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Spondylolisthesis and Spondylolysis in Gymnasts

What is spondylolisthesis?

Spondylolisthesis is the slipping of all or part of one vertebra forward on another vertebra. The most common type of spondylolisthesis is isthmic spondylolisthesis and it is commonly seen in children and young adults. It is most common in children 5-8 years old and it occurs in about 5% of the population. For gymnasts, it is thought that the slippage occurs as a result of repetitive hyperextension activities (bending backwards) which causes a shear stress at the pars interarticularis.

 

What is spondylolysis?

Spondylolysis is a stress fracture or defect of the pars interarticularis in a vertebra. A stress fracture can occur at the pars interarticularis due to repetitive movements of extension and rotation which leads to an increase in shear forces in the lumbar spine. As shear forces increase, pressures on the facet joints increase. These forces are then transmited to the pars interarticularis. Since the pars interarticularis is small, it is unable to absorb repetitive shock which leads to the stress fracture.

 

What is a vertebra?

Your vertebrae are the bones in your back which make up your spinal column or back bone. There are 7 cervical vertebrae (1), 12 thoracic vertebrae (2), and 5 lumbar vertebrae (3) in your spinal column. The function of your vertebrae are to give support to your skeleton, protect your spinal cord and to provide movement through the many muscular attachments and joints formed between each individual vertebra. Both spondylolysis and spondylolisthesis usually occur at the 5th lumbar vertebra. Less common is at the 4th lumbar vertebra.

 

What is the pars interarticularis?

The pars interarticularis is the part of the vertebra which is between the superior and inferior facets.

 

Can spondylolisthesis and spondylolysis occur together?

Yes, spondylolisthesis and spondylolysis can occur together. But, having one doesn't mean you'll develop the other one. Usually, a spondylolysis will occur before a spondylolisthesis. But once vertebral growth is complete, it is rare to see a spondylolisthesis progress to the next grade.

 

Grades of spondylolisthesis:

(as seen on x-ray)

Grade I - < 25% slippage of one vertebra on top of another vertebra.

Grade II - 25-50% slippage

Grade III - 50-75% slippage

Grade IV - > 75% slippage

 

Signs and symptoms:

Spondylolysis

• Insidious onset

• Pain with hyperextension (e.g. backwalkover)

• Initially pain only with sports, then may increase to pain with activities of

   daily living and progressing to pain which interferes with sleep

• Bending forwards is OK while bending backwards increases pain

• A hyperlordotic (increased curvature, not scoliotic) lower back

• Relative tightness of the hamstring muscles.

• Aching lower back, usually unilateral which can be localized along the

   belt line

• No nerve root pain (no burning/shooting pain down the leg)

Spondylolisthesis typical posture may include:

• Short torso (body)

• Flat buttocks

• Rib cage appears low

• Iliac crests (hip bones) are high

• Altered gait because of tight hamstrings

• Vertical sacrum

• Hips don't fully extend back

 

Athletic populations (sports) at risk:

• Gymnasts

• Divers

• Offensive linemen in football

• Pole vaulters

• Weight lifters

• Wrestlers

• Dancers

• High jumpers

 

Special tests:

Standing one-legged hyperextension test:

1. Stand on the leg of the same side on which there is pain (i.e., if the pain is

    on the right side, stand on your right leg). Then, gently lean backwards.

    If the pain is reproduced, this may be a positive sign for spondylolysis.

2. X-rays or CT-scans may be ordered by your physician to confirm or refute

    a diagnosis for spondylolysis or spondylolisthesis.

 

Treatment principles:

1. Restrict the aggravating activity. Usually a short period of bed rest is beneficial.

2. Participation in activities such as swimming, biking and limited weight lifting is permissible as long

    as it is pain-free.

3. Your doctor may prescribe a brace such as the modified Boston brace which prevents any

    extension of the lumbar spine

4. Exercises may include:

    Abdominal strengthening

    Hamstring stretching