Spondylolysis and Spondylolisthesis.
What is spondylolysis?
Spondylolysis refers to a stress fracture or other bony defect that occurs in the pars interarticularis — a small bridge of bone connecting the facet joints at the back of each lumbar vertebra. It is often seen in athletes who frequently hyperextend their spines, such as gymnasts and football players.
The pars interarticularis is the weakest point of the posterior vertebral arch, and repetitive extension and rotation loading — particularly in sports requiring repeated lumbar hyperextension — can produce a fatigue stress fracture at this site. L5 is the most commonly affected level, accounting for approximately 90% of cases, followed by L4. Spondylolysis affects approximately 3 to 6% of the general population and is present bilaterally in the majority of cases, though unilateral defects also occur.
The etiology is regarded as a stress fracture due to repetitive loading associated with a genetic predisposition. Lumbar MRI shows increased signal intensity before an actual fracture line develops — meaning early imaging can identify the condition before a frank fracture is present and allow more timely management.
In adolescent athletes, spondylolysis is one of the most common causes of lower back pain — it is present in approximately 47% of young athletes presenting with back pain compared to approximately 5% of the general paediatric population, reflecting the contribution of sporting loading patterns to its development.
What is spondylolisthesis?
Spondylolisthesis occurs when a vertebra slips forward onto the vertebra below it. It can result from a stress fracture (isthmic type), degenerative changes (degenerative type), trauma, or congenital abnormalities.
Understanding the type of spondylolisthesis is clinically important:
Grading of spondylolisthesis uses the Meyerding classification from Grade I (less than 25% slippage) through Grade IV (more than 75% slippage) to spondyloptosis (complete forward displacement). Most patients presenting to physiotherapy have Grade I or II slippage. Higher grades may require surgical consideration.
What are the symptoms?
Central or bilateral lower back pain that is typically worse with extension-based activities — standing, walking, gymnastics, football — and improved with flexion is the characteristic presentation of spondylolysis and isthmic spondylolisthesis. Pain is typically localised to the lower back and may radiate into the buttocks and thighs. Hamstring tightness is a consistent finding and is thought to be a protective response to pelvic instability from the spinal defect.
If the slippage is sufficient to compress nerve roots, sciatica and radiculopathy symptoms develop — leg pain, numbness and weakness in the distribution of the affected roots.
How is it diagnosed?
A combination of physical examination and imaging is used. X-rays identify the pars defect and measure the degree of vertebral slippage. MRI or CT scans provide a detailed look at the spine, detecting nerve compression and the extent of the defect. SPECT (single photon emission computed tomography) bone scan is the most sensitive investigation for identifying active pars stress reactions before a frank fracture is visible on CT. MRI with STIR sequences is increasingly used as the first-line investigation in young athletes given it avoids radiation and provides information about both the bony and neural structures.
How can physiotherapy help?
Physiotherapy is a front-line treatment for both conditions, aiming to reduce pain, address underlying factors such as hypermobility and weakness, and improve global and specific functional strength, particularly core strengthening to build strength in the abdominal and back muscles that provide better spine support.
For acute spondylolysis in young athletes — where early MRI shows bone marrow oedema indicating an active stress reaction — a period of activity restriction from the aggravating sport is the primary initial management, allowing the stress reaction to settle before bony healing can occur. Two-thirds of children with acute spondylolysis will undergo bony union with early activity restriction. Physiotherapy during this period maintains general fitness, addresses hamstring tightness, and begins the core stabilisation program that will underpin safe return to sport.
For established spondylolysis and Grade I-II spondylolisthesis, physiotherapy addresses the biomechanical contributors to pain and builds the active stabilising capacity that compensates for the passive structural deficit. Deep core retraining — specifically the multifidus and transversus abdominis — is the foundation of rehabilitation. These muscles provide the segmental stability that substitutes for the bony arch integrity that is compromised at the pars defect. Real time ultrasound guides this retraining by providing direct visualisation of the deep muscles.
Hip and gluteal strengthening is equally important — the gluteal muscles are the primary load-sharing partners of the lumbar spine, and their strengthening reduces the extension loading transmitted to the pars interarticularis. Hamstring stretching and neural mobilisation address the secondary tightness and sensitisation that develops in response to the spinal pathology.
Technique modification for athletes — reducing the degree of lumbar hyperextension in sport-specific movements, modifying training loads during rehabilitation, and correcting the technical patterns that are placing the highest stress on the pars — is as important as the direct rehabilitation program. A sport-specific return-to-training program guides graduated reintroduction of loading without premature stress on the healing or stabilising structure.
Clinical Pilates is an excellent rehabilitation environment for spondylolysis and spondylolisthesis — the deep core activation emphasis, controlled loading in neutral lumbar positions, and precise movement quality focus are directly aligned with the rehabilitation goals.
For patients whose condition was related to a workplace injury, WorkCover funded physiotherapy is available.
Our physiotherapists Yulia Khasyanova and Bethany Kippen both have experience in spinal conditions and are members of the Australian Physiotherapy Association. Mauricio Bara's APA Sports Physiotherapist credentials are particularly relevant for the young athlete presentations of spondylolysis that are most commonly seen in this condition.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Spondylolysis refers to a stress fracture or other bony defect that occurs in the pars interarticularis — a small bridge of bone connecting the facet joints at the back of each lumbar vertebra. It is often seen in athletes who frequently hyperextend their spines, such as gymnasts and football players.
The pars interarticularis is the weakest point of the posterior vertebral arch, and repetitive extension and rotation loading — particularly in sports requiring repeated lumbar hyperextension — can produce a fatigue stress fracture at this site. L5 is the most commonly affected level, accounting for approximately 90% of cases, followed by L4. Spondylolysis affects approximately 3 to 6% of the general population and is present bilaterally in the majority of cases, though unilateral defects also occur.
The etiology is regarded as a stress fracture due to repetitive loading associated with a genetic predisposition. Lumbar MRI shows increased signal intensity before an actual fracture line develops — meaning early imaging can identify the condition before a frank fracture is present and allow more timely management.
In adolescent athletes, spondylolysis is one of the most common causes of lower back pain — it is present in approximately 47% of young athletes presenting with back pain compared to approximately 5% of the general paediatric population, reflecting the contribution of sporting loading patterns to its development.
What is spondylolisthesis?
Spondylolisthesis occurs when a vertebra slips forward onto the vertebra below it. It can result from a stress fracture (isthmic type), degenerative changes (degenerative type), trauma, or congenital abnormalities.
Understanding the type of spondylolisthesis is clinically important:
- Isthmic spondylolisthesis — the most common type in young people — occurs when bilateral spondylolysis allows the vertebral body to slip forward. The pars defect disrupts the bony connection that normally prevents forward translation.
- Degenerative spondylolisthesis — the most common type in adults over 50 — occurs when facet joint and disc degeneration allow forward slippage without a pars defect. It is most common at L4-5 and is strongly associated with spinal stenosis as the slipped vertebra narrows the spinal canal.
Grading of spondylolisthesis uses the Meyerding classification from Grade I (less than 25% slippage) through Grade IV (more than 75% slippage) to spondyloptosis (complete forward displacement). Most patients presenting to physiotherapy have Grade I or II slippage. Higher grades may require surgical consideration.
What are the symptoms?
Central or bilateral lower back pain that is typically worse with extension-based activities — standing, walking, gymnastics, football — and improved with flexion is the characteristic presentation of spondylolysis and isthmic spondylolisthesis. Pain is typically localised to the lower back and may radiate into the buttocks and thighs. Hamstring tightness is a consistent finding and is thought to be a protective response to pelvic instability from the spinal defect.
If the slippage is sufficient to compress nerve roots, sciatica and radiculopathy symptoms develop — leg pain, numbness and weakness in the distribution of the affected roots.
How is it diagnosed?
A combination of physical examination and imaging is used. X-rays identify the pars defect and measure the degree of vertebral slippage. MRI or CT scans provide a detailed look at the spine, detecting nerve compression and the extent of the defect. SPECT (single photon emission computed tomography) bone scan is the most sensitive investigation for identifying active pars stress reactions before a frank fracture is visible on CT. MRI with STIR sequences is increasingly used as the first-line investigation in young athletes given it avoids radiation and provides information about both the bony and neural structures.
How can physiotherapy help?
Physiotherapy is a front-line treatment for both conditions, aiming to reduce pain, address underlying factors such as hypermobility and weakness, and improve global and specific functional strength, particularly core strengthening to build strength in the abdominal and back muscles that provide better spine support.
For acute spondylolysis in young athletes — where early MRI shows bone marrow oedema indicating an active stress reaction — a period of activity restriction from the aggravating sport is the primary initial management, allowing the stress reaction to settle before bony healing can occur. Two-thirds of children with acute spondylolysis will undergo bony union with early activity restriction. Physiotherapy during this period maintains general fitness, addresses hamstring tightness, and begins the core stabilisation program that will underpin safe return to sport.
For established spondylolysis and Grade I-II spondylolisthesis, physiotherapy addresses the biomechanical contributors to pain and builds the active stabilising capacity that compensates for the passive structural deficit. Deep core retraining — specifically the multifidus and transversus abdominis — is the foundation of rehabilitation. These muscles provide the segmental stability that substitutes for the bony arch integrity that is compromised at the pars defect. Real time ultrasound guides this retraining by providing direct visualisation of the deep muscles.
Hip and gluteal strengthening is equally important — the gluteal muscles are the primary load-sharing partners of the lumbar spine, and their strengthening reduces the extension loading transmitted to the pars interarticularis. Hamstring stretching and neural mobilisation address the secondary tightness and sensitisation that develops in response to the spinal pathology.
Technique modification for athletes — reducing the degree of lumbar hyperextension in sport-specific movements, modifying training loads during rehabilitation, and correcting the technical patterns that are placing the highest stress on the pars — is as important as the direct rehabilitation program. A sport-specific return-to-training program guides graduated reintroduction of loading without premature stress on the healing or stabilising structure.
Clinical Pilates is an excellent rehabilitation environment for spondylolysis and spondylolisthesis — the deep core activation emphasis, controlled loading in neutral lumbar positions, and precise movement quality focus are directly aligned with the rehabilitation goals.
For patients whose condition was related to a workplace injury, WorkCover funded physiotherapy is available.
Our physiotherapists Yulia Khasyanova and Bethany Kippen both have experience in spinal conditions and are members of the Australian Physiotherapy Association. Mauricio Bara's APA Sports Physiotherapist credentials are particularly relevant for the young athlete presentations of spondylolysis that are most commonly seen in this condition.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
