Low Back Pain in Dancers

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Medscape General Medicine. 1999;1(3) 

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The incidence of spondylolysis is substantially greater in female Caucasian dancers than in the general population; it is comparable to that found in gymnasts (four times higher).[7]Most authorities now agree that spondylolysis and prespondylolytic stress reaction are overuse injuries.[8,9,10] The mechanism of injury is repetitive microtrauma, resulting from repetitive extension and rotation of the spine. This may result in damage to any of the posterior elements of the lumbar vertebrae, but the pars interarticularis is the most common site of injury. Studies have suggested that hyperextension, in particular, causes shear stress at the pars, resulting in stress fracture [10] (Figures 4, 5).

Figure 4. Spondylolysis; stress fracture of the pars interarticularis as seen on oblique radiograph.
Figure 5. Oblique radiograph showing obvious L-5 spondylolysis. This fracture is apparent, which suggests it has been present for a long period of time.

Spondylolysis is not considered an incidental finding in the young dancer or athlete. It is considered a very serious injury requiring the earliest possible intervention to relieve pain and minimize the progression to spondylolisthesis. It is recommended that a full diagnostic work-up be initiated for any young athlete who has experienced symptoms suggestive of spondylolysis for more than 3 weeks. Studies, including those done at Children's Hospital in Boston, demonstrate that single photon emission computerized tomography (SPECT) bone scan is the best modality to identify these early lesions[11,12,13,14,15] (Figures 6A-D).

Figures 6A & 6B. A bone scan demonstrating increased activity of the posterior elements of the left L4-5 region in a 36-year-old ballet dancer who developed left lumbar back pain following a vigorous summer program.
Figure 6C. A CT scan of the same area, demonstrating left L4-5 facet arthrosis, with osteophyte and fracture of the inferior L4 facet.
Figure 6D. A CT scan of a 32-year-old ballet dancer who had intermittent low back pain radiating to the back of her left leg during leg extension movements. It reveals arthrosis of the L5-S1 facet joints.

The treatment for spondylolytic stress fractures, prespondylolytic stress reaction, and spondylolisthesis includes bracing and physical therapy until the injury heals or is asymptomatic. The principal focus of therapy is stretching exercises to maintain or regain flexibility, especially of the hamstring muscles. The dancer with persistent unilateral spondylolysis despite adequate bracing may return to full performance without the brace only after the symptoms have resolved. In this case, efforts are made to ensure that the contralateral pars does not fracture.[3,16,17] The assumption is made that pain always precedes a stress fracture and that if there is no pain, no damage is being done and healing may be taking place. A radiologically evident fracture may not heal with solid bone, but may become pain-free with fibrous healing. Recurrence is prevented by maintaining the pain-free state with a combined regimen of spine strengthening, flexibility, strict adherence to proper technique and occasional bracing as necessary.