Dr. Kelly Weaver joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. He talked about spondylolysis.
Read Dr. Weaver's radio talk on spondylolysis, a back injury affecting teenage athletes or listen here
Health Matters: Welcome back to Health Matters. Maury Eskenazi, Shannon O'Kelley and back with us, again, Dr. Kelly Weaver from The Everett Clinic, Board Certified in Physical Medicine and Rehabilitation. Doctor, tell us about your specialty.
Dr. Weaver: As a physical medicine specialist I look at people's problems with neck pain, back pain, knee pain and shoulder pain, things like that. But we are also trained in stroke and spinal cord injury. Most of what we do is kind of the aches and pains that we all get.
Health Matters: Absolutely. One of the problems that is really hard to diagnose and sometimes to detect is a spondylolysis or a spondy as we call. Let's talk about what a spondy is.
Dr. Weaver: Sure. That's a fairly common condition that comes up, and it goes sort of two different ways. The classic spondy in our practice is a younger athlete, often a little less than about 19 years old who has a sport that lands them in extension. A spondylolysis essentially is a stress fracture in one particular part of the low back. The lumbar spine kind of has three parts. It has a front part where the disks are. That is the load bearing part. It has a middle part that is a tube or a conduit, and all of the nerves that go to the legs pass through that tube. And then it has a back part. That is mostly the joints. Those are called facet joints, and they kind of keep your spine aligned and allow motion in different planes. But the connection between the middle part and the back part is a thin, flat plate of bone called the pars interarticularis. It is a weak spot, and if you stress it repeatedly, mostly by extending backward, bending over backward, like you are looking up at the sky, you will stress that. It is a piece of bone that does not take a lot of weight. If you do that a lot, eventually you start to form cracks and those cracks prorogate and eventually you actually will develop a gap. It is a tricky problem to diagnose because you cannot examine them and tell that it is there unlike a rotator cuff or an arthritic hip. X-rays often do not see it, which is sort of our first move when we see somebody with an acute spine problem is to get some x-rays. To really diagnose it, you need some sort of high-tech imaging that is expensive. Early on, you are kind of left to your own devices. You are asking the patient how they did it. There are a couple of classic things. The younger athlete, the baseball pitcher who goes into extension, the lineman who comes off the line to take his man and goes into extension, those are people who frequently get spondylolysis or spondys. Swimmers get it.
Health Matters: The extension...I have seen it a lot in gymnasts and soccer players when they kick really hard, any kind of forced extension. Tell us why the age is important to recognize these symptoms.
Dr. Weaver: It's a good question. What is different about the pars at 17 than it is the pars at 40. It probably is more structurally robust as you get older. It may be activity level. It may be that the disk changes and you can actually load the posterior, the back of your spine. I don't know. But, when we see pars fractures, the classic story is, kids in sports, things are going okay, kind of some aches and pains and then they start having back pain, back pain, back pain. We don't get that as much in adults and you just don't see a cured stress fracture of the pars interarticularis that much over the age of about 25.
Health Matters: The pain that these young athletes have it is this nagging symptom. It is just one of these things that that pain never completely resolves. They need to be looked at. And the important thing that I think people need to hear, x-rays don't pick it up.
Dr. Weaver: Correct. You need an MRI scan or a bone scan. CT scan is okay, but you get radiation with a CT scan that you don't get with an MRI. In the modern era, we are really falling toward MRI for these kids. It is also important to catch them early. If you catch it early, they will be symptomatic for a shorter period of time. You want to catch it while it is still an incomplete stress fracture, cracking just one side of the bone and it has not cracked all the way through. The other reason you want to catch it early is so that it does not crack all the way through the pars. Because that sets you up for motion. Once you lose the structural stability of an intact pars, they can start to slide. If a spondylolysis, a little crack is completed, then it, actually, the vertebra on top of it can slide forward and you get a different condition with a cool term and that is spondylolisthesis, which is...something you really want to avoid. A spondylolysis, an acute crack in this part of the spine, that is really common in childhood. Spondylolisthesis where they have cracked it and they start to slide where one vertebra moves forward on top of the other, that is actually very common in adults, in older people.
Health Matters: How do you fix that?
Dr. Weaver: That's hard. There truly is no fix for it. You can teach people how to work with what they have and this is where we get...
Health Matters: Core, core, core...
Dr. Weaver: Yeah, core, core, core, core, the glorious core.
Health Matters: The glorious core. Not for most patients, but you try to convince them it is core, yes.
Dr. Weaver: Your choices are basically doing a ton of abdominal work or having somebody put rods and screws in your back which works....
Health Matters: That doesn’t sound fun.
Dr. Weaver: No.
Health Matters: The spondylolysis?
Dr. Weaver: That's the nice thing is if you catch them early, they heal themselves. A lot of what I do is I sit in Clinic just with my ears open. A young kid under 18, back pain, oh, you're athlete? What's your favorite sport? Well, I'm a gymnast. Well, that’s a lot of extension loading. Those are people where I get an MRI scan early because I want to catch an incomplete crack before it goes all the way through the bone and they are at risk for sliding as an adult.
Health Matters: You would think that athletes would do exercises to build up so they would not have that problem. But, it's not that they are not strong kids and it's just that extension.
Health Matters: The moon and the stars line up just right by movement, the extension happens and all of a sudden they have this like this fissure or small fracture that can progress and probably because they are young their bones are not fully ossified and there is a weak spot there and they do not really feel it sometimes until it just becomes this nagging problem that does not go away. You shouldn't have nagging back pain at age 12, 13 and 14. These kids are complaining...usually...do you find they complain of night pain...
Dr. Weaver: Classically, they will have night pain, but often times they don't. The ones you worry about are the ones who have a lot of pain or a lot of pain with their workout and on their days off they are a little sore. Those are early signs. If you catch them early, you can fix the biomechanical sort of predisposing factors. We were talking outside about pitchers. When you see a pitcher with a spondy you check his shoulders first.
Health Matters: Absolutely.
Dr. Weaver: You want to go ahead and offload that extension onto some other joint and make sure they are not doing something that actually sets them up... Health Matters: Overcompensating.
Dr. Weaver: Correct.
Health Matters: We all tend to overcompensate at the back. That's where all of the movement starts and finishes and goes through. Dr. Weaver: It is really true. If you catch them early, you gotta pull them out of their sport.
Dr. Weaver: About once a month I sit there in my white coat and I play the bad guy and tell them I know you love basketball but you cannot play right now but this is how we are going to get you back to your sport.
Health Matters: In that timeframe you experience, you know, again, it is the hard part. These kids want to play. They want to be active. They don't understand why they have to stop. And what is your window there?
Dr. Weaver: You know, it depends. I always start with six weeks. Often times you brace them, put them in a wraparound plastic hard brace which works really well. You get them in therapy and you start to address the other things. At the two-week point, hopefully things are under control. At the one-month point, hopefully their pain is pretty bearable and you are starting to make a plan to return to the sport in about six weeks. Boy, there is a spectrum there. There are some who you brace them and their pain is gone or they are markedly better at three weeks.
Health Matters: Is there a certain sport that the rest should be longer, football...
Dr. Weaver: Often times they take a month to get the fracture and then you pull them and their season is over. So, yeah, football lineman, I want to see their range of motion very normal before I return them back to the line. You do things to get them back playing: pads only, no contact as much as you can but yeah, football, you pull them longer. Basketball, I tend to send them a little earlier. Playing soccer is a little in between. I worry about them overcompensating and doing the knee. Soccer with a bad back is asking for an ACL....
Health Matters: You don't want it to progress where it becomes instability and then you have this spondylolisthesis and that is a problem.
Dr. Weaver: It's hard because you see the kids and you see the 60-year-old and you know that that L5 vertebra is going to be with them for the rest of their lives. You want it intact.
Health Matters: Dr. Kelly Weaver, Everett Clinic...spondylolysis. Thanks for coming on with us.