Spondylolisthesis in Dancers
A Spondylolisthesis refers to the displacement of one vertebrae in relation to the one below. The displacement can be forward (anterior) or backwards (posterior) displacement. Forward slippage of one vertebra on another is referred to as anterolisthesis, while backward slippage is referred to as retrolisthesis. As the pain is felt in, and exaccerbated by extending the back, it is quite common in dancers and acrobats.
The condition is graded according to the degree of slippage of one segment upon the other.
- Grade I is anything up to 25% of the vertebrae
- Grade II is between 26%-50%,
- Grade III is between 51%-75%,
- Grade IV is between 76% and 100%, and
- Grade V, or spondyloptosis occurs when the vertebra has completely fallen off the next vertebra.
The only way that the vertebrae can slip forward is if there is a defect in part of the bone of the vertebrae. There are several reasons as to why this may occur:
- Congenital – the defect in the vertebrae occurs at birth and often in the facet region.
- Repeated trauma– This type of spondylolisthesis can be caused by repetitive trauma and is more common in athletes exposed to hyperextension motions including those seen in gymnastics and dance. The defect is in a portion of the vertebra called the pars interarticularis. This is the reaason why we strongly discourage strong hyperextended movements of the spine in young dancers.
- Degenerative spondylolisthesis – occurs due to arthritic changes in the joints of the vertebrae due to cartilage degeneration. This is more common in older patients.
- Traumatic spondylolisthesis – is due to direct trauma or injury to the vertebrae. his can be caused by a fracture of the pedicle, lamina or facet joints that allows the front portion of the vertebra to slip forward with respect to the back portion of the vertebra.
- Pathologic spondylolisthesis – is caused by a defect in the bone caused by abnormal bone, such as from a tumor.
Dancers with a Splonylolisthesis will usually have pain with extension, such as going into a back bend, or an arabesque. The pain is usually quite low, where the spine connect to the sacrum, and will often be difficult to settle with rest or heat. In extreme cases, where the spinal cord is affected, they may experience numbness or tingling in both feet or legs.
The condition can be easily identified using a plain film X ray. An X-ray taken from the side will show if one of the vertebrae has slipped forward compared to the neighboring vertebrae.
The X-ray will also show the magnitude of the slippage, which is usually measured by the percentage of the vertebrae that has slipped forward, for example, a Grade I is under 25% of the vertebral body, or 1/4 of the vertebrae.
The majority of cases of Spondylolisthesis in young people is due to excessive, uncontrolled training into extension. Prevention is always better than treatment, so we strongly advise teachers against letting young dancers work into extreme back bends, back scorpions and back mounts. Young spines are very mobile, and students will often not report pain while doing these exercises, however the constant pressure can lead to weakening of the bone in very important places. This can then lead to injury later on.
In adults, the condition is usually related to degeneration, secondary to instability. Maintaining a good strong core, and working on improving your posture in standing (especially when pregnant) is very important.
While we ususally discover this condition when a client presents with low back pain in the clinic, in the early stages it is not uncommon for a person with a spondylolisthesis to have no symptoms at all. Young students may be dancing with an unstable vertebrae without even knowing it.
The most common symptom of a low grade slippage (<50%) is that of lower back pain. Pain is usually worse in extension, such as in a back bend or in an Arabesque. Many performers put up with these symptoms for a long time before they come into the clinic for an assessment as they think that it is normal. Early detection is very important in preventing the injury from progressing, so if you do have lower back pain, then please get it checked out as soon as possible.
Other common symptoms include tightness of the hamstrings and decreased range of motion and stiffness of the lower back. Changes in gait and posture as well as an increased lumbar curve can be quite common.
Again, if the severity of the slippage is greater , then the symptoms can include pain, numbness, tingling or weakness in the legs due to nerve compression and irritation. Severe compression of the nerves can even cause loss of control of bowel or bladder function (cauda equina syndrome). This is very serious and requires immediate medical attention.
Treatment should commence with stabilising the area with the body’s muscular system. To address this we would look into some very specific core work with strong focus on the pelvic floor, transversus abdominis and lumbar multifidus. It is of paramount importance to have good timing and strength in the core, hip and pelvic region.
Using a Visual Ultrasound machine is extremely helpful in making sure that the client is using the correct muscles, rather than cheating with other global stabilisers.
Postural correction will also need to be addressed bringing the body back into a more optimal neutral alignment both statically and in dynamic movement.
Improving mobility of the upper back (Thoracic spine) and the front of the hip (Hip Flexors) is essential in helping to reduce the load on the low back in extended positions.
Regaining normal flexibility, especially of the hamstrings and posterior chain, is important to reduce the strain on the lower back and help to obtain more normal movement again.
If the situation is more severe, surgery may be needed to fuse the slipped vertebrae. This may be needed if you have:
- Severe pain that does not get better with treatment
- A severe slip of a spine bone
- Weakness of muscles in one or both of your legs
There is a chance of nerve injury with such surgery. However, the results can be very successful. You will need a consultation with a spinal surgeon for this.
With regard to dancing focus on regaining extension control will be very important to assist with:
- Arabesque / Attitude positions
- Port de bras
- Cambre or Back Bends
- Dance hall moves
- Lay backs
- Acrobatics and tricks.
Rehab will need to be gradual and structured starting from the inside -> out, and from isolation of specific muscle systems through to integration into dance moves and choreography.