Spondylolysis as a Cause of Low Back Pain in Swimmers

Low back pain (LBP) has recently become a common complaint in swimmers. The differential diagnosis of LBP in swimmers includes muscle and ligament sprains, Scheuerman disease, herniated disc, facet joint injury, tumors, infections, and spondylolysis. Although spondylolysis or listhesis is a frequent injury in the athlete, mainly in weightlifters, wrestlers, gymnasts, divers and ballet dancers, it is infrequently reported in swimmers. We have recently encountered four adolescent elite swimmers who complained of low back pain and were diagnosed as having spondylolysis. Three of the patients were either breast-strokers or butterfly swimmers. Plain radiography demonstrated the lesion in two patients. Increased uptake in bone scan was noted in all patients. CT was performed only in two patients and revealed the lesion in both. One patient was diagnosed within two weeks, and the diagnosis in the others was deferred for 2 - 7 months. The patients were treated successfully by reducing the intensity of their training program and the use of a corset for at least three months. Repeated hyperextension is one of the mechanisms for spondylolysis in athletes as is the case in breast-strokers and butterfly style swimmers. LBP in swimmers should raise the suspicion of spondylolysis. Plain radiography and bone scan should be performed followed by SPEC views, CT, or MRI as indicated. If the case is of acute onset as verified by bone scan, a Boston or similar brace should be used for 3 to 6 months in conjunction with activity modification and optional physical therapy. Multidisciplinary awareness of low back pain in swimmers, which includes trainers, sport medicine physicians, and physical therapists, should lead to early diagnosis and appropriate treatment.

Key words:

Adolescents, athletes, back pain.

References

• 1 Apley A G, Solomon L. The back. In: Apley AG, Solomon L (eds) Apley's System of Orthopaedics and Fractures. England; Butterworth Heinemann 1993 7th Ed: 374-378
• 2 Bodner R J, Heyman S, Drummond D S, Gregg J R. The use of single photon emission computed tomography (SPECT) in the diagnosis of low-back pain in young patients.  Spine. 1988;  13 1155-1160
• 3 Cameron J M, Goode A W, King J B, Garrett L P. The 'butterfly back syndrome'.  The Swimming Times Technical Supplement. 1986;  3 5-7
• 4 Ciullo J V, Jackson D W. Pars interarticularis stress reaction, spondylolysis and spondylolisthesis in gymnasts.  Clin Sports Med. 1985;  4 95-110
• 5 Congeni J, McColloch J, Swanson K. Lumbar spondylolysis: A study of natural progression in athletes.  Amer J Sports Med. 1997;  25 248-253
• 6 Constantini N, Calé-Benzoor M. Medicine and sports injuries. In: Dotan R (ed) Preparing Young Athletes for a High Elite Level. Netanya; Wingate Institute 1997: 5-17
• 7 Cyron B M, Hutton W C. Spondylolysis. The fatigue strength of the lumbar neural arch.  J Bone Joint Surg. 1978;  60 B 234-238
• 8 Cyron B M, Hutton W C, Stott J RR. Spondylolysis: The shearing stiffness of the lumbar intervertebral joint.  Acta Orthop Belg. 1979;  45 459-469
• 9 Devas M. Stress Fractures. Edinburgh; Churchill Livingstone 1975
• 10 Dillin W H, Watkins R G. Back pain in children and adolescents. In: Rothman RH, Simeone FA (eds) The Spine. Philadelphia; W. B. Saunders 1992 3rd Ed: 231-259
• 11 Drori A, Mann G, Constantini N. Low back pain in swimmers: Is the prevalence increasing? Program and Book of Abstracts. Tel Aviv, Israel; The Twelfth International Jerusalem Symposium on Sports Injuries 1996: 75
• 12 Fredrickson B E, Baker D, McHolick W J, Hansen A, Uvbicky J P. The natural history of spondylolysis and spondylolisthesis.  J Bone Joint Surg. 1984;  66 A 699-707
• 13 Hulkko A. Stress fractures in athletes: A clinical study of 368 cases. Acta Universitatis Ouluensis, Series D, Medica 1988: 169
• 14 Hutton W C, Stoff J RR, Cyron B M. Is spondylolysis a fatigue fracture?.  Spine. 1977;  2 202
• 15 Jull G A, Richardson C A. Rehabilitation of active stabilization of the lumbar spine. In: Twomey LT, Taylor JR (eds) Physical Therapy of the Low Back. New York; Churchill Livingston 1994: 251-273
• 16 Lusins J O, Elting J J, Cicoria A D, Goldsmith S J. SPECT evaluation of lumbar spondylolysis and spondylolisthesis.  Spine. 1994;  19 608-612
• 17 McCarroll J R, Miller J M, Ritter M A. Lumbar spondylolysis and spondylolisthesis in college football players.  Am J Sports Med. 1986;  14 404-406
• 18 Morita T, Ikata T, Katoh S, Miyake R. Lumbar spondylolysis in children and adolescents.  J Bone Joint Surg. 1995;  77 620-625
• 19 Mutoh Y, Takamoto M, Miyashita M. Chronic inquiries of elite competitive swimmers, divers, water polo players and synchronized swimmers. In: Ungerechts BE, Reichte K (eds) Swimming Sciences. Champaign; Human Kinetics 1988: 333-337
• 20 Nyska M, Nyska A, Swissa-Sivan A, Samuelof S. Histomorphometry of long bone growth plate in swimming rats.  Int J Exp Pathology. 1995;  76 241-245
• 21 Raynal L. Traumatic spondylolysis. Analysis of 4619 cases of lumbosacral spine.  Acta Orthop Belg. 1977;  43 653-659
• 22 Rossi F, Dragoni S. Lumbar spondylolysis: occurrence in competitive athletes.  J Sports Med Phys Fitness. 1990;  30 450-452
• 23 Saraste H. Long-term clinical and radiological follow-up of spondylolysis and spondylolisthesis.  Isr J Ped Orth. 1987;  7 631-638
• 24 Sevastikoglou J A, Spangfort E, Aaro S. Operative treatment of spondylolisthesis in children and adolescents with tight hamstrings syndrome.  Clin Orthop. 1980;  147 192-199
• 25 Swissa-Sivan A, Azoury R, Statter M, Leichter I, Nyska A, Nyska M, Menczel J, Samueloff S. The effect of swimming on bone remodelling and composition in young rats.  Calcified Tissue Int. 1990;  47 173-177
• 26 Swissa-Sivan A, Simkin A, Leichter I, Nyska A, Nyska M, Statter M, Bivas A, Samueloff S. Effect of swimming on bone growth and development in young rats.  Bone and Mineral. 1989;  7 91-105
• 27 Thomas M, Bell G R. Radiologic evaluation and imaging of the spine. In: Nicholas JA, Hershman EB (eds) The Lower Extremity and Spine - In Sports Medicine. St. Louis; Mosby 1995 2nd Ed: 1095-1112
• 28 Troup J DG. Mechanical factors in spondylolisthesis and spondylolysis.  Clin Orthop. 1976;  117 59-67
• 29 Troup J DG. The etiology of spondylolysis.  Orthop Clin North Am. 1977;  8 57-64
• 30 Ulmer J L, Mathews V P, Eister A D, King J C. Lumbar spondylolysis without spondylolisthesis: Recognition of isolated posterior element subluxation on sagittal MR.  Amer J Neuroradiol. 1995;  16 1393-1398
• 31 Weinstein S L. The thoracolumbar spine. In: Weinstein SL, Buckwalter JA (eds) Turek's Orthopaedics: Principles and Their Application. Philadelphia; J. B. Lippincott 1994 5th Ed: 470-477
• 32 Wiltse L L. Spondylolisthesis: Classification and etiology. Symposium on the Spine, American Academy of Orthopaedic Surgeons. St. Louis; CV Mosby 1969: 143-168
• 33 Wiltse L L, Jackson D W. Treatment of spondylolisthesis and spondylolysis in children.  Clin Orthop. 1976;  117 92-100
• 34 Yamane T, Yoshida T, Mimatsu K. Early diagnosis of lumbar spondylolysis by MRI.  J Bone Joint Surg Brit. 1993;  75 764-768