Stress fracture of the spine

Also called: Spondylolysis; spondylolisthesis; pars stress injury

Exercise strongly helps Strength Stretch

Low back pain in a young athlete doing repeated extension - gymnastics, cricket bowling, diving, dance. A stress fracture in the bony bridge of a vertebra, and unlike most back pain in teenagers it needs identifying rather than managing.

How common: Spondylolysis in around 6% of adults; the commonest cause of back pain in adolescent athletes

Open the Back Pain/Bulletproofing routine All problems

What it is

Spondylolysis is a stress fracture of the pars interarticularis, a small bony bridge on each side of the vertebral arch, almost always at the lowest lumbar level. It is caused by repeated hyperextension and rotation, and it is the single commonest identifiable cause of low back pain in adolescent athletes.

This is one of the few back pain presentations where getting a diagnosis genuinely matters. An early stress reaction can heal with rest; an established fracture often does not, and can go on to allow the vertebra to slip forward. Persistent one-sided extension-related back pain in a young athlete deserves imaging rather than reassurance.

What it feels like

Low back pain in an adolescent athlete, often one-sided
Worse with arching backward and with rotation
Worse during and after sport, better with rest
Reproduced by standing on one leg and leaning back on that side
Sometimes tight hamstrings alongside it, which is a recognised association

What causes it

Most people have more than one of these at once, and they feed each other. Read the list looking for the two or three that sound like your week rather than for the one true answer — the ones that describe you are the ones worth acting on.

Repeated hyperextension: Arching the back repeatedly loads the pars interarticularis in a way it tolerates poorly. Gymnastics, cricket fast bowling, diving, dance, tennis serving and throwing all involve it.
Extension combined with rotation: The combination is more damaging than either alone. Fast bowling and tennis serving involve both simultaneously, which is why those sports show the highest rates.
Adolescence: The pars is most vulnerable during the growth years. Rates are far higher in adolescent athletes than in adults doing the same sport.
Training volume: As with all bone stress injuries, the total load matters most. Bowling volume in cricket has been directly linked to pars injury rates and is now formally limited in youth cricket.
Rapid increases in load: Preseason, a training camp or a step up to a higher level. Bone adapts more slowly than fitness and the mismatch is where stress injuries appear.
Low energy availability: Under-fuelling relative to training load reduces bone quality and raises the risk of all bone stress injuries. It is common and under-recognised in young athletes.
Hip and thoracic stiffness: When the hips and mid-back will not extend or rotate, the lumbar spine supplies more of the movement - concentrating load on exactly the vulnerable structure.
Weak trunk musculature: Poor trunk control means the segment moves further and less evenly under load, increasing the stress on the bony bridge.
Continuing to play through the pain: The main determinant of whether an early stress reaction heals or becomes an established non-healing fracture. Adolescent athletes routinely under-report and continue.

Who tends to get it

Adolescent athletes in extension sports - gymnastics, cricket bowling, diving, dance, tennis, throwing
Anyone with a rapid increase in training volume
Young athletes with low energy availability
Those with stiff hips or thoracic spines, which force the lumbar spine to supply the range
Athletes playing year-round with no off-season

What makes it worse, and what settles it

Makes it worse

Continuing to train and compete through the pain, which prevents healing
Repeated extension and rotation loading
High bowling, serving or tumbling volumes without limits
Under-fuelling relative to training load
Assuming adolescent back pain is muscular without imaging when the pattern fits

Settles it

Getting it diagnosed, which is the step that changes the outcome
A genuine period of rest from the aggravating loading, which is what allows an early lesion to heal
Deep trunk and hip strengthening during and after the rest period
Hip and thoracic mobility work so the lumbar spine stops supplying the range
A graded, monitored return to sport with volume limits

What actually helps

The short version: A stress fracture of the pars interarticularis, from repeated extension and rotation - gymnastics, cricket, diving, dance

Strength work: Core: Transverse Abdominis; Abs: Obliques; Glutes: Max - anti-extension and anti-rotation emphasis

Stretching: Flexion-biased; Hips: Flexors; Legs: Hamstrings - hamstrings are classically tight here; AVOID repeated extension

Massage: Back: QL; Glutes; Legs: Hamstrings

Also worth doing: Rest from the provoking extension sport; bracing in adolescents

What the evidence says: Deep core and gluteal strengthening with extension avoidance. In adolescents, early diagnosis and relative rest allow the fracture to heal; late diagnosis does not.

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The qFIT routine for this

Ready-made routineBack Pain/Bulletproofing

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Get it checked if…

Back pain in an adolescent athlete that is worse with extension needs imaging - this is the diagnosis that gets missed and turns into a permanent slip

And whatever the body part: chest pain or unusual breathlessness on exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or one calf that is swollen, warm and painful. Any of those, stop and get assessed.

How it usually goes

Early stress reactions have a good chance of healing with three months of rest from the aggravating activity, and the earlier the diagnosis the better that chance. Established fractures often do not heal but can still become symptom-free with strengthening. The important message is that back pain in an adolescent extension-sport athlete that persists for more than a few weeks is worth imaging rather than managing as ordinary back pain.

Prevalence basis: Spine imaging cohorts

Others the same routine covers

These share the Back Pain/Bulletproofing routine, so the work is the same. If one of them also sounds like you, that is a reason to expect more from it, not less.

This is general information, not a diagnosis, and it cannot examine you. If it matches you, use it to ask better questions of a clinician rather than to replace one.

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