| 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 "don't" exercises that could possibly help prevent Spondylolysis from recurring and your thoughts on the subject. Thanks for your help.
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, it's L5). The pars essentially connects the vertebral body in front with the vertebral joints behind. It's 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 you're 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. Don't 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 don't even know about - simply because, according to the research, that's probably the case! There are more opportunities than ever to participate in organized sports, yet athletes don't 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 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 don't 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 they're wearing and do more barefoot work. Kids know they shouldn't 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, we've pursued a reactive - not proactive - model of addressing the issue. 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, let's 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 don't activate their glutes well. So, this internal rotation isn't 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 you're 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 can't fire your glutes in hip extension, you'll 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 Smith's Combat Coreis the best resource I've 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. It's easier to stabilize a spine that's 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 you'll 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, we've trained guys through their entire 12-16 week bracing protocols. When they're in the brace, aside from axial loading, there isn't much that can "get them" - meaning that they're 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 they're seeing a physical therapist at least 1-2 times a week during that protocol to get them out of it to entire that they don't 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 it's 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, we'll 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, he'll 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 isn't 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 can't be built without squatting? We have athletes and clients who do not squat - and they still get great results.
All the Best,
EC.
References:
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. |
