Stress Fractures in the Lower Back
UW Health's Sports Medicine doctors in Madison, Wisconsin, treat a wide range of common athletic injuries, including stress fractures in the lower back (spondylolysis).
Spondylolysis refers to a stress fracture commonly found in the low back (lumbar vertebrae) that occurs in a small percentage of the general population. However, this condition is quite common in young athletes, particularly those whose bones are still growing and developing.
Athletes participating in activities involving repetitive hyperextension of the low back are at greatest risk of developing this condition. Sports such as football, gymnastics, wrestling, soccer, tennis, swimming the butterfly, volleyball, high jumping, cheerleading and dance are associated with repetitive stress to the low back, which can lead to fatigue or fracture in the vertebrae.
Spondylolisthesis is often considered to be a complication of spondylolysis, when the stress fracture occurs on both sides of the spine (lumbar vertebrae), resulting in the “slipping” or forward (anterior) displacement of one vertebral body over another.
The spine or vertebral column consists of a series of 24 individual bones. Together, these bones serve to surround, protect and support the spinal cord and spinal nerves. The lumbar region of the spine, commonly referred to as the low back, is subject to the greatest amount of stress. As a result, the vertebrae in this area of the spine are bigger, thicker and sturdier than those of the neck (cervical spine) or mid-back (thoracic spine).
Each vertebra consists of an anterior vertebral body and a posterior bony ring called the vertebral arch. Two facets, a superior and inferior, are located on each side of the vertebral arch for each level of the spine. The superior facet articulates with the inferior facet for the vertebra immediately above while the inferior facet articulates with the superior facet for the vertebra immediately below. These facets allow each vertebral segment in the spine to move on the other for movements like bending forward, bending backward and rotation.
The area between the superior facet and inferior facet on the same side of the vertebra is called the pars interarticularis, which is the specific location of a spondylolysis (stress fracture or defect in the bone). If this fracture or defect occurs on both sides of the bone (bilateral spondylolysis), the vertebra can slip forward and result in spondylolisthesis.
Signs and Symptoms
Spondylolysis often presents as back pain of unknown origin with no particular mechanism of injury related to its onset. The pain often occurs only with activity during the early stages but can progress to pain which persists throughout the day that can ultimately interfere with activities of daily living. The most consistent finding in athletes with spondylolysis is pain with extending the low back (lumbar extension). Often times, bending forward (lumbar) to pick something off the ground is easy and pain free, but then returning back to an upright, standing position can be difficult and painful.
Initial treatment of athletes with spondylolysis is conservative with an emphasis on pain control. Athletes should avoid all activities that place an increased amount of stress at the site of the injury, including:
- Extension/hyperextension of the low back
- Impact loading activities such as running and jumping
- Any activities that result in collisions
Some athletes may benefit from wearing some form of back support or bracing. Once the pain is under control, the athlete can progress to rehabilitation activities that focus on control and stability of the lumbar spine and pelvis. Exercises will focus initially on core stabilization to assist with finding and maintaining a neutral pelvic position so that extension/hyperextension of the low back is minimized or eliminated.
Once the athlete is able to find and maintain this position in static positions, the exercises will be progressed to include advanced static core stabilization, dynamic core stabilization and ultimately return to sport specific activities.
As discussed earlier, many sports and activities place increased stress on the low back. All athletes, particularly those participating in high risk activities who are still growing and developing, should focus their efforts on core strengthening and stabilization to decrease their risk of injury. Since poor posture and muscle fatigue also put an athlete at increased risk of spondylolysis, limiting the amount of time spent performing high risk activities should also be considered.