REHABILITATION CONSIDERATIONS FOR SPONDYLOLYSIS IN THE YOUTH ATHLETE

Abstract

Low back pain in adolescent athletes is quite common, and an isthmic spondylolysis is the most common identifiable cause. Spondylolysis, a bone stress injury of the pars interarticularis, typically presents as focal low back pain which worsens with activity, particularly with back extension movements. Research on spondylolysis has focused on diagnosis, radiographic healing, the effects of bracing, and rest from activity. Although physical therapy is frequently recommended for adolescent athletes with spondylolysis, there have been no randomized controlled trials investigating rehabilitation. Additionally, there are no detailed descriptions of physical therapy care for adolescent athletes with spondylolysis. The purpose of this clinical commentary is to provide a brief background regarding the pathology of isthmic spondylolysis and provide a detailed description of a proposed plan for physical therapy management of spondylolysis in adolescent athletes.

Level of evidence: 5.

Keywords: Adolescent; Low Back Pain; Movement System; Stress Fracture.

Figure 1.

Depiction of an Isthmic Spondylolysis.

Figure 2.

Radiographic image of bilateral spondylolysis at L4 vertebra.

Figure 3.

Pressure Biofeedback Unit Test of the Transverse Abdominis. The patient is prone over a pressure biofeedback device, which is inflated to 70 mmHg. The therapist provides the cue “Draw in abdominal wall for 10 seconds without moving your back and while breathing normally.” The therapist records the length of time the patient can hold a ≥4mmHg drop, while monitoring for improper compensations. Performance is considered “good” with a duration of 10 seconds or greater.

Figure 4.

Multifidus Lift Test. Patient lies prone, with shoulders at approximately 120˚ of abduction and elbows at 90˚ of flexion. The therapist palpates immediately lateral and adjacent to the interspinous space of L4/L5 and L5/S1. The patient is instructed to lift their contralateral arm towards the ceiling approximately 5 cm. The therapist qualitatively assesses multifidus as contralateral arm is lifted. A normal contraction is described as a robust and obvious muscle contraction, while little or no palpable contraction is considered abnormal.

Figure 5.

Prone Double Leg Raise Test. The patient is positioned in prone with hands underneath their forehead. The therapist instructs the patient to raise both legs until their knees are off the table and hold the position. The test is timed until the patient can no longer maintain knee clearance or reports pain.

Figure 6.

Supine Double Leg Lowering Test. The patient is positioned in supine; the therapist elevates both of the patient's fully extended legs to the point at which the sacrum begins to rise off the table. The patient is instructed to maintain contact of the low back with the table while slowly lowering extended legs to the table without assistance. The examiner observes and measures when the lower back loses contact with the tabletop due to anterior pelvic tilt.