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Spondylolysis and Young Athletes
Written on January 17, 2008 at 1:05 pm, by Eric Cressey
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Subscriber-Only Q&A: Spondylolysis and Young Athletes
I received this email a few months ago and have been meaning to turn it into a Q&A
for quite some time, as spondylolysis is a topic that I think everyone should understand.
Q: I read you spoke at a seminar this sinter on the topic of spondylolysis showing
up in young athletes. I have a 16 year-old son who was diagnosed with this type of
stress fracture in his lumbar spine. He had grown 7 inches over the previous 9
months and our doctor contributed the cause to supporting muscles growth not
being able to keep up with the rapid bone growth along with hyperextension of the
lower back. He has recovered quite nicely with rehab being initially rest,
isolation and support of the lower back followed by core strengthening when the
pain subsided.
Occasionally, he will get very temporary flare up pain. Could you please give me
your opinion on the do and dont exercises that could possibly help prevent
Spondylolysis from recurring and your thoughts on the subject. Thanks for your
help.
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A: First off, here is some background for our readers. Spondylolysis refers to a fracture
of the pars interarticularis portion of a vertebra (95% of the time, its L5). The pars
essentially connects the vertebral body in front with the vertebral joints behind. Its
also known as a Scotty Dog fracture because the shape of the pars mirrors that of a
dog and when a fracture is present, it looks like that dog has a collar on (or has its
head chopped off, depending on whether youre a glass-is-half-empty kind of person or
not):
Symptoms may come on traumatically (contact injury) or insidiously (overuse, genetic
predisposition, or rapid bone growth during puberty). Pain is typically more lateral to
the spine than it is centralized.
We have had quite a few athletes come to us with the condition because we work with
a ton of athletes in rotational sports, predominantly baseball. In my humble opinion,
spondies are the new ACL epidemic. Dont believe me? Check out these numbers
from a 2000 study from Soler and Calderon (1):
-8% of elite Spanish athletes affected
-highest prevalence (27%) in those in track & field throws
-17% of rowers, 14% of gymnasts, and 13% of weightlifters had spondylolysis
-L5 most common (84%), followed by L4 (12%).
-Multiple levels of involvement in only 3% of cases
-Bilateral 78% of the time
-Only 50-60% of those diagnosed actually reported low back pain
-Males and females affected equally (although associated spondylolisthesis or
vertebral slippage was higher in females)
-Presence of spondylolysis is estimated at 15-63%, with the highest prevalence among
weightlifters.
I suspect that these rates are even higher now (eight years later) and in the U.S.,
where we have additional rotational and contact sports (as compared to Spain). These
numbers particularly the 40-50% asymptomatic figure speak directly to the fact
that inefficiency is on-par with (if not more important than) the spondylolysis
pathology itself. Multiple inefficiencies are to blame for this specific pathology and
many people are just waiting to reach threshold. With that in mind, to be honest, I train
all of our athletes under the assumption that they all have a disc herniation or vertebral
fracture that we dont even know about simply because, according to the research,
thats probably the case! There are more opportunities than ever to participate in
organized sports, yet athletes dont train any more than previously and DO spend
more time sitting.
In fact, about 14 million people or 3-7% of the general population have
spondylolysis (2), and previous research as shown that asymptomatic disc bulges and
herniations may be up in the 80% range (3).
These issues combined with the fact that 4.4% of six-year-olds present with pars
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defects has led to a standard rule in sports medicine where any adolescent athlete
with lumbar spine pain for more than three days duration is referred for a bone scan to
rule out a fracture. If a pars defect is detected, most doctors will prescribe 12-16 weeks
in a back brace: a practice that, while controversial, has yielded favorable healing
results.
Risk factors for pars defects have been subdivided into intrinsic and extrinsic. The *
indicates that these factors are at least partially under our control as strength and
conditioning coaches and trainers:
Intrinsic:
-Poor bone mineral density (*)
-Poor lower limb alignment and foot structure (*)
-Faulty muscular recruitment patterns (*)
-Height Taller (non-modifiable)
-Rapid growth (non-modifiable)
-Body Type muscle mass, longer spine (* to a degree, some non-modifiable)
-Poor conditioning/muscular fatigue (*)
-Bone pathologies (refer out)
-Menstrual/hormonal irregularities (refer out)
-Genetic predisposition: Inuit > Caucasian > African-American (non-modifiable)
Extrinsic:
-Inappropriate training regimen or surface (*)
-Sporting discipline: Sports demanding repetitive lumbar hyperextension, trunk
rotation, and/or axial loading (*short-term, potentially modifiable long-term)
-Footwear (*)
-Cigarette smoking (*)
-Insufficient nutrition calories, calcium, vitamin D (*)
We can help build bone density with appropriate resistance training and encouraging
athletes to consume plenty of calcium and vitamin D. We can train the lower extremity
out of alignment problems and faulty recruitment patterns. We can put some meat on
athletes to protect them from contact injuries. We can condition athletes so that they
dont fatigue prematurely and break down in their technique. We have some control
over the training surface. We can get young athletes out of the 10-pound cinderblock
basketball shoes theyre wearing and do more barefoot work. Kids know they shouldnt
be eating the right stuff and not smoking.
So, in spite of all these means of preventing spondylolysis, as is the case with ACL
problems, weve pursued a reactive not proactive model of addressing the issue.
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Trust me: you can save a kid a lot of pain and frustration if you prevent a fracture
instead of bracing it after the fact. So, lets talk about what are in my opinion the most
important things to address in young athletes to protect them from spondylolysis:
1. Train the feet and enhance ankle mobility. Think about what happens to someone
who thanks to modern footwear, muscular weakness, and/or structural predisposition
pronates too much. My good friend John Pallof describes the subtalar joint as a
torque converter meaning that tri-planar motion at/below the joint is converted into
tibial and femoral internal rotation. In other words, when you pronate
(land/decelerate), adequate stretch of the anti-pronators (particularly gluteus maximus
and biceps femoris) is necessary to decelerate that motion. Most people particularly
young athletes have very little posterior chain strength, and they dont activate their
glutes well. So, this internal rotation isnt decelerated effectively and the stress shifts
up a bit from the hip to the lumbar spine. Instantly, a foot and ankle issue has become a
lumbar spine issue (I could go on and on about how it relates to shoulder and elbow
issues in pitchers, too).
2. Improve rotary stability. The more an athlete moves at the lumbar spine, the more
likely he is to get injured. Using the baseball example again, there is considerable
research demonstrating that young pitchers have higher rotational velocities than
professional pitchers and the younger subjects control their rotation in a less efficient
manner. Rotate more, and do so in an inefficient (weak) way and youre bound to run
into problems at the lumbar spine (and elbow and shoulder, as well).
3. Improve their ability to resist extension. Most of the overuse spondy cases we see
are individuals who also have a tendency toward hyperextension. If you cant fire your
glutes in hip extension, youll substitute lumbar extension to attempt to get upright.
Combine that rapid, repeated lumbar extension with rapid, repeated lumbar rotation
and pars defects kick in. For this reason, I love basic movements like prone bridges
(and their variations) as well as more advanced progressions such as rollouts on the
stability ball and ab wheel (or bar rollouts).
(Note from EC: Jim Smiths Combat Coreis the best resource Ive seen with respect to
#2 and #3; for those interested in further reading, it provides dozens of exercises for
both objectives.)
4. Improve hip mobility. I have covered this above, but hip (and thoracic spine)
mobility work hand-in-hand with lumbar spine stability. Its easier to stabilize a spine
thats above a mobile set of hips.
5. Improve overall strength and power. The more force you generate in your lower
and upper body, the less motion youll need to utilize at the lumbar spine. Effectively,
by making the extremities, hips, and torso stronger, you allow the core to focus on
force transfer.
6. Implement appropriate deloading periods. Bone, like muscles and your
connective tissues, needs a break to recover here and there. Regardless of how perfect
your technique is, you lumbar spine will get chewed up if you swing a baseball bat for
five hours per day, seven days a week. Physiological adaptation is all about matching
tissue tolerance to tissue loading and providing adequate recovery time for adaptation
to occur.
Now, to get to the question at-hand, return-to-play after a period of bracing is a
different story. Believe it or not, weve trained guys through their entire 12-16 week
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bracing protocols. When theyre in the brace, aside from axial loading, there isnt much
that can get them meaning that theyre completely protected from rotation and
extension problems.
In fact, the brace does so much of the work for them that you need to make sure
theyre seeing a physical therapist at least 1-2 times a week during that protocol to get
them out of it to entire that they dont detrain the deep core stabilizers. The brace also
restricts full hip extension and flexion and thoracic spine ROM, to a degree so
mobility work is very important. If I had to briefly summarize our training programs
during bracing protocols, it would be upper body, single-leg movements,
pull-throughs, rotary stability training, mobility work, low-level linear plyos and
medicine ball throws.
And, you know what? That would summarize my recommendations for the short-term
when they get out of the brace because its what all athletes need! However,
post-spondy athletes are different in several regards:
1. They cannot handle compressive loading the same way, so it must be gradually
reintroduced. I have not allowed post-spondy guys to come back to squatting until at
least nine months post-bracing and I only do so if they have no residual symptoms. In
terms of axial loading, we always test the waters with a barbell reverse lunge with a
front squat grip. If that goes well, well try some front squatting. Most do well with trap
bar deadlifts although I do not bring them back to any Olympic lifts or straight-bar
deadlifting in the first-year post-bracing.
2. Sprint mechanics are definitely altered after bracing. I suspect that it has mostly to
do with the fact that kids lose hip flexion and extension range of motion and are
therefore forced to develop extra hip rotation strategies (usually external rotation) to
get range of motion. Others will simply lose hip flexion during the sprinting motion.
Typically, cueing knee-drive with these folks and doing some psoas activation work will
help to clear things up quickly.
3. We continue with training purely to resist rotation and only start to integrate
rotational exercises including medicine ball throws and cable woodchops after three
months. In most cases, though, the athlete will have returned to play by this point, so if
he is involved in a rotational sport, hell be encountering plenty of rotation already.
With respect to the athlete in question, if he is still having residual flare-ups (which do
happen relatively frequently), he simply isnt ready for more aggressive loading
presumably because he has some degree of instability in one or more directions. When
this is the case, we work around the issue but check to see if there is a specific deficit
that needs to be addressed. It may be as simple as poor breathing patterns or a lack of
hip rotation or it could be something that takes longer to address.
The important thing to remember is that athletes lift weights to get better at sports not
just to get good at lifting weights. Who is to say that a great football player cant be
built without squatting? We have athletes and clients who do not squat and they still
get great results.
All the Best,
EC.
References:
http://www.ericcressey.com/newsletter114html
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1. Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am
J Sports Med. 2000 Jan-Feb;28(1):57-62.
2. Wineberg, EP. Spondylolysis. http://www.emedicine.com/Radio/topic650.htm
3. Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without
back pain. N Engl J Med.1994 Jul 14;331(2):69-73.
1 Comment
Category Newsletters, Uncategorized | Tags: Back Pain,Building The Efficient
Athlete,Combat Core,Jim Smith,Magnificent Mobility,Newsletters,Rotator Cuff
Exercises,Rotator Cuff Rehab,Shoulder Exercises,Shoulder Health,Shoulder
Impingement,Shoulder Pain,Shoulder Rehab,Spondylolysis,Unstable Surface
Training,Weight Lifting Program,Weight Lifting Routine,Workout Program,Workout
Routine
One Response to Spondylolysis and Young Athletes
Cole Ellis Says:
July 7th, 2009 at 11:00 pm
Very comprehensive Eric. I liked your last statement about athletes lift to
improve in their sport, not necessarily to become better at lifting weights. A
squat is one of the best exercises, but if the squat continues to flare up the low
back, then performance will be impacted not in a good way. Its empowering
for athletes to work with in their functional range and spend time doing what
they are good at. Take Jerry Rice for example, he is one of the best WR of all
time yes Im an 49er fan, but his workout routine consisted of a variety of
exercises that did not revolve around heaving squatting. Point being, if you do
have a spondylolysis your athletic career is not over, it just means you have to
work around it.
I have no recollection of Jerry having a spondy by the way
Keep up the excellent articles EC, you are doing a great job.
Cole Ellis
1.
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