Spondylolysis and Triathlon Training

author : AMSSM

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Spondylolysis is often misconceived as having serious and debilitating outcomes, when in reality it is typically well tolerated by many individuals.

Member Question

I was just diagnosed with spondylolysis which is a result of a pars fracture, I guess. It's my L4/5 and my L5/S1. I'm wondering if this gets braced or fusion?  What are the pros and cons of each method of treatment? What about recovery? Can I continue to train and are there any limitations?

Answer from Joshua Lenhof DO and Melissa Novak, DO
Member AMSSM

Back pain is an incredibly common complaint seen in the office of many physicians who treat athletes involved in a variety of sports. While there are many causes of back pain for the general runner or hockey player, none have received as much public attention as spondylolysis, which quite literally translates to: spondylos = back and lysis = broken or “broken back syndrome.” Oftentimes, the public view of spondylolysis is quite misinterpreted as having grave outcomes and serious disability like the tragedy of Christopher Reeve, which was actually a high cervical neck fracture. In contrast to this misconception, spondylolysis is frequently an incidental finding on lumbar x-rays and is typically associated with stress fractures that subsequently result in back tenderness.    

In anatomical terms, spondylolysis is a fracture or “separation” of the pars intrarticularis, the bony junction between forward facing vertebra body and the spinal arch located in the back. In addition, 90% of these small fractures are found in the 5^th and 4^th lumbar bones (5). It should be noted that roughly 4-8% of the US population will have the defect in their lifetime, but many will never complain of symptoms and are incidentally diagnosed with imaging studies. While this may be true, some athletes with spondylolysis complain of back pain and roughly 23-63% of those athletes compete in sports such as football, rowing, dancing, gymnastics and running (2). Athletes who have back symptoms from this type of fracture may encounter diffuse/dull low back pain localized to the spine and travel to the buttock and back of the leg. Furthermore, this pain is specifically made worse with movements such as leaning backwards while standing and turning your back while your feet are planted.

More often than not, symptomatic spondylolysis is caused by repetitive mechanical stress from motions that include back extension and rotation of the lumbar spine. Excessive strain, poor mechanics and inadequate rest to the lower back region cause microfractures that add together to eventually form a full thickness break, similar to the way a paperclip will break if you were to bend it enough times. Another common problem found in athletes with spondylolysis is a weakness in core strength that would otherwise protect the back from extreme mechanical stress. On the other spectrum, acute spondylolysis injuries are far less common and usually occur after a particular hyperextension event such as falling during competition, direct blows to the back and even motor vehicle accidents. Pain is usually felt shortly after the inciting event with tenderness near the fractured vertebra. Although rare, some people fracture both bony junctions causing the vertebra to become unstable and occasionally cause nerve compression, poor alignment and forward movement of the unattached bone fragment.

So let’s say you have been diagnosed with symptomatic spondylolysis, what can we as physicians recommend for treatment? Well first off, the goal of treatment is to alleviate painful symptoms, prevent movement of the fracture and ensure safe return to activity. Just as the injury gradually progressed so too does the primary treatment, which includes rest from symptomatic activities and rehabilitation for roughly 3-6 months to allow bony healing and/or core muscle stabilization. Recent studies showed that rehabilitation directed at low impact aerobic conditioning, rest, core strengthening and gradual increase in activity was the most effective means of healing and had the best clinical outcomes (3,5). Many individuals in these studies eventually progressed back to their sport specific training and continued participating in their desired activity.

Ironically, most bony fractures in spondylolysis do not heal in patients successfully treated with rest and rehabilitation (3). This suggests that continued core strengthening, stabilization and adequate recovery after physical hyperextension and rotational activities are key to preventing further symptoms.

Bracing treatments have traditionally been used to encourage healing; however, there is little evidence in the literature that these cumbersome braces improve outcomes. Unlike casting a broken arm which can greatly reduce the amount of motion at the fracture site, the back is more complex and difficult to cast effectively. Studies have demonstrated that despite full chest and back casting/bracing, there is still a significant amount of motion at the 4^th and 5^th lumbar bones. As such, doctors rarely recommended this type of treatment (1,3,4,5).

Lastly, surgical treatment is reserved for patients with persistent pain greater than six months, recurrent fractures, and signs of unstable vertebral disk slippage seen with imaging. Possible procedures include spinal bone fusion or repair of the pars fracture with medical screws (5). The good news is that only a small percentage of patients require surgery and roughly 80-90% of patients with spondylolysis have successfully returned to sporting activity without surgical treatment. 

Overall, spondylolysis is often misconceived as having serious and debilitating outcomes, when in reality it is typically well tolerated by many individuals. If you experience symptoms from spondylolysis, gradual conservative treatment over 3-6 months is effective in returning most athletes back to their previous sport specific activity.

Joshua Lenhof DO.
Family Medicine Resident PGY2
Good Samaritan Regional Medical Center.

Melissa Novak, DO
Sports Medicine Physician
Oregon Health Sciences University

References:

1. Fujii K, Katoh S, Sairyo K. Union of defects in the pars intrarticularis of the lumbar spine in children and adolescents. The Radiological Outcome After Conservative Treatment. Journal of Bone Joint Surgery Br. 2004; 86:225-231.

2. Harvey C, Richenberg J, Saifuddin A, Wolman R. Pectoral Review: The Radiological Investigation of Lumbar Spondylolysis. Clinical Radiology. 1998;53:723-728.

3. Klein G, Mehlman CT, McCarty M. Nonoperative Treatment of Spondylolysis and Grade I Spondylolisthesis in Children and Young Adults A Meta-analysis of Observational Studies. Journal Pediatric Orthopedics. 2009; 29:146Y156.

4. Morita T, Ikata T, Katoh S, Lumbar Spondylolysis in Children and Adolescents. Journal of Bone Joint Surgery Br. 1995; 77:620-625.
    
5. Tallarico R, Madom I, Palumbo M. Spondylolysis and Spondylolisthesis in the Athlete. Sports Med Arthrosc Rev. 2008;16:32–38.

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date: May 29, 2014