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When Back Pain Stops a Young Athlete, Think Spondylolysis

Back pain in active children and adolescents is common. Fortunately, most back pain goes away on its own. But in some cases symptoms don’t improve, and the pain hangs on for weeks. When that happens in active kids who are still growing, doctors often look for a problem called spondylolysis.

Spondylolysis (pronounced “spon-dee-low-LYE-sis”) is a stress fracture of a narrow section of bone in the spine called the pars interarticularis. In still-growing children and adolescents, the “pars” is not yet fully developed and vulnerable to repeated stresses. A fracture of the pars is more common in sports that involve backward bending and repeated pressures on the back, such as gymnastics, football and basketball.

“Spondylolysis often develops in the most motivated, active and best athletes,” says Stan Herring, M.D., cofounder of The Sports Institute at UW Medicine and team physician for the Seattle Seahawks and Seattle Mariners.

“These young athletes always want to compete, and it is highly unusual for them to stop running in the middle of a game or competition because their back hurts so much. They just can’t go on. If a young, motivated athlete stops sports because of back pain, spondylolysis should be suspected until proven otherwise.”

The good news: If doctors find this stress fracture in its early stages, it has an excellent chance of healing without surgery, and the athlete can often return to sports free of significant pain and limitations.

The not-so-good news: The cure is not always popular. It requires extended rest, typically two or three months.

But first—to avoid resting an athlete who doesn’t need it—it’s critical to know more about the problem and the chance it will improve with treatment.

The young spine’s weak link

Spondylolysis is a common source of back pain in kids, and in some sports it can afflict 20 to 30 out of every 100 athletes.In young athletes, spondylolysis may account for up to half of all back pain. These athletes may hurt more during a hard landing after a jump, or when they bend their spine backwards while bearing weight. Sometimes, an exact cause may be difficult to pinpoint.

To understand the problem, it helps to know a few things about the spine. The spine is a column of bones called vertebrae stacked on top of one another. Each of the vertebrae has two wing-shaped vertebral bodies, one on the left and one on the right. The vertebral bodies and their surrounding muscles and ligaments lend stability to the spine and enable bending and twisting.

The weak link in this stabilizing system—the pars interarticularis—is a thin arch of bone within each vertebral body. A stress fracture can occur in one or both of the pars in a vertebral body.

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The treatment is rest

“If a fracture is present, it’s important to understand that relative rest, including removing the child from sports, is essential,” says Herring. “The fracture will not heal and the pain will not get better if a young athlete does not rest for some time—often three months, sometimes less. Even if the fracture doesn’t heal, with extended rest symptoms usually improve, and most athletes will return to play.”

Treatment with “relative rest” means it’s okay to go about daily activities, including doing things like walking to school and going up and down stairs. “Pounding, running, cutting, bending, jumping are probably not okay,” says Herring. “The very things that caused the pain in the first place are the things they need to stop.”

In an effort to aid fracture healing, some doctors prescribe a back brace to restrict spinal motion. However, research suggests that the results of treatment are usually the same with or without a brace. “We do not routinely brace our patients,” says Herring. “There are different approaches to this, and the outcomes are similar. We do consider bracing in some cases when rest alone is not effective.” Pars fractures rarely require surgery.

Many stress fractures can heal

To properly treat active young people, doctors who specialize in back pain use imaging tests to find out how recent and severe the problem is. “Some problems have a better chance of healing than others,” explains Herring.

  1. Very early stage stress reaction. A stress reaction means the bone is weakened but has not progressed to a fracture. The outlook with treatment is excellent. In one recent study, every case of a stress reaction healed with an average of two and one-half months of rest, and many within six weeks.
  2. Early stress fracture. A visible early hairline fracture can heal with two to three months of rest in more than 90 out of 100 cases. The chances of healing are significantly higher if the fracture is in one side of the vertebral body, rather than both sides.
  3. Progressive fracture. Stress reactions and early stress fractures that go untreated may progress to a complete fracture that creates a space where the bone breaks. This can lead to more serious symptoms and possible long-term problems. Yet even these can become symptom-free with rest of three months or longer and may heal in up to 80 out of 100 athletes.
  4. Chronic or terminal fracture. Older, chronic stress fractures are unlikely to heal. In young athletes, experts recommend rest for only as long as it takes to relieve pain. “This fracture is rarely the cause of pain in an adult,” says Herring.If a young athlete does not improve after proper treatment, doctors may do additional tests and imaging to look for other problems that may explain the pain.

Key Points

  • Spondylolysis is a stress fracture of a narrow bridge of bone in the spine called the pars interarticularis. It is a common injury in active young athletes with back pain.
  • Some types of stress fractures have a better chance of healing than others. Treatment usually requires an extended period of rest—often three months, but sometimes less. Surgery is rarely needed.
  • After treatment, many children and adolescents can return to sports free of significant pain and limitations. Even without bony healing of the fracture, symptoms usually improve.
  • If a young athlete does not improve after proper treatment, doctors may do more tests and imaging to find the cause of the pain.