Spondy’s can be a real pain in the back… and depending on the physician and part of the country you work, you may use a back brace sometimes, and other times won’t.
Here’s how we handle a pars defect fracture in different types of athletes at Champion.
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#AskMikeReinold Episode 261: Treating Spondylolysis in Athletes
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Okay. Hamp in Mississippi asks, how do you approach the treatment of Spondylolysis, pars defect stress fractures in athletes? Do you brace them for six to 12 weeks as some docs in my area recommend? The literature does not seem to back that up from what I can find.
I love questions [crosstalk 00:02:36]. What does the literature- the literature can back, anything or everything or nothing all at once. Right? We’re literally at the point where we’re doing meta analysis of a meta analysis of a meta analysis. At some point in time, we’re going to run out of meta analyses. It’s going to be crazy, but these are my favorite type of questions, because I’m just going to say, Dave, why don’t you start it off? And then if anybody has any other experience, they want to jump in. But Dave, can I just ask you just to make the episode a little bit more complete here, so we got a Spondylolysis, right? So just quickly define what that means compared to some of the other ones and maybe what you see most in our athletes and how, if that changes your treatment approach a little bit. Before you talk a little bit about the bracing and stuff like that, I just want to make sure that everybody’s on the same page with the information and we’re not talking about different pathologies.
Sure. I mean it definitely is important to highlight the spectrum of what you might see, because it does matter for bracing, especially on the east coast here. So yeah, obviously the earlier side of the pathology is just for Facet syndrome, right? So extension and rotation bugs, the Facet and the capsule you could argue, maybe the bone is getting stressed, but that’s kind of like what you see, typically not as much, usually someone, if they do kind of tweak their back, you don’t usually see that person because they just kind of deal with it. You know, they kind of goes away in a week and it kind of gets better. So if they rest, as you move farther up into either repetitive extension or repetitive rotation or repetitive compression and extension, you can get a stress reaction where the pedicle starts to show bony edema and kind of like a rotation, but it’s not actually fractured.
That’s like the second stage, the third stage would be a full break, which is Spondylosis, which is when the part is actually does fracture through, but it’s stable. So it’s not the pieces haven’t moved away from each other. And then if there’s translation, it’s Spondylolysis, which is where they grade it. 1, 2, 3 or 4, based on what 25% of like how far is one segment moving away from the other. So the reason that matters is because here in the east coast, right, it’s called the Boston overlap race for a reason it’s like made in Boston versus in the west coast. They don’t brace a lot of people at all, and I’ve talked to friends who are out in the west coast, they kind of just let them rest and stabilize themselves and try not to do activity. So I guess, I don’t know if I had the experience to say not bracing, what would happen in the clinical course, because pretty much everyone that I see is getting some version of a brace because the dogs around here seem to find that’s the best.
One of my friends is a physician Dr. McCovey and he has said, there are some studies out there that the pedicle itself is not actually stabilized when you wear the brace, the hard rigid brace. So it’s still kind of moving a little bit the segment, but people definitely have less symptoms when you’re, when you’re wearing the brace. So I don’t really know what the answer is because the literature is all over the place. But in my experience, most people typically don’t do well if they’re have a break and they’re not in a brace because they’re moving, they’re sleeping, the turning and tossing and you know, they’re just living their life. When you’re in a brace, maybe it forces you to be less active and you can feel better. I don’t really know the answer to that particularly, but usually what happens is based on what kind of thing you have, right?
If you have a joint base just Fossette syndrome, you’re probably not getting braced. If you have a stress reaction where they do a MRI and they do see an oblique line through the pars of the neural arch, they’ll probably brace you for like four to six weeks to try to get the bone just to kind of calm down. And if you do have a full spondy fracture, typically people around here are using a brace protocol of 12 weeks in a hard rigid brace. And then a step down a brace will either they’ll cut the brace or do a soft brace. And then if you have a full Spondylosis, it’s kind of a different story because you just talk about, is it their neuro involvement? You know, what’s the degree of his lighting. So that’s my experience kind of going through it. I don’t know if you want to.
Yeah. And Dave, I mean, it’s successful experience right too. So like that bracing, it works, right? And you know, it was funny that the students and I were we’re watching one of your patients recently that was wearing a brace and, she like walks in with a brace, takes it off. And then we were watching her walk with you to the gym, like with that like little duck walk that you do because you’ve been in a back brace for, for 12 weeks. So it’s kind of interesting.
I think that showed me two things, right? One is the back brace probably really works. It works on limiting your back motion, especially rotary because she developed this like compensation with how she walked with like just her hips and not moving her back. But you know, it also made me the students and I kind of think about this and talk about it a little bit about like, some of the aftermath of the bracing, right? And some of the other things that you have to work on because you were braced for so long. So if you have somebody with a spine that is, or isn’t braced, sometimes your treatment objectives may change a little bit because you’re dealing with some of the secondary stuff that occurs from it. But Dave, just for clarity sake though, what these people in a embrace, how long are they in a brace and can’t do rehab versus when can they start rehab? Usually.
Yeah. That’s definitely something that I think it’s similar to like what you see with meniscus stuff. And ACL’s, we thought these people shouldn’t be in rehab for a long time because we were worried about it. But as with all things, if you’re really understanding the pathology, you’re talking with a doc you’re kind of understanding what forces the sport is. You can start them very early. So I see people, literally one, like they go get their brace and they come to PT after. And a lot of the times what we’re doing is trying to figure out doing assessments on like the shoulders T spine and hips to figure out like, what was going on that caused you to maybe have your fracture. Like, are you limited in hip mobility, overhead, shoulder flexibility. And I think you can work on those impairments while the person is kind of calming down and doing some things to make their back feel better, and then do a neutral base core exercises by like week three or four.
So I think it can start earlier if you understand what’s going on. I think the big thing that I used to miss and a lot of other people miss, is a lot of spondys can come from different types of forces. You can get a spondy fracture or like a spinus process impingement from just like extreme back-bending like gymnast, get that. But also extension and rotation is a different kind of force that a baseball player would express. And then actually the patient, I think you’re talking about is a diver. So her pain came from compression and extension. So there’s three different people who all had L2 to L4 spondys, but they had very different sports, very different forces. So that kind of changes quite a bit of how my rehab goes, because if compression extension is the main force for this girl, it’s very different than like the baseball player who has extension rotation. I’m doing like rotational med ball work later with one person and doing like very high, vertical impact forces on the other one. So it’s not always about, you have a spondy, you just did the same protocol. Like it changes quite a bit.
Oh, absolutely. I had no idea she was a diver, but I just thought all your female patients that were shorter than me are gymnast. So that’s my criteria for figuring it out, but awesome. Mike, tell me a little bit, so I don’t think we get it to this level as much with our baseball athletes, but we certainly do. We’re probably more of the stress reaction stuff, but how is this different in rotary sports, like baseball and golf with stress fractures in, spondys like how bad does it need to be to brace, any other thoughts in a rotary baseball versus a little bit more gymnastics, which is probably a little bit of just like extreme range of motion and impact, like Dave said, I mean, I think they’re slightly different, right?
Yeah, totally. I would say just anecdotally, over the last four years, I’ve been a champion. I think we’ve, we’ve seen more in our rotational athletes, more spondy fractures. And I think it potentially comes down to these kids are getting bigger and stronger and able to swing the bat faster. They’re able to spin and golf club faster. It’s putting more stress on their spine potentially. And the volume of swings is so high. So we see that a lot in junior golfers where they may be relatively under-trained from a strength and power perspective, but their volume of swings is so high and they are going into extreme range of motion, especially the more hyper mobile athletes, the younger kind of more loosey goosey athletes in that impact position. They’re getting a lot of side bend and a lot of compression on the trail side of the lumbar spine.
And then through the follow-through, they’re coming into a lot of extension of their backs. So I definitely think that it is pretty prevalent in golfers. It may not get to the point of a Spondylosis or Spondylolysis. They may be in that stress reaction phase. But I think from my perspective, if I see a rotational athlete with pretty specific, low back pain, that bothers them with extension and rotation on testing, most of the time I’m referring those people out to get some kind of imaging to rule out a stress reaction or a stress fracture. It’s not necessarily something that I spend or that I would wait a really long time to refer out.
Yeah. I feel like sometimes when we try to treat that just symptomatically here, it’s like you bang your head against the wall and every time you start swinging again, it just, it’s just right there.
But the flip side of that is they may end up in a brace for 12 weeks, and then you’re looking at a pretty long recovery from that standpoint. And it’s tough to, like you got to said break the compensation pattern of being in a brace. So it often takes a few months after coming out of the brace to get them back into full activity.
I don’t think people quite, I don’t think physicians, but I mean, it is what it is, but I don’t think physicians really, you know, if it’s three months in a brace and three months more in rehab, that type of thing. I mean, six months is half a year of somebody’s very short athletic career. I mean, that’s a big deal, so, awesome. All right. Well, great stuff. Hopefully, hopefully that was helpful answering your question there, Hamp. Yeah and I think the biggest thing I got from Dave too, with in terms of the bracing Dave’s response was just that, it may be geographically dependent on the physician preferences of you are. So if you move or you have a physician that moves from a different part of the country comes here, maybe completely different, it is what it is, you know, I’m not sure we know the right answer, but I do know that on our end, there are things we can just watch out for and make sure that we’re addressing. So hopefully that helps. I really appreciate it. Please, head to iTunes, Spotify rate, review, subscribe. So we can keep doing these episodes for you. And we will see you on the next episode. Thanks again.