Comment Spondylolysis is a bony defect in the vertebral pars interarticularis. Bilateral spondylolysis can progress to spondylolisthesis—anterior slippage of one vertebral body over another. The fourth and fifth lumbar vertebrae are most commonly affected, and although both conditions may be present at birth, they are more frequently a result of repeated lumbar hyperextension. Gymnasts, football players, weight lifters, and dancers are more susceptible to this problem. The incidence of both conditions is approximately 6%, and spondylolisthesis is found in as many as 50% of athletes with persistent back pain.^1,2

Spondylolysis and spondylolisthesis may also be asymptomatic, and the degree of pain does not always correlate to the extent of slippage.³ The Phalen-Dickson sign, a knee-bent, hip-flexed gait, is strongly suggestive, as in this patient. Hamstrings are often tight, and forward flexion is restricted. Neurologic symptoms rarely occur with spondylolisthesis because the vertebra slips anteriorly, away from the spinal cord and nerve roots.

A technetium bone scan is the most sensitive tool for diagnosing early-stage stress reaction and acute fracture of the pars interarticularis. Early evaluation of a young athlete with a compelling history of back pain can prevent further injury progression.⁴ Lateral and oblique view radiographs demonstrate the classic "Scotty dog" appearance of spondylolisthesis.

Conservative treatment of stress reactions, spondylolysis, and spondylolisthesis includes 6 weeks to 6 months of rest from those activities that involve impact loading or lumbosacral hyperextension. Muscle relaxants and anti-inflammatory medications are helpful adjuncts.

Once pain free, the patient can begin physical therapy and an exercise program that strengthens the abdominal and paraspinal muscles and stretches the hamstrings.⁵ Patients can usually resume impact-loading activities gradually with gains from physical therapy and return to hyperextension activities if they cause no pain. To maximize healing, a young athlete with a stress fracture or stress reaction of the pars interarticularis should not return to full participation until he or she is pain free and has full lumbar range of motion. Continued strengthening and stretching exercises are recommended.

Surgical options are available for slippage greater than 50%, progression, pain unrelieved by rest and immobilization, or significant neurologic deficit. Early consultation with an orthopedic specialist is suggested.

The patient was counseled to avoid sports or strenuous physical activity for 6 weeks, use ibuprofen and the muscle relaxant cyclobenzaprine for pain and spasms, and undergo physical therapy. She was pain free after 4 months and returned to her usual sporting activities.

1. Herman MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylolisthesis in the child and adolescent athlete. Ortho Clin North Am. 2003;34:461-467.

2. Wimberly RL, Lauerman WC. Spondylolisthesis in the athlete. Clin Sports Med. 2002;21:133-145.

3. Eck JC, Riley LH. Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004;23:367-379.

4. Trainor TJ, Wiesel SW. Epidemiology of back pain in the athlete. Clin Sports Med. 2002;21:93-103.

5. George SZ, Delitto A. Management of the athlete with low back pain. Clin Sports Med. 2002;21:105-120.

M. LIZA LINDENBERG, MD, Family Medicine, Andrew Rader US Army health Clinic, Fort Myer, Va. The views expressed in this article are those of the author and do not necessarily represent those of the Department of the Army or the Department of Defense.