Spondylolysis in Dance and Gymnastics

What is spondylolysis?

Spondylolysis is one of the most common types of skeletal injury in pediatric dancers and gymnasts. It is a type of stress fracture that occurs in the pars interarticularis of the vertebrae (usually in the lumbar or low back region). The pars interarticularis is a thin area of the vertebral bone that forms the facet joints with the neighboring vertebra that are below and above it. Because the pars interarticularis is thin, it is a weaker region of the vertebral bone, and it is therefore more vulnerable to injury from repetitive stress and overuse.  Spondylolysis is more likely to occur in youth who are participating in activities that require frequent hyperextension, like dance and gymnastics.  However, this can also be seen in youth participating in diving, volleyball, football, tennis, and overhead throwing sports.

Spondylosis

Image from: Pediatric Orthopaedic Society of North America. “Spondylolysis and Spondylolisthesis.” American Academy of Orthopaedic Surgeons. September 2016. <http://orthoinfo.aaos.org/topic.cfm?topic=a00053> Accessed February 5, 2017.

What are the symptoms?

In some youth there are no obvious symptoms with spondylolysis. However, when youth do develop symptoms, the most common complaint is a slowly worsening, dull, low back pain, which may be unilateral or bilateral, but typically centered around the spinous process. The pain may feel similar to muscle strain and typically has a band like distribution at the spinal level. It may radiate to the buttock or the back of the thighs in the setting of spinal nerve impingement, which is less common. In general, the pain worsens with activity, especially lumbar extension, and improves with rest.

How is it diagnosed?

Taking a careful medical history and exam will help to determine if spondylolysis is likely. Letting your doctor know that you dance or participate in extension sports is important because youth who participate in sports that require frequent hyperextension are more likely to have spondylolysis.  Your doctor will also examine the back and spine to look for areas of pain, assess range of motion, and look for muscle weakness or muscle spasms. They may also assess the posture and how they walk.

If spondylolysis is suspected, then x-rays may be ordered to help confirm the diagnosis. X-rays will show a stress fracture in the pars interarticularis of the vertebrae when positive, usually in the lumbar region of the spine.  Oblique view spine xrays are needed to help increase the sensitivity of the test, which is still only 60-90% sensitive for pars stress fractures and will not catch majority of early stage spondylolysis. If no stress fracture is seen on x-ray, but suspicion of spondylolysis is high, then additional imaging may be ordered (this may include SPECT, CT, or MRI).

How is it treated?

Most youth with spondylolysis will improve with nonsurgical treatment such as rest, acetaminophen (Tylenol), and proper core flexion based physical therapy over the course of 3 to 12 months.

Rest can be difficult for a young athlete because it involves avoiding all activities (like hyperextension) that place excess stress on the low back in order to keep the dancer pain free so that the chances of boney healing at maximized.

Acetaminophen can be used to help reduce the discomfort of the spondylolysis. Nonsteroidal anti-inflammatory drugs (NSAID) like ibuprofen can also reduce back pain and inflammation caused by the spondylolysis, however there is some limited evidence that they may increase the risk of failure to heal.

Physical therapy plays an important role in the healing process as it can provide a strengthening and stretching program to keep the dancer remain active during recovery, minimize deconditioning, and strengthen the muscles of the core (muscles of the back and abdomen) with stabilization exercises. These exercises should begin with isometric type and progress flexion based exercises prior to advancing to any extension based core exercises after 2-3 months when pain is resolved and fracture healing is near complete.

Bracing can be used for dancers as well in order to limit movement and support healing; however there is still some controversy regarding the use of braces as there is insufficient evidence showing that braces are able to improve healing or impact overall outcomes.  However, for those whom get symptomatic relief or protection from end range extension they can be a reasonable option.

If spondylolysis remains untreated it can progress to spondylolisthesis. Spondylolisthesis occurs when the two halves of the fractured pars interarticularis separate allowing the injured vertebra to slip forward on the vertebra below it. Surgery may be needed in patients with spondylolisthesis with severe or high grade slippage typically with greater than 50% displacement.

Prevention

Maintaining adequate nutrition will help to support bone strength. Ensuring proper form and avoiding frequent hyperextension will help to minimize the stress placed on the pars interarticularis. Listening to your body and being seen if there is back pain. This will give you an opportunity to rest, recover, and perhaps correct improper form before spondylolysis (a stress fracture) develops. Pushing yourself to dance or train through the pain will only increase the risk of progression to spondylolysis.

Outcomes

Most youth are pain free after completing a course of treatment for spondylolysis. However, as noted above, it can take up to 6-12 months to heal. Most youth are able to gradually resume their participation in dance and other activities after 3 months of a proper physical therapy regimen.

More about Common Injuries in Gymnastics: Gymnastics Injuries

By Aurora Selpides, MD, MPH and Mo Mortazavi, MD

References

Gottschlich LM, Young CC. Spine injuries in dancers. Curr Sports Med Rep. 2011 Jan-Feb;10(1):40-4.

Pediatric Orthopaedic Society of North America. “Spondylolysis and Spondylolisthesis.” American Academy of Orthopaedic Surgeons. September 2016. <http://orthoinfo.aaos.org/topic.cfm?topic=a00053> Accessed February 5, 2017.

Yin, Amy X. et al.  Pediatric Dance Injuries: A Cross-Sectional Epidemiological Study. PM&R, Volume 8, Issue 4, 348 – 355

What is spondylolysis?

Spondylolysis is one of the most common types of skeletal injury in pediatric dancers and gymnasts. It is a type of stress fracture that occurs in the pars interarticularis of the vertebrae (usually in the lumbar or low back region). The pars interarticularis is a thin area of the vertebral bone that forms the facet joints with the neighboring vertebra that are below and above it. Because the pars interarticularis is thin, it is a weaker region of the vertebral bone, and it is therefore more vulnerable to injury from repetitive stress and overuse.  Spondylolysis is more likely to occur in youth who are participating in activities that require frequent hyperextension, like dance and gymnastics.  However, this can also be seen in youth participating in diving, volleyball, football, tennis, and overhead throwing sports.

Spondylosis

Image from: Pediatric Orthopaedic Society of North America. “Spondylolysis and Spondylolisthesis.” American Academy of Orthopaedic Surgeons. September 2016. <http://orthoinfo.aaos.org/topic.cfm?topic=a00053> Accessed February 5, 2017.

What are the symptoms?

In some youth there are no obvious symptoms with spondylolysis. However, when youth do develop symptoms, the most common complaint is a slowly worsening, dull, low back pain, which may be unilateral or bilateral, but typically centered around the spinous process. The pain may feel similar to muscle strain and typically has a band like distribution at the spinal level. It may radiate to the buttock or the back of the thighs in the setting of spinal nerve impingement, which is less common. In general, the pain worsens with activity, especially lumbar extension, and improves with rest.

How is it diagnosed?

Taking a careful medical history and exam will help to determine if spondylolysis is likely. Letting your doctor know that you dance or participate in extension sports is important because youth who participate in sports that require frequent hyperextension are more likely to have spondylolysis.  Your doctor will also examine the back and spine to look for areas of pain, assess range of motion, and look for muscle weakness or muscle spasms. They may also assess the posture and how they walk.

If spondylolysis is suspected, then x-rays may be ordered to help confirm the diagnosis. X-rays will show a stress fracture in the pars interarticularis of the vertebrae when positive, usually in the lumbar region of the spine.  Oblique view spine xrays are needed to help increase the sensitivity of the test, which is still only 60-90% sensitive for pars stress fractures and will not catch majority of early stage spondylolysis. If no stress fracture is seen on x-ray, but suspicion of spondylolysis is high, then additional imaging may be ordered (this may include SPECT, CT, or MRI).

How is it treated?

Most youth with spondylolysis will improve with nonsurgical treatment such as rest, acetaminophen (Tylenol), and proper core flexion based physical therapy over the course of 3 to 12 months.

Rest can be difficult for a young athlete because it involves avoiding all activities (like hyperextension) that place excess stress on the low back in order to keep the dancer pain free so that the chances of boney healing at maximized.

Acetaminophen can be used to help reduce the discomfort of the spondylolysis. Nonsteroidal anti-inflammatory drugs (NSAID) like ibuprofen can also reduce back pain and inflammation caused by the spondylolysis, however there is some limited evidence that they may increase the risk of failure to heal.

Physical therapy plays an important role in the healing process as it can provide a strengthening and stretching program to keep the dancer remain active during recovery, minimize deconditioning, and strengthen the muscles of the core (muscles of the back and abdomen) with stabilization exercises. These exercises should begin with isometric type and progress flexion based exercises prior to advancing to any extension based core exercises after 2-3 months when pain is resolved and fracture healing is near complete.

Bracing can be used for dancers as well in order to limit movement and support healing; however there is still some controversy regarding the use of braces as there is insufficient evidence showing that braces are able to improve healing or impact overall outcomes.  However, for those whom get symptomatic relief or protection from end range extension they can be a reasonable option.

If spondylolysis remains untreated it can progress to spondylolisthesis. Spondylolisthesis occurs when the two halves of the fractured pars interarticularis separate allowing the injured vertebra to slip forward on the vertebra below it. Surgery may be needed in patients with spondylolisthesis with severe or high grade slippage typically with greater than 50% displacement.

Prevention

Maintaining adequate nutrition will help to support bone strength. Ensuring proper form and avoiding frequent hyperextension will help to minimize the stress placed on the pars interarticularis. Listening to your body and being seen if there is back pain. This will give you an opportunity to rest, recover, and perhaps correct improper form before spondylolysis (a stress fracture) develops. Pushing yourself to dance or train through the pain will only increase the risk of progression to spondylolysis.

Outcomes

Most youth are pain free after completing a course of treatment for spondylolysis. However, as noted above, it can take up to 6-12 months to heal. Most youth are able to gradually resume their participation in dance and other activities after 3 months of a proper physical therapy regimen.

More about Common Injuries in Gymnastics: Gymnastics Injuries

By Aurora Selpides, MD, MPH and Mo Mortazavi, MD

References

Gottschlich LM, Young CC. Spine injuries in dancers. Curr Sports Med Rep. 2011 Jan-Feb;10(1):40-4.

Pediatric Orthopaedic Society of North America. “Spondylolysis and Spondylolisthesis.” American Academy of Orthopaedic Surgeons. September 2016. <http://orthoinfo.aaos.org/topic.cfm?topic=a00053> Accessed February 5, 2017.

Yin, Amy X. et al.  Pediatric Dance Injuries: A Cross-Sectional Epidemiological Study. PM&R, Volume 8, Issue 4, 348 – 355

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