Working Diagnosis:
Left sided lumbar spondylolysis and right pars stress reaction at L5 with grade 1 spondylolisthesis of L5 on S1

Treatment:
The patient was placed on restriction of activities involving significant extension movement through the lumbar spine, and he was referred to an orthopedic spine specialist. There he was prescribed a bone stimulator and physical therapy to focus on hamstring stretching, along with 1-hour home hamstring stretching daily. At the request of the patient and his parents, he will be allowed to finish the season limiting kicking to game day, followed by a period of 3 months with no kicking activities. If his pain persists, Teriparatide could be considered in order to accelerate bone healing.

Outcome:
The patient has continued to kick for his team but limited to game day only. Some pain has persisted with kicking, but overall greatly improved with the added rest throughout the week.

Author's Comments:
Lumbar spondylosis is relatively common in young male athletes. It results from recurrent axial loading of an extended lumbar spine. Repetitive forces on the posterior elements of the spine results in impingement of the pars intraarticularis causing micro fractures which are unable to fully heal secondary to persistent stress.

Kicking involves a kinetic change of motion featuring proximal to distal acceleration similar to throwing. There are 6 stages of kicking motion; approach, swing-limb loading, plant, hip flexion and knee extension, contact, and follow-through. During contact with the ball, the torso is extended and laterally sidebent to the non-kicking side at ball contact. The ground reaction forces made as the support foot contacts the ground occur in the vertical, posterior, and lateral (towards the non-kicking side) direction. In addition, eccentric hamstring contraction of the kicking leg in follow-through results in pelvic tilt which transfers forces to the lumbosacral region. A combination of these repetitive forces during contact and follow through leads to mechanical stress resulting in spondylolysis on the non-kicking side.

Editor's Comments:
Unlike in adults, a clinician should consider lumbar spondylosis in an skeletally immature athlete with acute low back pain and loaded hyperextension as part of their sport (gymnast, soccer player, football kicker).

A case series found that 53.8% of subjects developed a contralateral pars interarticularis fracture.

Treatment is aimed at reducing painful activities, stretching of the hamstrings and gluteus musculature, core strengthening, and a graded return to previously painful activities. Bracing or surgery may be necessary in those patients who are unresponsive to conservative treatment or have nerve involvement.

References:
Sairyo K., et al. Athletes with unilateral spondylolysis are at risk of stress fracture at the contralateral pedicle and pars interarticularis: a clinical and biomedical study. Am J Sports Med. 2005, Apr 33(4): 583-90.

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