Abstract
Background:
Spondylolysis is commonly seen in adolescent athletes with lumbar pain after acute or repetitive low back hyperextension. Nonoperative management and rest often lead to symptom resolution and return to sport in acute injuries. However, follow-up imaging confirming radiographic healing is rarely utilized.
Purpose/Hypothesis:
The purpose of this study was to investigate the relationship between age, sex, and radiographic healing in pediatric athletic patients with spondylolysis after nonoperative treatment. It was hypothesized that younger athletes would have better healing rates as older patients are closer to the end of bony growth.
Study Design:
Case series; Level of evidence, 4.
Methods:
A retrospective review was conducted of adolescent cases of spondylolysis treated by a single physician between September 1, 2022, and May 1, 2024. Patients included were <19 years of age, had a diagnosis of spondylosis as confirmed by magnetic resonance imaging with limited computed tomography (CT) imaging, and had a 3-month follow-up limited CT study. Patients diagnosed with chronic spondylosis or spondylolisthesis or treated surgically were excluded. Data collection included sex, date of birth, sports participation, date of injury and initial visit, fracture Hollenberg grade, fracture laterality, and fracture spinal level. Initial and 3-month follow-up limited CT imaging reports were also reviewed to evaluate healing status.
Results:
A total of 100 patients were included in the final analysis. The mean age at the time of injury was 15.0 years (range, 9-18 years). The most common spondylosis fracture grade seen was grade 2 (64%) across all age groups. After 3 months of nonoperative treatment, 93 fractures demonstrated partial or complete healing on follow-up imaging, whereas 7 fractures demonstrated no healing. No differences in healing rates were observed between the age groups or sexes. Notably, all the nonhealed fractures were bilateral, compared with 33 (35.5%) of the healed fractures (P = .001).
Conclusion:
The vast majority (93%) of acute adolescent spondylosis cases demonstrated radiographic healing after 3 months of nonoperative treatment.
Keywords: spondylolysis, pediatrics, imaging, sports medicine
Spondylolysis is a common diagnosis in adolescent athletes who have lumbar pain after acute or repetitive low back hyperextension. Spondylolysis is an abnormality of the pars interarticularis that connects the vertebra's superior and inferior facet surfaces. These abnormalities can vary in laterality (unilateral or bilateral) and spinal level. Defects in the pars interarticularis can occur by acute trauma or a chronic bony abnormality.
A 2018 European study found that the general population incidence of lumbar spondylolysis was between 3% and 10%. 18 The prevalence of spondylolysis was 39.7% in 153 adolescent patients presenting to the clinic with low back pain for >2 weeks. 22 Every patient diagnosed with spondylolysis in that study reported participation in youth athletics. A Canadian study reported that 30% of adolescent athletes evaluated with low back pain were diagnosed with spondylolysis. 27 These studies suggest that adolescent athletes have a markedly higher incidence of spondylolysis when compared with the general population. Spondylolysis is typically seen in sports like diving, wrestling, track and field, football, gymnastics, and Olympic weightlifting because of the repetitive stress put on the pars interarticularis. Frequent hyperextension of the lumbar spine increases the lumbar vertebral load, putting these athletes at risk of pars interarticularis fractures. 20 As a result of increased stress, the pars interarticularis can exhibit injury ranging from stress reactions to complete fracture.
Patients with symptoms will have low back pain worsened by lumbar extension. Low back pain on extension is not specific for spondylolysis, but in a study by Hirano, 11 81% of patients with radiograph-confirmed spondylolysis experienced back pain with lumbar extension. In adolescent athletes, low back pain can be subtle and radiate down the posterior lower extremity on lumbar extension. 5 On examination, focal tenderness may present in the axial lumbar spine with limited range of motion during extension of the back and lower extremity posterior chain.
Radiographic evidence of spondylolysis is required in combination with the physical examination and history to confirm the diagnosis. Radiographs are preferred initially because of cost and limited radiation exposure, helping guide the decision of whether to pursue additional imaging. 21 After radiographs are obtained, advanced imaging such as magnetic resonance imaging (MRI), computed tomography (CT) imaging, and single proton emission CT (SPECT) imaging offer higher sensitivity in diagnosing spondylolysis. When compared with SPECT, the sensitivity of CT is 85%.10,29 The sensitivity of MRI when compared with CT or SPECT ranges from 80% to 83%.1,19 A systematic review of pediatric imaging studies recommended MRI or CT after plain radiographic imaging.3,15 CT studies are preferred for a longitudinal care plan in addition to fracture classification due to demonstration of finer bony detail.4,7
After accurate diagnosis confirmed by imaging, healing rates are comparable between nonoperative and operative treatment. Overley et al 24 found that 92.2% of adolescent athletes treated nonoperatively and 90.3% treated operatively were able to return to athletic competition. Current treatment guidelines recommend nonoperative management of spondylolysis, including activity restriction followed by physical therapy (PT).14,20,23 There is significant variation in recommendations regarding the parameters of PT after a diagnosis of spondylolysis, including when to initiate treatment, how often it should occur, and for what duration. This heterogeneity results in a lack of standardized rehabilitation programs for postinjury recovery. Previous literature discusses initiating PT anywhere from early in the diagnostic process to waiting until the fracture has fully healed.2,28
On accurate diagnosis and nonoperative management with PT, most adolescent athletes will regain full function. PT is often preferred to surgical management, but there is a lack of data outlining an optimal protocol designed for athletes returning to sport after healing from spondylolysis. 9 Furthermore, it is unclear if these protocols should be altered based on age or skeletal maturity. It is unclear if repeat advanced imaging is indicated when following up with these patients. The purpose of this study was to investigate the relationship between age, sex, and radiographic healing in pediatric athletic patients with spondylolysis after nonoperative treatment. We hypothesized that younger athletes would have better healing rates as older patients are closer to the end of bony growth.
Methods
After institutional review board approval, a retrospective review was conducted of adolescent cases of spondylosis treated by a single physician (R.P.C.) and licensed physical therapist (C.A.D.) at an independent private orthopaedics practice between September 1, 2022, and May 1, 2024. International Classification of Diseases, 10th Revision (ICD-10), codes for spondylolysis were used to identify patients in our billing database. A total of 143 patients were initially reviewed for inclusion by the physical therapist and by 2 independent second-year medical students (N.P.Z. and N.F.B.). Patients included were <19 years of age, had a diagnosis of spondylosis as confirmed by limited CT imaging, and had a 3-month follow-up limited CT study. Exclusion criteria were patients diagnosed with chronic spondylosis or spondylolisthesis, those who underwent surgical treatment, or patients who did not undergo CT imaging at either time point.
Sex, date of birth, sports participation, and date of initial encounter were collected. Injury-specific details such as date of injury, fracture type, fracture laterality, and fracture spinal level were additionally collected. Finally, imaging reports were reviewed, and imaging modality, date, and results were collected.
Fractures were classified into 4 grades based on the Hollenberg classification system: grade 1 (stress reaction with intact cortical margins), grade 2 (incomplete stress fracture), grade 3 (acute complete stress fracture), and grade 4 (chronic stress fracture) (Figure 1, A-D). 12 Grade 4 fractures were excluded from this study due to their chronic nonhealing nature being outside of the aim of this project. Radiographic healing was determined by reviewing the radiologist's report for mention of the start of cortical bridging or bone formation. All imaging was reviewed by a fellowship-trained musculoskeletal radiologist.
Figure 1.
Sagittal magnetic resonance images obtained in patients in the current cohort, demonstrating the 4 grade fractures (circles) based on the Hollenberg classification system 12 : (A) grade 1 at L3 of a 15-year-old girl, (B) grade 2 at L3 of a 18-year-old boy, (C) grade 3 at L3 of a 17-year-old boy, and (D) grade 4 at L5 of a 14-year-old boy.
The radiographic protocol used in this study was a patient having initial radiographic imaging followed by MRI and then a limited CT scan study. A limited CT study for this purpose is defined as a modification of CT parameters adjusted for the height and weight of the patient with a limited scope of the image. This reduced image scope results in lower radiation exposure when compared with standard CT scans.
Patients treated by a single sports medicine physician were included to ensure uniformity of treatment protocols and imaging within the first 3 months after injury. All patients included in this study were treated with the same protocol, with the only variations based on patient compliance. Treatment was divided into 4 stages based on injury severity and response to PT. Patients began with a period of rest and protection; those patients with a grade 3 fracture, with bilateral fractures, or considered high risk were advised to wear a brace with a rigid thoracolumbosacral orthosis and to not participate in sports for the first 4 to 8 weeks after diagnosis. Once pain reduction was achieved (determined by the patient's perceived pain at rest and pain with normal activities of daily living), patients would progress to PT and the introduction of static stabilization with a focus on proximal pelvic control and limited lumbar extension. This is followed by active stabilization and finally return to sport. Patients remained asymptomatic during all phases of PT and return-to-sport progression. Typically, sports participation was halted until no pain was reported and the 3-month follow-up imaging confirmed partial or complete healing.
Statistical Analysis
A Student t test was used to compare continuous data. The chi-square test was used to compare categorical data. Results with a P value <.05 were considered statistically significant.
Results
A total of 100 patients (79 boys and 21 girls) met the inclusion criteria and were included in the final analysis. The demographics and sports participation data are summarized in Table 1. The mean age at time of injury was 15.0 years (range, 9-18 years). Stress fractures (grade 1) were seen in 9 patients, incomplete fractures (grade 2) were seen in 64 patients, and complete fractures (grade 3) were seen in 27 patients as determined by MRI and limited CT studies. There were 7 L3 level fractures, 24 L4 level fractures, and 69 L5 level fractures. There were 60 cases of unilateral spondylolysis and 40 cases of bilateral spondylosis. Table 2 summarizes spondylosis categorization and healing rates broken down by each age represented in our cohort (9-18 years).
Table 1.
Study Cohort Characteristics (N = 100)
| Value (%) | |
|---|---|
| Sex | |
| Male | 79 (79) |
| Female | 21 (21) |
| Spondylosis grade | |
| Grade 1 | 9 (9) |
| Grade 2 | 64 (64) |
| Grade 3 | 27 (27) |
| Spondylosis laterality | |
| Right-sided | 32 (32) |
| Left-sided | 28 (28) |
| Bilateral | 40 (40) |
| Vertebrae level of injury | |
| L3 | 7 (7) |
| L4 | 24 (24) |
| L5 | 69 (69) |
| Completed 12 wk of bracing | 68 (68) |
| Sports participation | |
| Basketball | 26 |
| Football | 24 |
| Soccer | 21 |
| Baseball | 18 |
| Hockey | 12 |
| Lacrosse | 10 |
| Track | 9 |
| Golf | 8 |
| Volleyball | 6 |
| Dance | 4 |
| Skiing | 3 |
| Gymnastics | 2 |
| Wrestling | 2 |
| Mountain biking | 1 |
Table 2.
Demographic and Spondylolysis Characteristic Differences Between Cohorts Based on Age at Time of Injury a
| Age, y | ||||||||
|---|---|---|---|---|---|---|---|---|
| 9-11 (n = 3) | 12 (n = 5) | 13 (n = 5) | 14 (n = 23) | 15 (n = 25) | 16 (n = 21) | 17 (n = 12) | 18 (n = 6) | |
| Spondylosis level | ||||||||
| L3 | 0 | 0 | 0 | 1 | 2 | 1 | 1 | 2 |
| L4 | 0 | 1 | 1 | 4 | 9 | 4 | 4 | 1 |
| L5 | 3 | 4 | 4 | 18 | 14 | 16 | 7 | 3 |
| Spondylosis grade | ||||||||
| Grade 1 | 0 | 0 | 0 | 0 | 5 | 1 | 3 | 0 |
| Grade 2 | 1 | 2 | 3 | 13 | 13 | 19 | 7 | 6 |
| Grade 3 | 2 | 3 | 2 | 10 | 7 | 1 | 2 | 0 |
| Results of follow-up SPECT scan | ||||||||
| Healed | 3 | 5 | 4 | 21 | 24 | 19 | 12 | 5 |
| Not healed | 0 | 0 | 1 | 2 | 1 | 2 | 0 | 1 |
SPECT, single proton emission computed tomography.
The PT records of 91 (of the 100) patients were reviewed. The 9 for whom PT records were missing went to PT outside of the organization and research personnel were unable to obtain those records. The mean PT start date was 9.0 weeks (range, 1-12 weeks) after injury date. Bracing was used in 68 patients, (75%) who each completed 12 weeks of bracing. 32 (25%) patients either chose not to utilize a brace or were unable to complete 12 weeks of bracing. There was no difference in healing between patients who utilized a brace and those who did not (P = .53).
After 3 months of nonoperative treatment, 7 patients demonstrated no healing on repeat limited CT imaging, 52 patients demonstrated partial healing, and 41 patients were fully healed. Return to sports participation was reported in 68 patients with a mean of 198.2 days (28.3 weeks) from injury date (median, 178 days; range, 57-441 days). Return-to-sport time was determined jointly by the patient, physical therapist, and coaching staff. There was no statistically significant difference in return-to-sport date based on radiographic evidence of healing (P = .074).
A total of 93 fractures demonstrated some or complete healing on follow-up imaging, whereas 7 fractures demonstrated no healing at the same visit. The mean age at injury was not statistically different between healing groups (15.0 years for the healed group compared with 15.1 years for the nonhealed group; P = .829). Additionally, there were no sex differences observed between the healing and nonhealing groups. Notably, all the nonhealed fractures were bilateral, compared with 33 (35.5%) of the healed fractures. Overall, 100% of grade 1, 95% of grade 2, and 85% of grade 3 fractures healed (Table 3). However, this difference was not statistically significant (P = .053). When comparing male and female patients, there were no statistically significant differences in spondylolysis characteristics or healing rates (Table 4).
Table 3.
Spondylosis Characteristics by Healing on Follow-Up Imaging a
| Healed (n = 93) | Not Healed (n = 7) | P Value | |
|---|---|---|---|
| Age, y | 15.0 | 15.1 | .829 |
| Sex | .652 | ||
| Male | 73 (92.4) | 6 (7.6) | |
| Female | 20 (95.2) | 1 (4.8) | |
| Fracture level | .030 | ||
| L3 | 7 (100) | 0 (0) | |
| L4 | 20 (83.3) | 4 (16.7) | |
| L5 | 66 (95.7) | 3 (4.3) | |
| Fracture laterality | .001 | ||
| Unilateral | 60 (100) | 0 (0) | |
| Bilateral | 33 (82.5) | 7 (17.5) | |
| Fracture grade | .053 | ||
| Grade 1 | 9 (100) | 0 (0) | |
| Grade 2 | 61 (95.3) | 3 (4.7) | |
| Grade 3 | 23 (85.2) | 4 (14.8) | |
Values are given as mean or n (%). Boldface type indicates statistical significance.
Table 4.
Spondylosis Characteristics by Sex on Follow-up Imaging a
| Male (n = 79) | Female (n = 21) | P Value | |
|---|---|---|---|
| Age, y | 15.1 | 14.5 | .136 |
| Fracture level | .129 | ||
| L3 | 4 (5.1) | 3 (14.3) | |
| L4 | 20 (25.3) | 4 (19.0) | |
| L5 | 55 (69.6) | 14 (66.7) | |
| Fracture laterality | .643 | ||
| Unilateral | 49 (62.0) | 11 (52.4) | |
| Bilateral | 30 (38.0) | 10 (47.6) | |
| Fracture grade | .070 | ||
| Grade 1 | 5 (6.3) | 4 (19.0) | |
| Grade 2 | 52 (65.8) | 12 (57.1) | |
| Grade 3 | 22 (27.8) | 5 (23.8) | |
| Results of follow-up SPECT scan | .652 | ||
| Healed | 73 (92.4) | 20 (95.2) | |
| Not healed | 6 (7.6) | 1 (4.8) |
Values are given as mean or n (%). SPECT, single proton emission computed tomography.
Discussion
Our data demonstrate that pediatric spondylolysis injuries heal at a high rate after 3 months of nonoperative treatment. We found no significant relationship between healing rates and age. There was no difference in healing rates between male and female participants. These consistently positive outcomes lead us to question the need for repeat imaging for the surveillance of pediatric spondylolysis. Advanced imaging in pediatric spondylolysis is highly debated due to questionable utility and increased burden placed on patients. Some argue against the need for initial advanced imaging because nonoperative management is preferred regardless of imaging results. Additionally, follow-up imaging remains controversial because it rarely dictates treatment and requires additional radiation exposure. Goetzinger et al 9 proposed an algorithm that attempts to maximize prognostic accuracy while minimizing harm, stating that after a physical examination, 2-view plain radiographs are ordered, and nonoperative management including PT is preferred. If nonoperative management fails, long-term follow-up advanced imaging with MRI would be most beneficial to reduce the radiation exposure. 9 Recent studies have demonstrated the utility of new MRI techniques such as 3.0-T MRI with T1-weighted volumetric interpolated breath-hold examination sequences in the diagnosis and monitoring of spondylolysis injuries.16,17 This imaging modality should be further investigated as an alternative to CT imaging with a significantly lower radiation burden. However, given our data, repeat imaging may not be indicated for pediatric patients with acute unilateral spondylolysis. These patients should be expected to heal well after 3 months of nonoperative treatment without complication. Patients with bilateral injuries or persistent pain at or after 12 weeks may require closer radiographic follow-up. It is suggested that patients with recurrent injury after initial healing (12 weeks) undergo repeat imaging to establish healing prognostics.
Our data suggest that most patients heal with nonoperative treatment and PT. However, this varied greatly depending on laterality and grade of the fracture as observed on initial CT imaging. Patients with bilateral fractures experienced significantly lower healing rates when compared with those with unilateral fractures (82.5% vs 100%; P = .001). Additionally, there was no significant difference in grade 3 fracture healing when compared with grade 1 and grade 2 fracture healing (85.2% vs 100% and 95.3%, respectively; P = .053). Our findings suggest clinical benefits to initial advanced imaging to elucidate these fracture characteristics, and additional research should be conducted to further investigate the prognostic benefits of radiographic evidence of spondylolysis. Furthermore, we observed a high incidence of L3 fractures (7%) when compared with previous studies. This is in accordance with more recently published incidence rates. These fractures were all seen in older patients (≥14 years of age), which may suggest a different cause for spondylolysis injuries as patients specialize in sports and become more skeletally mature.
After a spondylolysis diagnosis, adolescent athletes could benefit from core-strengthening exercises that target stabilizers of the lumbar spine. The transverse abdominis, internal oblique, and multifidus help to elevate intra-abdominal pressure and increase thoracolumbar fascia tension surrounding the lumbar spine, which increases lumbar stiffness.23,25,13 Adolescent athletes with spondylolysis commonly have low back pain during activities involving the lumbar spine (extension, rotation, and loading). This suggests that spondylolysis is a result of increased lumbar load, which leads to increased mechanical stress on the pars interarticularis. 6 Some recommendations suggest initiation of regular PT sessions promptly on suspicion or confirmation of spondylolysis, while others suggest a period of inactivity before engaging in PT. Conflicting recommendations exist regarding the use of external bracing in spondylolysis cases, including the timing of its application after diagnosis. Despite conflicting recommendations, nonoperative management, including activity restriction, limiting sports participation, PT, and external bracing, is the standard of care.2,14 However, a retrospective study of the records of 121 adolescents treated with external bracing after diagnosis found no statistically significant long-term benefits associated with factors like injury type, symptom duration, or previous instances of low back pain. 26 Routine use of external bracing in this patient population has not been shown to be any more effective than nonoperative treatment without bracing. 26 Our results did not demonstrate a statistically significant difference in radiographic healing after 12 weeks of bracing, noting that bracing was used for those with a higher risk of failure to heal.
Comprehending the natural healing processes, determining the best time to start treatment, ensuring proper progression, and carefully managing stress loads to the healing structure are pivotal for achieving positive outcomes in adolescent spondylolysis. When crafting treatment strategies for adolescent athletes, physical therapists must consider unique factors pertinent to this age group, such as their physical and emotional development (eg, capacity to understand and follow treatment plans) and social dynamics (eg, family and community support and adherence to scheduled appointments). 9 For adolescent athletes with spondylolysis, the literature providing a universally accepted treatment protocol for nonoperative and operative treatment is scarce. 6 This study draws attention to the minimal body of evidence investigating the treatment and outcomes of pediatric spondylolysis. Future investigation into the details of sports participation would elucidate the specific risk factors and may guide physical trainers and coaches on specific activities to encourage or avoid. Sports history information that would be useful to clinicians includes duration of participation, frequency of competition and training, intensity of competition and training, and conditioning modalities. Furthermore, the few studies investigating this topic focused primarily on functional outcomes and pain levels after PT without radiographic evidence of bone healing. These current findings suggest a potential prognostic benefit of initial MRI followed by limited CT imaging of adolescent spondylolysis while advocating for further investigation into the effect various PT protocols have on clinical and radiographic evidence of healing.
Limitations
A major limitation of our study was its retrospective nature. On chart review, there was inconsistent PT adherence, and it was difficult to verify return to sport and pain improvement after treatment. We were unable to follow patients beyond completion of PT, limiting our understanding of the long-term outcomes of these injuries. This emphasizes the need for randomized prospective trials investigating the effects of different PT parameters and their individual effects on radiographic healing, pain improvement, and return-to-sport time. Additionally, we reviewed radiologist reports to determine evidence of radiographic healing. This methodology was previously described by Gauthier et al 8 ; however, this can oversimplify a broad spectrum of healing stages. This likely contributes to our overall high healing rate. Finally, we had a small sample size of unhealed fractures.
Conclusion
Our data demonstrate that the vast majority (93%) of acute adolescent spondylosis cases demonstrated radiographic healing after 3 months of nonoperative treatment. We found no significant relationship between healing rates and age. There was no difference in healing rates between male and female participants. These consistently positive outcomes suggest that repeat imaging for the surveillance of acute pediatric spondylolysis may not be necessary in patients without persistent pain or bilateral injuries.
Footnotes
Final revision submitted September 5, 2025; accepted September 18, 2025.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from BRANY IRB.
ORCID iDs: Niklaus P. Zeller 
https://orcid.org/0009-0001-9787-3355
Rebecca Stone McGaver
https://orcid.org/0000-0001-9614-5383
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