What is spondylolisthesis?
Spondylolisthesis is an instability issue of the spine when one vertebral body slips forward on top of another. This is a common cause of low back pain in dancers. Spondylolisthesis occurs after a defect or fracture of the bony connection between two vertebral bodies (the pars interarticularis). This is referred to as a spondylolysis. If a spondylolysis occurs on both sides of the vertebral body, it may begin to slip forward.
Spondylolisthesis occurs most commonly in the lower back, at the fourth or fifth lumbar vertebra. In a grade I spondylolisthesis, the superior vertebral body will slip forward up to a quarter of the length of the vertebral body below it. Young girls have a highly elevated risk of developing a spondyloysis – up to 12%, compared to 6% in the general population. Often the condition evolves from a stress reaction of the vertebral spine.
How can it occur?
Spondylolysis in dancers is usually an overuse injury from intense ballet training and is most often seen in young children. It tends to be based on stress fractures of the pars interarticularis and can occur on one or both sides. Intense and repetitive forward/backward bending and twisting of the spine can cause these stress fractures. Less commonly, the condition may result from a direct injury to the back or an anatomical abnormality of the vertebral body.
Muscle dysfunction as well as “blocks” of the intervertebral joints and the pelvis play an important role with spondylolysis. The forces applied on the vertebral body from unilaterally cramped spine muscles can be immense and cause a lot of torsional stress. Spondylolysis is therefore more common in dancers with a scoliosis as they are more prone to dysbalance of their back muscles. Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with low back issues in dancers. It can affect the lumbar spine in many ways as it connects to four of the lumbar vertebrae in two different planes. Psoas dysfunction will pull the lumbar vertebrae forward, creating hyper lordosis (over arching of the spine) and will exert high pressure on the intervertebral disks and joints. Usually, only one of the two psoas muscles is tight and this will twist and torque both the lumbar spine and the pelvis. As a result, muscle dysfunction will extend toward the trunk (erector spinae muscle, quadratus lumborum muscle) and the lower extremity (rectus femoris muscle, hamstrings), causing severe muscle dysbalance. It is often mutually dependent on a weakness of the abdominal muscles and the glutes. This pattern of imbalance creates joint dysfunction, particularly at the last two lumbar segments: the si-joint and the hip joint.
What are the typical symptoms of spondylolisthesis?
Symptoms and the pain quality vary with the progression of the condition. Symptoms of an evolving sponylolysis are usually characterized by a sharp pinching pain in the low back especially when bending backwards. In a spondylolisthesis, the pain is rather of a dull character, often described as a deep ache in the lower back. You may experience low back pain that may extend to your buttocks but it usually does not radiate down to the legs. However, you may feel severe tightness in your hamstrings. Your back may feel blocked and your back muscles tight.
How can a spondylolisthesis be diagnosed?
Your doctor will examine your spine and review your symptoms as well as your current training activities. This will include a functional examination of the spine and pelvis to find out about joint dysfunction in the different areas of the spine and the pelvis. He will check for muscle dysfunction of the back muscles, the psoas and on the legs. Some basic neurological tests will be performed to find out if typical reflexes are normal and if any muscle weakness or palsy is present. Instability will not always be obvious in clinical examination. Your doctor may order specific X-rays, that are available to securely detect and measure the grade of a spondylolisthesis. An MRI scan can show a bony stress reaction of the pars interarticularis before it comes to a fracture and may help to prevent spondylolisthesis.
This x-ray of the spine shows a spondylolisthesis between the fifth lumbar vertebra (L5) and the sacrum (S1). Due to a rotation of the spine in the lumbar area, you can even see the fractured pars interarticularis which is usually impossible to see in a standard side-view X-ray.
What are the treatment options?
If you have severe or constant back pain or pain radiating to your legs, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
First aid of acute back pain includes taking a painkiller and resting in a comfortable position. A pillow under your knees may help when lying down. It is also recommended to apply warmth to the affected area, as it will help to alleviate muscle cramps. In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations. Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine.
Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Severe cases of spondylolisthesis or acute Spondylolysis may require wearing a brace or even having surgery. Your doctor and orthopedic surgeon will help you to choose the best option for you.
You have severe or lasting backpain pain and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.