Case 9: A 16-year-old level 9 gymnast has had right sided low back pain for the past three weeks. She denies a specific injury but notes pain with bending backwards or backwards tumbling. She has no radiation of pain and notes no improvement with ibuprofen or ice. She has pain with palpation just lateral to the right L5 spinous process and has pain with hyperextension and one legged hyperextension (Stork test) on the right.

Spondylolysis is the most common cause of low back pain in adolescents seeking medical evaluation; most commonly seen in the lower lumbar spine at L4 or L5. A spondylolysis is a stress fracture of the pars inter-articularis. Athletes who perform repetitive hyperextension, such as dancers, gymnasts, divers, wrestlers, rowers, soccer players, and football lineman, are at increased risk to develop spondylolysis. Low back pain may be unilateral or bilateral, of acute or insidious onset, or worsen after an inciting event. Some may experience radiation of pain into the buttocks. Pain with lumbar spine hyperextension or one-legged hyperextension (the stork test) is sensitive but not specific for spondylolysis (Fig. 10). Examination may also reveal hyperlordosis and tight hamstrings. Radiographs of the lumbar spine should include an AP, lateral, and left and right oblique to evaluate for a stress fracture. On oblique radiographs, the "broken neck" on the Scottie dog represents the pars defect (Fig. 11). Fractures visible on radiographs are usually older and may not have the capacity to heal further. As many acute stress fractures are not visualized on radiographs, if clinical suspicion is high, either a bone scan with single photon emission computed tomography (SPECT) or thin cut CT are recommended for further evaluation.

Physical Therapy Spondylolysis
Figure 10 Stork/hyperextension test.

Treatment consists of rest from ALL activity (sports, running, jumping, riding, lifting etc.) until the athlete is pain free. Controversy surrounds the need for a thoricolumbarsacral orthotic or a lumbar sacral orthotic to stabilize the back, prevent movement, and promote healing. If an athlete is deemed reliable to follow treatment guidelines and has no pain with activities of daily living, this author does not always use a brace. When the athlete is pain free at rest and with hyperextension, a monitored daily physical therapy program focusing on core stability and lumbar strengthening in neutral or flexion (avoiding extension) is recommended. Most athletes can return to play within 3 to 8 months of their stress fracture.

Most young athletes with spondylolysis report excellent functional outcomes after diagnosis, with poorer outcomes seen in those with bilateral defects. Complications of a pars interarticularis fracture include nonunion, chronic pain, and a spondylolisthesis. A spondolisthesis or "slip" occurs if there are bilateral pars defects with forward slippage of the anterior vertebral body. A spondylolisthesis can be seen and measured on a lateral

Oblique Lumbar Spine Pars Defect
Figure 11 Oblique view of the lumbar spine showing a normal pars interarticularis (black arrow). The pars interarticularis shows a lucency along the Scottie dog's neck (white arrow) representing a spondylolysis.

lumbar spine radiograph. A large slip (> 50% of the body width) can cause spinal cord compression symptoms and may require surgical management. As slips may worsen during growth periods, adolescents with bilateral spondylolysis should be radiographed every 6 months until maturity to evaluate for a slip or any progression of a slip.

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