Physical Therapy Guide to Spondylolysis and Spondylolisthesis
Spondylolysis (spon-dee-low-lye-sis), or lumbar stress fracture, is a stress fracture of a section of the lumbar spine. The area of the fifth lumbar vertebra is most often affected. The injury can occur on the left or right of the vertebra. Lumbar stress fractures occur in up to 11.5% of the general population in the United States. It is a common cause of low back pain in older children and youth. It most often occurs in young males, but also can occur in girls. Highly active teens who engage in activities like lifting heavy loads, repeated backward bending, or twisting of the trunk, are most at risk. Activities like football, hockey, gymnastics, or dance put athletes at higher risk. Only a small percentage of cases require surgery. The majority (85% to 90%) of young patients recover in three to six months with proper treatment. Recovery time can be longer and is different for each person.
Spondylolisthesis (spon-dee-low-lis-thee-sis), or slipped vertebra, is a condition that involves the forward slippage of one vertebra over the one under it. If a crack or stress fracture occurs on both sides of the vertebra it is called spondylolisthesis.
Lumbar stress fracture and slipped vertebra are often described together because they are similar in:
- The mode of injury.
- Age of the patient.
Physical therapists help people with these conditions recover and safely return to daily activities, work, and sports.
Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.
What Are Stress Fracture and Slipped Vertebra of the Lumbar Spine?
Lumbar stress fracture is a fracture of the part of the bony ring that connects the front part of the spinal column to the back part. The fracture occurs between the part of the bone that sticks out of the back of the spine and the part that sticks out of the side of the spine. Doctors sometimes refer to this condition as a "pars defect." Strain on the lumbar spine due to repeated activities in a growing child can cause this type of injury. It results in low back pain.
Slipped vertebra is the forward slip of a defective, unstable vertebra. There are five grades of slips, with grade I being the smallest amount of slippage and grade V being a slippage of 100%. With milder slippage, and a defect on just one side of the vertebra, physical therapy treatment is effective. Young athletes whose teenage growth spurt has not yet occurred are at greater risk for continued slippage. These athletes and are monitored until they are fully grown.
Key points to understand about lumbar stress fracture and slipped vertebra:
- Early detection and proper diagnosis of these conditions are important. With early diagnosis and treatment, people with these conditions can safely return to sport or an active lifestyle. If symptoms last a long time and you wait to get help, healing may take much longer.
- The majority of symptoms can resolve with rest and the help of a physical therapist.
- Surgery may be needed when treatment of more than six months fails, and symptoms persist.
- Both of these conditions need to be ruled out in a young athlete who is has low back pain that lasts for more than a few weeks. Active young athletes in sports such as football, hockey, gymnastics, and dance are at the greatest risk. This is especially true while the athlete is still growing.
- If an X-ray does not show a fracture, but a clinical exam suggests a high likelihood of lumbar stress fracture, your doctor may order an MRI to rule it out.
- These conditions are not a major cause of low back pain in adults. It can, however, occur high-level adult athletes who take part in high-risk sports.
Signs and Symptoms
Lumbar stress fracture or slipped vertebra may be present if you experience:
- Low back pain with or without buttock or leg pain. If leg pain is present, it is felt into the thigh, but generally not below the knee.
- Muscle spasms in your low back, buttocks, and thighs.
- Difficulty or pain with walking or standing for long periods.
- Symptoms that are relieved by sitting, slouching, or bending forward.
- Pain with sports or manual labor.
- Pain with bending backward, twisting the spine, or with throwing.
- Decreased flexibility of the leg muscles.
How Is It Diagnosed?
Your physical therapist will conduct a thorough evaluation that includes questions about your health history. Their goal is to assess the degree of your injury and to determine the cause and contributing factors. Your physical therapist also may gather information from forms you fill out before your first session. Their questions may include:
- How did your injury occur? Was there a single episode or did your condition become worse over time?
- How have you taken care of your condition? Have you seen other health care providers? Have you had imaging (e.g., X-ray, MRI) or other tests, and do you have the results of those tests?
- How long have you had pain? Did it come on suddenly or gradually?
- Does your pain occur with activity, at rest, or during the day or night?
- What activities or positions make your pain better or worse?
- Do you take part in activities like football, hockey, gymnastics, or competitive dance?
- Can you point with one finger to the area on your back that is painful?
- Do you have any other symptoms, such as fever, chills, or night sweats?
- Do you have trouble with bowel and bladder control?
After your physical therapist learns the specifics of your condition they will conduct a physical exam.
The physical exam most often will begin with watching some of the movements that were discussed in the interview. It will include the area of your main symptoms as well as other areas that may be involved, such as your hip. Your physical therapist may:
- Watch you walk.
- Have you bend forward to try to touch your toes, and bend back as far as you can.
- Ask you to stand on one leg and bend back.
- Ask you to turn your trunk from side to side.
Your physical therapist uses these tests to assess your leg and spine flexibility as well as your core strength. They may ask you if the testing changes your symptoms. They may gently but skillfully press specific areas of your low back and pelvis to see if they are painful. This information helps your physical therapist determine the cause of your pain, exactly where your pain is, and the best treatment to resolve your symptoms.
After the interview and physical exam, your physical therapist will discuss the findings with you. If your physical therapist suspects a stress fracture, they may refer you to an orthopedic or sports medicine doctor familiar with back injuries. The doctor may order imaging tests (X-ray, MRI) to confirm a diagnosis and rule out other conditions.
How Can a Physical Therapist Help?
Your physical therapist will design a targeted treatment program based on your condition and goals. It will be designed to safely return you to sport or daily activities. Your treatment plan may include:
Patient education. Your physical therapist will work with you to identify and change any external factors causing your pain. These factors can include the type and amount of exercise you do, your athletic activities, footwear, or the surfaces on which you practice and play. They may recommend changes in your daily activities.
Pain management. Your physical therapist will design a program to address your pain. This may include applying ice to the affected area. Applying heat also is helpful in some cases. Electrical stimulation gently targets nerve fibers that send pain signals to the brain. It also may be used together with ice to help relieve your pain. Your physical therapist also may recommend decreasing some activities that cause pain. Physical therapists are experts in prescribing pain-management techniques that reduce or avoid the need for medicines, including opioids.
Body mechanics. How you move and use your body for work and other activities can contribute to lumbar spine problems and pain. Your physical therapist will teach you how to improve your movements or body mechanics based on your daily activities. They also may make recommendations to improve the way you do certain activities, such as lifting and carrying objects.
Manual therapy. Often, manual therapy for lumbar stress fracture and slipped vertebra includes "soft tissue release" or massage for tight and sore muscle groups. These hands-on techniques may be used to correct tightness of muscles to promote normal movement.
Stretching exercises. Stretching exercises can help improve the flexibility of tight muscles. They also may help to improve movement in the spine and lower extremities and help decrease stress on the lumbar spine during daily activities.
Strengthening exercises. Strengthening helps to make the lumbar spine, pelvis, and hip joints more stable. This, in turn, helps to reduce strain on tissues, and pain. These movements are focused on weak muscles, including the lower abdominal, pelvic floor, and buttocks muscles.
Functional training. Once your pain, strength, and motion improve you will need to safely move back into more demanding activities. To lessen your risk of repeated injury, it is important to learn safe, controlled movements. Based on your unique movement assessment and goals, your physical therapist will create a series of activities to help you use and move your body more correctly and safely for years to come.
Can This Injury or Condition Be Prevented?
Lumbar stress fracture and some types of slipped vertebra may be preventable by educating individuals who are at higher risk of injury.
For the growing young athlete, it is necessary to manage how much, how intensely, and how often you exercise. Parents and coaches should:
- Limit a child’s participation to one high-risk sport at a time during a season.
- Limit participation to only one team at a time during a season.
- Require and enforce one to two days of rest from training per week.
- Gradually increase training volume, intensity, and frequency when a person is starting a new sport or activity.
Proper rest, nutrition, and hydration (drinking enough water daily) can improve bone health and overall well-being. Athletes who focus on these basic practices will increase their strength and stamina.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat lumbar stress fracture and slipped vertebra. However, you may want to consider:
- A physical therapist who is experienced in treating people with spine injuries and/or athletes. Some physical therapists have a practice with an orthopaedic or sports physical therapy focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic and/or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by clicking on Find a PT, an online tool built by the American Physical Therapy Association. Search for physical therapists by location and expertise.
General tips when you are looking for a physical therapist (or any other health care provider):
- Get recommendations from family, friends, or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who are athletes or active individuals with lumbar stress fracture.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of lumbar stress fracture and slipped vertebra. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Iwaki K, Sakai T, Hatayama D, et al. Physical features of pediatric patients with lumbar spondylolysis and effectiveness of rehabilitation. J Med Invest. 2018;65(3.4):177–83. Article Summary in PubMed.
Lawrence KJ, Elsar T, Stromberg R. Lumbar spondylolysis in the adolescent athlete. Phys Ther Sport. 2016;20:56–60. Article Summary in PubMed.
Schroeder GD, LaBelle CR, Mendoza M. The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic low back pain. Eur Spine J. 2016;25:2842–2848. Article Summary in PubMed.
Kim HJ, Green DW. Spondylolysis in the adolescent athlete. Curr Opin Pediatr. 2011;23(1):68–72. Article Summary in PubMed.
Kalichman L, Kim DH, Li L, et al. Spondylolysis and Spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34(2):199–205. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information. PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Aug 16, 2020
Revised: Aug 16, 2020
Content Type: Guide
Spondylolysis and Spondylolisthesis
PT, DPT, board-certified clinical specialist in orthopaedic physical therapy
PT, DPT, board-certified clinical specialist in orthopaedic physical therapy, on behalf of the Academy of Orthopaedic Physical Therapy