been building up in the backend for quite some time.
The way to more accurately talk about this injury is to refer to it as a bone stress injury.
There are three stages of a bone stress injury:
- Stress response. Your athlete’s MRI would show inflammation in the area, but they don’t have any pain yet.
- Stress reaction. Your athlete is now experiencing pain and the inflammation has become more prominent.
- Stress fracture. The bone has now worn down to the point that it has fractured.
This is why it’s so important to be vigilant when your young athlete has back pain. If you catch it early enough, you can right the ship before the bone actually breaks.
From here on out, we will refer to both bone stress injuries and spondys as the same thing. To be specific, a spondy is a bone stress injury in the pars that has progressed to a stress fracture.
The process continues
Now, let’s say you’ve got a tough athlete and they keep pushing through the pain. The process doesn’t stop at fracture.
The vertebral body can start slipping forward out of alignment. This is called a spondylolisthesis.
This slippage results in significant spinal instability. The nerves can be compressed and your athlete might start experiencing numbness, tingling, and weakness in their legs (in addition to the pain).
What about the muscle strain?
I don’t want to fear monger. It’s also very possible that your athlete’s extension-based back pain is a run-of-the-mill muscle strain.
There are about a trillion muscles that run through the lower back. Any one of those could be involved.
So, which is it?
Unfortunately, we can’t tell without imaging. There’s no one test that we can do in the clinic that will tell us what’s going on.
Our best tool is your athlete’s history. If they have been swinging, throwing, lifting, or some other extension based movement with a recent increase in volume, that’s a sign that we need to consider a bone stress injury. If the pain has lasted for more than a couple of weeks, that’s a sign that we need to consider a bone stress injury.
If your athlete has had back pain that doesn’t go away after about 3 weeks, then they should get imaging.
Furthermore, your athlete needs to have the right kind of imaging. They’ll probably get an x-ray first, because they’re cheaper and quicker. But, most spondys don’t show up on an x-ray. Your athlete would need an MRI.
What do I do about it?
If your athlete has a bone stress injury, some level of shut down is required. If they keep playing their sport, they’re going to keep putting stress on the bone.
If they keep putting stress on the bone, it’s not going to heal. In fact, it’ll probably just keep getting worse.
The further along the bone stress injury is, the longer the shut-down period will be. If it’s a low-grade injury, the shut down might be as short as 2-4 weeks. If it’s progressed to high grade, the shut down could be 2-3 months.
Depending on which physician you go to and how severe your athlete’s symptoms are, they might have to wear a back brace.
During the shut down period, your athlete can (and should) go to physical therapy to work on strengthening the muscles around the injury. The stronger the muscles are, the more they can protect the bone from undergoing excessive stress in the future.
After the shut down period, it is IMPERATIVE to have an appropriate return to sport plan.
Returning to sport is a continuum, not a binary moment. Your athlete needs a gradual ramp up in volume or they’re asking to get re-injured.
An extra note on genetics and spondys
There seems to be a genetic link to some spondys. If someone in your family had a spondy, then you might be more at risk of having a spondy.
The most likely reason would be that your pars is naturally thinner. The thinner it is, the less stress it can handle.
A quick thought on sunk costs
The Sunk Cost Fallacy: the tendency to follow through on an endeavor if we have already invested time, effort, or money into it, whether or not the current costs outweigh the benefits.
Your athlete is going to choose a career after high school. They’ll spend a few months or a few years training for that career (probably through college or trade school).
Then, they’ll most likely realize that they don’t actually like that job. Nobody gets it right on the first try.
Don’t let them justify staying in that field, just because they spent 2 or 3 years studying for it. That’s a sunk cost.
Those 2 to 3 years of “wasted time and money” pale in comparison to spending the next 30-40 years doing something that you hate.
More from me…
- 2024 is geared toward pumping out more educational content on social media. Follow me on Instagram @gtperformance_ to learn all about athlete development.
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- Everything in these newsletters and on our website is for educational purposes only and should not be taken as medical advice for you or you athlete. Consult directly with a healthcare professional.
Thanks so much for your help in spreading the word about athlete development!
Be >,
Zach
Dr. Zach Guiser, PT, DPT, CSCS