A 28-year-old female player presents with a six-month history of lumbar pain. She is unable to identify a specific incident that started her problem. She described a low-level ache that was only present during physical activity, and for a short period afterwards. On examination there was some tenderness over the lumbar spine in the midline and pain with lumbar extension.
A lateral x-ray image shows a pars interarticularis defect at the L5 level with a grade one spondylolisthesis of L5 on S1.
This player was managed with a progressive core activation programme. Over a period of three months there was a substantial improvement in her pain and function. She was happy with her progress and did not wish to pursue either any further investigation or treatment.
Spondylolysis and spondylolisthesis are relatively common causes of low back pain in young athletes. Spondylolysis most commonly occurs at L5 (90% of cases) followed by L4. As a result, the vast majority of cases of spondylolisthesis involve L5 slipping forward on S1. It is important to remember that these radiological findings are common and that in many cases the radiological findings are not relevant to a player’s presenting symptoms.
The Meyerding grading system is often used to describe the extent of a spondylolisthesis. This measurement is generally made on a standing lateral x-ray image. A grade I spondylolisthesis involves a translation of the cranial vertebra of up to 25%, with a grade II displaying a slip of up to 50%, grade III of up to 75%, grade IV up to 100% and a grade V lesion describing the ptosis of the cranial vertebra
Studies have shown that approximately 80% of patients will have a resolution of their symptoms with conservative treatment. Most studies have involved the use of anti-lordotic braces however this is not always needed as healing can occur with rigid, soft or no bracing. Grades I and II usually resolve with rest from aggravating activities, combined with abdominal and extensor stabilizing exercises and hamstring stretching. Potential indications for surgical treatment include a progressive slip, neurological complications and intractable pain.
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